• Access to Health Care for All? User Fees Plus a Health Equity Fund in Sotnikum, Cambodia.

      Hardeman, W; Van Damme, W; Van Pelt, M; Por, I; Kimvan, H; Meessen, B; Médecins sans Frontières, Phnom Penh, Cambodia. (Published by Oxford University Press, 2004-01)
      User fees in health services are a source of much debate because of their potential risk of negative effects on access to health care for the poor. A Health Equity Fund that identifies the poor and pays on their behalf may be an alternative to generally ineffective fee exemption policies. This paper presents the experience of such a Health Equity Fund, managed by a local non-governmental organization, in Sotnikum, Cambodia. It describes the results of the first 2 years of operations, investigates the constraints to equitable access to the district hospital and the effects of the Health Equity Fund on these constraints. The Health Equity Fund supported 16% of hospitalized patients. We found four major constraints to access: financial, geographical, informational and intra-household. The results of the study show that the Health Equity Fund effectively improves financial access for the poor, but that the poor continue to face many constraints for timely access. The study also found that the Health Equity Fund as set up in Sotnikum was very cost-effective, with minimal leakage to non-poor. Health Equity Funds managed by a local non-governmental organization seem to constitute a promising channel for donors who want to invest in poverty reduction. However, further research and experimentation are recommended in different contexts and with different set-ups.
    • A Comparison of Liposomal Amphotericin B with Sodium Stibogluconate for the Treatment of Visceral Leishmaniasis in Pregnancy in Sudan.

      Mueller, M; Balasegaram, M; Koummuki, Y; Ritmeijer, K; Santana, M R; Davidson, R N N; Médecins sans Frontières, 67-74 Saffron Hill, London EC1N 8QX, UK. (Published by Oxford University Press, 2006-10)
      OBJECTIVES: Little is known about the treatment of visceral leishmaniasis (VL) in pregnancy, especially in resource-poor settings. We present a series of pregnant women with VL treated with either sodium stibogluconate or liposomal amphotericin B (AmBisome), or both, in eastern Sudan over 16 months. METHODS: We did a retrospective analysis of all pregnant VL patients treated in the Médecins sans Frontières (MSF) Um el Kher centre between January 2004 and April 2005. We diagnosed VL with laboratory confirmation of clinical suspects, and recorded the outcomes of treatment for pregnant women and their foetuses. We carried out a manual search of relevant publications and a systematic search of the literature in the MEDLINE database. RESULTS: We treated 23 women with sodium stibogluconate, 4 with AmBisome and sodium stibogluconate and 12 with AmBisome alone. There were 13 (57%) spontaneous abortions in the sodium stibogluconate monotherapy group, and none in either of the other two groups. All spontaneous abortions occurred in the first two trimesters. All patients, except one in the sodium stibogluconate group who defaulted, were discharged as cured in good clinical condition. CONCLUSIONS: AmBisome treatment for VL appears to be safe and effective for pregnant women and their foetuses. We recommend the use of AmBisome as first-line treatment for these patients.
    • Cost-Effectiveness Analysis of Humanitarian Relief Interventions: Visceral Leishmaniasis Treatment in the Sudan.

