DEPARTEMENT VOLKSGEZONDHEID

 
INHOUD

1. Inleiding
2. Focus on
PROJECTS
Publications in international peer-reviewed journals
Other publications and abstracts

1. Inleiding

Het Departement Volksgezondheid stelt zich als opdracht bij te dragen tot de wereldwijde ontwikkeling van efficiënte, wetenschappelijk gefundeerde gezondheidszorgsystemen, gebaseerd op principes van gelijkheid, kwaliteit, toegankelijkheid en duurzaamheid. Met dat doel voert het Departement een geïntegreerde strategie waarin onderwijs, onderzoek en technische bijstand op elkaar inspelen (zie vorige jaarverslagen). De drie Eenheden Voeding en Kindergezondheid, Volksgezondheid, Epidemiologie en Ziektebestrijding vertegenwoordigen elk een specifieke expertise, die zich vooral uit in het onderwijs. Het onderzoek loopt eerder via taakgerichte werkgroepen met inbreng van een of meerdere eenheden, en mogelijk van andere departementen in en buiten het ITG. De onderzoeksprioriteiten zijn vooral gebaseerd op de relevantie voor de gezondheidszorgsystemen in de ontwikkelingslanden, de doelstellingen en waarden vervat in onze opdrachtverklaring, en de toegevoegde waarde of innovatie in de internationale gezondheidszorg.

Oriente, Ecuador: Discussion between a doctor of the health centre and a scientific research team.

De wetenschappelijk audit in 2001 toonde de hoge relevantie en kwaliteit van onze onderwijsactiviteiten aan maar zal ons niet tot zelfgenoegzaamheid verleiden. Ons onderwijs is niet los te zien van het onderzoek, capaciteitsversterking en internationale beleidsvorming maar blijft, zeker in tijdsbesteding, onze belangrijkste opdracht. Hiervoor verwijzen we echter naar het hoofdstuk Onderwijs. Ook lokale en institutionele capaciteitsversterking is een wezenlijk onderdeel van vrijwel al onze projecten, die we steeds in nauwe samenwerking met lokale instellingen en organisaties uitvoeren. Over dit perspectief leest men meer in het hoofdstuk Ontwikkelingssamenwerking.
Het onderzoek van het Departement werd globaal als goed geëvalueerd, maar de Wetenschappelijke Raad van Advies formuleerde waardevolle aanbevelingen om de coherentie, focus en internationale uitstraling te versterken. Het voorbije jaar spitsten we onze aandacht dan ook verder toe op vier specifieke, deels overlappende domeinen: toegankelijkheid, kwaliteit, ziektebestrijding en gezondheidsbeleid. Het is echter duidelijk dat vrijwel alle projecten en activiteiten van het departement een beleidsgericht doel dienen, en in zekere mate ook steeds de andere elementen omvatten. Een grote uitdaging voor de volgende jaren is onze onderzoeksmatrix verder te versterken zodat lokale, nationale en internationale activiteiten naadloos in elkaar overvloeien en elkaar wederzijds versterken. Onze invloed op het internationale gezondheidsbeleid zal alleszins diep geworteld blijven in de werkelijkheid van het terrein en de ware noden van de bevolkingen.

Surveying data collected for the Unmet Obstetric Need study in Matlab, Bangladesh.


Toegankelijkheid
Gebrekkige toegankelijkheid is wellicht het meest fundamentele probleem van de gezondheidszorg in ontwikkelingslanden. De oorzaken zijn meervoudig en doorgaans gecombineerd: de diensten zijn te ver af of fysiek moeilijk bereikbaar; voor velen zijn ze niet betaalbaar vanwege de extreme armoede; sociale en culturele factoren kunnen de aantrekkingskracht beperken; vaak is het beschikbare aanbod dermate pover dat mensen andere kanalen verkiezen.
In 2002 spitste het departementele onderzoek op dit gebied zich vooral toe op de studie van de financiële toegankelijkheid van gezondheidsdiensten in de eerste en tweede lijn. De hoofdmoot bestond uit actieonderzoek van mutualistische financieringssystemen in sub-Saharaans Afrika (o.a. Guinee-Conakry, Mali, D.R. Congo, Oeganda, Senegal). Enerzijds ging dit werk na onder welke omstandigheden mutualistische financieringssystemen, gebaseerd op verzekering en solidariteit, harmonieus ontwikkeld kunnen worden en met welke weerstanden dergelijke processen kampen. Anderzijds ontwikkelen we in dit onderzoek een groeiend netwerk met andere onderzoekers en instellingen. In België gaven we samen met verschillende universiteiten de aanzet tot een formeel “Belgisch Platform Toegankelijkheid tot Gezondheidszorg”. Een breed internationaal netwerk maakt het mogelijk onderzoekshypothesen over mutualistische systemen te formuleren, te verfijnen en op het terrein te testen.

