What are the Technical and Allocative Efficiencies of Public Health Centres in Ghana?

INTRODUCTION

Health systems in developing countries including Ghana are faced with critical resource constraints in pursuing the goal of improving the health status of the population. The constrained ability to adequately meet health care needs is exacerbated by inefficiency in the health care systems, especially within public health centres.

METHODS

The study used Data Envelopment Analysis (DEA) method, to calculate the technical and allocative efficiency of 113 randomly sampled health centres. A logistic regression model was also applied on whether a health centre was technically efficient or not to determine the factors that significantly influence the efficiency of health centres.

FINDINGS

The findings showed that 78% of health centres were technically inefficient and so were using resources that they did not actually need. Eight-eight percent were also allocatively inefficient. The overall efficiency, (product of the technical and allocative efficiency), was also calculated and over 90% of the health centres were inefficient. The results of a logistic regression analysis show that newer health centres and those which receive incentives were more likely to be technically efficient compared to older health centres and those who did receive incentives.

CONCLUSION

The results broadly point to grave inefficiency in the health care delivery system of the health centres and that lots of resources could be saved if measures were put in place to curb the waste. Incentives to health centres were found to be major motivating factors to the promotion of efficiency.

Internal dosimetry: towards harmonisation and coordination of research

The CONRAD Project is a Coordinated Network for Radiation Dosimetry funded by the European Commission 6th Framework Programme. The activities developed within CONRAD Work Package 5 ('Coordination of Research on Internal Dosimetry') have contributed to improve the harmonisation and reliability in the assessment of internal doses. The tasks carried out included a study of uncertainties and the refinement of the IDEAS Guidelines associated with the evaluation of doses after intakes of radionuclides. The implementation and quality assurance of new biokinetic models for dose assessment and the first attempt to develop a generic dosimetric model for DTPA therapy are important WP5 achievements. Applications of voxel phantoms and Monte Carlo simulations for the assessment of intakes from in vivo measurements were also considered. A Nuclear Emergency Monitoring Network (EUREMON) has been established for the interpretation of monitoring data after accidental or deliberate releases of radionuclides. Finally, WP5 group has worked on the update of the existing IDEAS bibliographic, internal contamination and case evaluation databases. A summary of CONRAD WP5 objectives and results is presented here.

In vitro dissolution of tritium-loaded particles from the JET fusion machine

With the experimental evolution of fusion power the levels of tritium used will increase as will the potential for human exposure. Tritium-loaded carbon particles produced during the experimental operation of the Joint European Torus fusion tokamak have been characterised in terms of size, elemental composition and specific activity of tritium elsewhere. The aim of this study was to characterise the dissolution of tritium from these particles in order to derive dose coefficients for this material and provide guidance on monitoring procedures should it be inhaled accidentally. The dissolution of tritium was measured for 100 d in lung serum simulant from two batches of materials, SG1 and SG2, which were obtained from carbon tiles originating from different positions in the reactor. Retention over this period followed a three-component exponential. About 1-5% dissolved within a minute, and up to a further 20% dissolved over 100 d for the SG1 materials but <1% for the SG2 materials. Dissolution between the SG1 materials varied greatly, whereas the SG2 materials were similar. As a result of this variability, the assessed dose from urinary excretion could be in error by up to two orders of magnitude depending on the material inhaled. It is recommended that (i) the dissolution is measured for a wider range of materials, preferably dusts collected in working areas, and (ii) in vivo studies are performed to characterise fully the urine excretion of tritium from these materials. This information could be used to provide improved guidance on dose assessment after special or routine monitoring, taking account of the likely variation of particle size and biological retention half times.

Comparative repeatability of guide-pin axis positioning in computer-assisted and manual femoral head resurfacing arthroplasty

The orientation of the femoral component in hip resurfacing arthroplasty affects the likelihood of loosening and fracture. Computer-assisted surgery has been shown to improve significantly the surgeon's ability to achieve a desired position and orientation; nevertheless, both bias and variability in positioning remain and can potentially be improved. The authors recently developed a computer-assisted surgical (CAS) technique to guide the placement of the pin used in femoral head resurfacing arthroplasty and showed that it produced significantly less variation than a typical manual technique in varus/valgus placement relative to a pre-operatively determined surgical plan while taking a comparable amount of time. In the present study, the repeatability of both the CAS and manual techniques is evaluated in order to estimate the relative contributions to overall variability of surgical technique (CAS versus manual), surgeon experience (novice versus experienced), and other sources of variability (e.g. across specimens and across surgeons). This will enable further improvements in the accuracy of CAS techniques.