      Griekspoor, A; Sondorp, H; Vos, T; Médecins Sans Frontières, Amsterdam, The Netherlands. (Published by Oxford University Press, 1999-03)
      Spending by aid agencies on emergencies has quadrupled over the last decade, to over US$6 billion. To date, cost-effectiveness has seldom been considered in the prioritization and evaluation of emergency interventions. The sheer volume of resources spent on humanitarian aid and the chronicity of many humanitarian interventions call for more attention to be paid to the issue of 'value for money'. In this paper we present data from a major humanitarian crisis, an epidemic of visceral leishmaniasis (VL) in war-torn Sudan. The special circumstances provided us, in retrospect, with unusually accurate data on excess mortality, costs of the intervention and its effects, thus allowing us to express cost-effectiveness as the cost per Disability Adjusted Life Year (DALY) averted. The cost-effectiveness ratio, of US$18.40 per DALY (uncertainty range between US$13.53 and US$27.63), places the treatment of VL in Sudan among health interventions considered 'very good value for money' (interventions of less than US$25 per DALY). We discuss the usefulness of this analysis to the internal management of the VL programme, the procurement of funds for the programme, and more generally, to priority setting in humanitarian relief interventions. We feel that in evaluations of emergency interventions attempts could be made more often to perform cost-effectiveness analyses, including the use of DALYs, provided that the outcomes of these analyses are seen in the broad context of the emergency situation and its consequences on the affected population. This paper provides a first contribution to what is hoped to become an international database of cost-effectiveness studies of health interventions during relief operations, which use a comparable measure of health outcome such as the DALY.
    • Could Nutritional Rehabilitation at Home Complement or Replace Centre-based Therapeutic Feeding Programmes for Severe Malnutrition?

      Gaboulaud, V; Dan-Bouzoua, N; Brasher, C; Fedida, G; Gergonne, B; Brown, V; Epicentre, Paris, France. vgaboulaud@epicentre.msf.org (Published by Oxford University Press, 2007-02)
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    • Development of dual-class antiretroviral drug resistance in a child coinfected with HIV and tuberculosis: a case report from KwaZulu-Natal, South Africa.

      Murphy, R A; France, H; Sunpath, H; Gordon, M L; Marconi, V; Kuritzkes, D R; McIntosh, K; Massachusetts General Hospital, and Brigham and Women's Hospital, Boston, MA, USA. richard.murphy@newyork.msf.org (Published by Oxford University Press, 2009-02)
      The treatment of concurrent HIV and tuberculosis (TB) in children <3 years of age has not been well-studied and is complicated by potential drug-drug interactions. The recommended antiretroviral therapy (ART) in coinfected children in South Africa consists of full-strength ritonavir, lamivudine and stavudine. We report on a child initiated on this regimen, during concurrent TB treatment, who promptly developed an adverse reaction, virologic failure and dual-class antiretroviral drug resistance, compromising subsequent salvage ART.
    • Effectiveness of Incidence Thresholds for Detection and Control of Meningococcal Meningitis Epidemics in Northern Togo.

      Kaninda, A V; Belanger, F; Lewis, R; Batchassi, E; Aplogan, A; Yakoua, Y; Paquet, C; Epicentre, 8 rue Saint-Sabin, 75011 Paris, France. (Published by Oxford University Press, 2000-10)
      BACKGROUND: Early outbreak detection is necessary for control of meningococcal meningitis epidemics. A weekly incidence of 15 cases per 100 000 inhabitants averaged over 2 consecutive weeks is recommended by the World Health Organization (WHO) for detection of meningitis epidemics in Africa. This and other thresholds are tested for ability to predict outbreaks and timeliness for control measures. METHODS: Meningitis cases recorded for 1990-1997 in health centres of northern Togo were reviewed. Weekly and annual incidences were determined for each district. Ability of different weekly incidence thresholds to detect outbreaks was assessed according to sensitivity, specificity, and positive and negative predictive values. The number of cases potentially prevented by reactive vaccination in 1997 was calculated for each threshold. RESULTS: Outbreaks occurred in 1995-1996 and in 1996-1997. The WHO-recommended threshold had good specificity but low sensitivity. Thresholds of 10 and 7 cases per 100,000 inhabitants in one week had sensitivity and specificity of 100% and increased the time available for intervention by more than one or two weeks, respectively. A maximum of 65% of cases could have been prevented during the 1997 epidemic, with up to 8% fewer cases prevented for each week of delay in achieving vaccine coverage. CONCLUSIONS: In northern Togo, thresholds of 7 or 10 cases per 100,000 inhabitants per week were excellent predictors of meningitis epidemics and allowed more time for a reactive vaccination strategy than current recommendations.
    • Konzo Outbreak, in the South-West of the Democratic Republic of Congo, 1996.

