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2008 Volume 44 Number 4
International Hospital Federation | Fédération Internationale des Hôpitaux | Federación Internacional de Hospitales
World Hospitals and Health Services
The Official Journal of the International Hospital Federation
www.ihf-fih.org
Editorial
IHF Newsletter
International Hospital Federation news
Conference and event calendar
Special feature
Mobility of Health Professionals
Policy
Emerging trends in Chinese healthcare: the impact of a rising
middle class
Management
Quality, risk management and patient safety: the challenge of
effective integration
Please tick your box and pass this on:
■ CEO
■ Medical director
■ Nursing director
■ Head of radiology
■ Head of physiotherapy
■ Senior pharmacist
■ Head of IS/IT
■ Laboratory director
■ Head of purchasing
■ Facility manager
Hospital Healthcare Unit Management: monitoring some
critical points
Clinical care
Reduced paediatric hospitalizations for malaria and febrile
illness patterns following implementation of a community-based
malaria control programme in rural Rwanda
HIV/AIDS, conflict and security in Africa: rethinking
relationships
Opinion matters
Capacity building in cardiac surgery in emerging countries:
an overview

CONTENTS
World Hospitals and Health Services
2008 Volume 44 Number 4
The Official Journal of the International Hospital Federation
Contents
03
04
05
07
Editorial Eric de Roodenbeke
International Hospital Federation news
Conference and event calendar
Mobility of Health Professionals (MoHProf)
ARTICLES
Policy
11 Emerging trends in Chinese healthcare: the impact of a rising
middle class Joyce Chang, David Wood, Jia Xiaofeng and Blair
Gifford
21
IHF NEWSLETTER
SPECIAL FEATURE
24
28
36
42
45
47
Management
Quality, risk management and patient safety: the challenge of
effective integration Margarida França
Hospital Healthcare Unit Management: monitoring some critical
points JP Escaffre
Clinical care
Reduced paediatric hospitalizations for malaria and febrile illness
patterns following implementation of a community-based malaria
control programme in rural Rwanda Amy C Sievers, Jenifer
Lewey, Placide Musafiri, Molly F Franke, Blaise J
Bucyibaruta, Sara N Stulac, Michael L Rich, Corine Karema
and Johanna P Daily
HIV/AIDS, conflict and security in Africa: rethinking
relationships Joseph U Becker, Christian Theodosis
and Rick Kulkarni
REFERENCE
Abstract translations in French and Spanish
Directory of IHF professional and industry members
OPINION MATTERS
Capacity building in cardiac surgery in emerging countries: an
overview V Velebit
EDITORIAL STAFF
Executive Editor:
Eric de Roodenbeke, PhD
Desk Editor:
Sheila Anazonwu, BA(Hons), MSc
EDITORIAL BOARD
Dr René Peters
Dutch Hospital Association
Norberto Larroca
Camara Argentina de Empresas de Salud
Dr Harry McConnell
Griffith University School of Medicine (Australia)
Dr Persephone Doupi
STAKES
EDITORIAL OFFICE
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01210 Ferney Voltaire, France
Email: info@ihf-fih.org
Internet: www.ihf-fih.org
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World Hospitals and Health Services is published
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World Hospitals and Health Services is listed in Hospital Literature
Index, the single most comprehensive index to English language
articles on healthcare policy, planning and administration.
The index is produced by the American Hospital Association
in co-operation with the National Library of Medicine. Articles
published in World Hospitals and Health Services are selectively
indexed in Health Care Literature Information Network.
The International Hospital Federation (IHF) is an independent
non-political body whose aims are to improve patient safety and
promote health in underserved communities. The opinions
expressed in this journal are not necessarily those of the
International Hospital Federation or Pro-Brook Publishing
Limited.
Vol. 44 No. 4 WORLD | World hospitals Hospitals and and health Health services Services | 13| 01

EDITORIAL
Present day crisis, long term
objectives
ERIC de ROODENBEKE, PhD
DIRECTOR GENERAL, INTERNATIONAL HOSPITAL FEDERATION
The end of 2008 and beginning of 2009 certainly present
bleak times as the financial market meltdown triggers an
economic crisis. Granted that these are early stages in
determining the importance and duration of the crisis, however,
the announcement from all central banks and major financial
institutions is of a year in which all countries will be hard hit and
experience much suffering. In her statement released mid-
November 2008, Dr Margaret Chan, Director General of the
World Health Organization (WHO), urged governments to use
lessons learnt from the past to counter the economic downturn
by increasing investment in the health sector. There are some
signs around the world that this message has been heard.
Without doubt, the health sector, regardless of any effort to
be made to mitigate the impact of the crisis, will experience
turmoil and some organizations will suffer the consequences
of the credit crunch. The impact of this credit crunch on the
household will be a decrease in buying power, which would
ultimately influence government spending and/or insurance
payments, particularly in those countries where healthcare is
primarily third party-funded.
Economic crisis, nevertheless, are phenomena that provide
opportunities and can accelerate the need for hospitals to
increase productivity gains while continuing efforts to
improve quality of care. A time of crisis provides an
opportunity for reflection to determine what is most
important instead of doing business as usual. This crisis just
emphasizes a continuous trend of accelerating innovation in
delivering care, as pursuit of past models can be considered
as being no longer viable. There is need to continuously
revisit activities by addressing the same three questions: Are
they relevant? Are they being delivered in the most effective
way? How can they be improved?
Some of the articles in this issue of the journal have taken
the lead in developing this new thinking. The very interesting
article on hospital healthcare unit management opens a new
paradigm for the reader. For so many years, the accepted
argument of the day has been that reducing length of stay in
hospitals was a necessary step in order to improve efficiency.
Results may not be so straight forward because social costs
are often underestimated when assessing the benefit of a
reduction in length of stay. This is of course very different
from reducing the need for hospitalization by an effective
prevention programme as demonstrated in the article on the
Malaria control programme conducted in Rwanda.
If thinking out of the box is a priority during this crisis
period, hospital leaders should not be pessimistic for the
future. The trends are all the same across the world:
regardless of efforts to reduce morbidity with a very effective
prevention and good life style, the growth in numbers and
ageing of populations, and the increase in economic status
will drive more and more people to health care facilities with
increased demands. The example of the rising Chinese
middle class is gives a flavour of this trend. The challenges to
be faced will be enormous, however, as primary hospital
stakeholders, this is where our abilities lie, and… yes we can
fix it!!.
The crisis may lead to a self protective attitude and a
limitation in the scope of concerns, but adoption of such a
short sighted attitude would be a mistake. Undoubtedly,
there would be need to address and resolve “local
emergencies”, however, the adoption of a far sighted attitude
will call for responses that will gain from a stronger solidarity
within the hospital world. A long-term vision presents a
picture full of opportunities for the hospital sector, provided
that steps are taken now, regardless of the impact of the
current crisis. This is the double challenge we, in the hospital
sector are facing: we need to look at the world through
bifocal lenses, in order to be able to simultaneously confront
the immediate crisis as well as look beyond the horizon to
make sure that we navigate in the right direction. For this
bifocal view, however, we need progressive lenses as some
issues, such as patient safety and quality management,
remain constant. A point brought to light by Margarida
Franca in her article, that progress in this area still need to be
made.
IHF is a platform for its members to share ideas and
resources that will help each of them to better face current
realities and future trends. But as with any platform, it is a
vehicle that enhances each member’s contribution.
Continued on page 4
Vol. 44 No. 4 WORLD | World hospitals Hospitals and and health Health services Services | 13| 03

IHF NEWSLETTER
International Hospital Federation news
The American College of Healthcare Executives’ announces Congress
THE AMERICAN COLLEGE OF HEALTHCARE
EXECUTIVES’ CONGRESS on Healthcare Leadership will
take place 23–26 March, 2009, in Chicago, United States.
This annual event is one of the largest gatherings of
healthcare leaders in the world, offering the best in
educational seminars and networking opportunities. This
year’s 108 seminars, general sessions and other events will
address crucial healthcare leadership topics such as patient
safety, technology, financial challenges and environmental
sustainability. Topics on global healthcare delivery include:
“Health diplomacy: building the Afghan national police
healthcare system,” “global healthcare trends and their Local
implications,” and “The challenges of hospitals in
developing countries.”
For more information, including travel and registration
information, visit ache.org/Congress.
Governing Council member profile Dr Delon Wu
DR DELON WU IS PRESIDENT OF THE
TAIWAN HOSPITAL ASSOCIATION and
Professor of Medicine at Chang Gung
University College of Medicine. He is a member of the Heart
Rhythm Society and a Fellow of the American College of
Cardiology and the American Heart Association. Dr Wu
graduated from the National Taiwan University College of
Medicine in 1966. After a year of military service, he went
to Chicago Cook County Hospital, where he received one
year of internship and one year of residency in medicine
between 1967 and 1969. He then completed his residency
training in medicine and two years of a fellowship in
cardiology at the University of Illinois Hospital between
1969 and 1973. He stayed at the University of Illinois as a
faculty member and was promoted to the rank of Associated
Professor until 1978 when he moved back to Taiwan to serve
as the Vice-Superintendent at Chang Gung Memorial
Hospital, which opened two years earlier. He stayed for four
years and have assisted this new hospital to establish an
operating and management system. Between 1982 and
1984, he was Professor of Medicine at University of Southern
California in Los Angeles. He moved back to Taiwan again in
1984 to organize a new medical school, Chang Gung
Medical College, and became the founding Dean of this new
medical school in 1987. In 1999, he was promoted to the
position of CEO of the Chang Gung Healthcare System,
which includes six hospitals and two universities. He retired
from this position in September 2006 after reaching the
mandatory retirement age and was conferred a life-long title
of “Top Advisor.”
Dr Wu is one of the pioneering investigators in cardiac
arrhythmias and has published more than 250 original
papers in peer-reviewed journals. He received “National
Award for Outstanding Scientific Contribution” and
“National Award for Outstanding Research in Medicine” by
the National Science Council of ROC five times since 1987.
Beside medicine, Dr Wu is a wine connoisseur and a fan of
opera and classical music. His wife, Iou-Jih, is a pediatric
hematologist and oncologist. They have one son, Lawrence,
a dentist practice in Walnut Creek, California.
Continued from page 3
IHF in the past, may have neither always fully maximized
nor risen to its full potential, and for this reason, I urge and
invite our members to contribute actively in reversing this
trend by making better use of this unique global platform.
The IHF secretariat is eager to respond to your suggestions
and proposals as well as to share new proposals.
IHF is organising on 12-14 May, 2009 a leadership summit
in Paris, which will bring together decision makers from all
strata of the international hospital sector. This will be a
unique opportunity to put forward and take home solutions
for the current crisis as well as enable preparation for the
future. I would welcome all active IHF members as well as
those wishing to play a more active role in the international
arena will be in Paris for what promises to be a unique event.
The first international hospital association was created in
1929, marking a symbolic year for a major global crisis;
2009 may also prove to be another historical date for a
revival of the hospital sector, where more solidarity across
the world may give birth to an opportunity to provide better
public health and quality care to all. IHF is ready to support
such a movement with members contributing to such a new
exploit. ❑
December 2008
Eric de Roodenbeke, PhD
Director General, International Hospital Federation
04 | World Hospitals and Health Services | Vol. 44 No.2

IHF NEWSLETTER
Conference and
event calendar
IHF EVENTS
2009
12-14 May 21-22 September
IHF Leadership Summit (By invitation only) MCC Hospital World 2009
Paris, France
Berlin, Germany
Dwight@ihf-fih.org
Dwight@ihf-fih.org/schilert@mcc-seminare.de
10-12 November
36th IHF World Hospital Congress *
Rio de Janeiro, Brazil
Dwight@ihf-fih.org
http://www.ihf-fih.org/http://ihfrio2009.com/
2011
29-31 March
37th IHF World Hospital Congress *
Dubai, United Arab Emirates
Dwight@ihf-fih.org
http://www.ihf-fih.org
COLLABORATIVE EVENTS
2009
23-26 March
American College of Healthcare Executives 2009 Congress on Healthcare Leadership
Chicago, USA
kbranz@ache.org; www. ache.org/Congress
26-27 March
Joint ICN/IHF/WMA MDR-TB Training Seminar
Health Care Worker Safety in the Context of Drug-resistant TB in Low and Middle Income Countries
Rio de Janeiro, Brazil
sheila@ihf-fih.org
July
Joint ICN/IHF/WMA MDR-TB Training Seminar
Health Care Worker Safety in the Context of Drug-resistant TB in Low and Middle Income Countries
Durban, South Africa
sheila@ihf-fih.org
October
Joint ICN/IHF/WMA MDR-TB Training Seminar
Health Care Worker Safety in the Context of Drug-resistant TB in Low and Middle Income Countries
Mumbai, India
sheila@ihf-fih.org
Events marked * are interpreted into English, French and Spanish. All other events will be
in English/host country language only. IHF members will automatically receive brochures
and registration forms on all the above events approximately 6 months before the start date.
IHF members will be entitled to a discount on IHF Congresses, pan-regional conferences
and field study courses.
For further details contact the: IHF Project & Event Manager, International Hospital
Federation, Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney Voltaire, France;
E-Mail: Dwight@ihf-fih.org Or visit the IHF website: http://www.ihf-fih.org
Vol. 44 No. 4 | World Hospitals and Health Services | 05

7 TH MCC CONGRESS ADVANCE NOTICE
MCC
www.hospitalworld.info
The International Congress
for Decision Makers
in the Hospital Market
2009
Strategic Options for the Hospital Market
21 st and 22 nd September 2009 in Berlin, Germany
■ The Hospital World of Today and Tomorrow
■ Think Global act Local: Successful Strategies of Internationalization
■ Emerging Markets: Saudi Arabia • Dubai • India • China • Eastern Europe
■ True Stories of Successful Cooperation among Healthcare Stakeholders
■ Reingeneering and Process-Optimizing as Tools to Enhance Performance,
Safety and Quality
■ Management of Increasing Financial Pressure: Opportunities and Threats in
a Highly Competitive Environment
■ The Future Role of Pharma, E-Health and IT for the Hospital Market
– Integrated Solutions for Patients
■ Innovative Human Resource Management
Join this congress and discuss
with our international experts!
Keep your Knowledge
at the State of the Art!
Register Now!
With
Simultaneous
Translation
Registration
MCC Hospital World 2009
September 21 – 22, 2009 in Berlin, Germany
Ellington Hotel Berlin
Nürnberger Str. 50-55
10789 Berlin, Germany
Phone: +49 (0)30 683 150
Fax: +49 (0)30 683 155 555
Organizer:
MCC - The Communication Company
Scharnhorststr. 67a, 52351 Düren, Germany
Phone: +49 (0)2421 12177-0
Telefax: +49 (0)2421 12177-27
E-Mail: mcc@mcc-seminare.de
Internet: www.mcc-seminare.de
MCC reserves the right to modify the program if necessary.
Any liability for misprints excluded.
Yes, I/we want to take part in this congress:
■ Standard rate for the two-day congress: € 1795.-
■ Special rate (two-day congress) for hospital employees and registered doctors: € 795.-
(VAT not included)
■ Buy 2 - Get 3! Yes, I/we will register three individuals from one company and we will receive a free ticket for the third person.
■ Please send me more information about opportunities for cooperation.
Last name
Position
Street Postcode City
First name
Company
Phone Fax E-Mail
Date
Signature and company stamp
how-a1.0-ihf

SPECIAL FEATURE
Mobility of Health
Professionals (MoHProf) 1
XXXXXXXXX
XXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX X
Belgium
South Africa
Health professional mobility is becoming one of the
most recurrent issues when dealing with human
resources in health. In 2000, 10.7% of employed
nurses and 18.2% of employed doctors in OECD countries
were foreign born. According to Krieger 2 , 13 million nonnational
citizens lived in the 15 European Unions (EU)
countries in 2000. This phenomenon is facilitated by the
worldwide context of globalization and can affect health
system organization, for receiving, transit or sending
countries.
EU Member States are increasingly affected by these
developments. The current absence of reliable or viable
qualitative and quantitative data with which to formulate
appropriate policies, precludes accurate understanding of
migration flows. As a consequence, the need has arisen to
develop European policies to adequately and urgently
address these issues.
For this reason MoHProf, the European Commissionsponsored
medium-scale collaborative project within the
Seventh Framework Programme, theme 1 , health, has been
launched with the aim of contributing, through research, to
the knowledge base and thereby facilitating the initiation of
appropriate European policies on human resource planning.
The project led by Wissenschaftliches Institut der Ärzte
Deutschlands gem. e.V. (WIAD) – Scientific Institute of the
German Medical Association), brings together a partnership
of expert scientific institutes and international healthcare
and professional organizations involved in research and
policy development on health professional mobility. A
Project Steering Group of regional research partners and
international organizations, has been created to manage,
assess and lead the research process of the overall initiative.
This Steering Group comprises of a Research Steering Group
and Project Advisory Committee. The primary task of the
former group is to conduct macro and micro research in
Country
Bulgaria
Germany
Philippines
Poland
South Africa
USA
Belgium
France
Table 1: Research Steering Group
Institute/organisation
Medical University of Varna
Scientific Institute of the German Medical
Association (WIAD)
The Institute of Health Policy and
Development Studies (IHPDS) of the
University of the Philippines Manila
Centre of Migration Research (CMR) of the
University of Warsaw
International Organization for Migration,
Mission with Regional Functions, South
Africa
Public Health Institute (PHI)
International Organization for Migration
(IOM), Mission with Regional Functions,
Belgium
International Hospital Federation
their respective countries as well as management of research
in selected countries within their respective regions (Europe,
Africa, Asia and North America). The tasks of the Advisory
Committee include advising on project activities, liaising
with target groups and disseminating project outcomes.
The role of the International Hospital Federation (IHF)
Hospitals are the biggest employers of health human
resources all over the world. As the worldwide body for
hospitals and healthcare organizations, the contribution of
and the role to be played by the IHF in this major European
and ultimately international initiative has been rightly
1.
http://www.mohprof.eu/LIVE/index.html (The information on this website reflects only
the views of its authors. The European Community is not liable for any use that may be
made of it.)
2.
Krieger H., 2004. Migration trends in an enlarged Europe. European Foundation for the
improvement of Living and Working conditions, Dublin.
Vol. 44 No. 4 | World Hospitals and Health Services | 07

SPECIAL FEATURE
Country
Belgium
Belgium
France
France
Switzerland
Switzerland
Table 2: Advisory Committee
Institute/organisation
European Medical Association (EMA)
International Organization for Migration
(IOM), Mission with Regional Functions,
Belgium
International Hospital Federation (IHF)
World Medical Association (WMA)
Global Health Workforce Alliance
International Council of Nurses (ICN)
recognized by the project initiators. For this reason, the IHF
has been appointed as both a partner of the Research Group
and member of the Advisory Committee. The IHF,
represented by the Director General, will have as its task,
supporting the development of guidelines and
recommendations, delivery of relevant material (statistics,
report, literature…) and coordinating contact between
project partners and its members. This is a welcome
opportunity for IHF to establish even closer working ties
with its members, particularly those involved in data
collection, as well as to disseminate results of the studies to
all its members.
Other participating scientific institutes and international
organizations include the International Organization for
Migration (Belgium); Medical University of Varna (MUV),
Bulgaria; Centre of Migration Research of the Warsaw
University (CMR), Poland; Institute of Health Policy and
Development Studies of the University of the Philippines
(IHPDS); Public Health Institute (PHI), USA; International
Council of Nurses (ICN); World Medical Association
(WMA); European Medical Association (EMA), Belgium;
Global Health Workforce Alliance (GHWA).
Research, methodology and policy
The overall research objective will address current trends in
the mobility of health professionals to, from and within the
EU. Activities will extend to non-European sending and
receiving countries, whilst focus will be on the EU, through
the conduct of comparative studies in a selected range of
representative states in order to determine the impact of
different types of migration on national health systems.
The methodological approach will involve the search for
quantities of migration flows, as well as detailed qualities like
professions, motives, circumstances and the social context,
i.e. push and pull factors. In addition there will be in-depth
interviews, based on thematic guidelines, with
representatives of these key stakeholders This innovative
approach, it is expected, will enable the collection of existing
data and statistics, but, above all, enable the generation of
Nurses
Doctors
Philippines
United Kingdom
Germany
Jamaica
Canada
India
Ireland
Nigeria
Haiti
Former Yug.
Mexico
China
Former USSR
Trinidad and Tobago
Poland
Algeria
France
Malaysia
New Zealand
Guyana
Italy
Netherlands
Puerto Rico
United States
South Africa
110 774
India
Germany
United Kingdom
Philippines
China
Former USSR
Algeria
Pakistan
Canada
Iran
Viet Nam
South Africa
Egypt
Morocco
Cuba
Poland
Chinese Taipei
Romania
Syria
Malaysia
Sri Lanka
Nigeria
Lebanon
Italy
United States
0 10,000 20,000 30,000 40,000 50,000 0 5,000 10,000 15,000 20,000
55 794
Figure 1: Foreign-born doctors and nurses in the OECD by main countries of origin (top 25), Circa 2000
08 | World Hospitals and Health Services | Vol. 44 No. 4