International IMMPACT Team on the occasion of the inauguration of the IMMPACT project in Burkina Faso.

Met een project over “Health Equity Funds” startten we het voorbije jaar een tweede belangrijke onderzoekslijn over financiële toegankelijkheid. Dergelijke fondsen financieren de gezondheidszorg voor de allerarmsten, vergelijkbaar met de sociale vangnetten in geïndustrialiseerde landen. Het Departement ondersteunt de conceptualisering en de opvolging van deze strategie in een veelbelovend experiment van de regionale gezondheidsdiensten en Artsen Zonder Grenzen in Cambodja. Samen met een aantal partners gaan we na of dergelijke initiatieven ook elders perspectieven hebben, onder meer in Afrika.

Kwaliteit en Human Resources

Advertisement for Mutual Health Organisations – Bobo-Dioulasso,Burkina Faso.

Gezondheidszorg moet niet alleen beschikbaar en toegankelijk zijn, maar ook van goede kwaliteit. Hiervoor zijn technische, klinische, bestuurlijke en operationele standaarden vereist, maar ook - en misschien vooral - goed opgeleid en gemotiveerd personeel. Te weinig en ongelijk verdeeld personeel, ontoereikende opleiding en ondersteuning, lage salarissen en povere motivatie spelen een cruciale rol in de vaak ondermaatse manier waarop zorgsystemen aan de behoeften van de bevolking beantwoorden.

Ecuador: Meeting between the mayor of an Indian community and those in charge of the Macas district health.

Kwaliteitsmanagement is, zeker onder dergelijke omstandigheden, niet gemakkelijk door te voeren in de gezondheidssector. Gezamenlijk onderzoek naar de weerslag van de organisatie-cultuur op het kwaliteitsbeleid in Niger, Zimbabwe, Guinee en Marokko bracht een aantal kritische problemen en factoren aan het licht. Een “professionele” en flexibele aanpak lijkt betere resultaten op te leveren om de efficiëntie en aanvaarding te verbeteren, dan een “bureaucratische” aanpak met gestandaardiseerde procedures.

Advertisement for condoms on the road Ouagadougou – Bobo-Dioulasso, Burkina Faso.

Een andere onderzoekslijn probeerde de omstandigheden te achterhalen waaronder (aangepaste) huisartsgeneeskunde, met nadruk op de professionele kwaliteit van de zorgverstrekking, een nieuwe impuls kan geven aan gezondheidszorgconcepten in ontwikkelingslanden. In 2002 voerden we studies uit in Cuba, Mali, Zuid-Afrika en Thailand.
We onderzoeken de kwaliteit van de zorgverstrekking ook in specifieke doelgroepen. Een onderzoeksproject over de “Preventie van moeder-kindtransmissie van HIV en ziekenhuiszorg voor HIV-geïnfecteerde kinderen” bestudeert de operationele efficiëntie van kortdurende anti-retrovirale therapie in Zuid-Afrika, Tanzania en Mozambique, en de implicaties voor het personeel. Het onderzoek naar “Near-Miss Audits” bestudeert de aanpak en afhandeling van ernstige gynaecologische complicaties via vrouwen die dergelijke problemen overleefden, en ontwikkelt een methode voor de identificatie van knelpunten en mogelijke verbeteringen in de prenatale zorg.
Capaciteitsopbouw op alle niveaus van de gezondheidssystemen is een alsmaar toenemende noodzaak, nog verergerd door de -AIDS--epidemie en in zekere mate zelfs door de internationale antwoorden op deze crisis. In 2002 startte het Departement een literatuur- en terreinonderzoek (“Capaciteitsversterking en -nieuwe uitdagingen in de volksgezondheid”) naar de verschillende strategieën voor management en capaciteitsopbouw in een aantal -Afrikaanse landen.

