Costs and revenue of health care in a rural Zimbabwean district

The District Health Executive of Tsholotsho district in south-west Zimbabwe conducted a health care cost study for financial year 1997-98. The study's main purpose was to generate data on the cost of health care of a relatively high standard, in a context of decentralization of health services and increasing importance of local cost-recovery arrangements. The methodology was based on a combination of step-down cost accounting and detailed observation of resource use at the point of service. The study is original in that it presents cost data for almost all of the health care services provided at district level. The total annualized cost of the district public health services in Tsholotsho amounted to US$10 per capita, which is similar to the World Bank's Better Health in Africa study (1994) but higher than in comparable studies in other countries of the region. This can be explained by the higher standards of care and of living in Zimbabwe at the time of the study. About 60% of the costs were for the district hospital, while the different first-line health care facilities (health centres and rural hospitals together) absorbed 40%. Some 54% of total costs for the district were for salaries, 20% for drugs, 11% for equipment and buildings (including depreciation) and 15% for other costs. The study also looked into the revenue available at district level: the main source of revenue (85%) was from the Ministry of Health. The potential for cost recovery was hardly exploited and revenue from user fees was negligible. The study results further question the efficiency and relevance of maintaining rural hospitals at the current level of capacity, confirm the soundness of a two-tiered district health system based on a rational referral system, and make a clear case for the management of the different elements of the budget at the decentralized district level. The study shows that it is possible to deliver district health care of a reasonable quality at a cost that is by no means exorbitant, albeit unfortunately not yet within reach of many sub-Saharan African countries today.     

Too frightened to care? Accounts by district nurses working with clients who misuse substances

Drug misusers have complex health and social care needs, and experience considerable difficulties in accessing the assessment, care and treatment that they require. Despite the development of specialist services in many parts of the UK, substance misuse is often marginalised within mainstream general healthcare, and many practitioners are unprepared for the challenges of working with this client group. The present paper reports findings from a qualitative study that aimed to explore district nurses' understandings and practices in relation to discrimination and inequalities issues. The research took place during 2003 in two city-based primary care trusts in the North of England. Semistructured interviews were undertaken with 18 'G' grade district nurses. The authors present findings that highlight some of the challenges and tensions district nurses encounter when providing care to clients who misuse substances. The discourses of 'prejudice' and 'risk' were intertwined throughout the data, and served to shape service provision for clients who misuse substances. This was reflected in the district nurses' accounts of their own practice and that of other services, suggesting that these clients receive suboptimal care. The discourse of 'risk' was also used by district nurses to construct themselves as 'vulnerable', and this helped to explain some of their own practices of care provision. Many participants acknowledged their limited knowledge and experience of working with this client group. There is an urgent need for district nurses and other health professionals to develop their practice with these clients, who may present as both vulnerable and dangerous, in order to ensure that care is provided equitably and safely.     

Liaison psychiatry for the 21st century: a review.

The development of liaison psychiatry services over the last 20 years is briefly reviewed--sophisticated liaison services have been confined to teaching hospitals. Limited manpower and other resources have prevented the development of liaison services in most district general hospitals; further developments are unlikely unless these deficiencies are corrected and psychiatrists take a more active role in developing links with physicians and surgeons. The time is right for such development as physicians are keen to extend our understanding of psychological and social factors in causing non-organic disorders, reduce unnecessary investigations and provide more comprehensive care. Increased collaboration between physicians and psychiatrists will provide a better service for many patients and this should be extended to all district general hospitals.     

Partnership working by default: district nurses and care home staff providing care for older people

Older people residents in care homes that only offer residential care rely on primary healthcare services for medical and nursing needs. Research has investigated the demands that care homes staff and residents make on general practice, but not the involvement of other members of the primary healthcare team. This paper describes two consecutive studies completed in 2001 and 2003 that involved focus groups and survey methods of enquiry conducted in two settings: an England shire and inner London. The research questions that both studies had in common were (1) What is the contribution of district nursing and other primary care services to care homes that do not have on‐site nursing provision? (2) What strategies promote participation and collaboration between residents, care home staff and NHS primary care nursing staff? and (3) What are the current obstacles and aids to effective partnership working and learning? A total of 74 community‐based nurses and care home managers and staff took part in 10 focus groups, while 124 care home managers (73% of the171 surveyed) and 113 district nurse team leaders (80% of the 142 surveyed) participated in the surveys. Findings from both studies demonstrated that nurses were the most frequent NHS professional visiting care homes. Although care home managers and district nurses believed that they had a good working relationship, they had differing expectations of what the nursing contribution should be and how personal and nursing care were defined. This influenced the range of services that older people had access to and the amount of training and support care home staff received from district nurses and the extent to which they were able to develop collaborative and reciprocal patterns of working. Findings indicate that there is a need for community‐based nursing services to adopt a more strategic approach that ensures older people in care homes can access the services they are entitled to and receive equivalent health care to older people who live in their own homes.     