SPECIAL FEATURE
200,000
Doctors
232,200
Nurses
189,300
163,600
150,000
100,000
105,100
111,200
50,000
0
OECD
Europe non-OECD
42,500
28,300 30,700
22,200
800
North Africa
Other Africa
Asia non-OECD
Latin America non-OECD
Oceania non-OEC D
OECD
Europ e non-O ECD
53,400
29,700
16,300
4,700
No rth Africa
Ot her Africa
Asia non-OECD
Latin America non-OECD
Oceania n on-OECD
Figure 2: Distribution of foreign-born doctors and nurses by main regions of origin in OECD countries, Circa 2000
new, qualitative data.
The policy dimension will comprise of recommendations
on human resource policies in European and third countries
for policy and decision makers on the basis of sound
empirical research. A key part will constitute development of
conceptual frameworks for monitoring systems relating to
mobility of health workers. Consultation meetings and
roundtables with policymakers will be an essential
component of the project.
Project schedule
The project will be undertaken in four phases over a threeyear
period, starting from November 2008. Four meetings
are planned, the first of which was held 13-14 November
2008 in Brussels (Belgium), to launch the project. The final
one will culminate in an international conference. Ad hoc
roundtable meetings are also planned.
The four phases and the respective timings of the project
will involve the following activities:
OECD member countries
Accession countries*
Enhanced Engagement countries*
Figure 3: The OECD at a glance
Vol. 44 No. 4 | World Hospitals and Health Services | 09

SPECIAL FEATURE
➜ Theory and methodology (1-6 months).
➜ Macro level qualitative and quantitative field studies
within EU and third countries (7-18 Months).
➜ Micro level qualitative and quantitative field studies
within EU and third countries (19-30Months).
➜ Development of empirically based policy
recommendations (month 31-36).
Expected outcomes
Etablishment of:
➜ Guidelines for research.
➜ Comprehensive, comparative reports on the macro, as
well as on the micro level – based on respective country
reports.
➜ Empirically based recommendations for human
resources policies, including conceptual frameworks for
monitoring systems.
➜ Various communication networks – website, roundtable
of policy makers, international conferences – to
disseminate project results and outcomes to a wider
public of target groups. ❑
Contact
Project coordination:
Dr Caren Weilandt
Wissenschaftliches Institut
der Ärzte Deutschlands (WIAD) gem. e.V.
Ubierstraße 78
D - 53173 Bonn
Tel: +49 (0) 228 8104-182
+49 (0) 228 8104-172 (reception)
Fax: +49 (0) 228 8104-1736
Email: caren.weilandt@wiad.de / wiad@wiad.de
International Hospital Federation (IHF)
Eric de Roodenbeke, PhD
Director General
International Hospital Federation
Immeuble JB SAY, 13 Chemin du Levant
01210 Ferney Voltaire, France
Tel: +33 (0) 450 42 60 00
Fax: +33 (0) 450 42 60 01
Email: ederoodenbeke@ihf-fih.org / info@ihf-fih.org
A5 IHF advert.ai 30/1/09 10:33:37
International Hospital Federation
Hospital Association Leadership Summit:
Defining the Role of the Hospital and Hospital Associations
May 12-14, 2009, Paris, France
The summit is open to the leadership of our “A” members as well as to qualified potential IHF “A” members. Corporate participants are welcome to attend day
three of the event. This event will provide a unique opportunity to address, for the first time on a global level, policy issues concerning hospital associations,
government relations as well as relations with other healthcare sector stakeholders.
Day One, Tuesday, May 12, 2009
The Role and Position of Hospital Associations: Thinking Ahead
Member Relations: Key Challenges – Key Success Stories
Day Two, Wednesday, May 13, 2009
Interaction of Hospital Associations with Governments and Regulatory Bodies
Financing Healthcare in the Context of the Financial Crisis – Discussions with Global Organisations (Initial invitees WHO, World Bank, OECD and IHP)
Day Three, Thursday, May 14, 2009
Global Dialogue between Suppliers and Hospitals and Hospital Associations
Please contact Mr. Dwight Moe (dwight@ihf-fih.org) at the IHF Secretariat for a detailed program and registration information.
Deadline for participant registration is March 15, 2009.
10 | World Hospitals and Health Services | Vol. 44 No. 4

POLICY: CHINESE HEALTHCARE TRENDS
Emerging trends in Chinese
healthcare: the impact of a
rising middle class
Abstract
JOYCE CHANG, MHSA
CONSULTANT, THE CHINACARE GROUP
DAVID WOOD
PRESIDENT AND SENIOR PARTNER, THE CHINACARE GROUP
JIA XIAOFENG, MD
LICENSED PHYSICIAN AND SURGEON
BLAIR GIFFORD, PHD
ASSOCIATE PROFESSOR OF INTERNATIONAL HEALTH MANAGEMENT, THE BUSINESS SCHOOL
AND SCHOOL OF PUBLIC HEALTH, THE UNIVERSITY OF COLORADO, DENVER
In this report, the authors examine a major phenomenon in the Chinese healthcare marketplace: the explosion of a
vigorous and demanding middle class and its impact on the future directions the industry should pursue.
Little is known about the expectations of the middle class regarding their healthcare needs other than through
anecdotal or informal sources. The views of the middle class are shaped by a variety of influences which include
exposure through direct personal contact with international healthcare facilities when traveling abroad or indirectly
through increased exposure to the entertainment industry with its abundance of hospital and medical dramas. In
addition to a general increased international awareness arising from more advanced education, the perspective of
the middle class consumer is also shaped by the reality of what is currently available in China and what is realistic
to expect. This report addresses this lack of factual data through an extensive survey of middle class consumers in
three major cities in China: Beijing, Shanghai and Chengdu.
The survey took a practical and pragmatic approach to exploring this issue. No attempt was made in this study to
explain why the consumer feels the way they do about their healthcare expectations. The purpose was simply to
outline what expectations the middle class have for the healthcare marketplace in China.
In some respects the results are not surprising. They are the expectations that people have in any country, any
where. They expect greater privacy and dignity in the care-giving process. They want to be more involved in the
decisions that are made regarding their care. They would prefer a personal, private physician as opposed to a
revolving door of faces they will never see a second time. They rely strongly on family and friends to advise them on
their choice of provider. They expect clean, well-maintained facilities, efficient systems and courteous personnel.
In other respects, the conclusions are not necessarily expected. They feel strongly that their hospital or provider
of care should be located in a residential area. They are willing in some circumstances to pay more for their care in
order to meet their expectations but not significantly more. Despite acknowledging that many of the facets of care
they seek such as greater respect for privacy and a generally perceived more positive attitude in the care-giving
process are found in foreign physicians, middle class consumers do not express a strong preference for foreign
physicians but opt instead for Chinese physicians.
In conclusion, the results provide an insight into the expectations held by middle class Chinese of their healthcare
providers and outlines a direction for future healthcare development.
Vol. 44 No. 4 | World Hospitals and Health Services | 11

POLICY: CHINESE HEALTHCARE TRENDS
The dual burdens of developing countries have fallen
hard on the population giant China: the fastest rate of
population ageing in the world accompanied by a
dramatic yet inequitable rise of standards of living has led
one-fifth of the world’s total population towards a
diversifying portfolio of chronic diseases. The needs of this
population, marked with the rise of a young urban middle
class, are currently unmet by the Chinese public hospital
system through the lack of access to care and dissatisfaction
with service.
Growing middle class
China’s economic transition from a command to market
economy in the past quarter of a century has led to
significant improvements in living standards 1 . Today, the
average annual disposable income 2 of China’s urban
households is 31,500 RMB (US$4,500) with the upper
middle class around 41,600 RMB (US$6,000) 3 . Adjusted for
purchasing-power parity, the urbanaffluent
of China’s population,
mostly concentrated in the “first
China” cities of Beijing, Shanghai
and Guangzhou, has a spending
power nearing global affluence.
These steady increases have fueled
consumer spending, increased
savings, and are projected to
continue throughout the rest of the
21st century.
However, the true size and
spending power lies within the
emerging young, massive urban
middle class. Making up more than
half of the urban population, this middle class is young
(compared to that of most developed markets), well
educated (majority college graduates) and is projected by the
Figure 1: Lifestyle of average Chinese urban household
1.
Blumenthal, D., Hsiao, W. “Privatization and its
discontents: the evolving Chinese health care system.”
N Engl J Med. 2005 Sep 15;353(11):1165-70.
2.
Disposable income = after-tax income.
3.
National Bureau of Statistics of China. 2007. China
Statistical Yearbook 2007. Beijing: China Statistics
Press; 2007 Sept.
Figure 2: Factors influencing hospital of choice (multiple choices, %)
Disposable
Income
Total
Exp end iture
Food Clothing Medical
Transport ation/
Commu nicat ion
Utilities
Beijing
Average 2,854 2,118 30.8% 9.7% 8.9% 14.6 % 8.2%
Middle
High 20% 3,299 2,350 30.2% 10.2% 8.3 % 14.7 % 8.6%
Top20% 5,231 3,3 60 24. 6% 10.2% 7.4% 19.4 % 9.1%
Shanghai
Chengdu
Average 2,953 2,109 35.6% 7.0% 5.2% 15.8% 9.7%
Middle
High 20% 3,285 2,259 36.1% 7.3 % 5.6% 13.9 % 10.0%
Top20% 6,126 3,761 27.7% 7.7% 5.1% 22.6% 9.3%
Average 50 8 1,37 8 35.3% 8.4 % 6.2% 19.4 % 9.7%
Middle
High 20% 1,868 1,652 31.1% 9.0% 6.2% 17.1% 11.6%
Top20% 2,613 2,613 26.3% 8.7% 6.4% 27.8% 7.4%
Sources: Beijing Municipal Bureau of Statistics. 2007. Beijing Statistical Yearbook 2007. Beijing: China Statistics Press; 2007 June.
Shanghai Municipal Statistics Bureau. 2007. Shanghai Statistical Yearbook 2007. Shanghai: NBS Survey Office; 2007 July.
Chengdu Statistic Bureau. 2006. 2006 Statistical Yearbook of Chengdu. Beijing: China Statistics Press; 2007 July
Table 1: Annual per capita basic condition of urban household (2006)
12 | World Hospitals and Health Services | Vol. 44 No. 4

POLICY: CHINESE HEALTHCARE TRENDS
Figure 3: Preferences in specialty care (%)
Figure 4: Source of dissatisfaction: Beijing (%)
2006 McKinsey Quarterly to make up the largest consumer
market in the world, commanding an annual amount of 20
trillion RMB. This unrealized force is widespread, rooted in
“first China” as well as the growing mid-size cities of “third
China,” such as Xian, Wuhan and Nanjing.
Spending power
The transition towards market economy has also altered the
behaviours and lifestyles of urbanites through greater access
to cheaper and higher quality goods. Combined with greater
earnings, the average urbanite no longer embraces the
traditional conservatism in personal financial management
but has instead adopted an evolved mentality which will
lead to increases in healthcare
expenditures.
A decade long survey conducted by
the Gallup Organization from 1994 to
2004 has revealed changes in the
Chinese consumer’s mindset. No
longer worried about being able to put
food on the table, the increased
standard of living has led to the
emergence of the Chinese “me”
generation. Youths are now motivated
by self-satisfaction and self-expression as
opposed to the traditional “give in
service to society” collectivist mindset.
Products now need to cater to emotional
as well as physical needs. Reflected in
spending patterns, the Chinese spend
the largest percentage of their wages on
food (including dining out), followed by
communication/transportation and then
utilities (water, gas and electricity),
indicating a trend of favouring lifestyle
satisfaction over pragmatism.
Other social factors
Furthermore, the shift of social
expenditure from public to private
sources as well as population ageing has
strengthened China’s transition towards
greater healthcare expenditure. As
health appropriations from the
government budget declined from
32.16% in 1978 to 17% in 2003 4 , two
direct outcomes were observed: the shift
of social expenditures to out-of-pocket
expenses place consumers at higher
financial risk and therefore more value
conscious; and the lack of a public
medical safety net has created an
incentive for saving. A McKinsey survey
confirmed that the top two drivers for
high Chinese saving rates are healthcare
and retirement.
China’s population ageing compounds
the equation as it has one of the
fastest ageing rates ever recorded. Improvements in public
health and living standards have led to the dramatic increase
in average life expectancy from 40.8 to 71.5 between 1955
and 2005. However, chronic health problems are positively
correlated with age. With over one-fifth of the world’s
elderly population 5 and increasing exposure to health risk
factors such as smoking, high-fat and high-calorie diets,
China is heading for a population disease profile that will be
high in cardiovascular disease, cancer and chronic
respiratory disease.
4.
Ministry of Health of the People’s Republic of China. Research Report on China’s
National Health Accounts. 2004.
5.
Kaneda, T. “China’s Concern Over Population Aging and Health.” Population Reference
Bureau. June 2006.
Vol. 44 No. 4 | World Hospitals and Health Services | 13

POLICY: CHINESE HEALTHCARE TRENDS
Today’s urban Chinese consumer
is neither complacent nor compliant
and will soon demand a customerfriendly
and quality-driven healthcare
environment. As a result, China’s
healthcare system will need to
accelerate its reforms to meet the
special needs of this growing
population. Currently, however, a
large gap exists between the demand
for these services and their
availability.
Survey sites
Beijing, Shanghai and Chengdu were
chosen for their representation of
present and future Chinese
consumer attitudes. Beijing and
Shanghai are established “first
Figure 5: Source of dissatisfaction: Shanghai (%)
China” metropolitans with sophisticated
consumers; whereas Chengdu, recognized as a
thriving “third China” city, is a governmentaldesignated
center for Southwest China.
Figure 6: Source of dissatisfaction: Chengdu (%)
Current health provider of choice
Contextual, social and medical need are core
factors contributing to utilization of medical care 6 .
To establish a consumer behaviour benchmark, a
series of questions were addressed to the surveyed
population to understand how provider choices
were made. Amongst all three cities, provider
location and staff technical qualification are key
determinants in the selection process. From a
social perspective, Chinese consumers place
great value and base their choices on the opinion
of friends and family, indicated by 69.6%
of the Shanghainese and 85.3% of Chengdu
respondents.
Finally in recognizing medical need, survey
responses indicate a strong market for the
development of specialty hospitals in all three
cities.
Satisfaction
Often described as a subjective measurement,
satisfaction in healthcare is measured
interdependently with outcomes of care and is a
reflection of the patient’s physical comfort;
emotional support received during the process
Figure 7: Physician preference in joint venture institutions (%)
6.
Anderson, R. “Revisiting the Behavioral Model and Access to Medical
Care: Does it Matter?”, Journal of Health and Social Behavior. 1995. 36(1):
1-10.
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POLICY: CHINESE HEALTHCARE TRENDS
Figure 8: Neighborhood preference (%)
of care; and respect for his/her preferences (involvement in
the decision-making process). Satisfaction is measured only
against an individual’s expectation, need or desire.
To assess how satisfied each city is with their current
provider of choice, the survey asked each respondent to
declare their state of satisfaction. Beijing’s response was
positive as 74.0% of the surveyed population
expressed satisfaction with the services received.
Shanghai responded with mixed results as 49.7%
stated they are satisfied and 49.1% claimed to be
dissatisfied. Chengdu responded with 75.5%
satisfaction and 14.7% dissatisfaction. However,
9.8% of the population did not respond to this
question. It may be concluded that the Chinese
consumers are generally satisfied with the services
received in their hospital of choice.
If the respondents were dissatisfied with their
care, they were asked to describe why (multiple
selections were allowed). Out of the three cities,
Shanghai had the highest rate of dissatisfaction at
49.1%. Causes for dissatisfaction were on the
whole consistent from city to city. Long waiting
lines and poor personnel attitude were the top two
drivers of dissatisfaction while quality of medical
care is not stated as a reason for dissatisfaction.
Perceptions of foreign joint-venture institutions
To accurately assess consumer behaviour in light of market
potential, perceptions of joint-venture institutions must be
addressed. First, survey responses indicate that few Chinese
middle class have experience in international joint-venture
Figure 9: Auxiliary services: Beijing (%)
Vol. 44 No. 4 | World Hospitals and Health Services | 15

POLICY: CHINESE HEALTHCARE TRENDS
Figure 10: Auxiliary services: Shanghai (%)
healthcare facilities. Respondents
were then asked to compare their
beliefs or perceptions of jointventure
facilities to state-owned
institutions. Not surprisingly,
foreign joint-venture facilities
are perceived to have greater
technical expertise, better
attitudes among staff and better
physical environments.
Further shaping the perceptions
of private institutions,
respondents were asked to
identify their preferences in
physician ethnicity in hope to
isolate values in seeking care.
This question broadens the
survey scope by addressing the
impact of culture in seeking
care (multiple selections were
allowed). Most middle class
Chinese express no preference
for expatriate or Chinese
physicians. Expatriate physicians
Figure 11: Auxiliary services: Chengdu (%)
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POLICY: CHINESE HEALTHCARE TRENDS
Figure 12: Charging preference (%)
are perceived to have a better attitude in dealing with their
patients and a greater respect for the privacy of the patient.
However, patients do feel that communication barriers and
cultural differences are issues with expatriate physicians.
Hospital preferences
Upon addressing the difference between joint-venture and
state-owned healthcare institutions, respondents were then
asked a series of questions to describe their personal
preferences in a hospital. This section allowed the survey to
shape a Chinese middle class’ demands and needs of a
hospital.
The survey has found that location plays a
significant role in hospital selection. A majority of
consumers prefer hospitals in a residential setting.
Respondents were then asked to identify
services which they feel should be available in a
hospital. The concept of service was inclusive of
medical services and auxiliary services. Specialty
demand amongst the Chinese is perceived to be
consistent, as Shanghai and Chengdu both
identified the same list of medical specialties of
importance, including: cardiovascular, oncology,
cardiology, dental and OBGYN. Restaurants and
rehabilitation centres were the two supplemental
hospital services most demanded by the urban
Chinese middle class.
Further tailoring need, the survey measured the
patient’s demand in the personalization of care. Often
overwhelmed with patient volume, Chinese public hospitals
have little resources and thus are unable to address in a
meaningful way patient values and needs. As a result,
patients receive limited privacy, little personalized attention
and poor continuity of care. Survey results reflect this
sentiment with an overwhelmingly consistent response
preferring greater privacy, private physician and personal
involvement in their healthcare decision making process.
The desire for personal involvement is further supported by
the consumer’s attention to pricing and desire for financial
Figure 13: Which source of hospital information do you find most reliable (%)?
Vol. 44 No. 4 | World Hospitals and Health Services | 17

