|
 |
|
|||||||
|
|||||||||
© 2001 American Public Health Association
COMMENTARY |
William Foege is with the Department of International Health, Rollins School of Public Health, Emory University, Atlanta, Ga.
Correspondence: William Foege, MD, MPH, Rollins School of Public Health, Emory University, 1518 Clifton Rd, Atlanta, GA 30322 (e-mail: wfoege{at}sph.emory.edu).
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONA VALUABLE TOOLA SHORT COURSE IN... |
|---|
The largest health disparities in the world are found in maternal and neonatal mortality figures between the industrialized countries and the poorest sections of the poorest countries. Young lives would be saved if the skills and knowledge that have been accumulated by health workers aroundthe world could be readily applied. The problems reside with lack of management resources rather than lack of scientific knowledge. The Healthy Newborn: A Reference Manual for Program Managersis a graduate course in management aimed at providing health to newborns and healthy newborns to communities.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONA VALUABLE TOOLA SHORT COURSE IN... |
|---|
THE RESPONSIBILITY OF caring for a newborn child is awesome, even for those who do such work professionally. Often everything goes as it should. When it does not, however, a lifetime can be determined by actions that take only minutes.
In precisely the places with the fewest resources, we find the largest problems. The transition from intrauterine to extrauterine existence is a period of drama and comparatively high risk. But more than that, it is a period of the largest health disparities in the world, namely those found in maternal and neonatal mortality figures between the industrialized countries and the poorest sections of the poorest countries.
Why such disparities? There is no unalterable reason. The differences come down to whether or not the skills and knowledge that have been accumulated by workers around the world, especially in recent decades, are actually applied. In the final analysis, the problem is usually one of management rather than of science. How can systems be developed, and how can health workers receive the training and support, to make those skills and knowledge available for the care of each child?
Occasionally, a publication turns out to be so useful that with its appearance a tradition is born. Control of Communicable Diseases in Man, a publication of the American Public Health Association, is an example. It filled a pressing need in the early years of the 20th century, and after 84 years and 17 editions it continues to assemble pertinent knowledge of communicable diseases and to update that knowledge periodically, providing public health officers with concise guidelines for diverse situations. I predict that The Healthy Newborn: A Reference Manual for Program Managers will have a similar destiny, proving so useful in salvaging young lives that frequent editions will update the information it contains.
|
A VALUABLE TOOL |
|---|
|
TOPABSTRACTINTRODUCTIONA VALUABLE TOOLA SHORT COURSE IN... |
|---|
Because newborn morbidity and mortality are a management problem, this manual is quite intentionally a management document. It focuses immediately on the needs of managers, who can make a difference for an entire geographic area. It provides a road map for district medical officers and program managers, outlining, in 4 sections, logical steps to improve newborn health.
Part 1 reviews what has been learned about why children die before birth or in the neonatal period. The section makes clear what can go wrong and the urgency that is required to avoid delays in care. The section also reinforces how much is known, emphasizing that the problem is not one of knowledge but of action and that much of the needed action can be accomplished at low cost. Part 1 ends with a useful summary table of the relationships between maternal conditions and perinatal outcomes.
Part 2 provides the tools to fill in the framework developed in Part 3. It includes the usual tools of epidemiology but also offers a simple mnemonic to introduce assessment principles for the health worker. Reminiscent of the UNICEF mnemonic "GOBI" ("growth monitoring, oral rehydration, breastfeeding, and immunization") to keep health workers thinking about priorities, the authors introduce "BABIES" ("birthweight, age at death, and boxes for intervention and evaluation system") as the basis for a health management information system to determine what goes wrong in local settings and what improvements are possible. The BABIES mnemonic provides readers with the useful concept of thinking in 2 dimensions— time of death and weight at birth—to summarize what can go wrong and what can be done to intervene.
Part 3 introduces a management model that a program manager can apply to a specific problem: define the problem, assess performance, design appropriate interventions, and monitor and evaluate the results. Step by step, this section takes the manager through every challenge to be faced, from collecting the right information in the right way to making the right decisions with that information. What is surprising is the completeness of the manual. Program managers can use their energy to apply the information contained in the manual to their districts and to get the pertinent information from their jurisdictions, rather than being forced to seek more information from the literature.