Bolivian women preparing the village fête.


Integratie en ziektebestrijding

Dit onderzoek spitst zich toe op tuberculose, TB-HIV co-infectie, “vergeten ziekten” en interventies met micronutriënten, en de versterking van partnerinstellingen in het Zuiden.

Het Departement werkt met vernieuwde energie aan onderzoek naar de epidemiologie en bestrijding van tuberculose. In Cochabamba (Bolivia) rondden we een studie af over de rol van de zelfstandige apothekers bij tuberculosebehandeling. We werken aan een literatuurstudie naar de frequentie van re-infectie versus herval bij recidieven, in het bijzonder bij HIV-seropositieve personen. We legden de basis voor een ambitieus netwerkproject rond kwaliteitsverzekering in de tuberculosezorg op klinisch, diagnostisch en organisatorisch vlak, in samenwerking met partners in Peru, Bolivia, Cuba en Engeland. Met de Universiteit van Kaapstad en Artsen zonder Grenzen startten we onderzoek naar de geïntegreerde bestrijding en behandeling van AIDS en TB in Zuid-Afrika. In Bolivia ondersteunden we de uitbouw van een laboratoriumnetwerk voor HIV-surveillance.

TB ward in Sotnikum hospital, Cambodia.

Zowel de audits van 2001 als een al lang bestaande verzuchting op het ITG leidden in 2002 tot een grondige analyse van de onderzoeksprioriteiten voor slaapziekte en leishmaniasis. Het Departement zal zijn operationeel onderzoek naar de bestrijding van deze ziekten versterken binnen de interdepartementale werkgroep “Neglected Diseases” (zie Focus on en hoofdstuk Parasitologie). We begonnen dit jaar al met een retrospectief onderzoek van urbane slaapziekte en een case-controlestudie van risicofactoren in Kinshasa (D.R. Congo). In samenwerking met de Wereldgezondheidsorganisatie startten we een vergelijkende studie van kosten en effecten van verschillende bestrijdingsstrategieën. We rondden een onderzoeksproject over leishmaniasis in Nepal af, in het bijzonder de validatie en vergelijking van bestaande en nieuwe diagnostische testen. Het vervolgonderzoek op recente epidemies van virale hemorragische koortsen (Marburgvirus in Watsa, D.R. Congo en Ebolavirus in Masindi, Oeganda) concentreerde zich op serologische en klinische evoluties van diegenen die het overleefden.

Water transport, rural Thailand.


In ons nutritionele onderzoek sloten we gecontroleerde klinische studies af over micronutriënten in Cochabamba, Bolivia (in samenwerking met de Universiteit van San Simon) en in Lima, Peru (met de Universiteit Cayetano Heredia). In Tanzania vergeleken we de impact van geoptimaliseerde bijvoeding en gewone voeding op de bio-beschikbaarheid van ijzer en zink. We bestuderen ook de invloed van de voedingsstatus van de zwangere vrouw op de latere ontwikkeling van het kind.

De departementele en institutionele focus op duurzame, geïntegreerde ziektebestrijding culmineerde dit jaar ongetwijfeld in het Internationaal Colloquium “Integratie van Ziektebestrijding” dat in november in Antwerpen plaatsvond (zie Focus on). Hiermee actualiseerde het ITG het debat over integratie in een internationale context van “neo-verticalisme”.

Transport of suger cane, Cambodia.