POLICY: CHINESE HEALTHCARE TRENDS
Figure 14: How did you hear about the hospital or clinic of your choice (%)?
Figure 15: Annual expenditure on healthcare (Health Insurance Premium
Excluded, (%)
transparency.
Finally, consumer’s preference on a hospital communication
channel was assessed. Across the board,
friends and family recommendation and personal
experience were listed as the top two sources for reliable
hospital information as opposed to media or
advertisements.
However, unlike other cities, 60.0% of the Beijing
residents do not feel that hospitals should market
themselves like other industries. When asked why,
91.4% felt hospital marketing is inappropriate, as
hospitals should focus their efforts on medical matters.
On the other hand, 67.7% of the Shanghai residents can
accept hospital marketing efforts. Of the percentage that
does not accept, 40.5% considered the credibility of
advertisements to be low. Chengdu’s healthcare
industry relies the greatest on media as 25.5% of the
respondents learned about their hospital of choice from
the media. However, the most prevalent reason for
provider choice is still friends and family
recommendation (78.4%) and previous personal
experience (65.7%).
Figure 16: Willingness-to-pay: better services
and Surroundings (%)
Willingness-to-pay (WTP)
Willingness-to-pay (WTP), as a measurement
of medical services values, is used in this study
to outline the financial and behavioural
boundaries of the middle class when seeking
health care. On the average, the survey
benchmarked that a typical Chinese middle
class consumer spends $500 annually on
healthcare.
To seek care outside of one’s insurance
network would indicate an increase in out-ofpocket
expenditure. Results from Shanghai and
Chengdu indicate that for better services
(especially complicated cases); consumers are willing to pay
more for their care. Consumers are also willing to pay more
Figure 17: WTP better services and surroundings: Shanghai (%)
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POLICY: CHINESE HEALTHCARE TRENDS
Figure 18: WTP Better Services and Surroundings: Chengdu (%)
to obtain higher quality of service, generally found in jointventure
institutions. Regional variability exists in responses
to how much more the consumer is wiling to spend.
Willingness-to-pay is then assessed for customer service,
physical surroundings and types of medical services
provided. For better customer service and physical
surroundings, majority of the surveyed populations are
willing to pay more (compared to local public hospital
rates). When asked how much more, around 30% of
Shanghai and Chengdu were willing to pay 2 to 3 times;
while 11.9% of Shanghai is willing to pay 3 to 4 times
more.
In their willingness to pay higher prices, consumers
focused on services such as severe cases requiring specialty
care, pediatric care and regular check-ups. In 2006, the
top three causes of death in urban China were cancer,
cerebrovascular disease and heart disease 7 .
Finally, willingness-to-pay for better services is further
refined by hospital stay conditions. In first tier Chinese
cities, the majority of consumers are
willing to pay more for a private room
during their hospital stays. ❑
Authors’ contributions
Joyce Chang, MHSA. With administrative
experiences in United States and China,
Joyce Chang has served as Management
Analyst and Marketing Manager at the New
Century International Children’s Hospital,
Beijing; Research Fellow at the Guanghua
School of Management at Peking University;
and an Administrative Intern at St Luke’s-
Roosevelt Hospital Center, New York City.
Joyce is a consultant with The ChinaCare
Group.
Joyce has a Masters in Health
Management and Policy with an emphasis
in Globalization and Health from the
Figure 19: Willingness-to-Pay: Type of Medical Services (%)
6.
National Bureau of Statistics of China. 2007. China
Statistical Yearbook 2007. Beijing: China Statistics Press;
2007 Sept.
References
Anderson, R. “Revisiting the Behavioral Model and Access to Medical Care: Does it
Matter?” Journal of Health and Social Behavior. 1995. 36(1): 1-10.
Beijing Municipal Bureau of Statistics. 2007. Beijing Statistical Yearbook 2007.
Beijing: China Statistics Press; 2007 June.
Blumenthal, D., Hsiao, W. “Privatization and its discontents: the evolving Chinese
health care system.” N Engl J Med. 2005 Sep 15;353(11):1165-70.
Chamon, M. and Prasad, P. “Why are Saving Rates of Urban Households in China
Rising?” International Monetary Fund Working Paper. 2008 June.
Chengdu Statistic Bureau. 2006. 2006 Statistical Yearbook of Chengdu. Beijing: China
Statistics Press; 2007 July.
Farrell, D., Gersch, U. and Stephenson, E. “The value of China’s emerging middle
class.” The McKinsey Quarterly, 2006 Special Edition. McKinsey & Company: 2006.
Grote, K.D., Levine, E.H. and Mango, P.D. “US hospitals for the 21st century.” The
McKinsey Quarterly, August 2006. McKinsey & Company: 2006.
Kaneda, T. “China’s Concern Over Population Aging and Health.” Population
Reference Bureau. 2006 June.
Lu, An. “Beijing sees fast car growth.” Xinhua News Agency. August 16, 2007.
Ministry of Education of the People’s Republic of China. “The 9th 5-Year Plan for
China’s Educational Development and the Development Outline by 2010.” 1996.
Ministry of Health of the People’s Republic of China. Research Report on China’s
National Health Accounts. 2004.
McEwen, W. et al. “Inside the Mind of the Chinese Consumer.” Harvard Business
Review. Harvard Business School Publishing Corporation: 2006.
National Bureau of Statistics of China. 2007. 2007 China City Statistical Yearbook.
Beijing: China Statistics Press; 2008 Feb.
National Bureau of Statistics of China. 2007. China Statistical Yearbook 2007.
Beijing: China Statistics Press; 2007 Sept.
People’s Daily. “China’s high private housing rate reflects contradiction in housing
market.” People’s Daily Online. July 4, 2006.
Shanghai Municipal Statistics Bureau. 2007. Shanghai Statistical Yearbook 2007.
Shanghai: NBS Survey Office; 2007 July.
Vol. 44 No. 4 | World Hospitals and Health Services | 19

POLICY: CHINESE HEALTHCARE TRENDS
School of Public Health at the University of Michigan.
David Wood is the President and Senior Partner of the
ChinaCare Group and has over 30-years of hospital
administration and healthcare consulting experience, both in the
United States and internationally. David was an Assistant
Director at the University of California hospital system; CFO
and Director of Hospital Operations at the University of
Colorado Hospitals; Senior Vice President at the Sydney Kimmel
Cancer Research Center; President of the Shakut Khanum
Cancer Hospital and Research Center in Pakistan; President of
the United Family Hospitals in China; and President of the New
Century International Children’s Hospital in Beijing. David’s
consulting activity has included assisting clients in a variety of
engagements all over the world including the United States,
China, Germany, England, Canada and Gambia. He is on the
China Advisory Board for Harvard Medical International and on
the Scientific Council for Nations Healthcareers.
David Wood has a graduate degree from California State
University and he has served as an assistant professor on the
faculty of the University of California and the University of
Colorado.
Dr Xiaofeng Jia is a licensed physician and surgeon with a
Masters in International Business Administration from Tsinghua
University’s School of Economics and Management. Dr Jia
attended medical school at the Capital University of Medical
Sciences and completed his surgical residency at Beijing Chao
Yang Hospital. In addition, Dr Jia also served as a Marketing
Specialist at the New Century International Children’s Hospital
in Beijing. Dr Jia is a consultant with The ChinaCare Group.
Dr Blair Gifford is an Associate Professor of International
Health Management in the Business School and School of Public
Health at the University of Colorado Denver. Dr Gifford is
currently a visiting professor at the Yale University School of
Public Health and has had past teaching and research
appointments at the University of Chicago and Northwestern
University. Blair has a PhD and MS in Sociology from the
University of Chicago and a BA in Economics from the University
of California at Santa Cruz.
20 | World Hospitals and Health Services | Vol. 44 No. 4

MANAGEMENT: QUALITY
Quality, risk management and
patient safety: the challenge of
effective integration
MARGARIDA FRANÇA
HOSPITAL ADMINISTRATOR, EXECUTIVE BOARD MEMBER OF THE HOSPITAL
DE MAGALHÃES LEMOS, PORTUGAL
Abstract
Nowadays we observe the development of three waves of intervention and change within healthcare services: quality
management, risk management and patient safety.
The Patient Safety movement has been launched at international level as a consequence of the Institute of
Medicine`s report – To Err is Human, and today patient safety constitutes one basic dimension of health quality
subjected to the direct intervention of supranational entities (WHO, EU) and Member States’ Governments.
The objective of this paper is to raise awareness about the value of quality improvement (QI) methodologies and tools
to sustainable healthcare quality outcomes.
Healthcare quality has started as a concern of the
professions and professionals based on an
organisational and local level approach. Medical care
has changed from this professional responsibility to a
national policy issue and more recently to an international
policy with the patient safety agenda.
Nowadays there is growing understanding worldwide
about the role of quality improvement on the health sector.
Most of these initiatives address problems related to access
to healthcare, service capacity, equity, efficiency and
continuity of care. However there is little research about the
effectiveness of the quality programmes and specific
methodologies for improving the practice. This fact is
directly related with the difficulty to measure outcomes and
with the complexity of healthcare sector organizations.
Despite this general evidence, countries have been
involved on the last two decades on the implementation of
multiple quality improvement initiatives, both nationally
and locally based.
In fact quality, or failures on quality delivery of care affect
directly four main stakeholders:
➜ the patients and their relatives;
➜ the providers;
➜ the community;
➜ the financing entities.
The World Health Organization’s Constitution considers
quality of care a human right: “the enjoyment of the highest
attainable standard of health is one of the fundamental
rights of every human being”.
At the same time citizens expect governments will ensure
quality of care and consequently, healthcare has a top place
on the political agenda of the European countries.
Portugal has embraced this movement and the
Recommendation Nº. R(97) 17 adopted by the Committee
of Ministers of the Council of Europe by creating, in 1999,
within the Ministry of Health an institute to address quality
improvement systems (QIS) – Instituto da Qualidade em
Saúde (IQS).
What do we know about quality improvement?
The fragmented health care solutions and the lack of
integration has been one of the main factors of quality
failures and ineffective health systems. The quality
improvement movement has been looking for answers and,
in consequence, has incorporated new dimensions on the
last years: patient safety, continuity of care, patient
centeredness and/or responsiveness.
On the 2000 decade, the IOM report To Err Is Human:
Building a Safer Health System has launched the patient safety
agenda worldwide. A new challenge has been accepted with
the support of the WHO World Alliance for Patient Safety
created in October 2004.
But there is still a lack of common understanding about
core aspects that need more research and further
development:
➜ general difficulties to compare health systems
performance at the international level and scarcity of
comparable data;
➜ lack of benchmarking mechanisms and learning culture;
Vol. 44 No. 4 | World Hospitals and Health Services | 21

MANAGEMENT: QUALITY
➜ lack of evidence about the effectiveness and adequacy
of quality improvement methods and tools;
➜ general difficulties to sustain and maintain the quality
management systems, both at the national and
organizational levels;
➜ unclear attitudes to finance and compensate quality
initiatives.
The way the delivery of healthcare is organised has
become one of the most important determinants of quality
of care. Despite this global evidence, there is no tradition of
sharing experiences in order to maximize the new design of
solutions and innovation. The Institute of Medicine on the
report Crossing The Quality Chasm, published in 2001,
identifies within one of the main recommendations the need
for cooperation among clinicians and institutions, in order
to ensure an appropriate exchange of information and
coordination of care.
Also, there is a need to contribute to the research on
quality and safety methods and tools, their effectiveness and
adequacy. The World Alliance for Patient Safety proposes a
challenging agenda for the years 2008-2009 on research to
patient safety to identify solutions within a cycle of four
crucial steps:
➜ measuring harm;
➜ understanding causes;
➜ identifying solutions;
➜ evaluating impact.
The First International Conference on Patient Safety
Research was held in Oporto, Portugal, on September 2007.
The main conclusions were around the need of more
funding and collaboration for research into patient safety,
more training in patient safety research, better data systems
and greater collaboration to attempt to contribute to the
improvement of healthcare.
Quality improvement at national level – the
Portuguese situation
The former Portuguese IQS has launched and coordinated,
between 1999 and 2006, several quality improvement
programmes on the National Health Service (NHS) hospitals
and primary care sector. IQS has also initiated the
publication of clinical guidelines. Hospital accreditation has
found a great interest and an organisational programme for
primary care centres has been strongly implemented as well.
This developmental work has been supported on
information and dissemination initiatives thought a web
page and various publications.
Risk management has been systematically introduced and
largely developed in hospitals of the NHS since 1999 within
the Programa Nacional de Acreditação de Hospitais developed
in partnership with the The Health Quality Service,
nowadays known as CHKS. The risk management standards
were the most difficult to comply with, despite the few
standards directly related to clinical areas. The initial areas of
service development were the traditional health and safety,
fire safety, infection control, waste disposal and security.
However this initiative at the hospital level has increased
awareness about the role of risk management on the NHS
and independent sector and has strongly contributed to the
spread of many local initiatives. Since the launch of the
programme on 1999, new standards on clinical areas have
been introduced to address clinical problems.
At the same time multiple initiatives have emerged all over
the country such as ISO certification of hospital services,
clinical audit, reporting systems, clinical indicators,
satisfaction questionnaires, peer-review, regulation, etc.
Patient safety has been nationally addressed by the
General Directorate of Health, focusing on the prevention
and control of health care associated infections.
However we must bear in mind that complexity and
specificity of the tools and competencies of these different
interventions can be source of polarization of projects and
initiatives, failures of communication and participation and
in many occasions, even negative competition.
IQS created on 1999 has been facing a reform since the
end of 2006 that ends up with its full integration on the
General Directorate of Health, starting the 1 January 2009.
After two years of reorganisation there is growing of
expectations about the future and a need to clarify what the
national agenda on quality improvement.
What future trends to quality improvement?
Quality improvement methodologies and tools were
originally developed in the manufacturing sector and its
application to service delivery has been a challenge that has
motivated experts on the last decades.
Quality improvement, risk management and patient
safety, despite the usual lack of integration, still share a few
common requisites to succeed:
➜ clearness of institutional leadership – both national and
local levels;
➜ clearness of goals supported on accountability
processes;
➜ continuous improvement philosophy;
➜ continuous monitoring and assessment;
➜ preventive based approach;
➜ multidisciplinary team work;
➜ evidence based decisions;
➜ systemic approach.
All these common requests seem to suggest the need to
integrate initiatives in a systemic approach that may
promote efficiency and sustainability.
The World Health Organization refers very strongly that
“effective quality and safety improvement is the result of
many activities using systematic methods over a period of
time”. What is or should be quality in the near future ought
to address this concept in order to avoid inefficient
consumption of resources. Quality programmes, even if not
large scale, consume resources that should be reflected on
the quality of care.
Conclusions
It is interesting to reflect on the antagonistic movement we
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MANAGEMENT: QUALITY
may observe internationally regarding the political agendas
of many countries. While some countries seem to prefer to
give prior attention to more “aggressive” social and
economic components, others have been deeply committed
launching statutory inspection initiatives within the national
quality agendas.
The success of the management of health services will
require the inevitable integration of the quality functions at
the organisational level. At the same time the new
requirements on patients mobility requires normalization of
care against high performance standards that we may only
achieve through learning, cooperation between countries
and patient empowerment and participation.
Portugal is now facing a new challenge regarding quality
improvement, but at the same time, an opportunity to set
up a more consistent strategy based on the previous
experience of IQS, on the most recent evidence based
research and patient expectations about outcomes of healthcare.
❑
References
1.
Department od Health. An organization with a memory. London, 2000, 91
2.
Donabedian, Avedis. The Quality of Care. How Can It Be Assessed? JAMA, 1988;
260: 1743-1748
3.
European Commission. Patient Safety – Making it Happen! Présidence
luxembourgeoise du Conseil de l’Únion européenne, DG Health and Consumer
Protection, Luxembourg, 5 April 2005
4.
European Commission. Medical Errors. Special Eurobarometer 241/Wave 64.1 &
64.3 – TNS Opinion & Social, January 2006, 27
5.
IOM. Crossing The Quality Chasm. A New Health System for the 21st Century.
National Academy Press. IOM, Washington D.C., 2001, 337
6.
Kazandjian, Vahé A. and M. França. If a tree fell in the forest but no one heard, is
it because they did not want to hear? Discussion Paper, First International
Conference on Patient Safety Research, Porto, Portugal, September 2007.
Available at http://www.patientsafetyresearch.org/
7.
Kohn, L, J. Corrigan and M. Donaldson. To Err is Human. Building a Safer Health
System. National Academy Press, IOM, Washington D.C., 2000, 287
8.
Legido-Quigley, Helena et al. Assuring The Quality Of Health Care In The European
Union. A case for action. WHO – European Observatory on Health Systems and
Policies, Observatory Studies Series N.º 12, 2008: 210
9.
Mainz, Jan. Defining and classifying clinical indicators for quality improvement.
Int J Qual Health Care, 2003, 15, (6): 523-530
10.
OECD. Health Care Quality Indicators Project. Conceptual Framework Paper,
«OECD HEALTH WORKING PAPERS Nº 23» Directorate For Employment,
Labour and Social Affairs Employment, March 2006: 36
11.
Øvretveit, John and D. Gustafson. Improving the quality of health care. Using
research to inform quality programmes, BMJ, Vol.326, 5 April, 2003, 759-761.
12.
Øvretveit, John. Strengthening the Practical Value of Quality and Safety Improvement
Research, Quality and Safety Improvement Research: Methods and Research Practice
from International QIRN, John Ovretveit and Paulo Sousa, 08 obras avulsas, ENSP
– Univ. Nova de Lisboa, Portugal, 2008, 35-43
13.
Staines, Anthony. Successful hospital and system quality programs: how did they
do it, and is there evidence of improvement? Quality and Safety Improvement
Research: Methods and Research Practice from International QIRN, John
Ovretveit and Paulo Sousa, 08 obras avulsas, ENSP – Univ. Nova de Lisboa,
2008, 209-223
14.
WHO. Constitution of the World Health Organization, Off Rec Wld Hlth Org 2,
100, amended WHA 26.37, WHA 29.38, WHA 39.6 and WHA 51.23
15.
WHO. Guidance on developing quality and safety strategies with a health system
approach., Copenhagen, Denmark, 2008, 48.
16.
WHO. WORLD ALLIANCE FOR PATIENT SAFETY. Research for Patient Safety.
Better Knowledge for Safer Care. WHO, 2008, 12
Vol. 44 No. 4 | World Hospitals and Health Services | 23

MANAGEMENT: HOSPITAL HEALTHCARE UNITS
Hospital Healthcare Unit
Management: monitoring some
critical points
JP ESCAFFRE
CAMPUS DES SCIENCES, UNIVERSITÉ DE RENNES 1, FRANCE
Abstract
Hospital healthcare unit strategic piloting is often cost-based. But this piloting appears to be of real relevance. It is
perhaps better to seek answers to some basic questions, such as: The reason hospitalization is preferred in the
majority of cases; How are health services viewed by the population at large and external stakeholders? Why do
patients and their families opt for a particular service in favour of another? What is the level of acceptance in the
demand for hospitalization in relation to bed capacity? How to evaluate health status development? What are the
consequences on such developments on staff workload, particularly their effects on a daily level? There is need to
develop a measurement tool in response to each of these questions.
Management of facilities in hospitals often require
cost analysis, for which Disease Related Group
(DRG) method as developed by Fetter, is the
primary tool of application. The aim of DRGs, however, is
fee rationalization as opposed to calculation for the
insurance company. Cost theory, in effect, is based on the
use of goods per product or per service delivered. It doesn’t
aim to calculate patient “cost” according to its assumed
characteristics. Although the Fetter method has been subject
to criticism 10 , this does not constitute the major issue at
stake, at least, in Europe. The issue at stake is geopolitical 5
in nature following lessons learnt from studies on the origins
of war in Europe. With the Continent’s unique history and
the widening of social gaps, it was necessary to ensure the
population received a minimum wage, accommodation,
pension and free access to health. These structures became
universal in all European countries after the Second World
War. Collective security is thus the fundamental issue at
stake, for which there is a price to pay. Determinants of
hospital running costs (staff, equipment, etc) are therefore
political rather than economic. This, undoubtedly, explains,
at least in France, why growth in hospital expenditure in the
long term does not correlate with its activities[9]. As a
consequence it is therefore inappropriate to measure
healthcare unit management through the use of cost
analysis.
What is the aim of healthcare delivery? One consideration
could be granting of physical and psychological autonomy
to the patient. Achievement of this goal may be by admitting
temporary dependence of the patient on the medical staff.
This practice extends beyond the clinical acts of diagnosis
and treatment per se. The latter are obviously essential for
medical staff, but are of limited relevance within the hospital
management sector.
The link between autonomy and dependence in the
relationship between patient and medical staff has changed
from home-based care to hospital care. Monitoring this link
seems to be a new challenge. Various strategic points on the
hospital management spectrum can be underlined: reasons
of demand for hospitalization, diversity in behaviour of
external actors towards hospital, patient intake capacity,
epidemiological patterns, effects of workload on medical
staff.
Effective and efficient managerial practices can be
developed in attempt to resolve these critical issues.
Although, at present, the fundamentals, namely access to
healthcare, of collective security are being eroded by
globalization, nevertheless, we believe, monitoring the
autonomy/dependence link to be the most appropriate
practice applicable to hospital healthcare services
management.
Reasons for acceleration in demand for hospital
care
Epidemiological make-up of the population is the major
determinant in the demand for hospitalisation. However,
except in exceptional circumstances, morbidity rates of outof-hospital
patients are higher than those hospitalized. Thus,
other factors beyond the need to provide care should be
considered. Without doubt the major determinant factor is
24 | World Hospitals and Health Services | Vol. 44 No. 4

