Global Health MD

Entries from August 2009

Accreditation for Hospitals Needs to be Simplified For Resource-Poor Settings

August 26, 2009 · Leave a Comment

Last month, officials from 13 African countries launched a global initiative to work with the WHO to standardize medical laboratories using a 5-step accreditation process established by the WHO-AFRO.  (This initiative is being sponsored by the Clinton Foundation and the American Society for Clinical Pathology).

Why should an organization invest the time and resources to obtain accreditation? Take a hospital as an example – accreditation bolsters an institution in many ways. It brings credibility to both patients and investors, it demonstrates a higher quality of care, reduces medical errors by improving processes and it allows the institution to recruit better quality providers (nurses, physicians, administrators etc.) . Even the process of preparing for accreditation allows an organization to reflect on it’s processes resulting in efficiency, transparency and accountability.

Where hospitals in the US are accredited by JCAHO, there exists an international arm of this organization called the JCI (Joint Commission International) allowing international organizations to apply for accreditation. The only problem is that the process itself is so arduous that for hospitals short on resources, it’s very difficult to allocate resources to go through this process.

That’s why I found it encouraging to see that the WHO, together with the Clinton Foundation and other partners, are working to create alternative, simplified process for accreditation of medical laboratories. If this works, I hope such models are created for both hospitals and medical education institutions as well.

Categories: Accreditation · Africa

Incentives for Better Family Planning in Developing Countries

August 22, 2009 · 1 Comment

When I read that the worlds’ population would soon reach 7 billion people, it wasn’t so much that we reached the next billion that was a surprise, it was the pace at which it happened.  Only 12 years after we reached 6 billion in 1999, we have added another billion people to the planet and unfortunately, the majority of growth is in developing countries. Also concerning is that one half of the world lives in poverty (living on less than $2 per day) and amazingly Africa will double it’s population by 2050.

These alarming numbers should have us thinking about how to slow the world’s growth. One obvious place to start is to prevent unintended growth i.e. unplanned pregnancies which are estimated to be over 70 million in developing countries. By reducing these unplanned births, we will not only slow the growth of our population but also on the flip side,  reduce the number of maternal deaths and complications, and unsafe abortions.  According to a UNFPA publication, it is  estimated that meeting the needs for modern contraceptives would prevent about one quarter to one-third of the 500,000 maternal deaths that occur each year in developing countries.  Since family planning is included as one of the Millenium Development Goals (MDGs), more countries and NGO’s will be looking to create or expand family planning programs.

So you can either advocate for family planning because you want to stop unnecessary births or stop unnecessary deaths – either way it’s an investment worth making.  So what kind of family planning programs work? As I mentioned in a prior blog entry, designing public health interventions should be an evidence-based process so looking for examples of success is the place to start.

The book “Case Studies in Global Health Millions Saved” describes the Bangladesh Family Planning Program as a  successful intervention. In a nutshell, their community-based approach coupled with the provision of a wide range of contraceptive services to the people increased contraceptive use from 3% to 54%.   The fertility rate in Bangladesh was reduced from 6.3 in the 1970′s to 2.7 in 2007.  The key components of this program include the deployment of outreach workers who conduct home visits offering contraceptive services and information, the provision of a wide range of contraceptive methods and the establishment of family planning clinics in rural areas.

It’s clearly not a one-size fits all problem – solutions will need to be created to suit each country’s needs and context.  The UNFPA’s 25th Anniversary edition of Outlook, entitled “Reducing Unmet Need for Family Planning: Evidence-Based Strategies is a good summary document.

The Bangladesh program does prove that once people were educated about their options, they made better decisions. Once the world’s most remote communities are connected to the internet (either wireless or by cable -  this day is inevitable and likely not far away) we will need to use our creativity to teach the world’s poor about contraception.  Maybe we could eventually offer a reduced fee for internet service for families with less than 3 kids…just a thought.

Better family planning is one way to stop both unintended growth and unnecessary death.

