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There are 6 messages in this issue.
Topics in this digest:
1. Jobs
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
2. JAPANESE ENCEPHALITIS - INDIA (UTTAR PRADESH
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
3. Buying results? Contracting for health service delivery in developing countries
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
4. Indian Supreme Court ruling makes arrest of doctors harder
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
5. japanese encephalitis in India
From: "elsiss" <ECRANE@samhsa.gov>
6. JAPANESE ENCEPHALITIS - NEPAL: SUSPECTED, REQUEST FOR INFORMATION
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
________________________________________________________________________
________________________________________________________________________
Message: 1
Date: Thu, 18 Aug 2005 20:37:39 -0700 (PDT)
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
Subject: Jobs
Job Title - Project Health Coordinator
Job Location - Sri Lanka (Ampara, in eastern Sri Lanka)
Organisation - Merlin
URL Address -
http://www.reliefweb.int/rw/res.nsf/db900SID/OCHA-6F7KBY?OpenDocument
*****************************
Job Title - Operations Coordinator
Job Location - Nepal (Kathmandu)
Organisation - World Vision
URL Address -
http://www.reliefweb.int/rw/res.nsf/db900SID/OCHA-6FDCPV?OpenDocument
*****************************
Job Title - Site Coordinator
Job Location - Nepal (Pokhara)
Organisation - Médecins du Monde
URL Address -
http://www.reliefweb.int/rw/res.nsf/db900SID/OCHA-6FDD2K?OpenDocument
*****************************
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
jawad@alumni.washington.edu http://www.DrJawad.com
Typhoid Net http://www.typhoid.net
________________________________________________________________________
________________________________________________________________________
Message: 2
Date: Sun, 21 Aug 2005 20:04:53 -0700 (PDT)
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
Subject: JAPANESE ENCEPHALITIS - INDIA (UTTAR PRADESH
JAPANESE ENCEPHALITIS - INDIA (UTTAR PRADESH)(02): SUSPECTED, REQUEST FOR
INFORMATION
***************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Sponsored in part by Elsevier, publisher of
Travel Medicine and Infectious Disease
<http://www.travelmedicine.elsevier.com>
Date: Sat, 20 Aug 2005 08:00:19 -0400 (EDT)
From: ProMED <promed@promedmail.org>
Source: Reuters AlertNet, 20 Aug 2005 [edited]
<http://www.alertnet.org/thenews/newsdesk/DEL270755.htm>
India's encephalitis death toll rises to 110
- ------------------------------------------
The death toll in an encephalitis outbreak in India's northern state of
Uttar Pradesh rose to 110 on Saturday with 20 more deaths reported in the
past 36 hours, a health official said.
Most of the dead were children and more than 170 people were in hospital,
many of them in critical condition.
"Encephalitis is a perennial problem during the rainy season, but the
situation appears to be quite alarming this time," said K.P. Kushwaha, a
health official in Gorakhpur town, worst hit by the outbreak.
Encephalitis, an acute form of brain fever, is caused by a virus spread by
mosquitoes and proliferates in water-logged parts of India during the
monsoon season. Last year, about 50 people died of the disease in Uttar
Pradesh. India has suffered serious flooding during this year's monsoon
season, which runs from June to September.
In Mumbai (also known as Bombay) and adjacent areas, 210 people have died
of diseases such as leptospirosis, gastroenteritis and malaria after the
worst floods in history hit the region 3 weeks ago.
- --
ProMED-mail
<promed@promedmail.org>
[The authorities have not yet identified the etiology of the current
outbreak of encephalitis in Uttar Pradesh State. The term 'Japanese
encephalitis' is used tentatively, only until the true cause is identified.