MANAGEMENT: HOSPITAL HEALTHCARE UNITS
the progressive fragmentation of the social fabric,
particularly the family, which has led to a decrease in
support structures, particularly at the death of family
members. The fragmentation is the result of the increase in
multinationals over the past 40 years, which has contributed
to the disappearance of local businesses and networks. For
the support structure, the capacity to absorb the impact has
been cumulative: namely the elderly, generally the group
that remain and those that move in search of employment.
The consequences are that for these two categories with
limited support network, the probability of hospitalization is
high. In France, for example, between 1983 and 2004 the
number of admissions increased by 20%, whilst the number
of beds decreased by 20% (due to regulation by length of
stay) 9 . However, during this same period, there was no
corresponding increase in population. Surveys conducted 4
showed that households of two adults and a child or of one
adult alone, had a 25% or more chance, within a two years
period, to be hospitalized against an 18% or less chance
with households of two adults and three children ,
integrated in a local social support network, regardless of
age. Even in acute services, the probability of hospitalization
for an isolated individual is three times higher than that of
an integrated individual, whatever the morbidity status.
Attempts, therefore to stem the trend in hospitalisation
would be irrelevant. The recommendation would rather be
for a restoration of the country’s economic landscape in
order to stabilize social networks and thereby strengthen the
capacity of social support networks in their delivery of care
to the sick. From a healthcare unit management perspective,
the recommendation would be the establishment of a
mechanism to regularly monitor (annually) the status of
social support networks within hospital catchment areas (en
essential indicator would be the evolution of household
composition).
Monitoring of admission channels
Hospital admissions are determined by several factors
determine hospital admissions:- condition of the patient
(degree of sickness); source of recommendation for
hospitalization; source of referral; means of arrival to
hospital. Monitoring these determinants has a
multifunctional purpose from a hospital management
perspective: it can reveal some seasonal variations, enable
calculation of the varying impact on healthcare services,
enable identification the various responses from those
external actors who are able to influence the decision
making process of the hospital. Table 2 provides a profile of
the seven groups through which hospital can be channeled.
Monitoring response of external actors
For strategic management purposes, monitoring of
responses of the population and external actors is vital.
Research by the author reveal that response of the
population can be prioritized under the 4 following
categories:
➜ Comfort and cleanliness of room and security (i.e.
number of staff on call).
➜ Admittance procedure and perceived quality of care.
➜ Food quality and relationship with medical staff
(attentiveness of doctors).
➜ Healthcare services organization, quality of equipment.
In light of this, any communication strategy focusing
solely on technological equipment can only be effective if
the targeted population has already been convinced of the
quality of the other determinants. The population’s opinion
is essentially based on its own experience: visit of a patient
(family or friend) or as a patient. Some distinctions have
been observed in hierarchies between the general
population and the individuals who have actually been
hospitalized. The latter often compare services received in
hotels to those in hospitals. Surveys reveal the following
hierarchy for hotel services:
➜ Welcome;
➜ Comfort and cleanliness of room;
➜ Quality of food quality.
Admission process is a major factor for the image of the
hospital with the patient. Poor admission will negatively
influence all other factors. In contrast, a good admission will
positively influence and allow for tolerance towards other
Hospitalisation
1 - Transfer
Channels
2 - Work place
3 - Public place
4 - Domestic accidents
5 - Alcoholism
6 - Intoxication
7 - Emergency
Demographic
patient
Characteritics
Elderly
Youth
-
Youth
-
-
-
Healthcare
delivered in
emergency
service
Medium
(monitoring,
minor surgery)
-
minor surgery
Quite important
Quite important
Major
Response rate
(% of non
hospitalised
patients)
Very low
Very high
Medium
Very high
Medium
Medium
Very low
Seriousness of care
Daily support
care
++
+
+
-
o
o
++
Physical care
++
+
++
-
+
+
++
Table 1: Specific characterisitcs of admission channels
Vol. 44 No. 4 | World Hospitals and Health Services | 25

MANAGEMENT: HOSPITAL HEALTHCARE UNITS
Maternity Unit
No. of daily
admissions
No. of days with
xi admissions
Efficiency Occupancy Fixed no.
of beds*
1 6 15,8% 99,6% 8
2 13 31,3% 98,7% 16
3 26 46,0% 96,7% 24
4 58 59,3% 93,6% 31
5 56 70,8% 89,3% 37
6 49 80,0% 84,1% 42
7 52 86,9% 78,3% 45
8 32 91,9% 72,4% 47
9 26 95,2% 66,7% 49
10 21 97,3% 61,4% 50
11 12 98,6% 56,5% 51
12 7 99,3% 52,2% 51
13 4 99,7% 48,4% 51
Total 365
Table 2: Maternity units
Number of existing beds: 40
100
95
90
85
80
75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13
factors. With regards to healthcare service delivery, the
hierarchy is as follows:
➜ Relationship with medical staff;
➜ Immediate evidence of quality in care;
➜ Rapport between family and medical staff.
➜ Waiting times for all services.
Contrary to popular belief, the latter is of least influence.
Finally there is need to research the responses of GPs, one
of the most influential external actor groups in the hospital
admission process and primary ‘provider’ of patients to
hospitals, although these hospitalised patients represent
30
29
28
27
26
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Occupancy
Number of beds to be reserve/day
Efficiency
Figure 1: Occupancy and efficiency of healthcare units
* For an 83%
occupancy rate
play.
6/3/03 14/3/03 22/3/03 30/3/03 ■31/3/03
■
Figure 2: Hospital, Internal Medicine, Medical Unit B, Numerical variation in daily
practical support, Period: 1 March 2003 – 31 March2003
■
■
only a small part of their activity. This
factor may account for indifference of
these GPs towards the hospital sector,
particularly in the case of specialized
physicians. The attitude of indifference,
however, has been found to be positively
influenced by the following factors:
➜ Strong relationships with hospital
doctors.
➜ Access to healthcare services.
➜ Information exchange.
The exchange of information, either
positively or negatively is made possible
only when the two former factors are in
Monitoring satisfaction of demand for admission
Frequent refusal for hospitalisation of patients, particularly
in the public sector due, generally to lack of beds, is an
unacceptable phenomenon. From a management
perspective, it is essential to determine the number of beds
which must be reserved each day for random admissions.
This needs to be monitored in coordination with the
number of beds which are reserved but remain unoccupied.
This information would enable calculation of the possible
number of beds for planned admissions, and as a result
allow for the total number of bed capacity for the unit in
question to be determined. The statistical theory for random
admissions is general governed by the law of aggregates (i.e.
contagious distribution: binomial negative distribution,
Neyman type A distribution). In the example provided
below, based on empirical data, “efficiency” refers to the
satisfaction rate of demand for admission. “Occupancy” is
the rate of occupancy of reserved beds (not to be mistaken
for the occupancy rate of all beds within the entire service).
According to this model, if 6 beds are reserved on a daily
basis for random admissions, only 80 % of demand would
be satisfied, and the occupancy rate of reserved beds would
be 84.1%. The bed capacity of the service should then be 42
beds instead of the existing 40.
■
■
■
■
■ Level 4
■ Level 3
■ Level 2
■ Level 1
Simulations can be realized with this
model, with, for example, in
determining the effects of merging
twoservice units.
Monitoring the overall health
status of patients admitted into
the unit
The question which begs asking in
this regard is: what health status
measurement tool would be most
appropriate to apply in the
management of patients within all
hospital care units? It is accepted that
diagnoses does not provide the
rational for the distribution of
existing resources. One would argue
26 | World Hospitals and Health Services | Vol. 44 No. 4

MANAGEMENT: HOSPITAL HEALTHCARE UNITS
100%
same healthcare facility.
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
P l : ht can.i nnes
ChirBH ChirC ChirG ORL
Figure 3: Hospital, Surgery, Distribution of physical support activities by unit, Period:
1 March 2003 to 31 March 2003
that, for the manager, the most appropriate tool is that
which enables measurement of the dependency levels
between patients and care providers. Three types of
dependencies, which are unrelated, can be highlighted:
dependency for daily home care support, dependency for
physical care, and dependency for social support (including
support for patients’ families). Surveys we conducted in all
types of hospital services and facilities showed that patients’
health status tend to generally improve or deteriorate for
each category of dependence (a physically immobile patient
requiring assistance generally would also require assistance
to eat, dress, etc). By this factor alone, the need for data
collection and its interpretation can be significantly reduced. i
The example below shows the evolution in health status of
patients in a healthcare unit and comparisons between the
health statuses of patients admitted into several units of the
References
■ Level 5
■ Level 4
■ Level 3
■ Level 2
■ Level 1
Monitoring workload and
attitudes of the care
providers
Workload comprises: direct
care to patients, interaction
with family members, bed
turnover activities (remaking,
cleaning, administration, etc.),
organizational structure of the
unit, and architectural design
of the facility. There seems no
obvious need, however, to
measure the volume of
workload? In effect, it is not
workload that governs the
expressed daily attitudes of
the care givers, but rather the daily variety in duties
experienced in their direct contact with patients and
depending on their levels of dependency. In our studies, it
was demonstrated that such attitudes are constant,
regardless of the unit of service (Levels of dependency did
little to influence changes in attitude). From this
observation, it is possible to create a very simple tool ii , with
which to simultaneously measure variations in workload in
direct care and attitudes. Thus, all manner of simulations are
applicable in management of healthcare services, for
example in determining which patient to admit to which
service unit or which category of care provider to assign to
which service unit, etc.
These, therefore, are believed to be the essential
instruments of control by which hospital healthcare units
can be strategically piloted. ❑
1.
Buinot, C. (Mai 2006), La conjoncture financière des hôpitaux publics en 2004
et 2005, Gestion hospitalière, pp.317-322.
2.
Canouï, P., Mauranges, A. (2001), Le syndrome d’épuisement professionnel des
soignants, Masson.
3.
Domenighetti, J.F. (1994), Marché de la santé : ignorance ou inadéquation?, édition
Réalités sociales
4.
Escaffre, J.P. (janvier 2008), Le contrôle de gestion des unités de Soins Hospitaliers.
Economica.
5.
Escaffre, J.P. (2005), De la globalisation aux DRG. Actes du colloque CALASS.
6.
Fetter, R.B., et alii. (June 1985), DRGS : how they evolued and are changing the
way hospitals are managed. Pathologist, Vol. XXXIX, N°6.
7.
Hammarstrom, A., JANLER, U. (2002), Early unemployment can contribute to
adult health problems, Journal of Epidemiology and community health, N°56, pp.
624-630
8.
Perronin, M., Sourty-Le Guellec, M.J. (2003), Influence des caractéristiques
sociales et environnementales du patient sur la durée de séjour, Bulletin
d’information en économie de la santé du CREDES, N°71.
9.
Quidu, F., Escaffre, J.P. (Mai 2008), Activités et masses financières des
établissements hospitaliers français: l’évolution à long terme, Gestion hospitalière.
Cahier 212.
10.
Swinarski Huber, Z. (2004), La problématique des AP-DRG ou comment calculer
des coûts hospitaliers justes en se basant sur une classification peu pertinente?,
Actes du colloque CALASS.
11.
Virtanen, P. et alii. (2002), Employment security and health. Journal of
epidemiology and community health, N°56, pp.569-574.
i.
See for example the Pendiscan tool: http://pendiscan.ifsic.univ
rennes1.fr/pendiscan/index.htm
ii.
idem Pendiscan tool.
Vol. 44 No. 4 | World Hospitals and Health Services | 27

CLINICAL CARE: MALARIA CONTROL
Reduced paediatric hospitalizations
for malaria and febrile illness
patterns following implementation
of a community-based malaria
control programme in rural Rwanda
AMY C SIEVERS
BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL, BOSTON, MA, USA AND RWINKWAVU HOSPITAL,
PARTNERS IN HEALTH, RWINKWAVU, RWANDA
JENIFER LEWEY
RWINKWAVU HOSPITAL, PARTNERS IN HEALTH, RWINKWAVU, RWANDA AND HARVARD MEDICAL SCHOOL, BOSTON,
MA, USA
PLACIDE MUSAFIRI
RWINKWAVU HOSPITAL, PARTNERS IN HEALTH, RWINKWAVU, RWANDA AND PROGRAMME NATIONAL INTÉGRÉ DE
LUTTE CONTRE LE PALUDISME, KIGALI, RWANDA
MOLLY F FRANKE
RWINKWAVU HOSPITAL, PARTNERS IN HEALTH, RWINKWAVU, RWANDA
BLAISE J BUCYIBARUTA
RWINKWAVU HOSPITAL, PARTNERS IN HEALTH, RWINKWAVU, RWANDA
SARA N STULAC
BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL, BOSTON, MA, USA AND RWINKWAVU HOSPITAL,
PARTNERS IN HEALTH, RWINKWAVU, RWANDA
MICHAEL L RICH
BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL, BOSTON, MA, USA AND RAND RWINKWAVU
HOSPITAL, PARTNERS IN HEALTH, RWINKWAVU, RWANDA
CORINE KAREMA
PROGRAMME NATIONAL INTÉGRÉ DE LUTTE CONTRE LE PALUDISME, KIGALI, RWANDA
JOHANNA P DAILY
BRIGHAM AND WOMEN'S HOSPITAL, HARVARD MEDICAL SCHOOL, BOSTON, MA, USA
Abstract
Background: Malaria control is currently receiving significant international commitment. As part of this commitment,
Rwanda has undertaken a two-pronged approach to combating malaria via mass distribution of long-lasting
insecticidal-treated nets and distribution of antimalarial medications by community health workers. This study
attempted to measure the impact of these interventions on paediatric hospitalizations for malaria and on laboratory
markers of disease severity.
Methods: A retrospective analysis of hospital records pre- and post-community-based malaria control
interventions at a district hospital in rural Rwanda was performed. The interventions took place in August 2006 in
the region served by the hospital and consisted of mass insecticide treated net distribution and community health
workers antimalarial medication disbursement. The study periods consisted of the December–February high
transmission seasons pre- and post-rollout. The record review examined a total of 551 paediatric admissions to
identify 1) laboratory-confirmed malaria, defined by thick smear examination, 2) suspected malaria, defined as fever
and symptoms consistent with malaria in the absence of an alternate cause, and 3) all-cause admissions. To define
the impact of the intervention on clinical markers of malaria disease, trends in admission peripheral parasitaemia
28 | World Hospitals and Health Services | Vol. 44 No. 4

CLINICAL CARE: MALARIA CONTROL
and haemoglobin were analyzed. To define accuracy of clinical diagnoses, trends in proportions of malaria
admissions which were microscopy-confirmed before and after the intervention were examined. Finally, to assess
overall management of febrile illnesses antibiotic use was described.
Results: Of the 551 total admissions, 268 (48.6%) and 437 (79.3%) were attributable to laboratoryconfirmed and
suspected malaria, respectively. The absolute number of admissions due to suspected malaria was smaller during
the post-intervention period (N = 150) relative to the preintervention period (N = 287), in spite of an increase in the
absolute number of hospitalizations due to other causes during the post-intervention period. The percentage of
suspected malaria admissions that were laboratory-confirmed was greater during the pre-intervention period
(80.4%) relative to the post-intervention period (48.1%, prevalence ratio [PR]: 1.67; 95% CI: 1.39 – 2.02; chi-squared
p-value < 0.0001). Among children admitted with laboratory-confirmed malaria, the risk of high parasitaemia was
higher during the pre-intervention period relative to the postintervention period (age-adjusted PR: 1.62; 95% CI: 1.11
– 2.38; chi-squared p-value = 0.004), and the risk of severe anaemia was more than twofold greater during the preintervention
period (ageadjusted PR: 2.47; 95% CI: 0.84 – 7.24; chi-squared p-value = 0.08). Antibiotic use was
common, with 70.7% of all children with clinical malaria and 86.4% of children with slide-negative malaria receiving
antibacterial therapy.
Conclusion: This study suggests that both admissions for malaria and laboratory markers of clinical disease
among children may be rapidly reduced following community-based malaria control efforts. Additionally, this study
highlights the problem of over-diagnosis and over-treatment of malaria in malaria-endemic regions, especially as
malaria prevalence falls. More accurate diagnosis and management of febrile illnesses is critically needed both now
and as fever aetiologies change with further reductions in malaria.
Combating malaria is currently the target of an
impressive resurgence in international commitment,
in particular in sub-Saharan Africa where the burden
of disease is greatest 1,2 . International institutions such as the
World Health Organization and the Global Fund to Fight
AIDS, Tuberculosis and Malaria, national commitments such
as The President's Malaria Initiative, and private
organizations such as the Bill and Melinda Gates
Foundation, have raised awareness and dedicated
substantial financial and technical support to malaria control
efforts. There have been encouraging early reports on the
results of these efforts, which in turn have helped further the
case for more investment in malaria control 3 . Indeed, the
Gates Foundation's recent call for malaria eradication might
have seemed unthinkable only a few years ago 4 .
Investments are being made in all areas of malaria control:
vaccine and drug development, vector control,
infrastructure development, and improving service delivery
and accessibility where it is most needed. Two approaches
with potential for immediate results are 1) exposure
reduction through long-lasting insecticide-treated bed nets
(LLINs), indoor residual spraying, and larvicides, and 2)
early treatment using community health workers. Multiple
studies have demonstrated the efficacy of these communitylevel
interventions in terms not only of reducing episodes of
malaria but improving child survival as a whole 5,6 . For
example, increasing LLIN coverage in Kenya from 6% to
67% correlated with a 44% reduction in overall child
mortality 7 . Early treatment through Home-Based
Management (HBM) of malaria is a key strategy supported
by Roll Back Malaria (RBM) 8 . RBM’s HBM programme is
designed to decrease barriers to children receiving
appropriate antimalarial therapy in a timely manner and
relies on a workforce without formal medical training, such
as community health workers and primary caregivers, to
identify illness and provide care. Given the relatively recent
implementation of the HBM strategy, limited outcomes data
exist at present. However, early reports are encouraging in
terms of both results and adherence 9-11 . Heavy use of
chloroquine has affected early outcome reporting, and the
broad transition across sub-Saharan Africa to artemisinin
combination therapies (ACTs) for HBM programmes is
anticipated to result in even greater successes 12 ].
Rwanda has undertaken an aggressive community-based
prevention and early treatment strategy as part of its national
malaria control programme with excellent preliminary
results, including a 66% reduction in childhood deaths
attributed to malaria 5 . The primary interventions are mass
distribution of LLINs to pregnant women and children
under five years of age and distribution of antimalarial
medications by community health workers. Additionally,
Rwanda adopted ACTs as first line treatment for
uncomplicated malaria at health centres and hospitals as a
slow rollout beginning in early 2006. This study attempts to
measure the impact of LLIN and communitybased
medication distribution on outcomes other than mortality
by examining changes in hospitalization patterns for malaria
and changes in markers of disease severity at a rural district
hospital, before and after implementation of the control
programme.
Methods
Study design and rationale
To determine the effect of a community-based malaria
prevention and early treatment programme, a retrospective
analysis of paediatric hospital admissions records before and
after the intervention was carried out. Study aims were to
determine whether there was a reduction in the proportion
of laboratory-confirmed clinical malaria admissions, among
children who were admitted for malaria, whether there was
an improvement in clinical markers of malaria disease,
specifically haemoglobin and peripheral parasitaemia. This
Vol. 44 No. 4 | World Hospitals and Health Services | 29