Gezondheidsbeleid

Zoals aanbevolen door de Wetenschappelijke Raad van Advies zullen we de komende jaren, naast het intensieve en vruchtbare werk op lokale en nationale niveaus, onze invloed ook meer op het internationale domein laten gelden. Het ITG propageert de uitbouw van toegankelijke, efficiënte zorgsystemen als universeel recht én als basis voor duurzame ziektebestrijding. In de huidige internationale context van projectmatige en economisch geïnspireerde ziektebestrijding willen we samen met onze partners onze stem krachtig laten horen. Onze internationale congressen “Health Care for All” (2001) en “Integration and Disease Control” (2002) maakten alvast duidelijk dat vele gezondheidswerkers, wetenschappers en overheden in ontwikkelingslanden dit standpunt delen, maar vaak niet gehoord worden in het Noorden. Samen zullen we trachten de vele nieuwe “globale initiatieven” in de goede richting bij te sturen om tot een versterking van de basisgezondheidszorg te leiden. Op verzoek van het Belgische Ministerie van Ontwikkelingssamenwerking begonnen we onder meer aan een kritische studie over de recente proliferatie van internationale “public-private partnerships” en de besluitvorming die er mee gepaard gaat.

De onderzoekslijn gezondheidsbeleid richt zich bovendien op een aantal specifieke thema’s en doelgroepen. Het onderzoek naar “Safe Motherhood” zoekt naar doeltreffende strategieën om moedersterfte en ernstige obstetrische morbiditeit terug te dringen en onderzoeksresultaten terug te koppelen naar beleidsvorming. We bestuderen het groeiende probleem van de ‘nutritionele transitie’ in ontwikkelingslanden waar veranderende eetgewoonten tot veranderende ziektepatronen leiden. We zoeken naar nieuwe beleidsopties voor het volgen en verbeteren van de ontwikkeling van jonge kinderen, daarbij voortbouwend op ons succesvolle symposium “Growth and development in under-fives” van 2001 (zie jaarverslag 2001).

Verschillende projecten gaan de impact na van veranderende socio-economische omstandigheden op de gezondheidssystemen. In Cambodja en China doen we onderzoek naar het hospitaalbeleid bij de overgang van een -centraal gestuurde naar een markteconomie. Vergelijkbaar onderzoek naar de invloed van economische liberalisering op gezondheidssystemen in Latijns-Amerika en, in tegenovergestelde richting, naar verbeterde planning en management in het uitgesproken openbare gezondheidsbeleid in Cuba, is al langer aan de gang. In landen als Jordanië trachten we de contractuele relatie van de gezondheidszorg met de overheid te bestuderen en te verbeteren.
Tenslotte gebruikt ook het Belgische Ministerie van Sociale Zaken onze internationale expertise om in eigen land mee te werken aan de totstandkoming van lokaal gecoördineerde gezondheidszorgsystemen. Hiermee is onze cirkel rond; de principes en waarden van een toegankelijke, kwaliteitsvolle en efficiënte gezondheidszorg zijn inderdaad universeel.

The IMMPACT Team.


2. FOCUS ON: Internationaal Colloquium « INTEGRATION AND DISEASE CONTROL » - Antwerpen, 26/27/28 november 2002



Het colloquium vond plaats van 26 tot 28 november 2002 in de gebouwen van de Fortis Bank te Antwerpen. We mochten 193 deelnemers verwelkomen, van wie 40% uit ontwikkelingslanden. Het thema was ‘Integration and Disease Control’ waarbij de klemtoon lag op de rol die de gezondheidsdiensten in ontwikkelingslanden spelen in de ziektebestrijding. Tijdens de academische zitting legde een aantal vertegenwoordigers van grote organisaties (WGO, GAVI, The Global Alliance for TB Drug Development) uit hoe en in welke mate ze bijdragen tot de versterking van gezondheidssystemen. De directeur van het ITG stelde dat verticale programma’s dikwijls falen, omdat zij geen structurele bijdrage leveren tot de ontwikkeling van het gezondheidszorgsysteem. Ook voor de vertegenwoordiger van staatssecretaris Boutmans (Belgische Ontwikkelingssamenwerking) is een politiek van geïntegreerd ziektecontrolebeleid een conditio sine qua non. De WGO pleitte voor een meer pragmatische aanpak van het hele probleem. In plaats van de ideologische tegenstellingen tussen horizontalisten en verticalisten te benadrukken, moeten er structurele oplossingen komen om een geïntegreerd controlebeleid te realiseren. De ‘Global Alliance for TB Drug -Development’ legde de nadruk op het belang van ‘public-private partnerships’.
Tijdens het colloquium werd een conceptueel kader, gelanceerd door het Departement Volksgezondheid, verder uitgewerkt. De leidraad bij integratie van ziektebestrijding moet zijn de kwaliteit en toegankelijkheid van de zorgverstrekking te verbeteren. Veel meer dan volledige programma’s moet men activiteiten in het basisgezondheidssysteem integreren, en dan nog slechts wanneer dat opportuun is. Bovendien heeft men relatief goed werkende gezondheidsdiensten nodig alvorens activiteiten kunnen worden geïntegreerd. In dit opzicht blijft een contextualisatie steeds noodzakelijk, naast een pragmatische aanpak. Integratie houdt tevens in dat het mogelijk moet zijn beslissingen te nemen op meer perifere niveaus, en dat is niet altijd even acceptabel voor de programmamanagers aan de top.