Getting a visit: how district nurses and general practitioners 'organise' each other in primary care

This paper examines the ways in which district nurses and general practitioners interacted and influenced each other's work within primary care services. The data presented here examine how the developments in the organisation of primary care affected the work of district nurses during a time of turbulent change. Qualitative data from 300 hours of participant observation and 40 semi-structured interviews with 33 district nurses were analysed using grounded theory, after which a literature review was undertaken. The findings from this study were interpreted using a Foucauldian notion of power and Fox's (1995) analysis of 'organisation'. The shift in power to general practitioners (GPs) has meant that they can exercise ever-increasing authority over nurses in their employ. Strict rules governed the process of inter-professional work and nurses and doctors used creative strategies to overcome the problems that existed between them. The data show that nurses could and did resist the power of GPs but this resistance generally elicited other more punishing forms of authority. Direct and indirect threats were commonplace. The data suggest that district nurses were moving into a closer, more business-like and tightly-controlled working relationship with general practitioners, through which competing discourses interplayed and circulated between GPs and district nurses in the organisation of primary care services.     

Services to families with children. A study of community work in Uppsala

This article describes some of the results of a study of services to families and children in a suburban district, Sweden. Services included in the study were: maternal and child health care, child psychiatry, services for handicapped children, school health care, day care services, community social services and family counselling services. The baseline studies comprised analyses of official goals expressed in legislation and recommendations, interviews with local politicians and administrators, record studies, studies of working time distribution and questionnaires to field professionals and families. The results indicate that services with traditional goals and well-defined tasks (e.g. health supervision) were more satisfied with their goal attainment, less inclined to collaborate with other services, and more occupied with direct client work than services with non-traditional goals and vaguely defined tasks (e.g. strengthening democracy).     

加强基层中医药服务背景下居民首诊医疗机构影响因素分析

目的 通过研究北京市石景山区居民首诊医疗机构的影响因素,为推动分级诊疗提供理论依据。 方法 于2016年3-5月,在北京市石景山区采用分层随机整群抽样法入户进行面对面问卷调查。采用多水平多分类logistic模型分析居民选择首诊医疗机构的影响因素。 结果 共调查1122名居民,24.6%,56.2%%和12.5%的居民一般情况下分别选择区内社区医疗机构、区内综合医院和区外综合医院首诊。多水平多分类logistic模型结果显示,性别、文化程度、离家最近的医疗机构类型以及是否清楚区内社区医疗机构中医药服务情况是居民选择区内社区医疗机构或区内综合医院首诊的影响因素;文化程度、离家最近的医疗机构类型、过去一年家庭人均总支出、是否清楚区内社区医疗机构中医药服务情况是居民选择区内社区医疗机构或区外综合医院首诊的影响因素。 结论 应继续提高石景山区社区医疗机构的诊疗水平及中医药服务能力,同时增进居民对社区中医药服务的认知度,从而推动分级诊疗的实现。     

Planning palliative care services

An audit was conducted to assess the use of, and satisfaction with, local services for the care of the dying, which have developed over the past seven years in South Glamorgan. These services include hospice inpatient, outpatient and day care facilities, home care specialist nursing, volunteer services and domiciliary medical consultations. All general practitioners in the district were surveyed about the services by postal questionnaire; respondents represented most of the practices in the district. The results show a variable level of uptake of services for those well established (excluding paediatric oncology), including a high level of satisfaction with the available services. The results identify a lack of provision for patients dying from a non-malignant disease.     

Willingness to pay for district hospital services in rural Tanzania

This paper describes a study undertaken to investigate the willingness of patients and households to pay for rural district hospital services in north-western Tanzania. The surveys undertaken included interviews with 500 outpatients and 293 inpatients at three district level hospitals, interviews with 1500 households and discussions with 22 focus groups within the catchment areas of the primary health care programmes of these hospitals. Information was collected on willingness to pay fees for certain hospital services, willingness to become a member of a local insurance system, and exemptions for cost-sharing. The willingness to pay for district hospital services was large. Furthermore, most respondents favoured a local insurance system above user fee systems, a finding which applied at all places and in all the surveys. More female respondents were in favour of a local insurance scheme. The conditions needed for the introduction of a local insurance system are discussed.     

Current comment. (xix). Why don't general practitioners refer their disabled Asian patients to district nurses?