Categories: Evidence-based public health · Family Planning · infant mortality · maternal health

Saving Newborn Lives Can Be Simple

August 8, 2009 · 1 Comment

Neonatal intensive care improves the survival and morbidity rates of newborns – particularly those with low birth weight (a common problem in developing countries) thus reducing the long-term impact on health costs.  It then follows, that if we can improve neonatal care, we can have a significant impact on the health systems, especially in developing countries where infant mortality rates are high and resources are scarce.

The statistics of neonatal mortality are concerning. One study stated … Afghanistan has the second highest infant mortality rate in the world, with its remote Badakhshan Province having the highest rate ever recorded. Statistics in Africa are also bleak, with Nigeria reporting an infant mortality rate of 100 per 1,000 live births.

Infant mortality is one of the windows into a health system. If infants are dying, it’s an indication that the system is failing. While tertiary care centers usually provide good neonatal care, we need to improve care for newborns in the communities, where the need for these services is greatest. We should focus on simple interventions that can be provided by community hospitals or clinics.

Fortunately, there are some simple interventions (cheap and easy to implement) that can impact neonatal care.  What follows is a list of some of these potentially simple interventions:

- Training in neonatal resuscitation (this includes nurses, physicians, including on-call staff at night). It is unlikely that you will find a nurse or pediatrician in community clinics who are specialized in neonatology.  It’s more practical to train general providers in emergency and basic care of the newborn.

-Keep babies warm. Babies who are cold, spend their energy warming their body and therefore lose calories doing this, rather if we keep them warm, they can retain those calories for their growth

- Hand-washing. Simply enforcing this universal rule in the provision of healthcare can cut down infection and therefore mortality rates.

- Using room-air to help newborns breathes, is a possible alternative to oxygen according to some studies. In community settings where oxygen tanks may not be available, teaching providers to use this technique could save lives.

- Vitamin K – should be administered at birth to all newborns to prevent bleeding since a newborn does not have the ability to make all the neccessary components to form a clot.

I’m sure there are others, but these are just a few to plant the seed that saving newborn lives can start with simple interventions.

Categories: Uncategorized

Maternal Health Challenges Include Mortality and Morbidity

August 1, 2009 · Leave a Comment

  • Every year about 536,000 women die from pregnancy-related causes, 99% of these are in developing countries.
  • The risk of a woman in some parts of Africa dying in childbirth is 1 in 7 vs. some countries in Europe it is 1 in 17,000
  • Maternal morbidity is an even bigger issue – over 10 million women each year suffer complications from childbirth which include obstetrical fistula, depression, infertility and impoverishment

We often talk about maternal mortality but the truth is, more women are disabled by childbirth than those who die from childbirth.  One of the complications is uterine prolapse.  According to the UNFPA website, uterine prolapse is often called  ‘fallen womb’, …a debilitating condition in which the supporting pelvic structure of muscles, tissue, and ligaments gives way, and the uterus drops into or even out of the vagina. This can limit a woman’s mobility, making it impossible for her to perform routine household chores or have sex. The condition is often accompanied by chronic back pains and urinary incontinence. Many women who suffer from it are abandoned by their husbands and end up as social outcasts in their own communities.

Other complications such as infertility, anemia, chronic infection and even depression have a significant impact on maternal health and well-being. These conditions often lead to social isolation, marital problems, difficulties with chores and challenges in maintaining a job for income, which then lead to a shortened life often lived in poverty.

A simple intervention that would have the biggest impact on mortality AND morbidity is a skilled birth attendant. In fact, this is one of the Millenium Goals. In sub-saharan Africa where nearly half of maternal deaths occur, only 46% of women give birth with a skilled birth attendant.  Rural women are far more likely to give birth without an attendant. The numbers show that lack of a birth attendant reflects a failing health system.

Global interventions should start by providing access to a skilled birth attendant for rural women in developing countries.  This one intervention would address two of our most pressing priorities in global health – maternal health (which includes mortality AND morbidity) and ineffective health care systems.

Categories: Africa · maternal health
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