Essential Concepts in Modern Health Services

Health services have the functions to define community health problems, to identify unmet needs and survey the resources to meet them, to establish SMART objectives, and to project administrative actions to accomplish the purpose of proposed action programs. For maximum efficacy, health systems should rely on newer approaches of management as management-by-objectives, risk-management, and performance management with full and equal participation from professionals and consumers. The public should be well informed about their needs and what is expected from them to improve their health. Inefficient use of budget allocated to health services should be prevented by tools like performance management and clinical governance. Data processed to information and intelligence is needed to deal with changing disease patterns and to encourage policies that could manage with the complex feedback system of health. e-health solutions should be instituted to increase effectiveness and improve efficiency and informing human resources and populations. Suitable legislations should be introduced including those that ensure coordination between different sectors. Competent workforce should be given the opportunity to receive lifetime appropriate adequate training. External continuous evaluation using appropriate indicators is vital. Actions should be done both inside and outside the health sector to monitor changes and overcome constraints

Medical Tourism and the Libyan National Health Services

Medical tourism is a term that is used frequently by the media and travel agencies as a catchall phrase to describe a process where people travel to other countries to obtain medical, dental, and/or surgical care [1,2]. Leisure aspects of traveling are usually included on such a medical travel trip [1]. The term is also used to describe a situation where doctors travel to other places to deliver services to endogenous populations [3].Many factors have led to the recent increase in popularity of medical tourism. Among these factors are the absence of a particular service and the high cost of health care in some countries of origin on one side, and the ease and affordability of international travel, and the improvement of technology and standards of care in host countries on the other side. This phenomenon cannot be separated from globalization and tendency for a more liberal world trade. In countries that operate from a public health-care system, it can take a considerable amount of time to get needed medical care. In Britain and Canada, for example, the waiting period for a hip replacement can be a year or more, while in Bangkok or Bangalore, a patient can be in the operating room the morning after getting off a plane [2]. The post-surgery mortality rate in the 15,000 heart operations done every year in Scots Heart Institute and Research Centre in Delhi and Faridabad is only 0.8%, which is less than half of most major hospitals in the United States or Europe [2]. However, the real attraction is price [2]. The cost of surgery in India, Thailand or South Africa can be one-tenth of the price of comparable treatment in the United States or Western Europe [2]. A heart operation as an example costs €32000 in the United States, €16000 in Europe, but less than €3000 in India. A full facelift that would cost $20,000 in the U.S. runs at about$1,250 in South Africa [2]. In addition, clinics in these countries provide single-patient rooms that resemble guestrooms in four-star hotels [2].Interventions aimed at medical tourism include cancer treatment, neurosurgery, organ transplantation, aesthetic treatment, dental treatments, eye surgery, kidney dialysis, « preventive health screening» and hip resurfacing [2]. Other opportunities are constantly being exploited. Examples include different services as aphaeresis tourism in India [4] and climatotherapy in Egypt [5].Medical tourism is a rapidly growing industry in many countries. India is becoming a «global health destination». Encouraged by the government, India is promoting the «high-tech healing» of its private healthcare sector as a tourist attraction [1,2]. More than 100 000 foreigners visited India for medical treatment in the year 2005. India estimates that medical tourism could bring as much as $2.2 billion per year by 2012. Besides India, popular international medical travel destinations include Singapore and Thailand. About 374, 000 visitors came to Singapore purely to seek healthcare in 2005, half of them from the Middle East [2]. South Africa promotes an attractive «medical safari» catchphrase: Come to see African wildlife and get a facelift in the same trip. Other countries include Tunisia which is attracting Italians, British and French besides the so- called traditional visitors from Libya and Algeria [6]. The list of countries currently promoting medical tourism include many others such as Argentina, Bolivia, Brazil, Cuba, Costa Rica, Jamaica, Jordan, Hungary, Latvia, Lithuania, Malaysia and the Philippines [2,3]. Some hospitals in certain countries are gaining the confidence of their customers by obtaining hospital accreditation from international bodies in the United States [2]. Dubai, already known for its festival and other luxury attractions, is planning to open the Dubai Healthcare City by 2010. This is expected to be the largest international medical centre between Europe and Southeast Asia and it is hoped to become an internationally recognized location of choice for quality healthcare and an integrated centre of excellence for clinical and wellness services, medical education and research [2]. An international medical travel conference (IMTC) was held in December 2006 and some web sites such as ArabMedicare.com were established to accompany the needs of this growing market.In spite of the aforementioned rewards, medical tourism is not without risks [3]. Medical tourism can do harm to national health services of the host as well as the country of origin. Besides cultural and language issues, there are risks inherent in traveling as accidents, exposure to different infectious diseases, risks from traveling soon after surgery, impossibility of treating chronic disease after a single consultation, the non familiarity of how a certain specialty applies to other communities, the on-off consultations, the limited possibility for follow up, the absence of record of the consultation [3], and most importantly fraud and abuse.The total amount of money spent by Libyans on both forms of medical tourism is difficult to estimate. It ranges between$100-200 millions per year for treatment abroad, but the accurate figures are not available. The form of medical tourism where doctors rather than patients travel, gained a momentum with the increased role of private practice in health service delivery. There is a real threat from the growing market of medical tourism in the region on the public health oriented national health system in Libya. The two neighboring countries that are mostly visited by Libyans have a lower performance of National Health Service in comparison to Libyan National Health services with an objective assessment as revealed by infant mortality rate, life expectancy at birth, maternal mortality ratio and proportion of low birth weight [7]. Giving the non-popularity of tourism among the Libyan population, traveling in itself is an important event in one’s life. We should not deny that in many cases quality of care, communication skills of health-care givers and patient satisfaction are better in visited countries. Demands are rarely seen to be an important element in the predominantly centralized planning of health services in Libya. Initial visits to these «tourist» private clinics are seen as means to attract other clients. This goes usually through undermining National Health Services in Libya. In many instances there is no justification for that. In addition to our tendency to idealize others, many of the criteria used by patients are very subjective and represent demands rather than needs. Some of these subjective criteria that we met were related to quality of food or clothes offered in hospitals or certain procedures that are seen as novel experience.It is unlikely that this phenomenon of medical tourism will decrease in magnitude. It is also unreasonable to think that a country with a small population will be able to deliver all service demands and needs of the population. For example, the cost-benefit analysis of some interventions as hepatic transplantation would not permit the minimum number of transplantations needed to insure quality unless these interventions are organized at the regional level. Solutions are multifaceted. These would include; improving hospital based services and ambulatory care; increasing responsiveness of national health services to patients’ needs as basic amenities that are highly valued by the consumers such as clean waiting rooms or adequate beds and food in hospitals; partnership with the private sector; delivering quality care with continuous evaluation by different indicators related to structure, process and outcome of healthcare services, and using clinical governance, performance management and SMART objectives and targets to evaluate performance of health establishments. Health insurance schemes can also play an important role in controlling this phenomenon as well as supervising treatment processes and ensuring stewardship