CLINICAL CARE: MALARIA CONTROL
study was approved by the Rwandan National Ethical
Committee as well as by the Institutional Review Board at
Brigham and Women's Hospital, Harvard Medical School.
Study centre and patients
This study was conducted at Rwinkwavu Hospital, the
district hospital for Southern Kayonza, a rural region in the
Eastern Province of Rwanda. The hospital is jointly managed
by the Ministry of Health, Partners in Health (PIH), and the
Clinton Foundation. Rwinkwavu Hospital serves as the
referral hospital for regions covered by seven affiliated health
centres in Southern Kayonza. In addition, patients requiring
blood transfusions were also referred to Rwinkwavu Hospital
from a neighbouring district during the study periods.
Southern Kayonza is located in a malaria-endemic zone with
two high transmission seasons, December through February
and April through June, and with sporadic cases arising
throughout the year.
The study was carried out over two consecutive malaria
high transmission seasons pre-intervention (December 2005
through February 2006) and post-intervention (December
2006 through February 2007). The eligible study
population included all children admitted to the paediatric
ward. Data for admitted children are entered into a
discharge registry, which is maintained by nursing staff and
includes basic demographic information, admission
diagnosis, clinical course and management, discharge
diagnosis, and clinical outcome. Children for whom there
was no discharge diagnosis in the discharge registry were
excluded from this study.
Description of intervention
The Rwandan Ministry of Health, supported by PIH and the
Clinton Foundation, embarked on an intensive communitybased
prevention and early treatment malaria control
programme. The prevention component was based on mass
distribution of LLINs. Beginning in March 2006, nets were
distributed by Rwinkwavu Hospital and its affiliated health
centres to pregnant women as part of routine antenatal care,
to all hospitalized children, to all malnourished children,
and to many patients with HIV. Additionally, the Ministry of
Health, supported by the Global Fund to Fight AIDS,
Tuberculosis and Malaria, organized mass distribution of
LLINs to children of five years of age or less in September
2006 as part of an integrated measles vaccine campaign. A
total of over 26,000 nets were distributed in southern
Kayonza, an area with approximately 28,000 individual
dwellings and a total population of 130,000. The majority of
LLINs were distributed via the vaccination campaign. The
early treatment component consisted of 300 community
health workers (CHWs), who were trained to distribute
antimalarials within each village to children of five years of
age or less with fever and symptoms consistent with
uncomplicated malaria. Additionally, CHWs were trained to
identify and refer children with more severe disease, and
poor po intake to their local health centres. Children who
were considered more severely ill or required IV hydration
by health centre clinical staff based on their clinical
judgement were in turn transferred to Rwinkwavu Hospital.
Finally, in December of 2006, we conducted a series of staff
training programmes aimed at improving hospitalbased
paediatrics care and malaria care in particular. This included
more rigorous guidelines for laboratory monitoring,
including checking admission haemoglobin for all children
with suspected malaria.
Between rollout in September 2006 and study end in
February 2007, 11,390 children were treated by CHWs
within the communities served by the seven health centres
affiliated with Rwinkwavu Hospital, and 1,408 (12%) were
referred to a higher level of care. Initial training and drug
supply was provided by the national malaria control
programme (Programme National Intégré de Lutte contre le
Paludisme, PNILP). Subsequent training, support and
monitoring were provided by PIH staff and data were
reported to PNILP. All therapeutic regimens were in
accordance with Rwanda Ministry of Health guidelines.
Drug supply was supported by the Global Fund to Combat
AIDS, Tuberculosis and Malaria. The communitybased
treatment regimen consisted of age-based blister packs of
sulphadoxine-pyrimethamine + amodiaquine (SP+AQ).
Hospitalized children received intravenous quinine until
able to tolerate oral medications, at which point they were
switched to oral quinine to complete a 7 day course of
treatment. Health centres were using AL for uncomplicated
malaria but this predated the onset of the study period.
General study procedures
Discharge registries were retrospectively reviewed to classify
each child as either a malaria or non-malaria admission and
obtain basic clinical and demographic data. Suspected
malaria admission was defined as being given a discharge
diagnosis of malaria in the registry. Suspected diagnosis of
malaria was made in children presenting with fever and
symptoms consistent with malaria in the absence of an
alternative diagnosis. Symptoms and findings suggestive of
an alternative diagnosis included productive cough, chest
radiograph findings consistent with pneumonia or
tuberculosis, meningeal signs with positive lumbar
puncture, or bloody diarrhea with abdominal pain. Even if
children had a positive malaria smear, they were not given a
primary diagnosis of malaria if their clinical diagnosis was an
alternative febrile illness. Laboratory- confirmed malaria was
defined as suspected malaria plus microscopic slide analysis
demonstrating peripheral parasitaemia. To assess severity of
malaria disease, the degree of admission peripheral
parasitaemia and haemoglobin were examined. Peripheral
parasitaemia was determined by examination of thick smears
and scored on a 1+ to 4+ scale. On this scale, 1+ is
defined as 1–10 trophozoites per 100 high power fields
(hpf), 2+ as 11–100 trophozoites per 100 hpf, 3+ as 1–19
trophozoites per single hpf and 4+ as >11 trophozoites per
single hpf. Parasitaemia was defined solely by the number of
parasites per field and was not standardized to white count.
Haemoglobin was measured from a venipuncture using
QBC Autoread Plus (QBC Diagnostics, Philipsburg PA).
Severe anemia was defined using WHO criteria ≤5 g/dl [13].
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CLINICAL CARE: MALARIA CONTROL
Data related to antibiotic and antimalarial use were also
recorded. In cases where information was missing from the
discharge registry, individual patient charts and laboratory
records were examined. To examine whether changes in
overall hospitalization patterns could account for trends in
malaria hospitalizations, all-cause admission diagnoses
during the pre- and post-intervention study periods were
examined. Finally, rainfall and temperature data were
collected from the Ministry of Infrastructure to assess
potential environmental factors that may have altered
transmission intensity and thus impacted the results.
Statistical analysis
The primary outcome was the proportion of suspected
malaria cases that were laboratory-confirmed, and this
proportion was compared across the pre- and postintervention
periods. To examine whether there was an
association between the intervention and markers of clinical
disease, the proportions of children with laboratoryconfirmed
malaria who had a high peripheral parasitaemia
(3+ or 4+) or severe anemia (haemoglobin < 5 g/dl)
during the pre- and post-intervention periods were
compared. Age-adjusted prevalence ratios, using Mantel-
Haenszel weights, were calculated to account for potential
confounding by age. Local climate data were obtained and
qualitatively examined to determine whether differences in
temperature or rainfall during the study periods could have
confounded the relationship between the intervention and
malaria outcomes. Data were analysed using SAS version
9.12 (The SAS Institute, Cary, North Carolina).
Results
A total of 554 paediatric admissions were recorded in the
discharge registry during the two study periods. Three
children did not have a discharge diagnosis and were
excluded from the analysis. Of the remaining 551
admissions, 322 (58.4%) occurred during the preintervention
period and 229 (41.6%) occurred during the
post-intervention period. Table 1 and 2 report the absolute
reductions in both suspected and laboratory-confirmed
malaria between the pre- and post- intervention periods.
Baseline characteristics of the enrolled children are shown in
Table 1. The gender distribution of admitted children was
comparable across study periods; however, age distributions
differed, with children in the post-intervention tending to
fall in older age categories (chi-squared p-value = 0.0006)
(Table 1). Fifty-one of 437 (11.7%) children admitted with
suspected malaria lacked smear results (Table 1), and the
percentage of children missing a smear result was similar for
the pre- and post-intervention periods (11.1% and 12.6%,
respectively; chi-squared p-value: 0.64). Among the 386
children with suspected malaria for whom smear results
were available (Table 1), the percentage of suspected malaria
admissions that were laboratory-confirmed was significantly
higher in the pre-intervention period (80.4%) than during
the post-intervention period (48.1%, prevalence ratio [PR]:
n (%)
PATIENT CHARACTERISTICS Pre Post Total p-value
Gender (N = 539)
F 161 (50.9) 110 (49.3) 271 (50.3) 0.71
Age (years) (N = 538)
5 35 (11.0) 51 (23.2) 86 (16.0)
ADMISSION DIAGNOSES
Total Admissions 322 229 551
Total Suspected Malaria Admissions 287 (89.1) 150 (65.5) 437 (79.3)
Total Other-Cause Admissions 5 (10.9) 79 (34.5) 114 (20.6)
Gastrointestinal infections 18 (51.4) 17 (21.5) 35 (30.7)
Trauma/burns/bites 5 (14.3) 15 (19.0) 20 (17.5)
Skin and soft tissue infections 2 (5.7) 11 (13.9) 13 (11.4)
Respiratory infections 1 (2.9) 11 (13.9) 12 (10.5)
Other infections 2 (5.7) 9 (11.4) 11 (9.6)
CHF 0 (0.0) 6 (7.6) 6 (5.3)
Neoplastic disease 1 (2.9) 2 (2.5) 3 (2.6)
Meningitis 0 (0.0) 3 (3.9) 3 (2.6)
TB 1 (2.9) 0 (0.0) 1 (0.9)
HIV complications 1 (2.9) 0 (0.0) 1 (0.9)
Other 4 (11.4) 5 (6.3) 9 (7.9)
Pre- and post-intervention patient demographic and admissions data are listed. There were 13 children (4 pre- and 9 post-intervention) for whom age was not
available. There were 12 children (6 pre- and 6 post-intervention) for whom gender was not available. Percents are recorded as proportion of the pre-intervention
total, post-intervention total, or overall admissions total. CHF-congestive heart failure; TB-tuberculosis.
Table 1: Patient characteristics and admissions data
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CLINICAL CARE: MALARIA CONTROL
n (%)
Pre Post PR*[95% CI] chi-squared p-value
Slide-positive (N = 386) 205 (80.4) 63 (48.1) 1.67 [1.39–2.02]

CLINICAL CARE: MALARIA CONTROL
indicators. This provides objective data, however the
prevalence of other important clinical manifestations of
disease severity such as coma, respiratory distress or other
accepted severe malaria syndromes were not captured 13 .
Through training and improvement of the medical record
template, these syndromes can be more routinely assessed.
Parasitaemia was utilized as an indicator of more serious
clinical disease. In areas of low transmission it can predict
more severe outcomes, whereas in other regions it is not
associated with more severe disease 13 . More careful
assessment of all clinical manifestations of malaria and
parasite burden would need to be studied to determine if
this is a valid marker of severe disease in this region.
More comprehensive evaluation of long-term impact will
require continued monitoring. One consequence of the
control of malaria is that laboratory-confirmed disease
comprised a much smaller percentage of malaria-like clinical
disease in the post-intervention period, leaving a higher
percentage of children with an often unclear diagnosis. This
suggests that enhanced control of malaria may lead to a
decrease in the positive predictive value of clinical
symptoms for the diagnosis of malaria and a need for clinical
caregivers to reassess empiric management of febrile
illnesses in formerly malaria highly endemic zones when the
prevalence of malaria declines. Other studies also suggest
rapid declines in malaria after implementation of prevention
and early treatment strategies, and indeed data specifically
referring to declines in malaria admissions are beginning to
be reported 16 . However, not all studies have shown that
home based management is effective, highlighting the need
for site specific outcome studies 11 . This study is unique in
examining rural hospitalization patterns as well as laboratory
markers for clinical disease and for reporting other types of
admissions as malaria cases decline.
An important issue raised in this study is how to manage
febrile illnesses when the prevalence of malaria declines and
febrile illnesses are less likely to be due to malaria. This
study found that with high malaria prevalence in the period
prior to the intervention, clinicians were much more likely
to be correct in attributing febrile illnesses to malaria than
they were in the period following the intervention (80% vs.
48%), when laboratory-confirmed cases of malaria were less
common. In much of sub-Saharan Africa’s malaria-endemic
regions, febrile illnesses are assumed to be malaria and are
often treated only with antimalarial medications 17,18 . This can
have devastating results for patients with other aetiologies of
fever, in particular severe bacterial infections 19,20 . Indeed, in
one large study in Tanzania diagnosis of malaria with
negative laboratory examinations correlated with increased
mortality unless antibacterial therapy was administered as
well 21 . This suggests a significant problem with undiagnosed
causes of fever and will require better diagnostic capabilities
and data as well as fundamental alteration of approaches to
treatment of febrile illnesses. Attempts to develop clinical
algorithms for diagnosing malaria have had mixed results,
and accuracy is dependent on local prevalence, which will in
turn be altered by successful malaria control efforts 22,23 . The
increased role of diagnostics, either slide microscopy or
rapid diagnostic tests (RDTs) will need to be further
explored as the epidemiology of febrile illnesses changes 24,25.
Over-treatment of malaria, as demonstrated in this study by
the large number of children with negative slides who were
given antimalarials, can become more problematic as
prevalence drops. Over-treatment can lead to parasite drug
resistance, inappropriate use of antimalarial medications,
and inaccurate diagnosis and management of other febrile
illnesses. Additionally, as malaria incidence declines children
may become more severely ill if immunity is decreased from
less frequent parasite exposure 26,27 . With further successes in
malaria control, the issue of accurate diagnosis and
treatment will become increasingly more critical in providing
optimal care for patients with fever in resource-limited
settings.
There are several possible limitations to this study,
foremost of which is missing data as a result of the
retrospective nature of the data collection. This study was
based on existing records and reporting standards, and not
specialized study protocols. It is unlikely that missing
malaria thick smear data account for the observed decrease
in laboratory-confirmed malaria during the intervention
period given the relatively equal distribution of missing
smear data between years. Furthermore, there were no
identified systemic changes in data gathering or reporting
between the intervention periods that would account for
this association.
Haemoglobin levels, an indicator of disease severity, were
higher in the post-intervention period. The trend towards
higher haemoglobin levels for all children, and not solely
those with laboratory-confirmed disease, is relevant in that
lower haemoglobin is often a marker of repeat malaria
infections in the community 28 . It is possible however, that
the results of the haemoglobin analysis are biased by the
significantly increased proportion of children receiving
haemoglobin tests in post-intervention period. This increase
in haemoglobin testing was likely due to ongoing intensive
staff training on malaria protocols, including strict
monitoring haemoglobin. If children who received
haemoglobin tests tended to be sicker than children who
were not tested in the pre-intervention period, this could
potentially explain the observed increase in haemoglobin
over time.
Confounding by other variables, such as changing
hospital utilization patterns or rainfall, are unlikely to
account for the observed decrease in laboratory-confirmed
malaria. These reductions occurred during a period where
admissions and service uptake for all other causes increased,
and the number of paediatric non-confirmed malaria-like
illness held constant. Similarly, the existence of a coincident
decrease in infectious mosquitoes due to differences in
weather conditions and rainfall is not substantiated by
differences in rainfall or temperature between study
seasons 29 . Children were significantly older in the postintervention
period, but this is likely due to the decreased
incidence of malaria admissions, which are overwhelmingly
predominant in younger children. Gender, however, was
equally distributed between the study periods. Many areas
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CLINICAL CARE: MALARIA CONTROL
of future study are raised by this study, falling primarily in
the two main categories of malaria control and management
of febrile illnesses in resource-poor settings, especially as
malaria prevalence falls. One of the primary needs in the first
category is to undertake further analyses to assist with the
continued refinement of malaria control programmes. The
CHW model has been very successful and enhancement of
their capabilities, such as the employment of rapid
diagnostics for malaria and monitoring of disease at the local
level, will be important. Additionally, it is not possible from
this study to determine the relative contributions of mass
LLIN distribution, early community-based treatment and in
the future the effect of ACT. Better defining which
interventions are most effective is also important for
programme design, and studies are currently underway
addressing optimal methods of prevention. Evaluation of the
effect of extension of LLIN coverage to populations not
considered at high risk for severe malaria may also further
impact malaria prevalence. Indeed, there are data to suggest
that increasing LLIN coverage to the entire community leads
to even greater reductions in malaria in traditional target
populations such as pregnant women and young children 30 .
Continued and more sophisticated measures of outcomes
on disease both at the local and hospital level will be
important in measuring effective interventions and
responding to changes in health needs over seasons and
years 31 . Cost-effectiveness analyses may additionally be
undertaken to assess the savings in both direct costs from
hospitalization and lost productivity and indirect costs such
as decreased school achievement and impaired cognitive
development.
Conclusion
The data for this study suggest that following intensive
community-based prevention and early treatment
programmes, there was a significant decline in admissions
for malaria and improvement of laboratory markers of
malaria disease at a time when admissions for all other
causes increased. There was also an increase in the
proportion of febrile illnesses diagnosed and treated as
malaria despite negative laboratory studies, thus suggesting
a need for clinicians to reassess management of febrile
illnesses as malaria prevalence falls. This model additionally
demonstrates the importance of government-sponsored
programmes enjoying support by non-governmental
organizations (NGOs) in effecting large-scale change in
resource-limited settings. Continued monitoring over time
and measurements of vector capacity and other variables
that may impact disease prevalence, as noted above, will be
necessary. However these data suggest that intensive
community-based prevention and early treatment
programmes can rapidly result in a reduction of severe
paediatric malaria in rural Africa, and that government NGO
collaborations are an effective mechanism for implementing
such programmes. ❑
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
AS worked on the malaria programme at Rwinkwavu,
extracted and analysed data, and drafted the manuscript. JL
was co-director of the Rwinkwavu malaria programme. PM
was director of the home-based management programme at
PIH. MF reviewed and edited the manuscript, provided the
statistical analysis, and assisted in study design. BB assisted
in data extraction and performed the mortality analysis. SS
directed the paediatric programme and provided support for
this study. MR directed Partners in Health Rwanda and
provided support for the malaria programme and this study.
CK is the head of PNILP, the national malaria control
programme for Rwanda, and lead the LLIN and home-based
management efforts. JD reviewed the manuscript extensively,
provided guidance in study design, implementation, and
statistical analysis, and helped draft the manuscript. All
authors reviewed and approved the final version of the
manuscript. All authors report no conflict of interest in this
study.
Acknowledgements
We would like to thank Christine Mushashi for assisting with data
extraction, the Ministry of Infrastructure for providing weather
data, the Clinton Foundation and the Global Fund to Fight AIDS,
TB and Malaria for providing funding, and most of all our
community health workers, without whose devotion, skill, and
hard work none of this would be possible. JPD is supported by
NIAID.
Published with the kind permission of Malaria Journal 2008,
7:167 doi:10. 1186/1475-2875-7-167, August 2008:
http://www.malariajournal.com/content/7/1/167
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Vol. 44 No. 4 | World Hospitals and Health Services | 35