Prof. G. Kegels, chairman of the meeting.

Gezondheidseconomen zouden niet autonoom moeten beslissen over de aard en de wenselijkheid van een gezondheidsprogramma. Belangrijker is hun bijdrage in de schatting van de kostprijs van interventies. Gezien de huidige trends in malaria- (resistentie), AIDS- (antiretrovirale medicatie) en TB-bestrijding (multidrug resistentie), is het duidelijk dat er veel meer geld nodig is dan totnogtoe beschikbaar. We moeten daarom af van de impliciet vaak gehanteerde vuistregel dat 3 USD per capita het maximum is dat voor gezondheidszorg kan worden uitgegeven. De hamvraag blijft echter: hoe kunnen we ervoor zorgen dat meer fondsen constant beschikbaar zijn?

Evaluatie vormde een ander discussiethema. Daar waar vroeger de klemtoon op impact en kostendoeltreffendheid lag, ligt tegenwoordig de klemtoon eerder op het proces van versterking van gezondheidsdiensten enerzijds en de output-meting anderzijds. Indicatoren die de ‘performance’ van basisgezondheidsdiensten aangeven, zijn dringend nodig. Het uiteindelijke doel moet hoe dan ook zijn: hoe kunnen we op objectiveerbare wijze aantonen dat gezondheidsdiensten naar behoren werken.






Ten slotte kwam ook in dit colloquium de toegankelijkheid (access) aan bod. Benevens de vaststelling dat er meer geld nodig is, vestigden verscheidene sprekers de aandacht op het feit dat de patiënt nu meestal betaalt voor zijn essentiële gezondheidszorg, hetgeen leidt tot financiële uitsluiting in sommige landen. Als er geen toegang tot gezondheidszorg is, hoe valt ‘gezondheidszorg voor iedereen’ dan te realiseren? En al blijft voor sommigen ‘gezondheid voor iedereen’ nog steeds het doel, niemand zal ontkennen dat het een niet zonder het ander te verwezenlijken valt.

The director pointed out that the struggle between horizontalistsand verticalists is an ancient one.


PROJECTS
Access to care

DynaM: Mutual Health Organisations in Guinea Conakry (West Africa):
This project, started in 1998, studies the development of Mutual Health Organisations (MHOs) in Guinea Conakry (West Africa) as a means to improve access to health care. In addition to potential impact on access, the research also investigated the social and political dimensions of this innovative model for organising health services’ users in Africa. The Guinean researchers involved have now organised themselves in a Guinean NGO called DynaM (i.e. Dynamic Mutualiste) which aims to coach the development of MHO initiatives in other parts of the country and the region in the years to come. The department will continue to provide technical and scientific support. In 2003, DynaM and ITM will co-organise a regional scientific conference in Conakry on MHOs.
ITM promoter: B. Criel
ITM collaborator: M. P. Waelkens
External collaborators: A. Barry (DynaM, Conakry, Guinea);Christian Mutualities Waas-Dender (Sint Niklaas, Belgium)
Support: ITM-DGDC Framework Agreement