Research into the needs of disabled people in Central Birmingham and their use of community health and social services has shown that Asian people are 'underusers' of these services, particularly district nursing. We have found that in this district, general practitioners (GPs) refer the majority of district nurses' disabled patients, but they are not referring Asians. Possible explanations--that elderly Asians have low contact rates with GPs, lack knowledge about the district nursing services, or refuse to use the service--are not supported by the research data. More likely explanations are offered--that GPs hold stereotyped views about Asians and their needs, have a misunderstanding of the role and function of the district nurse and inflexible assumptions about the 'typical' patient seen by the district nurse. Attention is drawn to the urgent need for GPs to address these issues and for further research as the numbers of older Asians are set to rise sharply.     

Survey of provision of echocardiography in Scottish district general hospitals

A telephone survey of echocardiography services in district general hospitals in Scotland was carried out in 1999. The study showed wide variation in the echocardiography services among the district hospitals in terms of equipment, personnel and service provision. The number of echocardiograms performed by a centre is partly dependent on the demand but is more critically influenced by the local provision of service. In particular, sufficient numbers of trained technicians hold the key to efficient high output services. The survey has provided a platform for comparison of echocardiography services among the district general hospitals in Scotland. We hope that this will encourage individual district hospitals to audit their echocardiography service with a special emphasis on the role of the technician.     

Expanding access to primary care without additional budgets? A case study from Burkina Faso

The aim of this study is to demonstrate the impact of increased access to primary care on provider costs in the rural health district of Nouna, Burkina Faso. This study question is crucial for health care planning in this district, as other research work shows that the population has a higher need for health care services. From a public health perspective, an increase of utilisation of first-line health facilities would be necessary. However, the governmental budget that is needed to finance improved access was not known. The study is based on data of 2004 of a comprehensive provider cost information system. This database provides us with the actual costs of each primary health care facility (Centre de Santé et de Promotion Sociale, CSPS) in the health district. We determine the fixed and variable costs of each institution and calculate the average cost per service unit rendered in 2004. Based on the cost structure of each CSPS, we calculate the total costs if the demand for health care services increased. We conclude that the total provider costs of primary care (and therefore the governmental budget) would hardly rise if the coverage of the population were increased. This is mainly due to the fact that the highest variable costs are drugs, which are fully paid for by the customers (Bamako Initiative). The majority of other costs are fixed. Consequently, health care reforms that improve access to health care institutions must not fear dramatically increasing the costs of health care services. This study was supported by a research grant of the German Research Foundation (Deutsche Forschungsgemeinschaft).     

A rapid assessment methodology for the evaluation of primary care organization and performance in Brazil

INTRODUCTION: This study presents a methodology for the rapid assessment of the organization and performance of primary care services at district level. It compares results from an earlier provider survey in Petrópolis, Brazil with those obtained directly from users of two types of primary care services (newly developed Family Health Program services or 'PSF'--Programa de Saúde da Família--and traditional services) in the same municipality. The aim is to demonstrate the validity of the methodology and its potential use in measuring and improving district-level primary care services in developing countries. METHODS: The study adapted a previously developed questionnaire to measure essential dimensions of primary care. Users (n = 468) were randomly selected from each of the 40 primary care clinics in the district and administered a question survey. Responses were used to create nine measures: an overall composite 'total primary care index' and eight sub-indices each pertaining to an essential primary care dimension. RESULTS: Primary care services show considerable variation in user experiences. Users of the new (PSF) clinics reported higher overall assessments of the total primary care index and the sub-indices for gatekeeping, comprehensiveness, family focus and community orientation than did users of traditional services (P < 0.05). The total primary care score was internally consistent with a Cronbach's alpha of 0.8, and could be reduced to only one principal component. User assessments of primary care services were predicted by self-rated health (OR 1.72) and the site of care (OR 1.03). User and provider assessments of the total primary care index were not significantly different, disagreeing on only two sub-indices (gatekeeping and family focus, P < 0.05). CONCLUSIONS: The study presents a rapid and valid method of obtaining information about clinic-level variation in primary care organization and performance at district level. The total primary care index was not sensitive to demographic or socio-economic characteristics of clients, was internally consistent and appears valid given similar results obtained using two different data sources. With some adaptation the instrument could potentially be applied in other developing countries.     

