Financial information at district level: experiences from five countries

Management information systems are intended to help managersmake decisions. But few management information systems in primaryhealth care include information on costs, even though resourceallocation and budgeting are key functions of primary healthcare managers. Drawing on five papers presented to a WHO conferenceon strengthening district health systems, this article illustratesthe potential usefulness of financial data to district managers.The examples come from individual districts in Ethiopia, Indonesia,Kenya, Sri Lanka and Tanzania.No original data were collectedfor the studies - much can be learned from budgets and expenditureledgers. Some problems were encountered with the reliabilityof the data - a particular confusion was between allocated andrealized budgets. Allocated budgets area stated intention tospend money; realized budgets show that the expenditure actuallyoccurred. For planning purposes, realized amounts are of moreinterest.Managers can use financial information to questionthe allocation of resources in various ways. Providing informationon how much is being spent on what activities enables an explicitconsideration of the desirability of the existing use of resources,relative to priorities. Comparing unit costs can raise questionsabout the relative efficiency of different units, be they healthcentres, vaccination points or wards. Looking at the distributionof resources according to geographical areas, or other waysof grouping people, provides background data for the considerationof equity. Finally, the paper discusses how financial informationmight be used to identify areas of wastage.The paper concludesthat health systems already produce a good deal of financialinformation. At present, however, this information is oftenonly used by accountants or finance officers. Financial informationshould be incorporated into the larger management informationsystem.     

Health care financing in Indonesia

This paper describes health care financing and expendituresin Indonesia, a developing country spending around $US 9.40per capita annually for health care (2.6% of GOP). Per capitahealth care spending has held constant in real terms over thelast five years. The public sector accounts for 36.8% of allhealth care expenditure, or 43.1% if health care spending bystate enterprises is included. About 13% of the population,almost all of them government employees and their families,are covered by some form of health insurance. In 1984, 62% ofthe population was spending privately – at then currentexchange rates – an average of $US 2.70 per capita annuallyfor health care, another 30% averaged $US 8.35 each, and theupper 9% $US 31.90. The Government is reviewing various ‘social financing’mechanisms with a view to expanding health insurance coverageboth for those in formal wage employment and the bulk of thepopulation which remains either on the land or is part of the‘informal’ sector. Steps are also being taken toincrease the efficient use of resources by, among other things,making greater use of evaluation techniques and economic methodologies.Such efforts are coupled with more decentralized authority beinggiven to the provinces and districts. Particularly importantto future health efforts is the further expansion of community-basedactivities, especially in the form of the Posyandu (integratedhealth post). Brotowasisto, MD, is the director of the Planning Bureau ofthe Ministry of Health. He studied epidemiology and public healthin Thailand and the United States, and has been a WHO consultantin the areas of diarrhoeal disease control and immunization.He has published a number of papers in these fields. He is apermanent member of the delegation of Indonesia to the WorldHealth Assembly and represents his country at the annual meetingof the WHO Southeast Asian Regional Office. Oscar Gish is WHO Senior Health Planner in Indonesia attachedto the Indonesian Ministry of Health and working, in particular,with the Planning Bureau of the Ministry's Secretariat. He hasconducted research and consultancy activities in Africa, Asiaand Latin America. He has also published articles and booksconcerned with health and health care issues in the Third World. Ridwan Malik, MD, is head of the Division of Evaluation andReporting, Bureau of Planning of the Ministry of Health. Hehas taken part in international workshops and conferences concernedwith epidemiology, public health administration, health financingand economics and health development. Paramita Sudharto, MD, is with the Bureau of Planning of theMinistry of Health where she has been engaged in a number ofplanning activities, in particular with studies concerned withfinancial and economic issues. Before joining the Bureau shewas responsible for primary health care development in Jakarta.     

CASTRATION INDUCES ACUTE VASOCONSTRICTION OF BLOOD VESSELS IN THE RAT PROSTATE CONCOMITANT WITH A REDUCTION OF PROSTATIC NITRIC OXIDE SYNTHASE ACTIVITY

PURPOSE: Previous studies demonstrating a rapid and drastic reduction of blood flow to the rat prostate gland resulting from castration caused us to consider the influence of castration on the state of vascular constriction and on the activity of the vascular tone-regulating factors (nitric oxide synthase and cyclic GMP) in the rat prostate. MATERIALS AND METHODS: Sections of ventral prostate glands obtained from intact and castrated rats were analyzed for the mean areas within smooth muscle-coated blood vessels using a computerized microscopic image analysis system. Nitric oxide synthase (NOS) levels were measured in prostatic extracts from unoperated or castrated rats using an enzyme assay system that measures conversion of 3H-L-arginine to citruline. Cyclic GMP levels were measured in prostatic extracts from unoperated or castrated rats using a competitive radioimmunoassay system. RESULTS: The mean area within ventral prostate smooth muscle-coated blood vessels was reduced 39% at 24 hours after castration (p = 0.039) and 47.7% at 48 hours after castration (p = 0.039). NOS activity measured in prostatic extracts was reduced 38% at 24 hours (p = 0.0012) and 51.6% at 36 hours after castration (p = 0.0001) compared with the control group of noncastrated rats. Finally, prostatic cGMP levels were reduced 55.8% (p = 0.0018) at 36 hours after castration when compared with controls rats. CONCLUSION: Within 24 hours after castration, the lumenal areas of smooth muscle-coated blood vessels in the rat prostate gland were found to be significantly reduced. This vasoconstriction was associated with a significant reduction of prostatic NOS activity as well as a reduction in the prostatic levels of the NOS co-factor, cGMP. Thus, acute vasoconstriction is a prominent early event associated with rat prostate regression in response to castration and likely contributes to the regression of the tissue.     