CLINICAL CARE: HIV AND SECURITY
HIV/AIDS, conflict and security in
Africa: rethinking relationships
JOSEPH U BECKER
SECTION OF EMERGENCY MEDICINE, DEPARTMENT OF SURGERY, YALE UNIVERSITY SCHOOL OF MEDICINE, NEW
HAVEN, CT, USA
CHRISTIAN THEODOSIS
EMERGENCY MEDICINE, UNIVERSITY OF CHICAGO, ILLINOIS, USA
RICK KULKARNI
MEDICAL DIRECTOR, ADULT EMERGENCY DEPARTMENT, YALE-NEW HAVEN HOSPITAL AND ASSISTANT PROFESSOR
OF SURGERY, SECTION OF EMERGENCY MEDICINE, DEPARTMENT OF SURGERY, YALE UNIVERSITY SCHOOL OF
MEDICINE, NEW HAVEN CT, USA
Abstract
The effect of conflict on HIV transmission and regional and global security has been the subject of much recent
discussion and debate. Many long held assumptions regarding these relationships are being reconsidered. Conflict
has long been assumed to contribute significantly to the spread of HIV infection. However, new research is casting
doubt on this assumption. Studies from Africa suggest that conflict does not necessarily predispose to HIV
transmission and indeed, there is evidence to suggest that recovery in the “post-conflict” state is potentially
dangerous from the standpoint of HIV transmission. As well, refugee populations have been previously considered as
highly infected vectors of HIV transmission. But in light of new investigation this belief is also being reconsidered.
There has additionally been concern that high rates of HIV infection among many of the militaries of sub-Saharan
Africa poses a threat to regional security. However, data is lacking on both dramatically elevated prevalence amongst
soldiers and a possible negative effect on regional security. Nevertheless, HIV/AIDS remain a serious threat to
population health and economic well being in this region. These issues are of vital importance for HIV programming
and health sector development in conflict and "post-conflict" societies and will constitute formidable challenges to
the international community. Further research is required to better inform the discussion of HIV, conflict, and
security in sub-Saharan Africa.
HIV and AIDS pose serious threats to global health.
While efforts to address the epidemic have been
complicated by innumerable social, cultural and
economic factors, one factor, that of conflict, and the societal
disarray that often follows, creates a unique environment
potentially conducive to epidemic spread. Indeed, poverty,
interrupted access to health resources, stress, and poor
nutritional support are commonly associated with conflict or
postconflict zones. The past two decades have witnessed a
multitude of conflicts and wars in regions of poor baseline
health and relatively high HIV prevalence. Sub-Saharan
Africa in particular, has witnessed multiple conflicts both
within and across national borders. Conflicts in this region
have created widespread population displacement.
Individuals deprived of their home social and economic
networks frequently engage in high-risk behaviours
increasing their vulnerability to HIV infection 1-4 . Despite
this, recent data suggests that conflict and population
displacement may not automatically equate elevated HIV
prevalence 5,6 . Likewise, recovery and reconstruction may not
necessarily lead to improvements in health and well being,
as the distinction between conflict and “post-conflict” states
is often artificial. Indeed, the “post-conflict” period is often
associated with persistent deterioration of law and order,
surpluses of arms and unemployed former combatants as
well as continued interruption of social and health
infrastructure. As HIV and conflict continue to menace
poorly resourced nations, there is concern that the impact of
these two factors will impact regional and global security.
However, no firm data exists demonstrating this effect. As
such, previously held assumptions regarding HIV, conflict,
recovery and their impact on security have undergone recent
examination and reconsideration.
In this document we review the recent data regarding the
HIV epidemic in populations affected by conflict in sub-
Saharan Africa. Further, we discuss recent discourse in relation
to the effect of HIV on security. Future directions and avenues
for intervention are examined with particular attention paid to
the issues facing nations emerging from conflict.
Epidemiology of HIV/AIDS in conflict
It has previously been considered evident that conflict aids
the potential transmission of HIV through the disruption of
protective social and family networks as well as the
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CLINICAL CARE: HIV AND SECURITY
interruption of vital social and health services 2-4 . It is also
known that populations living in conflict zones are
vulnerable to sexual violence, malnutrition, and substance
abuse. All of these are risk factors for HIV transmission or
the development of AIDS 1-4 . However, recent work suggests
that the relationship between HIV and conflict may not be
straightforward. During the last decade several African
conflict zones have demonstrated lower than expected HIV
prevalence. Sierra Leone, after decades of conflict had an
HIV prevalence of only 0.9% in 2002 5 . This was not
appreciably higher than estimates from years earlier in the
conflict and was lower than many neighboring countries not
involved in conflict, including Guinea, where HIV prevalence
ranged from 2.1 to 3.7%, depending on region 4-6 .The same
trend is notable in Southern Sudan where conflict between
pro-government militias and local rebel groups continues.
HIV prevalence has not climbed appreciably even after
several years of conflict and remains low in comparison to
neighbouring countries 6,7 . The explanation for these findings
is unclear, as these conflicts have unfortunately been rife
with sexual violence, population displacement and
disruptions of health and social infrastructure.
Other examples point towards a positive correlation
between conflict and HIV infection. The conflict between
Tanzania and Uganda in the 1970s is thought to have
contributed significantly to the spread of HIV in these two
countries 8 . Retrospectively, researchers have suggested that
occupation of communities in both these countries by
military forces as well as commercial sex work were at least
partially to blame for the increases in HIV prevalence 8 .
The interplay of conflict and HIV prevalence was
addressed in a systematic fashion in a recent study by
Spiegel et al 6 . The authors examined HIV prevalence data
from seven separate African conflict zones. Conflict
countries included in the study were Rwanda, Democratic
Republic of the Congo, Burundi, Uganda, Southern Sudan,
Sierra Leone and Somalia. While the authors acknowledge
deficiencies in the quality and comparability of the included
studies, they concluded that there is insufficient evidence to
suggest that conflict increases the epidemic spread of HIV, at
least in these geographic regions.
HIV prevalence in urban areas in Rwanda, Burundi and
Uganda seemed to decline after periods of conflict while the
rural prevalence remained stable 6 . In Juba, the largest town
in Southern Sudan the prevalence of HIV is known from
studies of outpatients to be 3.0% in 1995 and 4.0% in
1998. This is far below the prevalence of neighbouring sites
such as Mboki, in the Central African Republic, where HIV
prevalence was measured at 11%. Similarly, HIV prevalence
in the Acholi district of northern Uganda fell despite
ongoing conflict from 1993 to 2003 (27% to 11.3%) 6 . It is
likely that the relationship between HIV and conflict is not
a uniform one, and, given the unique character of each
conflict, generalizations are prone to error.
Post-conflict states
The end of formal hostilities frequently does not
automatically herald improvements in the health indices of
a given population. Nations emerging from conflict
frequently have persistent difficulty in addressing healthcare
needs. The cessation of hostilities commonly results in the
unemployment of scores of young, uneducated, and
unskilled men from either regular or irregular armed forces.
Given the lack of opportunity in the face of economic
privation, crime often spikes in the immediate post-conflict
period 9-11 . If these unemployed former combatants are
allowed to re-organize, secondary conflicts and organized
crime may develop 11 . The addition of peacekeepers to postconflict
settings can further complicate the geometry of HIV
transmission.
As has been seen in many African countries emerging from
conflict, refugees and displaced persons have preferentially
sought out large cities to seek employment and shelter after
repatriation 6,8 . The concentration of migrant populations
into already overcrowded cities, with inadequate or
damaged health infrastructure, creates the potential for
increased transmission of communicable diseases including
HIV 3,4,6 Additionally, the commonplace violence,
displacement, starvation and fear typical of the conflict
phase can destroy social networks and prevent the
concentration of people, therefore reducing the frequency of
circumstances under which individuals may be exposed to
HIV. The restoration of these networks, in the post-conflict
phase, coupled with persistent shortages in healthcare and
employment can create a fertile ground for HIV
transmission.
It would seem that the period of recovery in the postconflict
phase is potentially a worrisome time for HIV
transmission. Data is lacking and further study is required to
better characterize this relationship. A careful analysis is
required of the underlying determinants of HIV infection
and subsequent AIDS-related mortality in conflict and postconflict
societies.
Armed parties
At the end of the Cold War in the 1990s, the nature of
conflict changed as intra-state civil war became more
prevalent than conflict between states. These new conflicts
predominantly and asymmetrically affect the poorest of
nations of the world and often the poorest populations
within those nations. This change also reflects a shift away
from conflict involving regular, uniformed forces to conflicts
among and between rebel and insurgent groups and national
armies 4,10,12 . These internal struggles have required substantial
re-engineering of peacekeeping missions. In particular, recent
peace operations have been large (tens of thousands of
peacekeepers) and have increasingly employed peacekeepers
from areas of relatively high underlying prevalence (e.g. the
ECOWAS force in Liberia). Each of these armed populations
represent unique and poorly studied variables that are likely
to modulate transmission of HIV.
Regular military forces
Soldiers have long been considered a high-risk population
for HIV/AIDS. Indeed, initial data suggested that the
prevalence of HIV amongst militaries was far in excess of the
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CLINICAL CARE: HIV AND SECURITY
general populations in their home countries 2,3,12,13 . Multiple
risk factors for HIV infection have been attributed to
soldiers, including frequent commercial sex, risk taking
mentality, concomitant sexually transmitted infection (STIs)
and increasingly, injection drug use 1,2,4,8,10,13-15 . During conflict
these behaviours may be exacerbated by stress and
potentially limited command oversight. The role of
iatrogenic infection via non-sterile injections, blood product
transfusions, or medical procedures in the setting of a
military medical system under combat stress have yet to be
evaluated.
Soldiers are regularly sent to areas distant from their home
and family support networks. In these settings soldiers,
often the sole legal authority, are more likely to resort to
commercial sex and/or coercive sex 4,8,14,15 . And soldiers in
conflict regions may have more disposable income than the
general population, further permitting commercial sex and
risk taking behaviour.
Recent data has suggested that the relationship between
soldiers and HIV is not straightforward and studies have
failed to demonstrate dramatically elevated HIV prevalence
amongst military recruits. In 2000 the South African
Defence Force (SADF) tested 10% of its active duty soldiers
for HIV. A prevalence of 17% was found, which was not
appreciably higher than among the general population 16 .
Similar data has been found in Ethiopia where recruitment
screening during mobilization in response to the war with
Eritrea identified a relatively low seroprevalence of 2.8% 17 .
These findings are attributed in part to demographic studies
from South Africa and elsewhere demonstrating the
relatively low HIV prevalence among the 17–22 year old age
group (the age group from which recruits are drawn), as
compared to older men and women 16 . Further, compulsory
testing programs in many militaries, while problematic from
a human rights standpoint, may allow national armed forces
to at least initially select for an HIV-free population 18 .
There is data to suggest that soldiers are at increased risk
for contracting HIV, and that this risk increases with longer
durations of service. Indeed, data from the SADF suggests
an incidence of HIV infection of 1.2% per year of service 16 .
Furthermore, data suggests that in the absence of unusual
circumstances the HIV prevalence of a military unit will tend
to stabilize to that of the population in which it is stationed,
suggesting that the relatively low prevalence of newly
recruited troops will not remain static 16 . It is unclear to what
extent prevention and education campaigns can arrest this
trend, and alternatively to what extent deployment for
combat or peacekeeping may worsen this effect.
Demobilization after conflict is an additional concern.
Victory, defeat, negotiated truce and/or the arrival of
peacekeeping forces may herald the dissolution of all or part
of the national military or insurgent forces. These armed,
frequently uneducated, untrained and newly unemployed
combatants often participate in criminal activity in the postconflict
period. Economic and societal factors may force
these young men into cities to seek work, prolonging their
isolation from family support networks and increasing their
vulnerability to HIV infection. Demobilization of irregular
forces in South Africa has been linked withthe spread of HIV,
and a similar trend was seen in Cuban soldiers returning
home after tours of duty in the Angolan conflict 16 .
Multiple prevention initiatives have been adopted by the
world's armed forces. A survey of militaries across the globe
published in 2000, yielded the following statistics: 98% of
militaries provided some form of HIV prevention education,
58% provided mandatory testing of all recruits and 17%
turned away positive recruits 19 . Much research has been
generated regarding HIV infection in militaries.
Unfortunately, the majority of this data pertains to the
militaries of the developed world 20 . Higher rates of HIV
infection, illiteracy, and differing cultural and societal norms
in many of the militaries of sub-Saharan Africa render
extrapolation of such data difficult.
Some sub-Saharan countries have developed
individualized HIV prevention strategies for their armed
services. In Malawi, military recruits receive extensive
counseling and education regarding HIV/STD infection and
condom use 21 . Uganda has sought to de-stigmatize HIV
infection and thus HIV testing by providing care and
treatment for HIV positive service-members while protecting
their rights and employment. The armed forces of
Zimbabwe, Malawi and Zambia have instituted similar
programmes 21 .
While the utility of many of these approaches remains
untested, there is data to suggest a beneficial effect. A
program piloted on Nigerian military personnel
demonstrated that a “situationally focused” approach
detailing avoidance of high-risk behaviours and situations
could have beneficial effect on condom use and risk
behaviours. At six months, risk behavior reporting decreased
by 30% and by 23% at 12 months. Report of condom use
increased significantly at both time points as well in
comparison to baseline 22 .
Other interventions, such as universal condom
distribution to armed forces have encountered cultural and
religious barriers, but may hold promise in preventing
transmission. Data indicates that while the majority of
armed forces provide recommendations regarding condom
use, very few actually provide condoms to their soldiers 23 .
Furthermore, recent data suggests a high prevalence of risk
taking behaviour on the part of soldiers in the postdeployment
phase as they rejoin their families and social
networks 23 . As well, given the experience in southern Africa
regarding demobilization and HIV, postdeployment
interventions may be an important component of HIV
prevention strategies 16 . However, while a majority of services
offer pre-deployment counseling and education to their
troops very few offer post-deployment prevention
education 23 .
Peacekeepers
Recent focus on peacekeeping has emphasized equipping,
training and utilizing African forces in African peacekeeping
operations. As discussed, soldiers display a multitude of risk
behaviours potentially placing them at elevated risk for HIV
infection. Nigerian peacekeepers returning to their home
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CLINICAL CARE: HIV AND SECURITY
communities after operations in West Africa had rates of
infection more than double that of the country overall 24 .
There also appeared to be a dose response relationship, with
the rate of infection correlating directly with the amount of
time spent peacekeeping 24 . Incidence increased from 7%
amongst troops peacekeeping for one year to 10% after two
years and 15% after three years of deployment 24 .
Similar to combatants in conflict zones, peacekeepers
have been documented to engage in high-risk behavior
while participating in missions 10,15 . While it is assumed that
peacekeepers have access to healthcare, including treatment
of sexually transmitted infections and HIV Voluntary
Counseling and Testing (VCT), their sexual partners,
including commercial sex workers, may not have access to
these same resources. The impact of injection drug use on
the transmission of HIV amongst peacekeepers during
deployment has yet to be fully studied.
Several initiatives aimed at reducing HIV infection have
been developed for soldiers participating in peacekeeping
operations. The Department of Peacekeeping Operations
(DPKO) and UNAIDS have developed and distributed an
HIV/AIDS awareness card (with condom pocket) to
peacekeepers 10,15,16 . This card has been translated into 15
languages spoken in 90 of the troop contributing nations.
UNAIDS has also developed a programming guide, predeployment
“Standardized Generic Training Modules” and
peer education kits for HIV education and prevention in
troop contributing forces 10,15,16 . The DPKO endorses
voluntary counseling and testing (VCT), as well as the
availability of post-exposure prophylaxis (PEP) for
peacekeepers 15,16 . Furthermore, as a result of a cooperative
agreement between UNAIDS and DPKO, an AIDS advisor is
in place with each of the current 16 peacekeeping
missions 16 .
Insurgent groups
Very little is known about the role of irregular troops in the
spread of HIV. It can be argued that as these forces are
frequently under inadequate command oversight and have
access to limited medical support, they are potentially at
higher risk than the soldiers of regular and peacekeeping
forces. However, modern African insurgent groups are as
diverse as the causes for which they fight, precluding ready
generalization.
More so than in regular military forces, demobilization of
insurgent groups is often incomplete, yielding persistent
conflict despite any organized truce or cease-fire 25 . Further,
even those who are demobilized may be incompletely
incorporated into post-conflict society, remaining as
marginalized populations or continuing to fight in criminal
or insurgent groups. The dynamics of these relationships
remain unknown and there is clear need for research in this
area.
Refugees/internally displaced persons
Conflict and war often entails displacement of large groups
both within and across national borders. These populations
are frequently in crisis with their healthcare, nutritional,
safety and shelter needs. Further, while countries are
responsible for the care of individuals seeking safe haven on
their soil, refugees have persistently been excluded from the
planning and implementation of national HIV prevention,
testing and treatment programmes 4,26,27 . Given these factors
one could assume that refugee groups would therefore have
HIV rates far in excess of their host population.
This assumption has not been borne out by recent data.
Spiegel et al examined HIV prevalence in refugee groups in
comparison to their host communities 6 . Refugee
populations were not found to have HIV prevalence in
excess of the general populations of their hosts, and in many
cases were significantly less infected, undermining the
contention that refugee groups bring high rates of HIV
infection to their hosts. For instance, refugees from the
Democratic Republic of the Congo seeking refuge in the
Gihembe camp of Rwanda had measured HIV prevalence of
1.5%, while the surrounding community (Byumba) had a
prevalence of 6.7% 6 . Similarly, Sudanese refugees in the
Kakuma camp in Kenya had HIV prevalence measured at
5%, while the surrounding community (Lodwar)
demonstrated an HIV prevalence of 18% 6 .
The effect of displacement on refugee populations could
not be assessed due to the lack of reliable studies comparing
pre and post displacement prevalence. However, there was a
trend towards refugee groups slowly assuming the
prevalence of their host population, suggesting that the final
outcome is increased HIV prevalence amongst refugee
groups in sub-Saharan Africa. It seems the majority of
refugees in sub-Saharan Africa have fled from areas of low
prevalence into areas of higher prevalence 6 . This finding
points to another axis along which refugees – who have
historically been viewed as vectors – might better be viewed
as “victims”. As with soldiers and peacekeepers returning to
their home communities, there may be risk from repatriation
of previously low prevalence refugee populations who have
fled to areas of higher prevalence.
Security considerations
The interplay between HIV and conflict poses serious
challenges to the nations of sub-Saharan Africa. Security has
traditionally been thought of as pertaining exclusively to
relationships between states 13,28,29 . Recently, however,
thinking about security has evolved to include threats
against the health and economic wellbeing of states. Indeed,
the concepts of “collective security” or “biological security”,
as termed by former UN Secretary General Kofi Annan,
demands a consideration of the health and well being of
international populations 30 .
There exists little evidence to suggest that HIV is a threat
to the security of states in the traditional sense. However,
through forcing the redirection of funds from development
projects to HIV/AIDS care and via debilitating the labor
forces, HIV is altering the trajectory of development and
progress within many nations. Indeed, HIV/AIDS has
significantly lowered the life expectancy across sub-Saharan
Africa, reversing what had been decades of progress and
creating massive disparities in life expectancy between some
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CLINICAL CARE: HIV AND SECURITY
sub-Saharan nations and the rest of the world 23,30 . In 2000
the UN Security Council addressed the notion of HIV as a
threat to the security of nations. It was the first time a health
issue had been the subject of a UN Security Council
session 31 . The session noted that the HIV epidemic has, in
many sub-Saharan countries, reversed decades of economic
and social progress, and threatens substantial portions of the
labour force as well as the economically active populace in
multiple nations 10,31 .
HIV also indirectly impacts national governments, as
funds destined for social programmes, development or
security are reallocated to care for those infected and dying
from HIV-related problems. Economic limitations related to
the aftermath of conflict augmented by the cost of HIV/
AIDS related spending, and loss of tax revenue related to
increased mortality, may all profoundly limit medical and
social investment. Additionally, as nations transition out of
conflict, military populations with high HIV prevalence are
demobilized and the fragile social balance achieved by
cessation of hostilities may be jeopardized by the
progression of the epidemic. National governments
weakened by conflict may not be able to simultaneously
support and fund reconstruction while dealing with a
burgeoning HIV epidemic. As such, the ability of nations to
move from conflict to post-conflict states, and to support
and care for their populaces, may be constrained 10 .
Lastly, in the absence of aggressive screening and
prevention efforts, HIV has the potential to negatively
impact the readiness and effectiveness of national armed
forces. As soldiers become ill, funds and resources destined
for equipping and arming the military and security forces
may be reallocated to care for infected soldiers. For instance
estimates from Kenya indicate that at the main military
hospital 50–60% of inpatient hospital beds are occupied by
HIV infected soldiers 32 . While concrete examples of security
failure because of impaired readiness are lacking, it is
certainly feasible that, in regions of high HIV prevalence,
HIV/AIDS may negatively impact the ability of the armed
forces to provide security in the face of combat stress.
For the future: Research and programming
directions
In the above discussion several areas of need are clearly
identified. We currently do not have substantial data
regarding the effect of population displacement on HIV
transmission. We can of course speculate that HIV
prevalence increases in these settings, especially when
refugees flee from areas of low HIV prevalence to areas of
higher prevalence, or from rural to more urban areas.
However, as we have learned with the conflict and HIV
discussion, speculation is often done in error.
Data regarding post-conflict situations and the challenges
inherent to this unique situation is lacking. Injection drug
use is growing in sub-Saharan Africa, disproportionally so in
conflict and post-conflict regions, yet little data exists
describing this trend 33,34 . Research amongst displaced
populations or in conflict and post-conflict settings is rife
with difficulty and future studies must address the
numerous biases and operational difficulties inherent in this
work. Until adequate data is obtained it will be difficult to
formulate programming interventions regarding these
specific issues. Further work must characterize the current
approaches to HIV education, prevention and treatment
among the militaries of the world, especially those of sub-
Saharan Africa. Although military recruits may not have rates
of infection far in excess of the general population, it is likely
that they are at increased risk for HIV infection once
deployed though it is not clear the extent to which conflict
exacerbates this problem. Moreover, insurgent groups, often
extremely marginalized have not been adequately studied,
and data describing their role in the epidemic is lacking.
Lastly, it is of vital importance to continue to monitor the
progression of the HIV epidemic in peacekeeping and
security forces both in this region and globally. And critically
this effort should not cease with demobilization.
Conclusion
Recent data and discussion have caused reconsideration of
many long held assumptions regarding the complex
relationships between HIV, conflict and security. As such,
previous generalizations must give way to a paradigm which
recognizes the complexity inherent in these relationships
and seeks to understand individual crises in their specific
context. The data regarding HIV, conflict and security is
incomplete and further investigation is required.
Nevertheless, several constants can be endorsed: the HIV
epidemic poses severe challenges to the populations of sub-
Saharan Africa. Nations in this region must be proactive in
addressing the epidemic amongst both the general
population as well as the security and irregular forces.
Failure to address these issues could hamper the ability of
nations in this region to respond to crises, and as well
threaten development efforts and the reconstruction and
recovery that is vital in the post-conflict phase.
Numerous prevention and treatment efforts are underway
among the militaries of the world, but data on this is lacking.
While the effect of conflict and HIV on civilian populations
is discussed, a parallel investigation into the effect of conflict
on HIV in militaries should be widened. The interaction
between HIV, conflict and security is neither uniform nor
straightforward. Nor is it likely to be stable. A tailored,
coherent and thoughtful approach to these issues is required
to inform policy and intervention regarding these dynamic
relationships.
Competing interests
There was no funding source for this publication other than
the salaries of the three authors which are provided by their
institutions (Yale University, University of Chicago). The
authors attest that no other article or publication
substantially similar in content to this has been published or
is currently being considered for publication.
There is no further conflict of interest or financial
arrangement to be declared. No graphs, tables, or other
media requiring release or permission is included in this
manuscript. ❑
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CLINICAL CARE: HIV AND SECURITY
Authors’ contributions
All authors certify sufficient participation in the conception,
design, analysis, interpretation, writing, revising, and
approval of the manuscript.
Acknowledgments
Published with the kind permission of Journal of the International
AIDS Society 2008, 11:3 doi:10,1186/1758-2652-11-3,
September 2008 http://www.jiasociety.org/content/11/1/3
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Vol. 44 No. 4 | World Hospitals and Health Services | 41

