Programme activities: a major burden for district health systems?
Programme activities: a major burden for district health systems?
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DOI：
10.1111/j.1365-3156.2008.02174.x
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发表时间：
2008-12-01
影响因子：
3.3
通讯作者：
Kegels, Guy
中科院分区：
文献类型：
--
作者：
Coulibaly, Youssouf;Cavalli, Anna;Kegels, Guy
自古以来，人们就认识到处理健康问题的双重性质。古希腊的医神阿斯克勒庇俄斯有两个女儿，分别象征治疗和预防医学的帕那塞女神和福利和卫生女神。人们现在很清楚，这两种办法是混合在一起的：从一级和二级预防治疗到康复和促进行动的范围是一个连续体，而不是一系列泾渭分明的概念和活动。然而，这两种方法所针对的人群有一个根本的区别：治疗药物针对的是生病的人，通常是病情严重的人，而预防活动主要针对的是（尚未）生病或只是轻微生病的人。因此，预防活动可以定期组织，但治疗活动只有在人们生病时才及时进行，因此需要永久可用——理想情况下。在当今的卫生服务中，当然在发展中国家，这两种方法是结合在一起的，通常是在同一卫生结构中由同一卫生人员提供（世卫组织，2006年）。在过去的几十年里，越来越多的健康问题被确定为优先事项，这是基于它们对疾病总体负担的估计贡献和具有成本效益的措施的可得性，其中许多与二级预防有关（Hotez等人，2007年；Johns & Tan Torres Edejer， 2003年）。在一个典型的西非国家，这类问题和措施的清单可能（而且经常）包括麦地那龙线虫、结核病、补充维生素a、血吸虫病、土壤传播的蠕虫病、沙眼、疫苗可预防的儿童疾病、生殖健康和疟疾，对艾滋病毒的重视程度各不相同。所有这些卫生优先事项都是通过各种战略在区域和地区一级实施的，例如不间断的群众运动或定期的外联活动，每一项战略都需要对卫生工作者进行具体培训和临时动员，因此需要宝贵的时间和精力。在马里的农村卫生区Douentza，我们确定了负责一线卫生服务的合格工作人员在需要他们离开卫生中心的活动上花费的时间的相对重要性。我们区分了与他们的一般职责有关的活动和具体的方案活动，包括地区群众运动。2006年的数据收集自地区报告以及行政区域和区域文件。这些资料涉及第一线保健机构（共有15个保健中心，其中14个位于农村地区，1个位于该地区的中心城镇）及其主管护士。表1显示，2006年，区中心城镇保健中心的护士有81个工作日缺勤，农村保健中心的护士有118个工作日缺勤。这种缺勤天数的差异与农村地区护士到达培训活动通常进行的地区中心城镇所需的时间有关。在“最坏情况”情况下（该情况适用于该地区中心城镇以外的大多数保健中心），护士每年缺勤的总天数（118个工作日）占全年总工作日（每年225天）的一半以上（52%）。在这118天中，69天（58%）直接归因于具体的方案活动，群众运动是主要组成部分（表1）。大规模分发药物以控制和消除沙眼、血吸虫病和土壤传播的寄生虫病以及维生素A。
The dual nature of dealing with health problems has been recognized since antiquity. Asklepios, the god of medicine in ancient Greece, had two daughters: Panacea–the goddess of healing and cures, and Hygeia–the goddess of welfare and hygiene, symbolizing curative and preventive medicine respectively. It is well understood nowadays that these two approaches blend: the range from primary and secondary prevention over curative to rehabilitative and promotive action is a continuum rather than a series of neatly separated concepts and activities. Nevertheless, there is a fundamental difference in the people the two approaches are dealing with: curative medicine deals with people who are ill, often acutely so, whereas preventive activities are largely directed at people who are not (yet) ill or only slightly so. Therefore, preventive activities can be organized in a periodic fashion, but curative activities are timely only when carried out at the moment people are ill and thus need to be permanently available–ideally. In present day health services, certainly in developing countries, both approaches are combined, most often in the same health structure and by the same health personnel (WHO 2006). Over the last decades an increasing number of health problems have been identified as priorities, based on their estimated contribution to the overall burden of disease and the availability of cost-effective measures, many of which are related to secondary prevention (Hotez et al. 2007, Johns & Tan Torres Edejer 2003). In a typical West-African country, a list of such problems and measures may (and often does) include Guinea worm, tuberculosis, vitamin A supplementation, schistosomiasis, soil transmitted helminthiasis, trachoma, vaccine preventable child illnesses, reproductive health and malaria, with variable importance given to HIV. All these health priorities are implemented at regional and district level through various strategies such as punctuated mass campaigns or regular outreach activities, each of which requires specific training and temporary mobilization of health workers, and thus valuable time and attention. In Douentza, a rural health district in Mali, we determined the relative importance of the time spent by qualified staff in charge of first line health services on activities requiring their absence from the health centre. We distinguished activities related to their general duties, and specific programme activities, including district mass campaigns. Data for the year 2006 were collected from district reports and administrative district and regional documents. The information concerned first line health care structures (a total of 15 health centres, with 14 situated in rural areas and one in the district’s central town) and their nurses in charge. Table 1 shows that in 2006 the nurse in charge of the health centre was absent during 81 working days in the case of the district central town health centre, and during 118 working days in the case of rural centres. This difference in days of absence is related to the time needed for the nurses in rural areas to reach the district’s central town, where training activities generally take place.In the ‘worst case’scenario, which applies to the majority of health centres situated outside the district’s central town, the total annual nurse’s absence (118 working days) represents more than half (52%) of the annual total number of working days (225 days per year). Of these 118 days, 69 (58%) were directly attributable to specific programme activities, with mass campaigns being the principal component (Table 1). Mass drug distributions to control and eliminate trachoma, schistosomiasis and soil-transmitted helminthiasis as well as vitamin A …