Academic journal article Bulletin of the World Health Organization

Epidemiology's Contribution to Health Service Management and Planning in Developing Countries: A Missing Link

Academic journal article Bulletin of the World Health Organization

Epidemiology's Contribution to Health Service Management and Planning in Developing Countries: A Missing Link

Article excerpt

Two hypotheses are examined in the light of experience and the literature: (1) health service planning requires little epidemiological information, and (2) health services rarely get useful answers to relevant epidemiological questions.

In the first hypothesis, the theoretical robustness of the concept of a minimum package of activities common to all facilities belonging to the same level of the system and the extent to which it is unaffected by variations in the frequencies of most diseases are examined. Semi-quantitative analyses and analysis of routine entries and participation suffice to adapt this package to the local context. Some of the methods which give a fundamental role to epidemiological information are criticized. With regard to the second hypothesis, the pertinent contributions epidemiology may make to health service organization are reviewed. These include identification of diseases that justify special activities (health maps and interepidemic surveillance), determination of the activities that should be added to the health centres, the political usefulness of rare impact assessments, and the relevant demographic elements. Finally an epidemiological agenda is proposed for specialized centres, districts, universities, and the central decision-making level of health ministries in developing countries.

Introduction

The problem

While health service officials in developing countries have more often to deal with polyvalent services(a) than with specialized programmes, the many epidemiological publications that are concerned with the latter contrast with the scarcity of pertinent information for the former. This article discusses this statement and shows how epidemiology might be made more useful.

The conventional approach: a link between descriptive epidemiology and health planning.

"Epidemiology is concerned with the patterns of disease occurrence in human populations and of the factors that influence these factors" [1]. It may be subdivided into descriptive, causal (or analytic), and experimental epidemiology [2]. Descriptive epidemiology studies the geographic, temporal, and social variations in the frequency of morbidity. Causal epidemiology tries to assemble the arguments that reveal the existence of a cause-and-effect relationship with a disease [3]. As similarities in the distributions of the supposed cause and effect are one of these arguments (indeed, Feachem [4] calls them "micro-epidemiology"), the boundary between these two fields is fuzzy. Experimental epidemiology, including therapeutic trials and quasi-experimental designs, induces changes in the environment and studies their consequences. The goal of decision analysis, which is sometimes considered an integral part of epidemiology, is to improve clinical decisions. It studies parameters such as specificity, sensitivity, and the predictive value of signs, symptoms, and test results.

Health planning is the art of projecting health service developments in the future by specifying the kinds and amounts of resources, as well as the ways they will be mobilized and distributed. A planning approach which may be considered a classic, because of its age and the number of schools that defend it [5-8], links descriptive epidemiology mechanically to the organization of health services. This approach postulates the following.

(1) To define a health activity one must identify the priority problems (those that are frequent and serious), using the indicators of descriptive epidemiology. Coefficients (frequency, lethality, and technical and operational vulnerability rankings) are combined by an algorithm, after which the index is ranked. This technique is derived from the one developed by CENDES (Center Development Studies, Central University of Venezuela, Caracas) in the early sixties [9] and perfected later by:

-- the Institute of Medicine's method of classifying the diseases by frequency and duration of each stage for different age classes [10],

-- the years-of-potential-life-lost (YPLL) approach [4, 11, 12], emphasizing premature death, for which various methods exist (one sums up the years lost between the age of each death due to a specific cause and a cut-off point such as life expectancy, another considers only those years lost between the ages of 20 and 65 so as to concentrate on the years of potential economic activity);

-- the so-called iterative-measurement-loop method [13], which gives decision-making a theoretical framework based on disease frequency. …

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