Three residents/fellows new to femoral head resurfacing and three experienced hip arthroplasty surgeons performed 20-30 repetitions of each of the CAS and manual techniques on at least one of four cadaveric femur specimens. The CAS system had markedly better repeatability (1.2°) in varus/valgus placement relative to the manual technique (2.8°), slightly worse repeatability in version (4.4° versus 3.2°), markedly better repeatability in mid-neck placement (0.7 mm versus 2.5 mm), no significant dependence on surgeon skill level (in contrast to the manual technique), and took significantly less time (50 s versus 123 s). Proposed improvements to the version measurement process showed potential for reducing the standard deviation by almost two thirds.

This study supports the use of CAS for femoral head resurfacing as it is quicker than the manual technique, independent of surgeon experience, and demonstrates improved repeatability.

Using lay counsellors to promote community-based voluntary counselling and HIV testing in rural northern Ghana: a baseline survey on community acceptance and stigma

Access to voluntary counselling and HIV testing (VCT) remains limited in most parts of Ghana with rural populations being the least served. Services remain facility-based and employ the use of an ever-dwindling number of health workers as counsellors. This study assessed approval for the use of lay counsellors to promote community-based voluntary counselling and testing for HIV and the extent of HIV/AIDS-related stigma in the Kassena-Nankana district of rural northern Ghana. A cross-sectional questionnaire survey was conducted. Logistic regression was used to identify predictors of the tendency to stigmatize people living with HIV/AIDS (PLWHAs). Focus group discussions were held and analytical coding of the data performed. The majority (91.1%) of the 403 respondents indicated a desire to know their HIV status. Most (88.1%) respondents considered locations outside of the health facility as preferred places for VCT. The majority (98.7%) of respondents approved the use of lay counsellors. About a quarter (24%) of respondents believed that it was possible to acquire HIV through sharing a drinking cup with a PLWHA. About half (52.1%) of the respondents considered that a teacher with HIV/AIDS should not be allowed to teach, while 77.2% would not buy vegetables from a PLWHA. Respondents who believed that sharing a drinking cup with a PLWHA could transmit HIV infection (OR 2.50, 95%CI 1.52-4.11) and respondents without formal education (OR 2.94, 95%CI 1.38-6.27) were more likely to stigmatize PLWHAs. In contrast, respondents with knowledge of the availability of antiretroviral (ARV) drugs were less likely to do so (OR 0.40, 95%CI 0.22-0.73). Findings from the thirteen focus group discussions reinforced approval for community-based VCT and lay counsellors but revealed concerns about stigma and confidentiality. In conclusion, community-based VCT and the use of lay counsellors may be acceptable options for promoting access. Interventional studies are required to assess feasibility and cost-effectiveness.

Coordination of research on internal dosimetry in Europe: the CONRAD project

The EUropean RAdiation DOSimetry Group (EURADOS) initiated in 2005 the CONRAD Project, a Coordinated Network for Radiation Dosimetry funded by the European Commission (EC), within the 6th Framework Programme (FP). The main purpose of CONRAD is to generate a European Network in the field of Radiation Dosimetry and to promote both research activities and dissemination of knowledge. The objective of CONRAD Work Package 5 (WP5) is the coordination of research on assessment and evaluation of internal exposures. Nineteen institutes from 14 countries participate in this action. Some of the activities to be developed are continuations of former European projects supported by the EC in the 5th FP (OMINEX and IDEAS). Other tasks are linked with ICRP activities, and there are new actions never considered before. A collaboration is established with CONRAD Work Package 4, dealing with Computational Dosimetry, to organise an intercomparison on Monte Carlo modelling for in vivo measurements of (241)Am deposited in a knee phantom. Preliminary results associated with CONRAD WP5 tasks are presented here.