Health Equity Funds
Since 2002 the Department has been investigating the potential of HEFs in a variety of contexts to finance health care for the poorest (those who, for instance, cannot afford to pay an insurance premium). These funds are conceptually similar to Social Welfare systems as they exist in the West - i.e. OCMW-like systems that fund health care (and other basic services) for those who fall through the gaps in the safety net of existing Social Security systems. The main objectives are: i) Exploring the institutional aspects of these HEFs e.g. as public organisations that take care of the poorest. ii) Studying the impact of HEFs on the health system. This multidisciplinary field research is nested in existing projects and networks.
ITM promoter: W. Van Damme
ITM collaborators: B. Meessen (co-promoter), B. Criel (co-promoter),M. P. Waelkens
External collaborators: MSF Belgium and The Netherlands;MOH Cambodia; Memisa Belgium
Support: ITM-DGDC Framework Agreement

Cuban health system reform: decentralisation of the emergency care subsystem
Cuba’s national health system is particularly effective, but since the ’90s it has been affected by a lack of equipment and medicines, leading to functional deficiencies. As a result, the provision of emergency care at hospital level became fraught with organisational problems and flawed solutions, resulting in overcrowded hospital units with scarce resources. To achieve greater efficiency and effectiveness, Cuba is setting up a programme of quality improvement of its first-line health services, including an extra muros emergency care system in which first-line polyclinics and their community-based networks of general practitioners play an important role. This research assesses the consequences on the first line and hospital levels and evaluates their effectiveness (by analysing the shifts in patient flows), cost-efficiency and acceptability. Findings suggest that in a simple health system, decentralisation of emergency services seems to diminish the pressure on hospital emergency units and increase the utilisation of the decentralised units, with a further shift of the utilisation rates towards general practitioners. In more complex (metropolitan) health systems trends are complex, and show the potential of reform, but suggest the risk - in urban settings - of a perverse effect, redirecting patients from their GP towards the decentralised emergency services. The analysis of patient flow shifts have also proven to be a useful managerial tool for evaluating the perceived GP quality.
ITM promoter: P. Van der Stuyft
ITM collaborator: P. De Vos
External collaborators: Pedro Mas, Mariano Bonetti (INHEM, Havana, Cuba)
Support: European Union


Quality and human resources

Family medicine in developing countries
While geographical accessibility of first-line health services is improving, the quality of care on the first line remains, in many settings, unsatisfactory, which helps to explain low utilisation rates. Family medicine may breathe new life into primary health care by emphasising the quality of individual care and professionalism. This research deals with the potential of family medicine to strengthen first-line services and health care systems as a whole, whether providers are nurses or doctors. Case studies were carried out in countries where family medicine is presently developing as an outgrowth of the existing health care system (South Africa, Mali) or as part of health care reforms (Cuba, Thailand). Major issues addressed are: (1) The convergence of concepts of family medicine, so far mainly developed in the North, with concepts of primary health care. Different views on family medicine are identified as a possible foundation for professional identities of first-line care providers (doctors or nurses). (2) Human resources: doctors are increasingly working as first-line providers in the South. This potential for improved quality is not automatically realised in practice: doctors on the first line may also generate adverse effects for the quality of care and for the system. Currently conditions for replacing nurses by doctors on the first line are being investigated. (3) Organisation: the organisational conditions under which family medicine develops are essential for the quality of care and the public service orientation of the system. These conditions were examined in different settings.
ITM promoter: M. Van Dormael
ITM collaborators: S. Dugas, E. Hesse
Support: ITM-DGDC Framework Agreement

Cuba: A centre for family medicine. The doctor lives on the first floorof the “Consultario”.

Health District Development (Dosso Region, Niger)
This research, started in 2002, is embedded within project “Appui au développement des districts sanitaires de la Région de Dosso”. Its goal is to test strategies at different levels (district, regional and central) to strengthen the health districts of this rural region of Niger. Conditions to achieve common strategic views, coherence and shared responsibility between these levels and the funding agency are scrutinised. The project addresses efficient use of scarce human resources; stability and motivation of care providers; tasks, skills and attitudes of managerial staff at the district and regional levels; financial access to care; quality of care; role of the provincial hospital in the system. One of the districts is developed as a training district for the country, which implies investigating training-related issues for managerial and operational staff. The research process is conducted jointly by the health authorities and field actors, and by external experts providing scientific guidance. An expected by-product is a contribution to institutional strengthening.
ITM promoter: M. Van Dormael
ITM collaborators: S. Dugas, R. Meloni
External collaborators: R. Tonglet, Project Promoter (Université Catholique de Louvain, Ecole de Santé Publique); Regional and District Medical Office Dosso, Ministry of Public Health (Niger)
Support: Belgian Technical Co-operation (BTC)

Dosso, Niger: The village chief in discussion with a nurse of the health centre and the doctor in charge of the district.