      Bonmarin, I; Nunga, M; Perea, W; Epicentre, 8 rue St Sabin, Paris, France. i.bonmarin@invs.sante.fr (Published by Oxford University Press, 2002-08)
      In August 1996, cases of poliomyelitis were reported in Kahemba zone, in the south-west of the Democratic Republic (DR) of Congo. The diagnosis was reviewed and charged to Konzo, a spastic paraparesis attributed to food cyanide intoxication. In order to describe the phenomena, a community-based survey took place and found 237 people affected. The highest prevalence was found in the most isolated part of the zone. The patients suffered from an isolated non-progressive spastic paraparesis of abrupt onset. Children and women were the most affected groups, especially women after childbirth. Most of the patients developed the disease after 1990 with 101 cases in 1996. Cassava processing was the same over time and in all the villages. The study did not fully explain the increased number of cases in 1996 but suggested that complementary investigations regarding micronutrient intakes, especially vitamin A, would be necessary.
    • Predictors of the Quality of Health Worker Treatment Practices for Uncomplicated Malaria at Government Health Facilities in Kenya.

      Zurovac, D; Rowe, A K; Ochola, S A; Noor, A M; Midia, B; English, M; Snow, R W; Médecins Sans Frontières-France, P.O. Box 39719, Nairobi, Kenya. dzurovac@wtnairobi.mimcom.net (Published by Oxford University Press, 2004-10)
      BACKGROUND: When replacing failing drugs for malaria with more effective drugs, an important step towards reducing the malaria burden is that health workers (HW) prescribe drugs according to evidence-based guidelines. Past studies have shown that HW commonly do not follow guidelines, yet few studies have explored with appropriate methods why such practices occur. METHODS: We analysed data from a survey of government health facilities in four Kenyan districts in which HW consultations were observed, caretakers and HW were interviewed, and health facility assessments were performed. The analysis was limited to children 2-59 months old with uncomplicated malaria. Treatment was defined as recommended (antimalarial recommended by national guidelines), a minor error (effective, but non-recommended antimalarial), or inappropriate (no effective antimalarial). RESULTS: We evaluated 1006 consultations performed by 135 HW at 81 facilities: 567 children received recommended treatment, 314 had minor errors, and 125 received inappropriate treatment (weighted percentages: 56.9%, 30.4%, and 12.7%). Multivariate logistic regression analysis revealed that programmatic interventions such as in-service malaria training, provision of guidelines and wall charts, and more frequent supervision were significantly associated with better treatment quality. However, neither in-service training nor possession of the guideline document showed an effect by itself. More qualified HW made more errors: both major and minor errors (but generally more minor errors) when second-line drugs were in stock, and more major errors when second-line drugs were not in stock. Child factors such as age and a main complaint of fever were also associated with treatment quality. CONCLUSIONS: Our results support the use of several programmatic strategies that can redress HW deficiencies in malaria treatment. Targeted cost-effectiveness trials would help refine these strategies and provide more precise guidance on affordable and effective ways to strengthen and maintain HW practices.
    • Safe Water for the Aral Sea Area: Could it get Any Worse?

      Small, I; Falzon, D; van der Meer, J; Ford, N; Médecins Sans Frontières, Aral Sea Programme, Tashkent, Uzbekistan. (Published by Oxford University Press, 2003-03)
      The environmental adversities around the Aral Sea in Central Asia have been the subject of recent research. Attempts at sustainable provision of palatable drinking water in low chemical and microbial contaminants for the 4 million people in the two countries around the Aral littoral have been largely unsuccessful. In the last few years, severe drought has further depleted the amount of available water. This shortage has negatively impacted on agriculture, and accentuated the out migration of people. An appeal is made to assist the local population in this arid area to cope with the acute and chronic deterioration of water security.