The French Health Care System; What can We Learn?

All public systems look for the best organizational structure to funnel part of their national income into healthcare services. Appropriate policies may differ widely across country settings. Most healthcare systems fall under one of two broad categories, either Bismark or Beveridge systems. There is no simple ideal model for the organization of health services, but most healthcare systems that follow the Beveridge healthcare model are poor performers. The Libyan Health system is a low responsive, inefficient and underperforming system that lacks goals and/or SMART. (Specific, Measurable, Achievable, Realistic, Time specific) objectives. A look at different organization models in the world would reinforce efforts to reorganize and improve the performance of the Libyan National Healthcare services. The French Health Care System (FHCS) ranked first according to the WHO and the European Health Consumer Powerhouse. The FHCS was described to have a technically efficient, generous healthcare system that provides the best overall health care. This makes the FHCS a practical model of organization having many of the essential aspects of a modern national health service. In this review, we describe the main features of the FHCS, current challenges and future trends with particular attention paid to aspects that could be of importance to the Libyan Healthcare System

Libyan National Health Services The Need to Move to Management-by-Objectives

In the last four decades, there has been a substantial horizontal expansion of health services in Libya. This resulted in improvement in morbidity and mortality, in particularly those related to infectious disease. However, measures such as the national performance gap indicator reveal an underperforming health system. In this article, we discuss aspects related to the Libyan health system and its current status including areas of weakness. Overcoming current failures and further improvement are unlikely to occur spontaneously without proper planning. Defining community health problems, identifying unmet needs, surveying resources to meet them, establishing SMART (specific, measurable, achievable, and realistic and time specific) objectives, and projecting administrative action to accomplish the proposed programs, are a must. The health system should rely on newer approaches such as management-by-objectives and risk-management rather than the prevailing crisis-management attitude

Human bone marrow-derived mesenchymal stem cells

Mesenchymal stem cells (MSCs) have elicited a great clinical interest, particularly in the areas of regenerative medicine and induction of tolerance in allogeneic transplantation. Previous reports demonstrated the feasibility of transplanting MSCs, which generates new prospects in cellular therapy. Recently, injection of MSCs induced remission of steroid-resistant acute graft-versus-host disease (GVHD). This review summarizes the knowledge and possible future clinical uses of MSCs

The epidemiology of chronic pain in Libya: a cross-sectional telephone survey.

