Suchergebnisse

Background: Diarrhoeal diseases constitute a major disease burden on children in low- and middle-income countries (LMC), with an estimated 2 million 0-4 years old dying annually due to diarrhoea. Dehydration is the main cause of these deaths. An oral remedy based on glucose and sodium to treat dehydration was developed in the 1960s. Significant efforts have since been made to promote the use of Oral Rehydration Therapy (ORT). Adoption of ORT has lead to significant child mortality reductions. Meanwhile, little change in diarrhoea morbidity in low- and middle-income countries has been reported. Main aim: The main aim of this thesis is to make a contribution to improved child health in low- and middleincome countries by enhancing knowledge on diarrhoeal diseases control, especially on case management and morbidity reductions. Methods: The first two studies were conducted in Northeastern (NE) Brazil, a region of 9 states and a population of 51 million. The first study evaluated diarrhoea case management through a household cluster survey of 6 524 children 0-4 years old. The second study used a health facility survey to assess quality of diarrhoea child care in 78 randomly selected primary care facilities. The third study was methodological and analysed paired results from two types of household surveys in eight countries to assess their validity. In the fourth study, diarrhoea management in LMC from 1986 to 2003 was analysed for four variables from up to 107 cross-sectional surveys. In the fifth study three indicators of diarrhoea morbidity in the state of Ceará in NE Brazil were assessed for trends 1998-2005 and the association between determinants and morbidity studied. Results: The household survey in NE Brazil showed that 982 children (15%) had suffered from diarrhoea during 15 days preceding the interview. ORT was given to 24%. 95% of the caretakers knew about rehydration solutions, but only 18% prepared them correctly, the most common error being the use of insufficient water. The health facility survey in NE Brazil showed that case management based on ORT was established in health services but also pointed to deficiencies in management. Utensils for administration of ORT were available in only half of the facilities. Health workers showed deficiencies in history taking, examination and communication to parents. Still, in 84% of 75 observed child visits ORT was prescribed. In the study on results from comparable surveys, around half of the survey pairs showed a statistically significant variation, rejecting a hypothesis of no difference. This pointed to the possibility of systematic errors in data collection in household surveys. The study of data on case management from household surveys showed limited progress in diarrhoea management in LMC 1986–2003. Achievements in ORT use were far below global targets set at the beginning of the 1990s. An estimated 307 million children did not get ORT and 356 million did not get more to drink during diarrhoea at the beginning of the 21st century. The study in Ceará, Brazil provided some evidence that diarrhoea morbidity went down slightly 1998-2005. The decline was strongest for diarrhoea admissions. Few determinants of morbidity could be associated with the three indicators of diarrhoea morbidity. Conclusions: This thesis has pointed to achievements and problems in diarrhoeal diseases control from 1986 to 2005. ORT became well known in that period. At the same time, unsatisfactory adoption and application of ORT in the late 1980s documented from Brazil persisted in most LMC over the 1990s. Also, diarrhoea case management was found to meet logistical and managerial problems in primary health services, contributing to inadequate utilization of ORT. Much more research is needed on how to improve diarrhoea case management in LMC. Findings from Ceará, Brazil in the thesis support other studies that have shown limited decline in diarrhoea morbidity in LMC. More research is needed on the interaction between morbidity, case management and mortality for proper understanding of priority setting in diarrhoea control. Efforts to reduce diarrhoea morbidity should be further strengthened, especially among the poorest. The thesis has also documented the need for further research on how to strengthen the methodology of household surveys, a key instrument in impact evaluation. The thesis highlights that there is little time for complacency in strengthening diarrhoeal diseases control. Around 300 million children in the LMC appear not to get Oral Rehydration Therapy, the treatment that is essential for prevention of death from diarrhoea. This fact should lead international organisations, donors and national governments to again give high priority to diarrhoeal diseases, especially in low-income countries where diarrhoea is a daily life-threatening condition to many children.

Introduction: In many low- and middle-income countries emergency care is provided anywhere in the health system; however, no studies to date have looked at which providers are chosen by patients with perceived emergencies. Ecuador has universal health coverage that includes emergency care. However, earlier research indicates that patients with emergencies tend to seek private care. Our primary research questions were these: What is the scope of perceived emergencies?; What is their nature?; and What is the related healthcare-seeking behavior? Secondary objectives were to study determinants of healthcare-seeking behavior, compare health expenditure with expenditure from the past ordinary illness, and measure the prevalence of catastrophic health expenditure related to perceived emergencies. Methods: We conducted a cross-sectional survey of 210 households in a rural region of northwestern Ecuador. The households were sampled with two-stage cluster sampling and represent an estimated 20% of the households in the region. We used two structured, pretested questionnaires. The first questionnaire collected demographic and economic household data, expenditure data on the past ordinary illness, and presented our definition of perceived emergency. The second recorded the number of emergency events, symptoms, further case description, healthcare-seeking behavior, and health expenditure, which was defined as being catastrophic when it exceeded 40% of a household´s ability to pay. Results: The response rate was 85% with a total of 74 reported emergency events during the past year (90/1,000 inhabitants). We further analyzed the most recent event in each household (n=54). Private, for-profit providers, including traditional healers, were chosen by 57.4% (95% confidence interval [CI] [44-71%]). Public providers treated one third of the cases. The mean health expenditure per event was $305.30 United States dollars (USD), compared to $135.80 USD for the past ordinary illnesses. Catastrophic health expenditure was found in 24.4% of households. Conclusion: Our findings suggest that the provision of free health services may not be sufficient to reach universal health coverage for patients with perceived emergencies. Changes in the organization of public emergency departments and improved financial protection for emergency patients may improve the situation.

Background: Non-governmental organizations (NGOs) have a key role in improving health in low-and middle-income countries. Their work needs to be synergistic, complementary to public services, and rooted in community mobilization and collective action. The study explores how an NGO and its health services are perceived by the population that it serves, and how it can contribute to reducing barriers to care. Design: A qualitative exploratory study was conducted in remote Ecuador, characterized by its widespread poverty and lack of official governance. An international NGO collaborated closely with the public services to deliver preventative and curative health services. Data were collected using focus group discussions and semistructured interviews with purposively sampled community members, healthcare personnel, and community health workers based on their links to the health services. Conventional qualitative content analysis was used, focusing on manifest content. Results: Emerging themes relate to the public private partnership (PPP), the NGO and its services, and community participation. The population perceives the NGO positively, linking it to healthcare improvements. Their priority is to get services, irrespective of the providers structure. The presence of an NGO in the operation may contribute to unrealistic expectations of health services, affecting perceptions of the latter negatively. Conclusions: To avoid unrealistic expectations and dissatisfaction, and to increase and sustain the populations trust in the organization, an NGO should operate in a manner that is as integrated as possible within the existing structure. The NGO should work close to the population it serves, with services anchored in the community. PPP parties should develop a common platform with joint messages to the target population on the providers structure, and regarding partners roles and responsibilities. Interaction between the population and the providers on service content and their expectations is key to positive outcomes of PPP operations. ; Funding Agencies|Karolinska Institutet; Linkoping University; Ecuador

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further. ; Funding Agencies|Centre for General Practice and Primary Health Care, County Council of Ostergotland, Sweden; County Council of Ostergotland, Sweden