An analysis of Liberia's 2007 national health policy: lessons for health systems strengthening and chronic disease care in poor, post-conflict countries

Background

Globally, chronic diseases are responsible for an enormous burden of deaths, disability, and economic loss, yet little is known about the optimal health sector response to chronic diseases in poor, post-conflict countries. Liberia's experience in strengthening health systems and health financing overall, and addressing HIV/AIDS and mental health in particular, provides a relevant case study for international stakeholders and policymakers in other poor, post-conflict countries seeking to understand and prioritize the global response to chronic diseases.

Methods

We conducted a historical review of Liberia's post-conflict policies and their impact on general economic and health indicators, as well as on health systems strengthening and chronic disease care and treatment. Key sources included primary documents from Liberia's Ministry of Health and Social Welfare, published and gray literature, and personal communications from key stakeholders engaged in Liberia's Health Sector Reform. In this case study, we examine the early reconstruction of Liberia's health care system from the end of conflict in 2003 to the present time, highlight challenges and lessons learned from this initial experience, and describe future directions for health systems strengthening and chronic disease care and treatment in Liberia.

Results

Six key lessons emerge from this analysis: (i) the 2007 National Health Policy's 'one size fits all' approach met aggregate planning targets but resulted in significant gaps and inefficiencies throughout the system; (ii) the innovative Health Sector Pool Fund proved to be an effective financing mechanism to recruit and align health actors with the 2007 National Health Policy; (iii) a substantial rural health delivery gap remains, but it could be bridged with a robust cadre of community health workers integrated into the primary health care system; (iv) effective strategies for HIV/AIDS care in other settings should be validated in Liberia and adapted for use in other chronic diseases; (v) mental health disorders are extremely prevalent in Liberia and should remain a top chronic disease priority; and (vi) better information systems and data management are needed at all levels of the health system.

Conclusions

The way forward for chronic diseases in Liberia will require an increased emphasis on quality over quantity, better data management to inform rational health sector planning, corrective mechanisms to more efficiently align health infrastructure and personnel with existing needs, and innovative methods to improve long-term retention in care and bridge the rural health delivery gap.     

Intratubular and peritubular capillary hydrostatic and oncotic pressures after chronic renal sympathectomy in the anaesthetized rat

The possible role of peritubular capillary physical forces in the diuretic-natriuretic effects of chronic renal denervation was investigated in Inactin-anaesthetized non-diuretic control (C) and unilaterally denervated (D) rats. Micropuncture techniques were combined with measurement of intratubular and peritubular capillary hydrostatic pressures and afferent and efferent arteriolar plasma oncotic pressures were determined, as well. Compared to data of C rats and of innervated kidneys, marked denervation diuresis and natriuresis were seen without changes in GFR. Both late proximal and early distal (F/P)_In values were significantly lower in D kidneys with similar SNGFR. Afferent (π_a) and efferent (π_e) arteriolar oncotic pressures were unchanged by denervation (C-π_a = 23.3 ± 0.79, π_e = 29.9 ± 0.87 mm Hg; D-π_a = 23.2 ± 0.94, π_e = 29.8 ± 1.04 mm Hg). Proximal intratubular hydrostatic pressure was moderately but significantly higher in D kidneys (C=11.9±0.5, D=13.7±0.3 mm Hg,P<0.01), while peritubular capillary pressures were: efferent arteriole (C=13.9±0.5, D=13.4±0.6 mm Hg, NS). It is concluded that the tubular effects of chronic renal sympathectomy are not dependent on changes in Starling forces of the peritubular environment.     

Development of Design Methods for a Centrifugal Blood Pump with a Fluid Dynamic Approach: Results in Hemolysis Tests

The purpose of this study was to examine the relationship between local flow conditions and the hemolysis level by integrating hemolysis tests, flow visualization, and computational fluid dynamics to establish practical design criteria for centrifugal blood pumps with lower levels of hemolysis. The Nikkiso centrifugal blood pump was used as a standard model, and pumps with different values of 3 geometrical parameters were tested. The studied parameters were the radial gap between the outer edge of the impeller vane and the casing wall, the position of the outlet port, and the discharge angle of the impeller vane. The effect of a narrow radial gap on hemolysis was consistent with no evidence that the outlet port position or the vane discharge angle affected blood trauma in so far as the Nikkiso centrifugal blood pump was concerned. The radial gap should be considered as a design parameter of a centrifugal blood pump to reduce blood trauma.     

Outcome following pulmonary haemorrhage in very low birthweight neonates treated with surfactant.