EFFICACY AND SAFETY OF TRANSURETHRAL ALPROSTADIL IN PATIENTS WITH ERECTILE DYSFUNCTION FOLLOWING RADICAL PROSTATECTOMY

Purpose

A retrospective analysis of the MUSE* clinical trial was performed to evaluate the efficacy and safety of transurethral alprostadil in patients with erectile dysfunction after radical prostatectomy.

Materials and Methods

Patients received doses of transurethral alprostadil in the clinic and those for whom a suitable dose was determined were treated at home with active drug or placebo for 3 months. Patients had undergone radical prostatectomy no less than 3 months before study entry.

Results

Of the 384 patients in whom radical prostatectomy was identified as a cause of erectile dysfunction 70.3% had an erection believed sufficient for intercourse in the clinic and 57.1% on active medication had sexual intercourse at least once at home. The product of clinic and home success rates (70.3 x 57.1%) was an overall success rate (the likelihood of active treatment to lead to intercourse at home) of 40.1%. The frequency of most adverse effects of radical prostatectomy was comparable to that of other organic etiologies of erectile dysfunction (1,127 patients). The percentage of patients with hypotension in the clinic was lower after radical prostatectomy compared to other erectile dysfunction etiologies (0.8 versus 4.2%, p <0.001) but the percentage of patients with urethral pain/burning was higher (18.3 versus 10.4%, p = 0.027). No urinary tract infection, fibrosis or priapism occurred in the post-radical prostatectomy patients.

Conclusions

Transurethral alprostadil is a well tolerated and efficacious method of treating erectile dysfunction after radical prostatectomy, although psychological changes associated with cancer and surgery may limit home response. The severe neurovascular deficit associated with prostatectomy neither limits the efficacy of transurethral alprostadil nor increases the risks.     

TRANSDIFFERENTIATION OF PROSTATE CANCER CELLS TO A NEUROENDOCRINE CELL PHENOTYPE IN VITRO AND IN VIVO

PURPOSE: To better understand the source of neuroendocrine cells associated with human prostate cancer progression, we studied the ability of a cultured prostate cancer cell line, LNCaP, to transdifferentiate into neuroendocrine-like cells in vitro and in vivo. MATERIALS AND METHODS: Cyclic AMP concentrations were measured in extracts of LNCaP cells cultured in the presence of normal or hormone-deficient medium (containing charcoal-stripped serum) with the use of an immunoassay. Quantitative RT-PCR procedures were used to determine whether hormone depletion affects TGF-beta2 mRNA expression. Western blotting procedures (for neuron specific enolase [NSE]) were used to determine whether TGF-beta2 supplementation or antibody neutralization might affect the ability of cultured LNCaP cells to transdifferentiate to neuroendocrine-like cells. Finally, tumors formed from LNCaP cells xenografted into male nude mice were evaluated for the presence of neuroendocrine cells (prior and subsequent to castration of the host mouse) using an immunohistochemical stain for chromogranin A. RESULTS: LNCaP cells cultured in a hormone-deficient medium have a mean 9-fold increase in cyclic AMP (p = 0.02) and a significant decline in the expression of TGF-beta2 mRNA when compared with cells grown in normal medium. Supplementation or depletion of TGF-beta2 did not affect the neuroendocrine conversion of LNCaP cells as assessed by NSE expression patterns. LNCaP tumors growing in castrated male nude mice were found to have significantly increased numbers of chromogranin A positive neuroendocrine cells (46/high powered field) when compared with tumors growing in intact male mice (3/high powered field) (p = 0.0038). CONCLUSIONS: Exposure of LNCaP cells to a hormone deficient medium drastically increased cyclic AMP production and this may identify the biochemical pathway through which hormone depletion induces a neuroendocrine conversion of prostate cancer cells. Hormone depletion also reduced TGF-beta2 mRNA expression and this finding was consistent with our inability to demonstrate any effect of TGF-beta2 on neuroendocrine conversion in vitro. Finally, our demonstration of increased neuroendocrine cells found in LNCaP tumors growing in castrated immunodeficient mice suggests that the neuroendocrine cells associated with advanced human prostate tumors in vivo, arise from prostate cancer cells through the transdifferentiation process.