North–South exchanges between First-line Care Practitioners
Exchange visits between first-line practitioners are likely to provide mutual support, decrease the sense of isolation and foster professional identities for first-line care. They offer opportunities to discuss practical problems (clinical and organisational) with peers and promote self-evaluation. As such, they represent a tool for professional continuous education. This strategy is being tested in exchanges between practitioners from the North and the South, in support of two field experiences: (1) exchanges between rural doctors from France and Mali. (2) Exchanges between health centre-based care providers from Guinea and Haiti on the one hand, and Belgium on the other. The ITM has been asked to evaluate these exchange visits. The hypotheses to be tested are that exchange visits (1) enable conceptualisation of one’s own practice; (2) affect professional role images for first-line care; (3) provide practical insights to improve clinical practice and practice organisation; and (4) strengthen self-reflection and professionalism. These benefits are expected for practitioners from both the North and the South.
Mali-France exchange project:
ITM promoter: M. Van Dormael
ITM collaborators: J. Van der Vennet
External collaborators: O. Doumbo (Université du Mali, Faculté de Médecine); I. Greindl (ESP-ULB); (Fédération des Maisons Médicales);A. Sow (Fraternité Médicale Guinée); M. Laroche (Genesis Haiti)
Support: AUF

Near Miss Audits
Ex post investigations of cases of maternal mortality are difficult, because maternal death is a relatively rare event, and psychological resistance can be expected among the actors involved. The ‘Near Miss’ concept attempts to tackle these difficulties by concentrating on cases of women who barely survived severe obstetric problems. The number of these patients is higher than that of maternal deaths, and health care actors involved are less reluctant to collaborate in an investigation (audit) of the mechanisms that were involved. Therefore, by targeting these ‘near misses’, better insight can be gained into the problems of operational handling of severe obstetric problems, and locally-adapted mechanisms can be developed to improve the system’s management of these cases. Documentation and analysis of these audit mechanisms contribute to a better understanding of the potential of this approach as a tool for creating awareness and initiating action, and for a more effective health policy.
ITM promoter: V. De Brouwere
ITM collaborator: F. Richard
External collaborators: Centre de Recherche en Reproduction Humaine et en Démographie (Cotonou, Benin); INAS (Morocco); Cellule de Recherche en Santé de la Reproduction (Abidjan, Côte d’Ivoire); London School of Hygiene and Tropical Medicine; Istituto per l’Infanzia (Trieste, Italy)
Support: European Union (INCO-DC)

Optimising Scientific Guidance at District Level
Improving access to and quality of care in local health systems requires continuous efforts that can be stimulated by external assistance. Such ‘scientific guidance’ is the object of this investigation, which seeks to determine what kind of approach is most effective in which context. In collaboration with the Moroccan National Institute for Health Administration (INAS) and the Moroccan Ministry of Health, several approaches (involving several packages of inputs and methods) are being documented and analysed for outcome, context and mechanisms. A ‘professional’ approach (highly flexible with respect to the context) rather than a ‘bureaucratic’ approach (using standardised procedures) appears to be a major determinant of effectiveness and acceptability.
ITM promoter: V. De Brouwere
ITM collaborators: G. Kegels, P. Blaise
External collaborators: INAS (Morocco); Ministry of Health (Morocco)
Support: ITM-DGDC Framework Agreement