REFERENCE
World Hospitals and Health Services 2008 Volume 44 Number 4
QUALITE, GESTION DU RISQUE ET SECURITE DES PATIENTS : LE
DEFI D’UNE INTEGRATION EFFICACE (QUALITY, RISK
MANAGEMENT AND PATIENT SAFETY: THE CHALLENGE OF
EFFECTIVE INTEGRATION)
Nous allons peut-être observer actuellement le développement de trios
vagues d’intervention et de changements au sein des services de santé :
gestion de la qualité, gestion des risques et sécurité des patients.
Le mouvement Sécurité des Patients a été lancé à l’échelle internationale
par suite du rapport de l’Institut de Médecine “L’erreur est humaine”, et
aujourd’hui, la sécurité des patients occupe une place fondamentale dans la
qualité des soins soumise à l’intervention directe des entités supranationales
(OMS, UE) et des gouvernements des Etats-membres.
L’objectif de cet article est de faire prendre conscience de l’intérêt de
l‘amélioration de la qualité (QI), et des méthodologies et instruments
menant à des solutions durables concernant la qualité des soins de santé.
Mots clefs : amélioration de la qualité, sécurité des patients, programmes de
qualité, gestion du risque.
LES TENDANCES QUI SE DESSINENT EN MATIERE DE SOINS
MEDICAUX EN CHINE: L’ IMPACT DE L’EMERGENCE D’UNE
CLASSE MOYENNE (EMERGING TRENDS IN CHINESE HEALTHCARE:
THE IMPACT OF A RISING MIDDLE CLASS)
Dans ce rapport, les auteurs examinant un phénomène majeur sur le
marché de la santé en Chine: l’explosion d’une classe moyenne énergique
et exigeante et les répercussions sur les futures orientations de l’industrie
médicale.
L’on ne sait pas grand-chose des attentes de la classe moyenne à l’égard
de leurs besoins en soins de santé, sinon de sources officieuses ou
anecdotiques. Les idées de la classe moyenne sont façonnées par diverses
influences dont l’exposition par contact personnel direct avec les
établissements de santé internationaux l’occasion de voyages à l’étranger
ou indirectement par une exposition croissante à l’industrie des spectacles
avec sa pléthore de séries dramatiques médicales ou hospitalières. Outre
une meilleure prise générale de conscience de la scène internationale qui est
le fruit d’une éducation plus avancée, les perspectives du consommateur de
classe moyenne sont également soumises à la réalité de ce qui est
actuellement disponible en Chine et de ce à quoi l’on peut raisonnablement
s’attendre. Ce rapport tente de remédier à ce manque de données factuelles
au moyen d’une vaste enquête auprès des consommateurs de classe
moyenne dans trois grandes villes de Chine : Beijing, Shanghai and
Chengdu.
Une approche pratique et pragmatique a été adoptée pour mener cette
enquête. L’étude n’a pas tenté d’expliquer pourquoi le consommateur
ressent ce qu’il ressent concernant ses attentes en matière de soins. Le but
était simplement définir dans les grandes lignes les attentes de la classe
moyenne concernant le marché de la santé en Chine.
A certains égards, les résultats ne sont guère surprenants. Ce sont les
attentes de tout le monde quel que soit l’endroit ou le pays. Ils souhaitent
moins de promiscuité et plus de dignité dans les processus de soins. Ils
veulent participer davantage aux décisions prises concernant leurs
traitements. Ils préfèreraient un médecin personnel privé plutôt qu’un
défilé de visages qu’ils ne reverront plus. Ils comptent fortement sur leurs
parents et amis pour les conseiller quant au choix des fournisseurs de
services. Ils demandent des installations propres, bien entretenues, des
systèmes efficaces et un personnel courtois.
A d’autres égards, les conclusions peuvent être plus inattendues. Ils sont
fermement d’avis que leur hôpital ou service de santé doit être situé dans
un quartier résidentiel. Dans certaines circonstances, ils sont prêts à payer
davantage pour recevoir des soins répondant à leurs attentes, mais pas
beaucoup plus. Tout en reconnaissant que c’est auprès des médecins
étrangers qu’ils bénéficieront de nombreux aspects des soins qu’ils
souhaitent recevoir, comme un plus grand respect de leur vie privée et une
Résumés en Français
attitude perçue comme plus positive dans le processus de soins, les
consommateurs de classe moyenne n’expriment pas de préférence marquée
pour les médecins étrangers, mais optent plutôt pour les médecins chinois.
En conclusion, les résultats donnent une idée des attentes des Chinois
de classe moyenne concernant les prestataires de santé et un aperçu de
l’orientation des futurs développements des services médicaux.
GESTION D’UNITES HOSPITALIERES : CONTROLER QUELQUES
ASPECTS CRITIQUES (HOSPITAL HEALTH CARE UNIT
MANAGEMENT: MONITORING SOME CRITICAL POINTS)
Le suivi stratégique d’unités hospitalières est souvent basé sur les coûts, qui
paraissent jouer un rôle important. Toutefois, il faudrait peut-être poser
certaines questions fondamentales, à savoir: Pour quelle raison
l’hospitalisation est préférée dans la majorité des cas ? Comment les services
de santé sont perçus par la population en générale et par les parties
prenantes extérieures? Pourquoi les patients et leurs familles choisissent un
service particulier plutôt qu’un autre? Quel est le taux d’acceptation face à
la demande d’hospitalisation par rapport au nombre de lits? Comment
évaluer le développement du statut de santé? Quelles sont les conséquences
de ces développements sur le travail du personnel, notamment quels sont
leurs effets dans le quotidien? Il serait souhaitable d’élaborer un instrument
d’évaluation pour pouvoir répondre à ces questions.
LE VIH/SIDA, LES CONFLITS ET LA SECURITE EN AFRIQUE:
NOUVELLE OPTIQUE (HIV/AIDS, CONFLICT AND SECURITY IN
AFRICA: RETHINKING RELATIONSHIPS)
Les effets des conflits dans la transmission du VIH et la sécurité régionale et
mondiale ont fait l’objet de nombreuses discussions et débats. De
nombreuses idées qu’on répète de longue date concernant ces relations
sont maintenant réévaluées. On a longtemps cru que les conflits
contribuaient significativement à la propagation de l’infection à VIH.
Toutefois, de nouvelles recherches jettent le doute sur cette hypothèse. Des
études émanant d’Afrique indiqueraient que les conflits ne prédisposent pas
nécessairement à la transmission du VIH et qui plus est, certains signes
indiqueraient que le rétablissement qui suit l’état post-conflit est
potentiellement dangereux du point de vue transmission du VIH. Par
ailleurs, on considérait autrefois que les populations de réfugiés
constituaient un important réservoir d’infection et source de dissémination
du VIH. Mais à la lumière de nouvelles enquêtes, il faut également revoir
cette conviction. Par ailleurs, l’on s’inquiète que les taux élevés d’infection
au VIH parmi les militaires de l’Afrique sub-saharienne constituent une
menace pour la sécurité régionale. Néanmoins, on manque de données
concernant la prévalence fortement élevée parmi les soldats et la possibilité
d’un effet négatif sur la sécurité régionale. Quoiqu’il en soit, le VIH/SIDA
reste un grave danger en matière de santé publique et bien-être économique
dans cette région. Ces questions sont d’une importance capitale concernant
les programmes de lutte contre le VIH et le développement du secteur
sanitaire dans les sociétés lors de conflits et à la suite de conflits, et poseront
des défis majeurs à la communauté internationale. Il conviendrait de mener
d’autres enquêtes pour mieux informer les discussions sur le VIH, les
conflits et la sécurité en Afrique sub-saharienne.
BAISSE DES HOSPITALISATIONS PEDIATRIQUES DUES AU
PALUDISME ET AUTRES MALADIES FEBRILES PAR LA MISE EN
ŒUVRE D’UN PROGAMME ANTIPALUDEEN A BASE
COMMUNAUTAIRE DANS LE RUANDA (REDUCED PAEDIATRIC
HOSPITALIZATIONS FOR MALARIA AND FEBRILE ILLNESS PATTERNS
FOLLOWING IMPLEMENTATION OF COMMUNITY-BASED MALARIA
CONTROL PROGRAMME IN RURAL RWANDA)
Contexte : La communauté internationale s’est actuellement fortement
engagée dans la lutte contre le paludisme. A cet égard, le Ruanda a entrepris
une campagne à deux niveaux pour combattre le paludisme par une
42 | World Hospitals and Health Services | Vol. 44 No. 4

REFERENCE
distribution massive de moustiquaires insecticides de longue durée et la
distribution d’antipaludiques par les agents de santé extra-hospitaliers.
Cette étude s’efforce de mesurer l’impact de ces mesures sur les
hospitalisations pédiatriques dues au paludisme et sur des marqueurs de
laboratoires évaluant la sévérité de la maladie.
Méthodes: Une analyse rétrospective a été menée sur les dossiers
d’hôpitaux avant et après les opérations de lutte contre le paludisme dans
la communauté dans un hôpital de district du Ruanda rural. Ces
interventions ont eu lieu en août 2006 dans la région desservie par l’hôpital
et consistaient en une distribution massive de moustiquaires traitées aux
insecticides et de médicaments antipaludiques par les agents de santé
travaillant dans les communautés. Les périodes étudiées portaient sur les
saisons de forte transmission de décembre à février. L’étude des dossiers
examinait au total 551 admissions en pédiatrie pour mettre en évidence 1)
paludisme confirmé par les examens biologiques, définis par frottis en
goutte épaisse, 2) paludisme soupçonné, défini par des fièvres et
symptômes correspondant au paludisme en l’absence d’autres cas, et 3) les
admissions multi-causes. Pour définir l’impact de l’intervention sur des
marqueurs cliniques de la maladie paludéenne, on a analysé des tendances
à l’admission de la parasitémie et de l’hémoglobine. Pour définir la précision
des diagnostics cliniques, les tendances relatives aux admissions pour
paludisme confirmé au microscope avant et après l’intervention ont été
examinées. Pour finir, on a décrit une évaluation générale des
antibiothérapies contre les maladies fébriles en général.
Résultats: Sur un total de 151 admissions, 268 (48,6%) et 437 (79,3%)
étaient respectivement attribuales au paludisme confirmé par le laboratoire
et au paludisme soupçonné. Le nombre absolu d’admissions était plus
faible pendant la période post-intervention (N = 150) par rapport à la
période pré-intervention (N = 287), en dépit d’une augmentation du
nombre absolu d’hospitalisations pour d’autres motifs pendant la période
post-intervention. Le pourcentage d’admission pour paludisme soupçonné
confirmé par les tests de laboratoire était plus élevé pendant la période préintervention
(80,4%) par rapport à la période post-intervention (48,1%,
taux de prévalence [PR]: 1,67; 95% CI: 1,39 – 2,02; valeur p au chi-carré
< 0,0001). Parmi les enfants admis pour paludisme confirmé par les
analyses de laboratoire, le risque de parasitémie était plus élevé durant la
période pré-intervention que la période post-intervention (PR ajusté selon
l’âge : 1,62; 95% CI: 1,11 – 2,38; valeur p au Chi carré = 0,004), et le
risque d’anémie sévère était plus de deux fois supérieur pendant la période
pré-intervention (PR ajusté selon l’âge : 2 ,47; 95% CI: 0,84 – 7,24; valeur
p au Chi carré = 0,08). Les antiobiothérapies sont fréquentes, avec 70,7%
de tous les enfants atteints de paludisme clinique et 86,4% d’enfants avec
paludisme négatif aux frottis recevant un traitement antibactérien.
Conclusion: Cette étude indique que les admissions pour paludisme et
pour marqueurs de laboratoire de la maladie clinique parmi les enfants
peuvent diminuer rapidement grâce aux efforts de lutte antipaludique par
les agents travaillant dans la communauté. Par ailleurs, cette étude souligne
les problèmes de sur-diagnostic et de sur-traitement du paludisme dans les
régions de paludisme endémique, en particulier lorsque la prévalence
paludéenne baisse. Il est urgent d’obtenir des diagnostics plus exacts et de
mieux gérer les maladies fébriles aussi bien maintenant que lorsque
l’étiologie des fièvres changera avec un autre recul du paludisme.
World Hospitals and Health Services 2008 Volume 44 Number 4 Resumen en Español
CALIDAD, GESTION DE RIESGOS Y SEGURIDAD DEL PACIENTE:
DIFICULTADES DE UNA INTEGRACION EFICAZ (QUALITY, RISK
MANAGEMENT AND PATIENT SAFETY: THE CHALLENGE OF
EFFECTIVE INTEGRATION)
Hoy en día somos conscientes de que hay una evolución hacia tres tipos de
intervención, además de una transformación en el seno de los servicios de
salud: gestión de la calidad, gestión de riesgos y seguridad del paciente.
El Movimiento en pro de la Seguridad del Paciente, fundado a escala
internacional a consecuencia del Informe del Colegio Médico – Errar es de
Humanos, y hoy en día la seguridad del paciente constituye una parte
fundamental de la calidad de los servicios de la salud sujeta a la intervención
directa de entidades supranacionales (OMS, UE) y Gobiernos de los Estados
miembros.
Con este artículo se pretende aumentar el grado de conciencia en lo que
respecta a la importancia de los métodos e instrumentos destinados a mejorar
la calidad de los cuidados de la salud mediante la obtención de unos
resultados de calidad sostenibles.
Palabras clave: mejorar la calidad, seguridad del paciente, programas de
calidad, gestión de riesgos.
NUEVAS TENDENCIAS EN LA ATENCION DE LA SALUD CHINA:
IMPACTO DE UNA CLASE MEDIA CRECIENTE (EMERGING TRENDS
IN CHINESE HEALTHCARE: THE IMPACT OF A RISING MIDDLE CLASS)
En este informe, los autores estudian el impacto de un fenómeno importante
en la atención de la salud china: la explosión de una enérgica, a la vez que
exigente clase media y su impacto sobre la trayectoria que esta industria
debería seguir en el futuro.
No se sabe mucho acerca de las expectativas de la clase media china en lo
que respecta a sus necesidades en materia de salud, como no sea de manera
anecdótica o a través de fuentes extraoficiales. La opinión de la clase media
está determinada por una variedad de influencias entre las que se incluye la
experiencia vivida, bien sea mediante el contacto personal directo con los
establecimientos sanitarios internacionales en sus viajes al extranjero, o
indirectamente mediante una expansión cada vez mayor del mundo de los
espectáculos con sus numerosos dramas hospitalarios y médicos. Además de
que cada vez es mayor la toma de conciencia a nivel internacional a
consecuencia de una educación superior, las perspectivas del consumidor de
clase media están gobernadas por la realidad de los medios con los que cuenta
la China en la actualidad y las expectativas realistas de la población.
Este artículo se ocupa de esta carencia de datos concretos mediante una
encuesta a gran escala de los consumidores de clase media en tres de las
capitales más importantes de la República China: Beijin, Shanghai y Chengtu.
Con el fin de explorar este tema, la encuesta adoptó un enfoque práctico y
pragmático, es decir, en el trabajo de investigación no se intentó explicar
porqué el usuario se siente de una manera u otra acerca de sus expectativas
con respecto a los cuidados de salud sino que simplemente se proponía trazar
unas líneas generales de lo que la clase media espera de la industria sanitaria
en la República China.
En cierto modo, los resultados no fueron sorprendentes puesto que la
población china tiene las mismas expectativas que los habitantes de cualquier
otro país. A la población china le gustaría tener más intimidad y dignidad en
el cuidado que reciben de los servicios de salud. También desean implicarse
más en las decisiones que se adoptan en lo que respecta a sus cuidados.
Preferirían contar con los cuidados de un médico personal y privado, en lugar
de una serie de caras nuevas que no volverán a ver por segunda vez. Confían
firmemente en los consejos de sus familiares y amigos en cuanto a la elección
de sus prestadores de servicios de salud. Esperan encontrarse con unas
instalaciones limpias y bien cuidadas, un sistema eficaz y personal cortés y
educado.
Por otro lado, las conclusiones no fueron necesariamente las previstas.
Creen firmemente que su hospital o proveedor de servicios debería estar
ubicado en una zona residencial. Según las circunstancias, están dispuestos a
pagar algo más por la asistencia que reciben, aunque no mucho más. Si bien
reconocen que muchos de los aspectos de la
asistencia que les gustaría que mejorasen, tal como mayor respeto por la
intimidad y una actitud más positiva en términos generales, son más propios
de los médicos extranjeros, los usuarios de clase media no demuestran tener
una preferencia muy marcada por los médicos extranjeros y optan más bien
por los profesionales de su país.
En suma, los resultados nos ofrecen una percepción de las expectativas que
Vol. 44 No. 4 | World Hospitals and Health Services | 43

REFERENCE
la clase media china tiene de sus proveedores de asistencia sanitaria y expone
a grandes rasgos los pasos a seguir en el futuro para el sistema de salud de la
República China.
GESTION DE LOS CUIDADOS DE SALUD EN LOS SERVICIOS
HOSPITALARIOS: SEGUIMIENTO DE ALGUNOS DE LOS ASPECTOS
CRUCIALES (HOSPITAL HEALTH CARE UNIT MANAGEMENT :
MONITORING SOME CRITICAL POINTS)
Los estudios estratégicos experimentales sobre la gestión de los cuidados de
salud en los servicios hospitalarios suele estar basada en los costos, algo que
parece ser de suma importancia. Quizás sería más conveniente buscar una
respuesta a algunas de las preguntas más básicas, tal como: el motivo por el
que en la mayoría de los casos se prefiere el ingreso hospitalario; la opinión
de la población en general, así como la de los tenedores de apuestas externos
sobre los servicios de salud; ¿porqué tanto los pacientes como sus familiares
eligen un servicio determinado en contraposición a otro?; ¿cual es el nivel de
aceptación en lo que respecta a las demandas de hospitalización en relación
con la capacidad de camas?; ¿cómo evaluar la evolución del estado de salud?
¿cuales son las consecuencias de esa evolución sobre la carga de trabajo del
personal, muy especialmente su efecto a nivel cotidiano?. Con el fin de dar
respuesta a todas estas preguntas será necesario idear un instrumento de
evaluación.
VIH/SIDA, CONFLICTO Y SEGURIDAD EN AFRICA:
REFORMULACION DE LA RELACION ENTRE ESTOS DOS ASPECTOS
(HIV/AIDS, CONFLICT AND SECURITY IN AFRICA: RETHINKING
RELATIONSHIPS)
El efecto del conflicto sobre la transmisión del VIH y la seguridad regional y
global ha sido objeto de muchos comentarios y debates en los últimos
tiempos. Muchas de las suposiciones de hace tiempo en cuanto a estas
relaciones están siendo objeto de una reformulación. Durante mucho tiempo
se ha pensado que la guerra civil ha contribuido de manera muy considerable
a la propagación de la infección del VIH. Sin embargo, un estudio reciente
está suscitando dudas acerca de esta teoría. Estudios realizados en África
parecen sugerir que el conflicto civil no es necesariamente el culpable de la
transmisión del VIH. De hecho, hay indicios que parecen sugerir que la
recuperación en la posguerra puede ser todavía más peligrosa desde el punto
de vista de la transmisión del VIH. Por otro lado, en el pasado se ha
considerado que los refugiados son vectores altamente infectados de
transmisión del VIH, si bien a la luz de los nuevos resultados esta creencia
también está siendo objeto de nuevas consideraciones. Además, hay gran
preocupación por el peligro que el elevado índice de infección del VIH entre
muchos de los militares del África subsahariana pueda representar para la
seguridad regional. No obstante, los datos no apoyan que el número de
soldados infectados sea tan elevado, ni que el efecto sobre la seguridad
regional sea tan negativo. Lo que sí es seguro es que el VIH/SIDA continúa
siendo un grave peligro para la salud de la población y para el bienestar
económico de esta región. Estos temas son de importancia primordial para la
programación con respecto al VIH, así como para el desarrollo del sector de
la salud en las sociedades en conflicto y en épocas posteriores a los conflictos
y que constituirán un reto muy importante para la comunidad internacional.
Con el fin de analizar la cuestión del VIH, el conflicto y la seguridad del África
subsahariana será necesario someter estos temas a una investigación más
profunda.
REDUCCION DE LAS HOSPITALIZACIONES PEDIATRICAS POR
CAUSA DE LA MALARIA Y OTRAS ENFERMEDADES FEBRILES TRAS
LA PUESTA EN MARCHA DE UN PROGRAMA DE LUCHA
ANTIPALÚDICA BASADO EN LA COMUNIDAD EN LA REGION
RURAL DE RUANDA (REDUCED PAEDIATRIC HOSPITALIZATIONS
FOR MALARIA AND FEBRILE ILLNESS PATTERNS FOLLOWING
IMPLEMENTATION OF COMMUNITY-BASED MALARIA CONTROL
PROGRAMME IN RURAL RWANDA)
Antecedentes: en la actualidad, la comunidad internacional está muy
comprometida con los programas de lucha antipalúdica. Como parte
integrante de este compromiso, Ruanda ha puesto en práctica un nuevo
método a dos niveles, encaminado a luchar contra la malaria mediante la
distribución a gran escala de redes cazainsectos tratadas con insecticida de
acción prolongada y a través del reparto de medicamentos antipalúdicos por
parte de trabajadores de salud de la comunidad. Este estudio tenía por
objetivo calcular las repercusiones de estas medidas sobre las
hospitalizaciones pediátricas por motivos de la malaria, así como los
indicadores de laboratorio sobre la gravedad de la enfermedad.
Métodos: se llevó a cabo un análisis retrospectivo de los archivos hospitalarios
de los casos de malaria basados en la comunidad en el medio rural de Ruanda,
tanto antes como después de poner en marcha las medidas antipalúdicas.
Estas medidas se pusieron en práctica en agosto de 2006 dentro del área
cubierta por el hospital y consistieron en la distribución a gran escala de redes
tratadas con insecticida y el reparto de medicamentos antipalúdicos por parte
de trabajadores de salud de la comunidad. El estudio se realizó en el periodo
comprendido entre diciembre y febrero, temporada de alto nivel de contagio,
tanto antes como después de la puesta en marcha del programa. En este
estudio excepcional se examinaron 551 ingresos pediátricos con el fin de
identificar:
1) casos de malaria confirmados por el laboratorio, determinados mediante
la realización de un examen de la gota gruesa y un frotis,
2) sospecha de malaria, determinada por fiebre y síntomas relacionados
con la malaria y carentes de otros motivos, y
3) todo tipo de ingresos.
A fin de determinar las repercusiones de las medidas para la lucha
antipalúdica en los indicadores clínicos, se analizaron los índices de ingresos
por parasitología periférica y hemoglobina. Además, con miras a determinar
la exactitud de los diagnósticos clínicos, se examinó el índice de ingresos por
casos de malaria confirmados mediante el examen con el microscopio antes y
después de la puesta en marcha del programa. Por último, y para evaluar el
tratamiento global de las enfermedades febriles, se hizo una descripción del
uso de antibióticos.
Resultados: de los 551 ingresos, 268 (48.6%) y 437 (79.3%)
correspondían a los casos confirmados por el laboratorio y a los casos
sospechosos de sufrir paludismo, respectivamente. El número total de
ingresos con sospecha de padecer malaria fue inferior en el periodo siguiente
a la intervención (N = 150) que el de los sospechosos ingresados antes de
ésta (N = 287), si bien se observó un aumento en el total de
hospitalizaciones por otros motivos tras el periodo posterior al programa
antipalúdico. El promedio de ingresos con sospecha de padecer malaria y
confirmados por el laboratorio fue superior antes de ponerse en marcha el
programa (80.4%) que después (48.1%, índice de prevalencia [PR]: 1.67;
95% CI: 1.39 – 2.02; chi cuadrado valor p < 0.0001). Entre los niños
admitidos con malaria confirmada por el laboratorio, el riesgo de alto
parasitismo fue más elevado durante el periodo anterior a las medidas que en
el posterior (PR ajustado por edad: 2.47; 95% CI: 0.84 – 7.24; chi cuadrado
valor p = 0.08). El tratamiento con antibióticos fue frecuente, puesto que al
70.7% de todos los niños con malaria clínica y al 86.4% de los que no la
padecían se les administró el tratamiento antibacteriano.
Conclusiones: con este estudio se demostró que tanto los ingresos por
malaria, como los indicadores de laboratorio de enfermedades clínicas entre
los niños pueden reducirse rápidamente mediante la introducción de
medidas de lucha antipalúdica basadas en la comunidad. Por otro lado, el
estudio pone de relieve el problema de los diagnósticos erróneos y los
tratamientos excesivos para la malaria en regiones endémicas, especialmente
cuando se observa una reducción en el número de casos afectados por esta
enfermedad. Es de suma importancia que, tanto en la situación actual como
conforme cambien las etiologías febriles, con la consiguiente reducción del
número de personas afectadas por la malaria, los diagnósticos sean más
exactos y los tratamientos de las enfermedades febriles sean más adecuados.
44 | World Hospitals and Health Services | Vol. 44 No. 4