Obviously, the extraordinarily high death tolls indicate that encephalitis
this monsoon season seems to be unusually severe. The fact that there have
been 64 new deaths in the 3 days since the previous report dated 17 Aug
2005 (see also: 20050818.2421) is alarming indeed. Again, ProMED-mail would
greatly appreciate any further information concerning the so-called
perennial problem referred to in the Reuters report. - Mod.RY]
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
jawad@alumni.washington.edu http://www.DrJawad.com
Typhoid Net http://www.typhoid.net
________________________________________________________________________
________________________________________________________________________
Message: 3
Date: Sat, 20 Aug 2005 04:29:06 -0700 (PDT)
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
Subject: Buying results? Contracting for health service delivery in developing countries
The Lancet 2005; 366:676-681
DOI:10.1016/S0140-6736(05)67140-1
Buying results? Contracting for health service delivery in developing countries
Benjamin Loevinsohn a and April Harding a
Summary
To achieve the health-related Millennium Development Goals, the delivery of
health services will need to improve. Contracting with non-state entities,
including non-governmental organisations (NGOs), has been proposed as a means
for improving health care delivery, and the global experience with such
contracts is reviewed here. The ten investigated examples indicate that
contracting for the delivery of primary care can be very effective and that
improvements can be rapid. These results were achieved in various settings and
services. Many of the anticipated difficulties with contracting were either not
observed in practice or did not compromise contracting's effectiveness. Seven
of the nine cases with sufficient experience (greater than 3 years' elapsed
experience) have been sustained and expanded. Provision of a package of basic
services by contractors costs between roughly US$3 and US$6 per head per year
in low-income countries. Contracting for health service delivery should be
expanded and future efforts must include rigorous evaluations.
Back to top
Background
Substantial improvement in the delivery of health services will be necessary to
achieve the health-related Millennium Development Goals (MDGs). For example,
63% of child deaths in developing countries could be prevented through the full
implementation of a few effective and low-cost interventions.1 Hence,
discovering better ways of delivering these services is critically important.
Although many countries undoubtedly need to allocate more resources to health
services, experience suggests that simply throwing money at the problem of
service delivery is unlikely to have much of an effect.2 Another response to
the challenge of improving service delivery has been to use public funds to
contract with non-state entities, such as non-governmental organisations
(NGOs), universities, individual practitioners, or for-profit companies.
Contracting for health service delivery has some potentially attractive
features,3 including the possibility of: (i) ensuring a greater focus on the
achievement of measurable results, especially if contracts define objectively
verifiable outputs and outcomes; (ii) overcoming the constraints that prevent
governments from effectively using the resources made available to them (often
referred to as absorptive capacity issues); (iii) using the private sector's
greater flexibility and generally better morale to improve services; (iv)
increasing managerial autonomy and decentralising decision-making to managers
on the ground; (v) using competition to increase effectiveness and efficiency;
and (vi) allowing governments to focus more on other roles that they are
uniquely placed to undertake, such as planning, standard setting, financing,
regulation, and the various public health functions.
There are potential difficulties with contracting,410 including concerns that:
(i) contracts will not be feasible at a sufficiently large scale to make a
difference at a country level; (ii) contracts will be more expensive than
government provision of the same services, partly indicating greater
transaction costs; (iii) contracts might increase inequities in health service
delivery; (iv) governments will have limited capacity to manage contracts
effectively; and (v) even if successful, contracting will not be sustainable.
This review was undertaken to: (i) examine the effectiveness of contracting
taking into account the methodological rigour of the evaluations; (ii) examine
the extent to which anticipated difficulties have occurred during
implementation; and, (iii) make recommendations about future efforts in
contracting. We focused on the effectiveness of contracting in terms of health
service delivery outputs or outcomes, costs, and scale. Our review did not
examine in detail the political economy issues associated with the decision to
implement contracting in developing countries.
Back to top
Methodology
There are several different approaches to contracting for health service
delivery, so clarifying definitions will facilitate meaningful dialogue (table
1). As an example, under a management contract (entry 3 in table 1) a
government will contract with a non-state entity or an individual to manage
existing government services in a specified area. Under a service delivery
contract (entry 4 in table 1) the government decides which services the
contractor will provide and where, whereas the contractor will both manage and
supply the production infrastructure, such as personnel, equipment, drugs, etc.
