Pettifor, JM

Rothberg, AD

English

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EDITORIALPUBLIC HEALTH PROGRAMMES,PACKAGES AND PROCESSESSeveral recent submissions to the SAMJ have provided readerswith insight into public health strategies, and the pertinentcomments of the various authors have flagged both positiveand negative aspects of these strategies. We refer specifically tothe article by Mathews, van Rensburg and Coetzee on thesyndromic approach to sexually transmitted diseases/ thecomment by Zar et al. on the Integrated Management ofChildhood illness (IMCI),' and the paper by Chopra et al. onthe implementation of primary health care (PHC)3The common thread running through these articles is theneed to identify and cost-effectively manage common localhealth problems (affordable, accessible, appropriate health care).Implicit in all the papers is also the recognition that at thecoalface, this broad-based approach will often be dependentupon health care providers with fairly basic clinical skills andlimited ability to differentiate between subtle variants ofclinical processes. So, what we need are reliable systems orprocesses that are affordable, have acceptable specilicity andsensitivity and ensure adequate management of the patient,while also dealing with preventive aspects at individual andcommunity levels. Such systems obviously also require definedand reliable referral processes to ensure tJ,at every patientultimately receives the right care in the right facility.Most of the papers either refer or allude to paediatricTable I. Strengths and weaknesses of various PHC programmesProgrammes Strengthsintervention programmes that were promoted in the 1980s andwere grouped together as the GOBI-FFF strategy. The focus ofthe strategy was on growth monitoring, oral rehydrationtherapy, breast-feeding, immunisation, family planning, foodsupplementation and female education, and it was hoped thatthese simple low-cost interventions would help to reduce thevast number of childhood deaths and to strengthen primaryhealth care infrastructure, especially in the underdevelopedworld.'However, as pointed out by Zar et al.,' while specificinterventions for diarrhoea, malnutrition and commonchildhood infections are effective:-? a single focus for a sickchild is often inappropriate as co-morbidities occur frequently,particularly in deprived and developing communities. Forexample pneumonia and diarrhoea are frequent complicationsin children who present with either measles or malnutrition_The recognition among public health medicine experts thatintervention must go beyond single presenting features andmust address the patient fully and in the context of his/hercommunity, has led to the development of the strategies andframeworks discussed in the various papers. I -' A question thatarises is whether the targeted communities, most of which areclinically underserved, can realistically expect to be serviced byeither multi-skilled individuals or by teams of health careworkers who have both the time and the full range of skills,from pure clinical to comprehensive public health. The answeris that health system co-ordinators have generally recognisedthe clinical and human resource limitations, and have designedWeaknessesSpecific interventions4-? Selective; targets problem areasPromotes clinical rigour and specificitySyndrornic approach todisease management'Integrated managementof childhood illness2Corepackageofprimaryhealth careSelective; targets problem areasRecognises and treats co-morbiditiesDoes not require very skilled personnelTargets problem areas plus likelyco-morbiditiesAddresses community issues andengages communityAims for cost-effective minimuminterventionFocuses on national needInvolves communities, regionaland central governmentAcknowledges roles of privatesector and NGOsPromotes equityDoes not address broader issues, e.g. socio-economicfactorsTends to ignore co-morbiditiesRequires clinical skillsMay lack specificity and sensitivityRisk of treatment protocols becoming screening tools(i.e. diagnosis by failure to respond)Does not address broader issuesMay become expensive as coverarge expands to coverfull range of clinical possibilitiesLoses specificityReduces clinical rigourTime-consumingMay compromise-on clinical sensitivity and specificityat level of individualLoses focus on local issues and problems (because it isa national package)EDITORIALand/or adopted programmes that rely on pattern recognition,management algorithms and clinical pathways. Trade-offs thatoccur are described in Table 1.Table I, which presents the programmes as incrementalstrategies going from single disease to disease complex, andfrom isolated patient to patient in society, highlights thequestion raised by Chopra et al.,' viz. is primary health care apackage or a process? The table would suggest that if sold as apackage it might lose more than it gains. However, ifimplemented as a national process that empowers districts,focuses on relevant local problems and draws on one of themore comprehensive programmes to achieve its clinical andsocial goals, then the gains will almost certainly prevail,particularly if attention is given to the strengths of the selectedprogramme, and every effort is made to eliminate theweaknesses.AD RothbergJ M PettiforDepartmrnt of Paediatrics and Child HealthUniversity of the WitwatersrandJohannesburgDecember 199 ,Vol. , 0.12 SAMJINFECTIONCONTROLMANUALJoan Pearse1997, soft cover 442 pagesR195A practical guide for theprevention and control ofinfection in the healthsettingThe Infection Control Manual is the firstinfection control manual written specifically forSouth Africa and the first handbook for thoseactive in the field of infection control and hospitalsectors. The manual includes the most importantpolicies and protocols and an overview ofmedical microbiology and infection controladministration. Many years of research havegone into developing this manual and it has beenreviewed by many experts in the infection controlarena.Some chapters include:Part 1: Infection control in the hospital setting.The importance of infection control.Infection control administration.Part 2: Microbiology - overview.Part 3: Policies and protocols for: patient care,special pathogens, environment andequipment.Decontamination of the hospitalenvironment.Hospital employee health.Part 4: Infection control in the community sptting,including community nursing and ruralclinics.Order from the South African MedicalAssociation,Private Bag X1, Pinelands 7430Tel (021) 531-3081, fax (021) 531-4126e-mail: multimedia@samedical.co.zaPrepayment by cheques, Visa orMastercard required.Please allow 2 - 3 weeks for delivery.

Public health programmes, packages and processes

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Public health programmes, packages and processes

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