REFERENCE
Directory of IHF professional
and industry members
The International Hospital Federation is grafeful to its “D” members (listed below) who
support the world wide activities of the IHF through their membership. The IHF
recommends that you give consideration to their products and services.
AUSTRALIA
Dr Harry McConnell
Director
INTERNATIONAL e-HEALTH ASSOCIATION
(ISHED)
JTA International- GPO BOX 1080
QLD400, Brisbane
AUSTRALIA
Tel: +61 731 144 615;
Fax: +61 732 102 161
Email: harry@ihn.info
Website: www.ehealth2002.org
BARBADOS
Mr Jeremy AN Voss
Chief Architect
TVA CONSULTANTS LTD
Grosvenor House, Harts Gap, Hastings,
Christ Church
BARBADOS
Tel: +246 426 4696;
Fax: +246 429 3014
Email: tvabgi@sunbeach.net
BELGIUM
Ms Brigitte Baten
AGFA GEVAERT NV
Septestraat 27, B-2650 Mortsel
BELGIUM
Tel: +32 3 444 2111;
Fax: +32 3 444 7908
Email: caroline.burm@agfa.com
Website: www.agfa.com
BRAZIL
Dra W Santos/Mr J Fco dos Santos
HOSPITALAR FEIRAS CONGRESSOS E
EMPREENDIMENTOS LTDA
Rua Padre João Manuel, 923 - 6º andar
01411-001 - São Paulo - SP
BRAZIL
Tel: +55 11 3897 6199;
Fax: +55 11 3897 6191
Email: waleskasantos@hospitalar.co.br;
waleskasantos@aol.com;
Website: www.hospitalar.com.br
DENMARK
Mr Stefan Bjork
Senior Adviser
NOVO NORDISK A/S
Novo Alle, 2880 Bagsvaerd
DENMARK
Tel: +45 44 448 888;
Fax: +45 44 490 555
Email: stbj@novonordisk.com
Website: www.novonordisk.com
FINLAND
Mr Sami Aromaa
Director Global Communications
INSTRUMENTARIUM 0YJ
P O Box 900, 31 Datex - Ohmeda
FINLAND
Tel: +358 10 394 11;
Fax: + 358 9 278 7913
Email: anni.toivakainen@datexohmeda.com
Website: www.datex-engstrom.com
FRANCE
Mr Carlo Ramponi
Managing Director
JOINT COMMISSION INTERNATIONAL
13 Chemin du Levant,
Batiment JB SAY - 4th Floor
01210 Ferney Voltaire
FRANCE METROPOLITAINE
Tel: +33 450 42 60 82;
Fax: +33 450 42 48 82
Email:cramponi@jcrinc.com
Website: www.jcrinc.com
INTERNATIONAL ASSOCIATION OF INFANT
FOOD MANUFACTURERS (IFM)
194 Rue de Rivoli
75001 Paris
FRANCE MÉTROPOLITAINE
Website: www.ifm.net
GERMANY
Managing Direktor
Architect and Engineers
FAUST CONSULT GmbH
Biebricher Allee 36, D-65187 Wiesbaden
GERMANY
Tel: +49 611 890 410;
Fax: +49 611 890 4199
Email: faust@faust-consult.de
Website: www.faust-consult.de
Mr Hardy Low
Chief Executive Officer
MCC–MANAGEMENT CENTER OF
COMPETENCE
Scharnhorststrasse 67a, D-52351, Duren
GERMANY
Tel: +49 2421 121 77 11;
Fax: +49 2421 121 77 27
Email: loew@mcc-seminare.de
Website: www.mcc-seminare.de
Herr H Hassenpflug
Director of Communications
SYSMEX EUROPE GmbH
Bornbach 1, 22848 Norderstedt
GERMANY
Email: hassenpflug@sysmex-europe.com
Website: www.sysmex-europe.com
HONG KONG
Mr Andrew Lee
Chief Controller - GCA Region
TUV ASIA PACIFIC MANAGEMENT HOLDING
Unit 601 Tech Centre, 72 Tat Chee Avenue
Kowloon Tong
HONG KONG
(Special Administrative Region: China)
Tel: +852 27885150;
Fax: +852 27845127
Email: andrew.lee@tuvhk.com
Website: http://www.tuev-sued.com
INDIA
Dr Shyama S Nagarajan
Manager
ICRA
4th Floor, Kailash Building
26 Kasturba Gandhi Marg,
110001, New Delhi
INDIA
Tel: +91 11 233 57940;
Fax: +91 11 233 57014
Email: shyama@icraindia.com
Website: www.icraindia.com
IRAN
Mohammad Hossein Adabi, MD
Managing Director
KARAMED
Apt #5, No. 42 Bahar,
Garmsare Garbi
Shiraz Jonobi, Molasadraj,
Tehran 48446
IRAN
Tel/Fax: +9821 8861 5011
Email: mhadabi@hotmail.com/
info@karamed.com
Internet: www.karamed.com
ISRAEL
Dr M Modai
President & Chief Executive Officer
SAREL SUPPLIES & SERVICES FOR
MEDICINE - ISRAEL
Sarel House, Hagavish St., Industrial Zone
42504 South Nethanya
ISRAEL
Tel: +97 298 922 089;
Fax: +97 298 922 147
Email: joshua@sarel.co.il; Website:
www.sarel.co.il
KOREA
Mr Jae Hoon Choi
Chief Executive Officer
EZMEDICOM CO. LTD.
JinSuk Building
1536-26 Seocho-dong, Seocho-gu,
Seoul, 137-073
KOREA
Tel: +82 2 3016 7701;
Fax:+82 2 3616 8802
Email: jhchoi@ezmedicom.com
Internet: www.ezmedicom.com
YUHAN NHS
3F Landmark Building 77-11
Samsung-Dong, Kangnam-Gu
Seoul
KOREA
LEBANON
Dr Faouzi Adaimi
President
FEDERATION DES HOPITAUX ARABES
Autoroute Jounieh, Immeuble Bouza Bashir,
1er Etage, BP 2914, Journieh
LEBANON
Tel: +961 990 0110;
Fax: +961 990 0111
Email: hndl@terra.net.lb
MALAYSIA
VAMED Healthcare Services SDN BHD
Level 18, Menara KUB.com,
Megan Phileo Avenue
Jalan Yap Kwan Seng, 50450 Kuala Lumpur
MALAYSIA
Tel: +60 3 2711 6636;
Fax: +60 3 2711 6639
E-mail: enquiry@vamedhealthcare.com
Website: www.vamedhealthcare.com
NIGERIA
PROVIDENCE VENTURES LIMITED
45 Idumagbo Avenue, P O Box 418
Marina, Lagos
NIGERIA
Vol. 44 No. WORLD 4 | World hospitals Hospitals and and health Health services Services | 13| 45

REFERENCE
PHILIPPINES
Mr Ashok K. Nath
Chairman
OPTIONS INFORMATION COMPANY
# 10 Garcia Villa Street, Lorenzo Village
1223 Makati City
PHILIPPINES
Tel: +632 813 0711;
Fax: +632 819 3752
Email: ashok@optionsinfo.com;
oic@oiceventasia.com
Website: www.oiceventsasia.com
SOUTH AFRICA
Dr Susan Chalmers
Managing Director
WOUND CARE (PTY) LTD
PO Box 2763, 7129 Somerset West
SOUTH AFRICA
Tel: +27 21 852 8655;
Fax: +27 21 852 8656
Email: info@chemspunge.co.za
Website: www.woundcare.co.za
SWEDEN
ANOTO
Emdalavägen 18
22369 Lund
SWEDEN
Tel: +46 46-540 12 00
Fax: +46 46-540 12 02
Internet: www.anoto.com
Senior Vice-President/Chief Medical Officer
CAPIO AB
PO Box 1064, S-405 22 Goteborg
SWEDEN
Tel: +46 31 732 40 00;
Fax: +46 31 732 40 99
Email: monica.angervall@capio.com
Website: www.capio.com
H Josefsson
Partner/Architect
WHITE ARKITEKTER AB
Post Box 2502, S-40317 Goteborg
SWEDEN
Tel: +46 31 608 600;
Fax: +46 31 608 610
Email: hakan.josefsson@white.se
Website: www.white.se
UNITED ARAB EMIRATES
Mr Thumbay Moideen
President
GULF MEDICAL COLLEGE HOSPITAL AND
RESEARCH CENTRE
PO Box 4184, Ajman
UNITED ARAB EMIRATES
Tel: +971 674 31333;
Fax: +971 674 31222
Email: gmchrc@emirates.net.ae
Website: www.gmchospital.com
INDEX CONFERENCES & EXHIBITION EST
Dubai Health Care City Block B, Office No 303
PO Box 13636, Dubai
UNITED ARAB EMIRATES
Tel: +971 4 265 1585; Fax: +971 4 265 1581
Email: index@emirates.net.ae
Website: www.indexexhibitions.com
UNITED KINGDOM
Mr David Selwyn
Secretary
ASSOCIATION OF PRIMARY CARE GROUPS
& TRUSTS (APCGT)
5-8 Brigstock Parade, London Road, Thornton
Heath Surrey CR7 7HW
UK - ENGLAND
Tel: +44 208 665 1138;
Fax: +44 208 665 1118
Email: info@apcgt.org; Website:
www.apcgt.co.uk
Mr Bryan Pearson,
Managing Director
FSG COMMUNICATIONS LTD
Vine House, Fair Green, Cambridge CB5 0JD
UK - ENGLAND
Tel: +44 1638 743 633;
Fax: +44 1638 743 998
Email: bryan@fsg.co.uk; Website:
www.fsg.co.uk
Mr Witney M. King
Managing Director
INTERNATIONAL HOSPITALS GROUP
LIMITED
The Manor House Park Road, Stoke Poges
Bucks SL2 4PG
UK - ENGLAND
Tel: +44 1753 784 777;
Fax: +44 1753 784 784
Email: wmk@igroup.co.uk, info@ihg.co.uk
Website: www.ihg.co.uk
Mr S Robert Wendin
MARSH EUROPE
Tower Place East Tower, London EC3R 5BU
UK - ENGLAND
Tel: + 44 207 357 3556;
Fax: +44 207 929 2705
Email: robert.wendin@marsh.com
Website: www.marsh.com
MÖLNLYCKE HEALTH CARE
Two Omega Drive, Irlam, Manchester M44 5BJ
UK - ENGLAND
Tel: (+44) 0870 6060766;
Fax:(+44) 0870 6081888
http://www.molnlycke.com
The Directors
PRO-BOOK PUBLISHING LTD
13 Church Street
Woodbridge
Suffolk IP12 1DS
UK - ENGLAND
Tel: +44 (0) 1394 44 6005
Fax: +44 (0) 5601 525 315
Email: info@probrook.com
Website: www.pro-brook.com
Mr Paddy Markey
Manager
REGENT MEDICAL LIMITED
Two Omega Drive Irlam, Manchester M44 5BJ
UK - ENGLAND
Tel: +44 161 777 2611;
Fax: +44 161 777 2601
Email: paddy.markey@regentmedical.com
Website: www.regentmedical.com
UNITED STATES OF AMERICA
Dr M N Cowans
AEROMEDICAL GROUP INC
1828 El Camino, Suite 703, Burlingame,
CA 94010
USA
Chris Collom
Director Media Relations
ARAMARK HEALTHCARE
1101 Market Street, 19th Floor,
Philadelphia
PA 19107-2988, USA
Tel: +1 215 238 3593
Email: collum-chris@aramark.com
Website: www.aramarkhealthcare.com
Mr W Davenhall
Health & Human Services Solutions Manager
ESRI
380 New York Street, Redlands, CA 92373
USA
Tel: +1 909 793 2853;
Fax: +1 909 307 3039
Email: bdavenhall@esri.com;
Website: www.esri.com
Patricia A Schneider
Vice President
GLOBAL MED-NET INC
A Goeken Group Company
1751 Diehl Road, Suite 400, Naperville,
IL 60653
USA
Tel: +1 630 717 6700;
Fax: +1 630 717 6066
Email: pas81@aol.com; Website:
www.globalmednet.net
Mr Ahmed Ahsan
President & CEO
HORIZON STAFFING SERVICES
Corporate Headquarters
1169 Main Street, Suite 350, East Hartford
CT 06108, USA
Tel: +1 860 282 6124;
Fax: +1 860 610 0078
Email: ahmed@horizonstaff.com
Website: www.horizonstaff.com
HOSPIRA WORLDWIDE INC.
275 North Field Drive H1-2s
Dept 049u
Lake Forest
IL 60045, U S A
Dr Christos A. Papatheodorou, MPH, FACS
INTERACTIVE HEALTH MANAGEMENT
SOLUTIONS LLS
1200 South Federal Highway, Suite 202,
Boynton Beach
FL 33435
USA
Tel: +1 561 731 5881;
Fax: +1 561 731 5877
The President
MEDICAL SERVICES INTERNATIONAL, INC
20770 Highway, 281 No, Suite 108 # 184,
San Antonio
TX 78258-7500, USA
Tel: +1 210 497 0243;
Fax: +1 210 497 2047
Email: jramseymsi@aol.com
Jeff Fadler
Executive Vice-President & COO
MEDIFAX EDI INC
1283 Murfreesboro Road, Nashville
TN 37217, USA
Tel: +1 615 843 2500 Ext. 2103;
Fax: +1 615 843 2539
Email: jeff.fadler@medifax.com
Website: www.medifax.com
Ms Justin P. Lannan
Marketing
Mediaguide America
3801 Kennett Pike
PO BOX 4413
Greenville, DE 19801
U S A
Tel: +1 302 425 5900;
Fax: + 1 302 425 5911
Email: jlannan@mediguideamerica.com
Website: www.MediGuide.com
PHASE 2 CONSULTING
1136 E. Wilmington Avenue, Suite 200
Salt Lake City, UT 84106
U S A
Tel: +1 801 363 3046
Fax: +1 801 596 2127
Email: lapeterson@phase2consulting.com
Website: www.phase2consulting.com
Mr John R. Schlosser
Senior Director
SPENCER STUART
10900 Wilshire Boulevard Suite 800,
Los Angeles
CA 90024, USA
Tel: +1 310 209 0610;
Fax: +1 310 209 0912
Email: jschlosser@spencerstuart.com
Website: www.spenserstuart.com
46 | World Hospitals and Health Services | Vol. 44 No. 4

OPINION MATTERS
Capacity building in cardiac
surgery in emerging countries:
an overview
V VELEBIT
CARDIOVASCULAR DEPARTMENT, HÔPITAL DE LA TOUR, FRANCE
Abstract
Cardiac surgery in the developed world is advancing rapidly towards extremely expensive and time-consuming
technologies such as robotic surgery, whereas, at the same time, access to life saving treatment by simple cardiac
surgery is denied to many patients in the emerging world. This widening gap of access to technologies in distinct
parts of the world has been eloquently described by one of the foremost US cardiac surgeons, Dr James Cox, in his
presidential address to the American Association of Thoracic Surgery in San Diego in May 2001. Dr Cox
demonstrated the startling figures shown in the table below and pleaded for involvement of surgeons from the
developed world in capacity building in the emerging countries.
Developing cardiac surgery can be achieved in several
ways 2 : either by having medical staff from emerging
countries spend several years learning in centers in
the developed world or else by having fully trained teams
from developed countries go abroad to educate, advise and
dispense treatment to both local staff and local patients.
This second method has the advantage of giving immediate
relief to patients, creating jobs for locals and transmitting
knowledge, and particularly the notion of team-work, to
them. We have adopted this latter system and used it in four
distinct long term projects in four countries and will present
our experience briefly.
Our projects were made in Sarajevo, Bosnia and
Herzegovina between 1998 and 2002, in Skopje Macedonia
2000–2004, in Algiers, Algeria 2002–2004 and in Tbilisi,
Georgia 2002-2007. Bosnia and Macedonia had never had
cardiac surgery on their territories and in Georgia it had
become virtually extinct because of civil strife. Over the ten
years spent on these projects, over 100 one-week team visits
were made and over 1,200 patients were operated in these
countries.
The visits consisted of 5 to 7 working days during which
patients were examined, evaluated, operated and followed
through their post-operative course. Visits were repeated
monthly. The team consisted of 5 to 7 members, comprising
a surgeon, an anesthetist, a cardiologist, a perfusionist
(technician running the heart-lung machine), a scrub nurse,
and nurses and respiratory therapists as needed. Teaching
was mainly at the bedside or practical teaching in the
operating room, intensive care or catheterization laboratory,
on a one to one basis. As soon as training in one specialty
was completed, we reduced our team, allowing locals to take
over. Towards the end of each project, only a surgeon would
be visiting and essentially overseeing and assisting the local
surgeons who would be performing the operations.
In this way three of the four projects were successfully
terminated, success being the independent management of
cardiac cases without foreign involvement. All three centers
are pursuing independent activities 1, 4 and 6 years after our
engagement was terminated. The fourth project (Algiers)
was not a success in as much as the government demand
was to develop coronary surgery in an institution where
valvular surgery was already being performed, but coronary
surgery was not considered a priority by the local surgeons.
There is no doubt that the chances of success are
dependent on the type of institution (public, university or
private) where the project is to be made as well as the
country and the general level of development of medical
infrastructures. The notions of public utility, of interference
with local habits and of susceptibilities in the staff must also
be reckoned on.
One centre/no. inhabitants
United States 120,000
Europe 1,000,000
Asia 16,000,000
Africa 33,000,000
Table 1: Distribution of cardiac surgery centres in the world
(from J Cox 1 )
Vol. 44 No. 4 | World Hospitals and Health Services | 47

OPINION MATTERS
It is also important to assess the freedom of action of the
visiting team. A private institution, with minimal hierarchy
among the staff and great freedom to participate in these
projects, is undoubtedly an advantage. All members of our
teams were volunteers for the travel and for work abroad.
University hospitals are dependent on junior staff and are
essentially oriented towards training this staff, thus they have
less freedom to spend time abroad, unless it is to recruit
patients or experiment new approaches or techniques.
These establishments must also follow institutional rules
and are subject to review committees rendering their
involvement more complex and cumbersome.
There may also be some concern for the safety of patients
in relation to the intermittent nature of the visits and the
progressive take-over by the local staff. We were worried by
these issues and undertook a retrospective review of the
results of our visits at three different stages of our project in
Tbilisi, Georgia between 2002 and 2007 3 . We looked at the
morbidity and mortality of patients at the initial stage, when
the foreign team was doing everything, the middle stage
when the responsibilities were shared and the end stage
when most work was done by local staff, since only a foreign
surgeon was present. We controlled the difficulty of the
cases, in order to ascertain there was no change over these
three periods.
The results of this study show, to our great satisfaction,
that the reduction of the foreign team, did not alter the
initial good results. This is probably due to the efficient
transfer of knowledge, better team-work and more
motivation of the local team when responsibility was given.
The weaning process, after adequate education, can be
achieved efficiently and the local team may pursue its
activity independently.
Conclusion
We are convinced that capacity building in cardiac surgery
in emerging nations may be achieved by regular intermittent
visits by foreign teams with a planned and rational approach,
aimed essentially at education and support of the local staff.
The data we have obtained over the past ten years confirm
this approach as effective, patient friendly and safe for
patients. ❑
References
1.
Cox J L Presidential address: Changing boundaries J Thorac Cardiovasc Surg
2001;122:413-418
2.
Pezzella AT. Progress in International Cardiac Surgery: Emerging Strategies Ann
Thorac Surg 2001;71:407–8
3.
Velebit V et al. The Development of Cardiac Surgery in an Emerging Country. A
completed project Tex Heart Inst J 2008;35(3):301-6
48 | World Hospitals and Health Services | Vol. 44 No. 4