Table 1 shows the different approaches for contracting, which are not
exhaustivethere are clearly hybrids. For example, the line between a
management contract and a service delivery contract blurs when the contractor
uses government health workers, but pays them substantially more than their
civil service salaries. There has been some experience with national
governments signing agreements with local governments (entry 2 in table 1) that
pertain to achieving specific goals.
Click to view table
Table 1 Arrangements of service delivery
Although potentially interesting, this arrangement rarely entails a true
contract that the parties enter voluntarily, and the contractor can be fired
for poor performance (although other rewards and sanctions might be available).
There were few examples that we identified in which instances of this approach
have been assessed. Government or donor grants (where governments or donors
issue requests for proposals and then make grants to the NGOs), to NGOs (entry
5 in table 1), in which the NGOs define where and what services are delivered,
are quite common, particularly in HIV/AIDS prevention and treatment. However,
these are generally not true contracts, partly because the government generally
has little say in what services are delivered, or where, and how they will be
assessed. We review experience with management and service delivery contracts,
rather than contracts between different levels of government or grants to NGOs.
The focus of this review is instances in developing countries of governments or
their agents contracting with identifiable non-state providers to deliver
primary health-care services including nutrition (but excluding hospital care
or ancillary services such as drug procurement and distribution) in which some
explicit form of evaluation was undertaken. To be included in the review, the
project had to have been explicitly investigated by measures of quality of
care, or outputs, such as increase in the amount of services provided. The
evaluations also had to, at a minimum, entail before and after or controlled
designs. Hence, evaluations that described the process of contracting but did
not measure some tangible outputs were excluded. Furthermore, we excluded
studies that only provided after evaluations with no before data or without
contemporaneous controls. In instances in which there were before and after
data for experimental and control groups, the double differences were
calculated. The double difference is the difference between the follow-up and
baseline results in the experimental group minus the difference between
follow-up and baseline results in the control group. Wherever possible,
differences are expressed in percentage points. Although we did not plan to
exclude experiences of contracting with for-profit providers, the search
criteria generated only cases with non-profit providers.
Back to top
Experience of contracting
Table 2 summarises ten studies that met the inclusion criteria.1121 Of these
ten examples, four had before and after controlled designs, three had
controlled designs with a single measure in time, and the remaining three were
before and after assessments. There was only one randomised trial. Three of the
studies relied on routinely obtained data from health information systems of
unknown accuracy, whereas the remainder relied on information from household
and health facility surveys.
Click to view table
Table 2 Summary of contracting experiences
From the studies reviewed, contracting with NGOs to deliver primary health or
nutrition services seems to be very effective and impressive improvements can
be achieved rapidly. Good results have been achieved in various settings and
for many different services ranging from nutrition services in Africa to
primary health care in Guatemala.17,20 All the studies found that contracting
yielded positive results; however, the most rigorously assessed cases tended to
show the largest effect. For example, the service delivery contracts in
Cambodia increased immunisation coverage by 40 percentage points compared with
19 in the control districts (a double difference of 21 percentage points). In
the four studies with controlled before and after designs, the median double
differences ranged from 3·4 to 26·0 percentage points (figure 1, table 3).
These cases combined examined 31 main indicators, and all but one of the double
differences was positive (ie, favoured contracting). Larger double differences
were seen for those factors that are easier to change such as immunisation,
vitamin A, and antenatal care coverage. Smaller changes were recorded for
factors that require important behavioural changes, such as family planning and
institutional delivery.
Click to enlarge image
Figure 1. Double differences (in percentage points) in coverage rates from
studies with controlled before and after methodology
SDC=service delivery contract, MC=management contract, PHC=primary health care.
Click to view table
Table 3 Full immunisation coverage in Cambodiacalculation of double
difference
Six of the ten studies compared contractor performance with government
provision of the same services. All six showed that the contractors were more
effective than the government, on the basis of several measures related to both
quality of care and coverage of services. In the studies reviewed here, the
differences between contractor and government performance tended to be large.