武汉社区外环境承包灭鼠评估

目的评估武汉社区外环境承包灭鼠是否有效,分析影响灭鼠服务质量的因素。方法每城区检查6社区,记录服务机构、外环境鼠迹、毒饵站、满意率等情况,对服务质量评分。用SPSS多元线性回归分析城区类别及服务机构性质等对中标社区数的影响,分析服务机构的性质、城区类型等与外环境鼠迹及分数之间的关系。结果全市抽查84个社区,检查42 000延长米外环境,查见72处鼠迹,平均2 000延长米鼠迹3.4处。本区服务机构平均每区承包44.9个社区,是外区服务机构平均每区承包数的1.5倍,嫡系服务机构平均每区承包54.2个社区,是非嫡服务机构平均每区承包数的1.8倍,SPSS分析名义变量"本区"的P=0.002,"嫡系"的P=0.035。当因变量为分数的转换值时,代表服务机构有无资质、是否甲级资质、是否本区、是否嫡系的名义变量P0.05。结论全市平均外环境鼠迹达到爱卫标准。各区招标倾向于使用嫡系及本区的服务机构,该倾向有其合理性。     

Will more inputs improve the delivery of health services?: Analysis of district vaccination coverage in Pakistan

In order to determine whether physical resources or technical inputs can make a difference to the delivery of health services, we carried out a study that examined the large variation in district level vaccination coverage in Pakistan. Vaccination coverage was assessed by district-wise cluster surveys and the predictor variables were collected from census data and from a survey of 99 district health offices. Information was collected on basic supplies, physical infrastructure, management, training, socio-economic variables, and a variety of other indicators. Univariate and multivariate analyses were carried out. A model including female literacy rate, TV ownership, and provincial dummies explained 48% of the variation in DTP3 coverage. Very few of the other variables examined were significantly correlated to coverage. Possible explanatory variables like adequacy of syringe and vaccine supply, the number of vaccinators per capita, recent training of managers, frequency of supervision, availability of micro-plans, and turnover of managers were not correlated with coverage. While the Government of Pakistan has ensured that many physical resources and technical inputs have been provided to the district health offices, this does not appear able to explain the relatively low overall coverage or the variation between districts. Bolder initiatives and innovations are likely needed to improve delivery of basic health services.     

Ethnic Health Care Advisors: A Good Strategy to Improve the Access to Health Care and Social Welfare Services for Ethnic Minorities?

Empirical studies indicate that ethnic minorities have limited access to health care and welfare services compared with the host population. To improve this access, ethnic health care (HC) advisors were introduced in four districts in Amsterdam, the Netherlands. HC advisors work for all health care and welfare services and their main task is to provide information on health care and welfare to individuals and groups and refer individuals to services. Action research was carried out over a period of 2 years to find out whether and how this function can contribute to improve access to services for ethnic minorities. Information was gathered by semi-structured interviews, analysing registration forms and reports, and attending meetings. The function’s implementation and characteristics differed per district. The ethnicity of the health care advisors corresponded to the main ethnic groups in the district: Moroccan and Turkish (three districts) and sub-Sahara African and Surinamese (one district). HC advisors reached many ethnic inhabitants (n = 2,224) through individual contacts. Half of them were referred to health care and welfare services. In total, 576 group classes were given. These were mostly attended by Moroccan and Turkish females. Outreach activities and office hours at popular locations appeared to be important characteristics for actually reaching ethnic minorities. Furthermore, direct contact with a well-organized back office seems to be important. HC advisors were able to reach many ethnic minorities, provide information about the health care and welfare system, and refer them to services. Besides adapting the function to the local situation, some general aspects for success can be indicated: the ethnic background of the HC advisor should correspond to the main ethnic minority groups in the district, HC advisors need to conduct outreach work, there must be a well-organized back office to refer clients to, and there needs to be enough commitment among professionals of local health and welfare services.     

A national public health service.

The development of the British public health services is briefly reviewed and it is suggested that two types of epidemiologist (Community Physician) are necessary in each locality: one concerned with medical administration and health care planning-the medical administrator, and the other with the prevention of disease-the clinical epidemiologist. A new nation public health service is proposed to revive disease prevention with four main features: (1) A district Clinical Epidemiologist who is a member of the district department of community medicine with responsibility for prevention but with no district administrative duties. (2) A District Epidemiology Unit comprising other appropriate staff. (3) National specialist epidemiology units within the NHS with service roles to support and coordinate the District Clinical Epidemiologists. (4) A national authority within the NHS with responsibility for prevention and for administering the national specialist units.     

Expansion of antiretroviral treatment to rural health centre level by a mobile service in Mumbwa district, Zambia

Problem

Despite the Government’s effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages.

Approach

The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa.

Local setting

Mumbwa is a rural district with an area of 23 000 km² and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital.

Relevant changes

The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases “lost to follow-up”. This might be due to the closer involvement of the community and the better support offered by these services to rural clients.

Lessons learnt

These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.