AIM: To determine if pulmonary haemorrhage after surfactant treatment increases short and long term morbidity and mortality in neonates weighing <1500 g at birth. METHODS: Neonates weighing <1500 g at birth who developed pulmonary haemorrhage after surfactant treatment were identified from a database. Based on the change in FIO2, pulmonary haemorrhage was classified as mild, moderate, or severe. Controls were matched for birthweight, gestational age, Apgar scores and hospital. Chronic lung disease (CLD) was defined as the need for supplemental oxygen at 36 weeks of corrected gestational age. RESULTS: From January 1990 to May 1994, 94 of 787 (11.9%) neonates treated with surfactant developed pulmonary haemorrhage. Ten were excluded because of incomplete data or lack of controls. Eighty four were included for further analysis; two acceptable matches were found in 75, while only one match was possible in nine. For the pulmonary haemorrhage group, the mean (SD) birthweight was 917 (238) g, gestational age 27 (1.9) weeks. Pulmonary haemorrhage was severe in 39 (46%), moderate in 22 (26%), and mild in 23 (27%). Moderate and severe pulmonary haemorrhage were associated with chronic lung disease or death, OR 4.4 (confidence interval 1.3-15.7) and OR 7.8 (CI 2.6-28), respectively, while mild pulmonary haemorrhage was not, OR 1.8 (CI 0.55-5.8). pulmonary haemorrhage was associated with major intraventricular haemorrhage (IVH), OR 3.1 (CI 1.5-6.4), but not with minor IVH, OR 1.3 (CI 0.6-2. 6). In the survivors who could be assessed at >/=2 years, the differences in neurodevelopmental outcome among the two groups were not significant. CONCLUSIONS: In neonates treated with surfactant moderate and severe pulmonary haemorrhage is associated with an increased risk of death and short term morbidity. Pulmonary haemorrhage does not seem to be associated with increased long term morbidity.     

7-溴化乙氧苯四氢巴马汀抗心律失常作用的机理

7-溴化乙氧苯四氢巴马汀(7-bromoethoxybenzene-tetrahydropalmatine,EBP)10及30μmol/L均能明显延长豚鼠乳头状肌动作电位时程(APD),但对动作电位幅度(APA),静息电位(RP),超射(OS),零期最大上升速率(V_max)无显著影响。EBP能按剂量抑制犬浦氏纤维慢内向电流(I_si)及钾外向电流(I_x)的峰值。     

Postnatal growth failure in preterm infants: ascertainment and relation to long-term outcome

OBJECTIVE: Traditional measure of postnatal growth failure assessment has poor discriminatory power for long-term outcomes. Our objective was to identify measure of postnatal growth failure associated with long-term outcome in preterm infants born at < 28 weeks' gestation. PATIENTS AND METHODS: Four measures of defining postnatal growth failure at 36 weeks corrected gestational age: (1) weight < 10(th) centile, (2) weight < 3(rd) centile, (3) z score difference from birth > 1 and, (4) z score difference from birth > 2; were compared for their predictive values and strength of association with adverse neurodevelopmental outcomes at 18-24 months. RESULTS: Postnatal growth failure defined as a decrease in z score of > 2 between birth and 36 weeks corrected gestational age had the best predictive values compared to other postnatal growth failure measures, however, it was significantly associated with psychomotor developmental (P=0.006) but not with mental developmental indices (P=0.379). CONCLUSION: Postnatal growth failure defined by z score change influenced psychomotor but not mental tasks in this cohort. This method of ascertainment could be useful to identify infants who might benefit from nutritional interventions.     

Use of the Complete Rockall Score and the Forrest Classification to Assess Outcome in Patients with Non-variceal Upper Gastrointestinal Bleeding Subject to After-hours Endoscopy: A Retrospective Cohort Study

Objectives:

To evaluate the usefulness of the Forrest classification and the complete Rockall score with customary cut-off values for assessing the risk of adverse events in patients with upper gastrointestinal bleeding (UGI-B) subject to after-hours emergency oesophago-gastro-duodenoscopy (E-EGD) within six hours after admission.

Methods:

The medical records of patients with non-variceal UGI-B proven by after-hours endoscopy were analysed. For ''high risk'' situations (Forrest stage Ia–IIb/complete Rockall score > 2), univariate analysis was conducted to evaluate odds ratio for reaching the study endpoints (30-day and one-year mortality, re-bleeding, hospital stay ≥ 3 days).

Results:

During the study period (75 months), 86 cases (85 patients) met the inclusion criteria. Patients ''age was 66.36 ± 14.38 years; 60.5% were male. Mean duration of hospital stay was 15.21 ± 19.24 days. Mortality rate was 16.7% (30 days) and 32.9% (one year); 14% of patients re-bled. Univariate analysis of post-endoscopic Rockall score ≥ 2 showed an odds ratio of 6.09 for death within 30 days (p = 0.04). No other significant correlations were found.

Conclusion:

In patients with UGI-B subject to after-hours endoscopy, a ''high-risk'' Rockall score permits an estimation of the risk of death within 30 days but not of re-bleeding. A ''high-risk '' Forrest score is not significantly associated with the study endpoints.