For example, in India an NGO achieved a treatment completion rate that was 14
percentage points higher than the public services in a nearby area, and at a
lower cost.19
Several possible difficulties have been raised about contracting, some of which
can be addressed by the examples reviewed.
First, contracting is able to provide services on a large scale. Half the
examples studied involved populations of millions of beneficiaries, and in one
example contracts now cover a third of rural Bangladeshequating to more than
30 million people.14 Second, contracting can be more cost effective than
directly provided government services. The studies from Pakistan, urban
Bangladesh, Hyderabad, India, and the management contracts in Cambodia,
indicate that non-governmental entities did better even when they had the same
or fewer resources than public institutions. Although the services provided
under the different contracts are not strictly comparable, a basic package of
primary health services in rural areas ranged from US$2·82 per head per year in
Cambodia to US$6·25 per head per year in Guatemala. These amounts represent
less than 1% of the gross national income.
Third, contracting can increase coverage, even in poor, remote areas. With the
resources and the explicit responsibility, many contractors were willing and
able to work in difficult areas that had previously been under served. However,
only the assessment in Cambodia explicitly addressed the issue of whether
contracting could improve equity. It found that when contracts explicitly
included targets for reaching the poor, contractors were able to greatly
improve health services for the most marginalised groups. The results from this
study also showed that contractors were considerably better than the government
at reducing inequities (figure 2).
Click to enlarge image
Figure 2. Change in equity (concentration index) of services in Cambodia
FIC=fully immunised child coverage in children aged 1223 months, VIT A=Vitamin
A coverage in the past 6 months in children aged 659 months, ANC=antenatal
care coverage, HF DEL=proportion of mothers delivering in a health facility,
MBS=use of modern birth spacing, USE=utilisation of publicly financed health
facility by people who were sick in the past month, CC=control/comparison,
MC=management contract, SDC=service delivery contract. A concentration index
summarises the extent to which services are equitably provided across income
groups.22 Technically, it represents twice the area between the perfect
equality line and the actual cumulative distribution in a Lorenz curve and, can
range from −1 to +1. By convention a negative concentration index for
services represents greater equity ie, the distribution is pro-poor. A Lorenz
curve has the cumulative distribution of some benefit/service on the vertical
access and income percentiles on the horizontal axis. This approach is commonly
used in describing the distribution of income, in which the concentration index
is referred to as the Gini coefficient.
Last, contract management is often difficult for governments, but does not seem
to prevent improvements in service delivery. Even in rural and urban Bangladesh
and Guatemala, where observers felt contract management was not done well,
contractors were still successful at implementing large-scale programmes. The
fact that in some situations, such as Senegal, contract management was done
well, suggests that the problem is tractable. The cases with successful
contract management seem to have benefited from either external management
support or having only a few contracts.
In view of its apparent success, the sustainability of contracting is a genuine
concern. Nine of the examples of contracting reviewed had more than 3 years of
elapsed experience to judge whether they were sustained or not. Seven of the
nine contracts have been continued and expanded, often substantially.
(Information about two examples is not available). In Guatemala, Cambodia,
rural Bangladesh, Haiti, Pakistan, and India, the scope of contracting has more
than doubled from what it was initially. However, it might still be too early
to say whether the approach is sustainable in instances in which the donors
introduced the contract.
Back to top
Discussion
Under real world conditions and at a large scale, contracting has achieved
impressive and rapid results. The cases we review suggest but do not prove that
the most successful approaches to contracting maximise the amount of autonomy
given to contractors. This factor is shown clearly in the studies from Bolivia
and Cambodia, especially in Cambodia where service delivery contracts did
better than management contracts. This finding is consistent with the
experience in hospital autonomy in which the ability to manage labour seems to
be critically important to improved performance.23
The successful approaches also focus on outputs and outcomes, rather than
inputs, a finding that accords with those of other studies.24 In practice this
focus on outcomes requires careful attention to monitoring and assessment.