BACKGROUND: Chronic pain is a public health problem although there is a paucity of prevalence data from countries in the Middle East and North Africa. The aim of this study was to estimate the prevalence of chronic pain and neuropathic pain in a sample of the general adult population in Libya. METHODS: A cross-sectional telephone survey was conducted before the onset of the Libyan Civil War (February 2011) on a sample of self-declared Libyans who had a landline telephone and were at least 18 years of age. Random sampling of household telephone number dialling was undertaken in three major cities and interviews conducted using an Arabic version of the Structured Telephone Interviews Questionnaire on Chronic Pain previously used to collect data in Europe. In addition, an Arabic version of S-LANSS was used. 1212 individuals were interviewed (response rate = 95.1 %, mean age = 37.8 ± 13.9 years, female = 54.6 %). RESULTS: The prevalence of chronic pain ≥ 3 months was 19.6 % (95 % CI 14.6 % to 24.6 %) with a mean ± SD duration of pain of 6 · 5 ± 5 · 7 years and a higher prevalence for women. The prevalence of neuropathic pain in the respondents reporting chronic pain was 19 · 7 % (95 % CI 14 · 6-24 · 7), equivalent to 3 · 9 % (95 % CI 2 · 8 to 5 · 0 %) of the general adult population. Only, 71 (29 · 8 %) of respondents reported that their pain was being adequately controlled. CONCLUSIONS: The prevalence of chronic pain in the general adult population of Libya was approximately 20 % and comparable with Europe and North America. This suggests that chronic pain is a public health problem in Libya. Risk factors are being a woman, advanced age and unemployment. There is a need for improved health policies in Libya to ensure that patients with chronic pain receive effective management

A comparative analysis of the Libyan national essential medicines list and the WHO model list of essential medicines

Aim and Objectives: To examine the concordance of the Libyan Pharmaceutical List of Essential Medicines (LPLEM) with the World Health Organization Model List of Essential Medicines 2009 (WMLEM 2009). Methods: The concordance between generic medicines listed in the WMLEM 2009 (standard reference list) and the LPLEM 2006 (comparator list) was evaluated. Results: The total number of Basic Essential Medicines (BEMs) listed on the WMLEM 2009 was 347. The total number of generic medicines listed on the LPLEM was 584. Although the LPLEM has more listed medicines, only 270 (77.6%) of BEMs from the WMLEM were listed as available. However, 25 of the 77 missing medicines were deemed to have appropriate alternatives. A total of 52 medicines from the WMLEM 2009 were therefore missing from the LPLEM. Discrepancies compared to the WMLEM 2009 were identified in 15 out of 29 therapeutic sections. The highest discrepancy rate from the WMLEM 2009 was in the anti-infective section (35 missing medicines). Missing BEMs were noted in many subclassifications of the anti-infective medicines section, but omissions were particularly prevalent in the antibacterial medicines subsection (11 missing medicines). Antituberculosis medications had the highest discrepancy rate for antibacterial BEMs with one-third of the single medicines recommended by the WHO in the WMLEM 2009 not listed on the LPLEM. Of the 314 additional medicines on the LPLEM, 18 were deemed to be irrational non-essential medicines. Conclusion: The LPLEM does not include several essential medicines recommended by the WHO in the WMLEM 2009. These discrepancies may have serious public health implications for management of some infectious diseases, particularly, tuberculosis and HIV

A cross-sectional study of prevalence and risk factors for stunting among under-fives attending acute malnutrition treatment programmes in north-western Nigeria: Should these programmes be adapted to also manage stunting?

BACKGROUND: Stunting and severe wasting can co-occur in under-fives, predisposing them to increased risks for morbidity and mortality. The Community Management of Acute Malnutrition (CMAM) programme, which provides outpatient malnutrition care for severely wasted children, has been successful at managing severe wasting, but there are limited data on stunting among entrants into these programmes. METHODS: We performed secondary analysis of data collected from attendees of two CMAM centres in north-western Nigeria. Using WHO reference standards, we determined the prevalence of concurrent stunting (height/length-for-age <-2 SD) among severely wasted children (weight-for-height z-scores <-3 SD). We identified individual and household-level risk factors for concurrent stunting using multivariable logistic regression analysis. RESULTS: Our cohort comprised 472 severely wasted children and the majority (82.8%) were stunted. Age groups of 12-23 mo (adjusted OR [AOR]=2.38, 95% CI 1.26 to 4.48) and 24-35 mo (AOR=7.81, 95% CI 1.99 to 30.67), male gender (AOR=2.51, 95% CI 1.43 to 4.39) and attending the rural malnutrition clinic (AOR=3.08, 95% CI 1.64 to 5.79) were associated with a significantly increased probability of stunting. CONCLUSIONS: Stunting prevalence is high among severely wasted children attending CMAM programmes in north-western Nigeria. Policymakers need to adapt these treatment programmes to also cater for stunting, taking into account practical programmatic realities such as available expertise and scarce resource allocation