TIARA: treatment initiatives after radiological accidents

This paper describes the objectives, and reviews the progress, of the European project 'Treatment Initiatives After Radiological Accidents' (TIARA). TIARA forms part of the 'Preparatory Action for Security Research' (PASR) launched by the European Commission in 2004. The Preparatory Action is intended to reach preliminary conclusions on the needs for the security of EU citizens. It prepared a comprehensive Security Research Programme as part of the Commission's Seventh Framework Programme proposal, which was adopted in 2006 and launched in 2007. The principal purpose of TIARA is to constitute a European network that will participate in facilitating the management of a crisis in the event of the malevolent dispersal of radionuclides into the public environment.

Water desorption from an oxygen covered Pt(111) surface: Multichannel desorption

Mixed OH/H2O structures, formed by the reaction of O and water on Pt(111), decompose near 200 K as water desorbs. With an apparent activation barrier that varies between 0.42 and 0.86 eV depending on the composition, coverage, and heating rate of the film, water desorption does not follow a simple kinetic form. The adsorbate is stabilized by the formation of a complete hydrogen bonding network between equivalent amounts of OH and H2O, island edges, and defects in the structure enhancing the decomposition rate. Monte Carlo simulations of water desorption were made using a model potential fitted to first-principles calculations. We find that desorption occurs via several distinct pathways, including direct or proton-transfer mediated desorption and OH recombination. Hence, no single rate determining step has been found. Desorption occurs preferentially from low coordination defect or edge sites, leading to complex kinetics which are sensitive to both the temperature, composition, and history of the sample.

Trend and causes of neonatal mortality in the Kassena-Nankana district of northern Ghana, 1995-2002

OBJECTIVES

To describe the trend and causes of neonatal deaths in a rural district in northern Ghana.

METHODS

Descriptive analysis of data collected from the Navrongo Demographic Surveillance System and verbal autopsies conducted on all neonatal deaths from 1995-2002.

RESULTS

Of 1118 recorded neonatal deaths 1068 (95.5%) could be analysed. Only 13.2% of deaths occurred at the health facility; 62.7% occurred in the early neonatal period, with prematurity (38%) and birth injuries (19%) as leading causes. Infectious causes (66%) were the major contributors to late neonatal deaths. Infanticide accounted for 4.9% of all neonatal deaths. The cause-specific mortality rate for neonatal tetanus remained under 2.5% throughout the 8-year period. Overall, the neonatal mortality rate declined at an average of 2.5 per 1000 live births per year: Down by nearly 50% from 40.9 (95%C.I. 34.1-46.8) in 1995 to 20.5 (95%C.I.17.3-22.7) in 2002.

CONCLUSION

The various health interventions undertaken in this district have had the collateral effect of causing decline in neonatal mortality. Neonatal mortality could be further reduced by preventing and treating neonatal infections, having skilled attendance at delivery and the elimination of infanticide. Data from demographic surveillance sites may be useful in monitoring trends in child mortality.

Unmet need for essential obstetric services in a rural district in northern Ghana: Complications of unsafe abortions remain a major cause of mortality

AIM

The aim of this study was to review 4 years of hospital data on antenatal services, deliveries and maternal deaths as the baseline evaluation for a programme to improve care.

METHODS

Descriptive analyses were made of data extracted from the monthly returns charts and clinical notes on all maternal deaths from January 2001 to December 2003 at the district hospital in the Kassena-Nankana district of rural northern Ghana.

RESULTS

The majority (56.6%) of women first attended an antenatal clinic during the second trimester, and about 70% had haemoglobin levels of <10 g/dl. A total of 3160 deliveries were recorded. The prevalence of female genital cutting was 21.4%. Hospital and population rates of Caesarean section were 9.1 and 1.8%, respectively. Only one-third of women in need of a Caesarean section were able to access this intervention. Twenty-four maternal deaths were recorded, giving a hospital maternal mortality ratio of 759 per 100,000 live births. Complications of unsafe abortion (29.1%) and haemorrhage (20.8%) were the leading causes of death. Seventy-one percent of deaths occurred in women living within 15 km of the district hospital, and 50% occurred within 24 h of arrival.

CONCLUSION

Late recourse to the health facility and complications of unsafe abortion are major contributory factors to maternal mortality in this district. A high level of unmet need for essential obstetric services, including access to contraceptive services, exists in this district. Decentralizing the availability of essential obstetric services through health centres to community level is necessary to reduce maternal mortality in developing countries.