These approaches use contracts of a fairly large size. To obtain economies of
scale, reduce the contract management burden on the government, and facilitate
monitoring and evaluation, each contract should probably include more than
500000 beneficiaries.
There are several methodological limitations with this review: (i) half the
cases were based on reports in the grey literature, some of which had not been
peer reviewed; (ii) the methodologies and outcome measures varied substantially
between studies; (iii) the experimental designs and different outcomes made it
impossible to undertake a formal meta-analysis; (iv) there are likely to be
other examples of contracting that we were unable to identify and these may
have had less positive results (although this type of positive results bias is
usually more profound when only published work is used); and (v) there could
have been a pilot-test bias in the examples considered. Because contracting is
new and different, it could have benefited from greater attention from
managers, donors, and the NGOs, thereby limiting the external validity of the
studies. There is some reason to believe that this problem is not very serious
because many of the contracting examples were done on a very large scale and
provided services to many millions of beneficiaries. The history in the USA and
Australia of contracting for social service delivery suggests that the initial
experiences were problematic and that results improved as governments and
contractors ironed out the difficulties they encountered.25,26
We should also keep in mind that all the cases discussed here focused on
primary care and nutrition services (although two included first level hospital
care as well)services for which outputs are fairly easy to measure. Other
health services, especially specialist inpatient care, present larger
measurement challenges. Furthermore, the providers in these cases were
non-profit organisations. Although contracting with for-profit entities,
especially self-employed doctors, is common in developed and middle-income
health systems (panel)there is little experience in low-income countries with
for-profit providers being given contracts for primary health care.
Panel: Contractor versus government performance in middle-income countries
There are only a few examples of initiating contracting for primary health-care
services in developed countries. Most countries that contract have always done
so. Nevertheless, a few opportunities have arisen to assess the effect of
initiating contracting. Several central European countries have initiated
contracting for packages of primary health-care services. Where contracted
services have been compared with those that continued to be provided by
salaried doctorsresults have generally been favourable. In Croatia, evidence
of higher productivity was noted in contracted practices, including indicators
of patient accessibility.27 In Estonia, where salaried doctors converted to a
contracted status, a before and after analysis showed allocated efficiency
indicators improved; technical efficiency indicators, such as annual number of
visits per doctor and number of visits per inhabitant, improved; and,
immunisation rates rose from 74% to 88%.28
With the methodological concerns about the cases studied, there is still a need
for future contracting efforts to include rigorous evaluations. However, the
current weight of evidence suggests that contracting with non-governmental
entities will provide better results than government provision of the same
services. Contracting should no longer be considered an untested intervention
or a so-called leap of faith.
We realise that our findings will be controversial. Contracting with non-state
providers is often seen as arising out of an ideological desire to privatise
publicly financed health services and ultimately to limit or end governments'
involvement in health care.29,30 However, the discussions held during the
preparation of this review indicated that the impetus for all the contracting
initiatives studied was the inadequate quality and coverage of government
services, especially for poor people. For example, the case from Pakistan arose
because a district governor and his advisers became frustrated with the poor
quality of existing government provision of primary health care. Their approach
involved no reduction in health care expenditures.