What is noteworthy about the approach is the involvement of the community in every step of the process. This is not a mysterious medical system doing something to the community. It is the community understanding the problem and therefore helping to solve the problem. The result will be stronger newborns in a stronger community. After studying part 3, a program manager who started with the most rudimentary understanding of the problems of newborn mortality can be in a position to comprehend and change the risks for an entire district and to fully engage the community.
Part 4 gets to the reason for all of the preliminaries. It packages the possible interventions, summarizes the delays that lead to adverse outcomes, and provides very specific intervention instructions for every period from pregnancy through birth to emergency newborn care. And finally, for those who want even more detail, it includes an impressive list of references for additional information and a CD-ROM with additional resources.
The manual is not restricted to theory. The reader can be inspired by examples such as the case of Gadchiroli district in Maharastra State, India, where neonatal mortality was documented at 60 per 1000 live-born children. A management package was introduced that included training of mothers, training of traditional birth attendants, resuscitation skills, and detection and management of neonatal problems. The program reduced neonatal mortality by more than 60% within 3 years. The cost of the package was $5.30 per child, and the cost per life saved was calculated to be less than the cost of a measles vaccination program.
|
A SHORT COURSE IN MANAGEMENT |
|---|
|
TOPABSTRACTINTRODUCTIONA VALUABLE TOOLA SHORT COURSE IN... |
|---|
Reviewing the manual took me back to an experience I had 3 decades ago. Having been given the responsibility of running a large public health program, I felt the need to enroll in a management course. It was one of the most useful educational experiences of my life. I realized, however, that although medical school had also been a course in management, that fact had been carefully and cleverly camouflaged by a focus on the science. As medical students, we were given the feeling that we could always go into administration if our clinical skills were inadequate. Management was degraded. Never mentioned was the fact that the entire purpose of medical school was management.
Patients are seen because they are not in an ideal health position. By taking a careful history, performing a physical examination, and ordering appropriate laboratory and radiologic tests, the physician attempts to understand the gap between where the patient is and where he or she should be. (This is in fact a surveillance system or health management information system.) A plan is then developed to move the patient to the selected goal—with monitoring and evaluation carried out via temperature and blood pressure readings, laboratory tests, and so forth—and midcourse corrections are made if progress is less than ideal. Classic management techniques are employed, but somehow they are never called management.
This manual is transparent. The difference between whether a body of knowledge improves health or does not improve health comes down to management. The Healthy Newborn is a graduate course in management aimed at providing health to newborns and healthy newborns to communities. It is a wonderful and practical addition to our global-health tool chest that will be useful to everyone—to the minister of health attempting to develop appropriate health programs for an entire country, to district medical officers focusing on a particular region, to those who train local traditional birth attendants, and to those attempting to educate an entire community. The authors deserve our gratitude.
|
|
|
Footnotes |
|---|
Peer Reviewed
The production and publication of The Healthy Newborn: A Reference Manual for Program Managers was made possible through the CARE–CDC Health Initiative, an initiative funded by the R. W. Woodruff Foundation through CARE, the CDC Foundation, and the World Health Organization Collaborating Center in Reproductive Health in Atlanta. Information about availability, distribution, cost, and contact persons can be found at www.cdc.gov/nccdphp/drh.
Accepted for publication July 18, 2001.
This article has been cited by other articles:
|
|
 |
|
  P M Jeena, R Bobat, G Kindra, P Pillay, S Ramji, H M Coovadia, and K Nielsen The impact of human immunodeficency virus 1 on largyngeal airway obstruction in children Arch. Dis. Child., September 1, 2002; 87(3): 212 - 214. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. L. Riley, R. Jossy, L. Nkinsi, and L. Buhi The CARE-CDC Health Initiative: A Model for Global Participatory Research Am J Public Health, October 1, 2001; 91(10): 1549 - 1552. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | SEARCH RESULT |