The IL-6 G-174C polymorphism may be associated with ischaemic stroke in patients without a history of hypertension

BACKGROUND

Recent data suggest that inflammatory reactions are involved in the pathogenesis of cerebral ischaemia.

AIM

To investigate whether certain inflammatory genetic polymorphisms are associated with the occurrence of ischaemic stroke.

METHODS

We investigated the prevalence of six polymorphisms in cytokine genes (IL-6, TNF-alpha, TNF-beta, IL-1beta, IL-10, and IL-1Ralpha) in a group of ischaemic stroke patients (n = 105) and in a control population (n = 389). We analysed the prevalence of these polymorphisms in different stroke subtypes and in relation to outcome six months post-stroke.

RESULTS

There was no significant variation in cytokine gene polymorphism frequencies between control and stroke populations or for different stroke subtypes. Subgroup analysis demonstrated that the prevalence of the IL-6 -174 CC genotype was significantly lower in stroke patients without a history of hypertension compared to controls.

CONCLUSION

The IL6 -174 CC genotype may be protective against stroke in those patients who have no history of hypertension. Further studies are required to verify these findings.

The structure and crystallization of thin water films on Pt(111)

When water is adsorbed on Pt(111) above 135 K several different ice structures crystallize, depending on the thickness of the ice layer. At low coverage water forms extended islands of ice with a (square root(37) x square root(37))R25(o) unit cell, which compresses as the monolayer saturates to form a (square root(39) x square root(39))R16(o) structure. The square root(39) low-energy electron diffraction (LEED) pattern becomes more intense as the second layer grows, remaining bright for films up of 10-15 layers and then fading and disappearing for films more than ca. 40 layers thick. The ice multilayer consists of an ordered square root(39) wetting layer, on which ice grows as a crystalline film which progressively loses its registry to the wetting layer. Ice films more than ca. 50 layers thick develop a hexagonal LEED pattern, the entire film and wetting layer reorienting to form an incommensurate bulk ice. These changes are reflected in the vibrational spectra which show changes in line shape and intensity associated with the different ice structures. Thin amorphous solid water films crystallize to form the same phases observed during growth, implying that these structures are thermodynamically stable and not kinetic phases formed during growth. The change from a square root(39) registry to incommensurate bulk ice at ca. 50 layers is associated with a change in crystallization kinetics from nucleation at the Pt(111) interface in thin films to nucleation of incommensurate bulk ice in amorphous solid water films more than 50 layers thick.

Voluntary counseling and HIV testing for pregnant women in the Kassena-Nankana district of northern Ghana: is couple counseling the way forward?

This study reports the results of a cross-sectional questionnaire survey undertaken in the Kassena-Nankana district of Ghana to assess the perception and attitude of 270 antenatal clinic attendants towards voluntary counseling and HIV testing. It was found that although 92.6% (95% CI 88.8-95.4) of respondents indicated a willingness to get tested, only 51% (95% CI 45.0-57.2) considered HIV testing for pregnant women to be useful. Most (93.6%) indicated they would like their husbands (partners) to know the result of the test and 52.2% indicated that their husbands would be willing to accompany them to antenatal clinic (ANC) at least once during the pregnancy. The perception of the usefulness of HIV testing (OR = 8.5, 95% CI 1.8-40.0), the willingness to disclose test result to the husband (OR = 13.3, 95% CI 4.0-44.5) and perceived willingness of husband to accompany wife to antenatal clinic (OR = 5.2, 95% CI 1.4-19.8) were found to be independent predictors of a woman's willingness to get tested. The willingness to disclose test result to husband (OR 3.2, 95% CI 1.1-10.5) and knowledge of at least one mode of MTCT HIV transmission (OR = 2.1, 95% CI 1.2-3.6) were found to be independent predictors of a woman's perception that getting tested was useful. The results suggest that for pregnant women in this district, the willingness to get tested for HIV does not equate with the perception of the test's usefulness, and that spouses are likely to exert strong influence on the attitude of pregnant women towards VCT. Couple counseling facilitated through couple-friendly ANC services should be explored as strategy for the intended VCT program in this district.