Far from limiting government involvement in health care, contracting may be one
way of keeping publicly financed health care relevant. Governments in
developing countries are currently responsible for only a modest role in
providing curative services, even for the poor. For example, in south Asia, 80%
of children in the lowest income quintile who are brought to care for acute
respiratory tract infections use a private provider.2
Although some argue that long-term government provision of services is
essential, contracted provision is a well established model for delivering
primary health-care services. In most of continental Europe, for example,
social health insurance funds contract with independent providers. In Canada,
the UK, and New Zealand, tax-based funding bodies similarly contract with
independent providers (or groups) for provision of virtually all primary
health-care services. Even in Scandinavia, where the government role in service
provision is the greatest among Organisation for Economic Co-operation and
Development (OECD) countries, private providers deliver a substantial amount of
primary care. In Norway in 2001, 66% of primary care services were provided by
private, contracted doctors, whereas 19% were delivered by salaried doctors.31
Back to top
Recommendations
On the basis of the success thus far, contracting frequently merits
consideration in developing countries that are seeking to rapidly improve
service delivery and achieve the MDGs. There is enough evidence supporting
contracting to have it, at least, tried on a larger scale. Future efforts at
contracting should continue to include rigorous evaluations to better determine
its effectiveness, obtain robust estimates of the effect size, and test it
under various conditions. Such operational research should also address
remaining issues such as the effects of contracting on equity, the usefulness
of performance-based bonuses, its cost-effectiveness compared with grants to
NGOs, and different approaches to establishing the price of contracts.
Ultimately, any debate about the effectiveness of contracting must be settled
by systematically obtained evidence.
Back to top
Search strategy and selection criteria
We did a computerised search of the published work using Electronic Collections
On-Line (ECO), Periodical Abstracts, EconLit, WorldCat, Public Affairs
Information Service (PAIS), and PubMed. The electronic search was supplemented
by a manual review of journals that often publish articles related to health
systems in developing countries (Health Policy and Planning and Social Science
and Medicine). To find as many examples as possible of contracting, experts
from six development institutions were contacted and asked about examples of
contracting of which they were aware. Previous reviews of contracting in
developing countries49 were also examined. Once cases were identified,
structured interviews were conducted with people who had intimate knowledge of
the particular experience in nine out of the ten cases included in the review.
Back to top
Contributors
B Loevinsohn conceived the idea of the paper, did much of the research, and
helped write the article. A Harding co-authored the report.
Conflict of interest statement
B Loevinsohn was instrumental in setting up and funding the Cambodia and
Bangladesh Urban PHC contracting initiatives. A Harding declares no conflict of
interest. No external financing was received for this study.
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Affiliations
a World Bank, 1818 H Street NW, Mailstop MC11-1106, Washington DC, USA
Correspondence to: Dr Benjamin Loevinsohn
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
jawad@alumni.washington.edu http://www.DrJawad.com
Typhoid Net http://www.typhoid.net
________________________________________________________________________
________________________________________________________________________
Message: 4
Date: Thu, 18 Aug 2005 20:28:20 -0700 (PDT)
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
Subject: Indian Supreme Court ruling makes arrest of doctors harder
BMJ 2005;331:422 (20 August), doi:10.1136/bmj.331.7514.422-f
Indian Supreme Court ruling makes arrest of doctors harder
New Delhi Ganapati Mudur
http://bmj.bmjjournals.com/cgi/content/full/331/7514/422-f
The Indian Supreme Court has ruled that doctors may be criminally prosecuted
only for gross negligence or a high degree of negligence and that "a simple
lack of care, an error of judgment, or an accident is not proof of negligence."
Indian doctors and some consumers groups have hailed the judgment, which will
make the arrest of doctors for medical negligence harder but leaves intact the
existing provisions for patients to claim compensation under consumer laws.
However, a representative of the Peoples Health Movement cautioned that the
judgment needed to be followed up by action by medical associations to ensure
that doctors are available to give independent opinion in negligence cases.
In its ruling last week the court said criminal prosecution of a doctor could
take place only if "the accused did something or failed to do something which
in the given circumstances no medical professional would have done or failed to
do." It said a doctor could not be held liable for negligence merely because a
better alternative or course of treatment was available.
The judgment was in response to an appeal by Jacob Mathew, who had been
criminally prosecuted for the death of a patient 10 years ago at the Christian
Medical College in Ludhiana, Punjab.
Dr Mathew had unknowingly attached an empty oxygen cylinder to the patients
breathing apparatus. The court ruled that although Dr Mathew could not be
accused of criminal negligence, the hospital "may or may not be liable under
civil law."