The structure of the mixed OH+H2O overlayer on Pt{111}

The structure of the mixed p(3 x 3)-(3OH + 3H2O) phase on Pt[111] has been investigated by low-energy electron diffraction-IV structure analysis. The OH + H2O overlayer consists of hexagonal rings of coplanar oxygen atoms interlinked by hydrogen bonds. Lateral shifts of the O atoms away from atop sites result in different O-O separations and hexagons with only large separations (2.81 and 3.02 angstroms) linked by hexagons with alternating separations of 2.49 and 2.813.02 angstroms. This unusual pattern is consistent with a hydrogen-bonded network in which water is adsorbed in cyclic rings separated by OH in a p(3 x 3) structure. The top-most two layers of the Pt atoms relax inwards with respect to the clean surface and both show vertical buckling of up to 0.06 angstroms. In addition, significant shifts away from the lateral bulk positions have been found for the second layer of Pt atoms.

Doses from the consumption of Cardiff Bay flounder containing organically bound tritium

ICRP dose coefficients for the ingestion of organically bound tritium (OBT) by adults and children are intended for general application to unspecified forms in diet and may not be applicable to intakes of a specific form of OBT. To obtain information relating to OBT in fish from Cardiff Bay, the retention of tritium in adult rats was determined after administration as either tritiated water (HTO) or dried flounder flesh containing OBT. Two components of retention were obtained in each case. The first component, attributable to tritium equilibrating with body water, had a half-time of retention of 3 days in each case, and accounted for 97% of the intake as HTO and 70% after intake of OBT in flounder. Results were consistent with rapid catabolism of a large proportion of flounder OBT to HTO. The second component of retention, attributable to OBT in rat tissues, accounted for 3% of tritium intake as HTO and 30% after intake as flounder OBT; the half-times of retention were 10 days and 25 days, respectively. The results obtained after administration as HTO are consistent with published animal data and correlate with the ICRP assumptions for adult man of half-times of 10 days for 97% behaving as HTO in body tissues and 40 days for 3% incorporated into OBT in body tissues. The results obtained after administration of flounder OBT suggest that appropriate assumptions for retention in adult man are 70% with a 10 day half-time and 30% with a 100 day half-time. These assumptions result in an ingestion dose coefficient of 6 x 10(-11) Sv Bq(-1). This compares with the ICRP value for OBT ingestion by adults of 4.2 x 10(-11) Sv Bq(-1), based on half-times of 10 days and 40 days applied to equal proportions of retained tritium. It is proposed that a dose coefficient of 6 x 10(-11) Sv Bq(-1) should be applied to tritium in flounders from Cardiff Bay. It is further proposed that this dose coefficient should be applied to all ingestion intakes by adults relating to this source of exposure, unless specific information is available showing that a significant proportion of the intake is HTO. The same proposals apply to dose coefficients derived here for flounder OBT consumption by children.

Hydrogen bonding in mixed OH+H2O overlayers on Pt(111)

The stability of OH on Pt(111) has been investigated to determine the role of hydrogen bonding in stabilizing the overlayer. We find that the optimal structure is a mixed (OH+H2O) phase, confirming recent density-functional theory predictions. The reaction O+3H(2)O forms a hexagonal (sqrt[3]xsqrt[3])R30 degrees -(OH+H2O) lattice with a weak (3x3) superstructure, caused by ordering of the hydrogen bonds. The mixed overlayer can accommodate a range of H(2)O/OH compositions but becomes less stable as the H2O content is reduced, causing defects in the hydrogen-bonding network that lift the (3 x 3) superstructure and destabilize the overlayer.

Radionuclide biokinetics database (RBDATA-EULEP): an update

The main activity of the RBDATA-EULEP project is the development of an electronic database of information on the biokinetics of radionuclides after intake by inhalation, ingestion or injection. It consists of linked tables of publications and experiments, with details and comments on the materials, procedures and results. By March 2004 it contained information on more than 1600 experiments from 600 publications. It will be extended and Internet access will also be provided.

Comparison of absorption after inhalation and instillation of uranium octoxide

Values for the absorption parameters were compared after inhalation or intratracheal instillation of 1.5 microm mass median aerodynamic diameter (MMAD) 233U3O8 particles into the lungs of HMT strain rats. The two sets of parameter values were similar, as were the calculated dose coefficients and predicted biokinetics for workers. Hence the inhalation and instillation techniques can probably both be used to generate values of the absorption parameters for U3O8.