"No doctor takes up a case to harm a patient," said Krishan Aggarwal, a
cardiologist and president of the Delhi Medical Association. "Doctors were
being arrested because of misinterpretation of the law. Medical negligence laws
are now equivalent to what they are in the US or the UK."
Consumers representatives have said that the ruling could improve relations
between patients and medical professionals. "Doctors have been criminally
prosecuted for frivolous reasons. Many doctors now look at every patient as a
potential litigant," said Bejon Misra, chairman of the Consumer Coordination
Council, a coalition of 55 consumers groups.
Spelling out guidelines on the criminal prosecution of doctors, the Supreme
Court said that before arresting a doctor accused of negligence investigating
officers would need to get an independent opinion from a government doctor.
"Ive never been in favour of the arrest of doctors, but medical associations
should follow this by appropriate house cleaningperhaps by empanelling doctors
who would offer honest opinions in cases of medical negligence," said
Bappukunju Ekbal, a neurosurgeon and convenor of the Peoples Health Movement
in India.
Consumer organisations estimate that several thousands of cases of medical
negligence are pending in Indias consumer courts. Doctors concede that
patients or investigators find it difficult to get an independent opinion.
"There is a fear of being branded as traitors," said Sanjay Nagral, a member of
a panel of doctors who have offered to testify in negligence cases.
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
jawad@alumni.washington.edu http://www.DrJawad.com
Typhoid Net http://www.typhoid.net
________________________________________________________________________
________________________________________________________________________
Message: 5
Date: Mon, 22 Aug 2005 16:20:20 -0000
From: "elsiss" <ECRANE@samhsa.gov>
Subject: japanese encephalitis in India
Hi,
I can't remember seeing a recent post on this, if you have already,
please disregard.
http://www.alertnet.org/thenews/newsdesk/SP304814.htm
I seem to remember seeing another article about Japanese encephalitis,
saying it was the first time it had reached this far north in India;
if I can find it, I will forward it.
Thank you for providing this terrific service!
-Elizabeth Crane
________________________________________________________________________
________________________________________________________________________
Message: 6
Date: Mon, 22 Aug 2005 19:25:00 -0700 (PDT)
From: Dr Rana Jawad Asghar <jawad@alumni.washington.edu>
Subject: JAPANESE ENCEPHALITIS - NEPAL: SUSPECTED, REQUEST FOR INFORMATION
JAPANESE ENCEPHALITIS - NEPAL: SUSPECTED, REQUEST FOR INFORMATION
*************************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>
Sponsored in part by Elsevier, publisher of
International Journal of Antimicrobial Agents
<http://intl.elsevierhealth.com/journals/ijaa>
Date: Sun, 21 Aug 2005 05:46:59 -0400 (EDT)
From: ProMED <promed@promedmail.org>
Source:Radio Australia - News, 21 Aug 2005 [edited]
<http://www.abc.net.au/ra/news/stories/s1442632.htm>
An outbreak of encephalitis in southwest Nepal has claimed at least 20
lives in the past week with more than 60 new cases reported at the weekend.
The government has now rushed medicines and special teams to southwest
Nepal to deal with the outbreak.
The virus is normally carried by mosquitoes, which flourish as annual
monsoon rains sweep the area in August-September.
An outbreak of the disease across the border in northern India [Uttar
Pradesh] has killed at least 99 children, with another 140 undergoing
treatment.
- --
ProMED-mail
<promed@promedmail.org>
[More information on this outbreak including laboratory
results/confirmation would be appreciated. - Mod.MPP]
Rana Jawad Asghar MD. MPH.
Coordinator South Asian Public Health Forum
jawad@alumni.washington.edu http://www.DrJawad.com
Typhoid Net http://www.typhoid.net
________________________________________________________________________
________________________________________________________________________
Check our new website at
http://www.saphf.org
Also please dont forget to tell your friends and colleagues about South Asian Public Health Forum. Thanks!
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