Strengthening human and institutional capacities in response to new public health challenges
In the face of the world’s health crises and the accelerating pace of change in international health policy and institutions, capacity building is a strong and continuous necessity in developing countries. Increased capacities are and will be needed at all levels of the health systems, from central policy formulation via middle management to operational health care delivery. However, capacity building strategies are mostly far from evidence-based and generally poorly understood. This project is an attempt to explore the question through (i) a systematic review of the published scientific and grey literature on stewardship and capacity building and (ii) a systematic documentation of implicit and explicit historical capacity building mechanisms as can be found in a range of developing countries. On the basis of this documentation and conceptual framework, hypotheses can be generated, together with some provisional conclusions that can be subject to initial validity testing.
ITM promoters: W. Van Lerberghe, V. De Brouwere
ITM collaborators: N. Boffin, B. Marchal, G. Kegels
External collaborators: INAS (Morocco); Universities of Tunis and Monastir (Tunisia); ad hoc groups of ICHD alumni in Haiti; D.R. Congo; Burkina Faso; Chad; Mali
Support: DGDC, AIDS Impulse Programme

Quality management and organisational culture
Quality assurance and various models of quality management are high on the agenda of virtually all organisations. Originating in the manufacturing and service industries, the application of quality management techniques in the health sector is fraught with difficulties. The question explored in this research is how to understand and predict effectiveness of particular quality management approaches in light of the type of problem to be addressed and of the organisational configuration and culture prevailing in the health care organisation. As this question applies to a variety of highly heterogeneous contexts, in-depth case studies are worked out with a view to developing a workable typology of quality management (or problem-solving) approaches, problems and organisational cultures. This case-study methodology will lead to the formation of theoretical frameworks with highly practical implications for what might work for whom in which context.
ITM promoter: G. Kegels
ITM collaborator: P. Blaise
External collaborators: INAS and Ministry of Health (Morocco); Ministry of Health (Tunisia); Ministry of Health (Zimbabwe); Medicus Mundi Belgium
Support: Miscellaneous

Improving prevention of mother-to-child transmission of HIV and hospital care of children infected with HIV, with particular emphasis on human resources
In industrialised countries, paediatric HIV infection is on the verge of being eliminated as a result of the standard of care using antiretroviral therapy, elective Caesarean section delivery and avoidance of breastfeeding. The challenge of implementing effective, affordable, safe and acceptable interventions for reducing mother-to-child HIV transmission (MTCT) remains much graver in resource-poor countries. Short-course antiretroviral treatments have been tested in low-resource settings and are on the verge of being implemented on a wider scale. Still, a large number of HIV-infected children will continue to rely on the health system and the health workforce. Staff needs to be motivated to care for and treat these patients. Rapid technological and therapeutic advances in the management and treatment of HIV/AIDS need to be translated into workable practices for resource-poor settings, and appropriation of updated knowledge and skills by health personnel needs to be stimulated. The first objective is analysing the operationalisation of short-course ARVT MTCT currently in practice, and identifying important and vulnerable bottlenecks in the service settings. The studies will try to translate the demonstrated efficacy of these interventions in trial settings into effectiveness in the clinical service delivery of a developing country, using existing programmes in Dar Es Salaam (Tanzania) and South Africa. The second objective is to understand the problems hospital personnel faces with inpatient paediatric HIV patients, relating to diagnostic capacity, treatment adherence, workload and job satisfaction, and perceived interference with the efficient use of resources.
ITM promoters: P. Kolsteren, G. Kegels
ITM collaborators: N. Hammami, A. De Baets, T. Delvaux, B. Colebunders,T. Jonckheer
External collaboration: Muhimbili Maternity Hospital, Dar es Salaam (Tanzania); Ministry of Public Health Mozambique; University of Pretoria South Africa
Support: DGDC, AIDS Impulse Programme

Ecuador: the creation of a public health institute supporting public-oriented health services and systems
Institutional collaboration between the ITM Department of Public Health and the Catholic University of Ecuador (PUCE) began in August 1998. It seeks to develop an approach to the organisation of health care systems emphasising the public interest and the right to health care in a neo-liberal political context. The strategy consists of creating a public health institute (ISP) endowed with teaching, research and service delivery functions. Teaching focuses on a two-year MPH programme relying on problem-based learning and concepts from the ITM Master of Public Health. Since 1999, three cohorts of students were drawn from three Latin American countries. At the same time, action research projects were developed with the MPH students, mainly focusing on topics such as the delivery of quality care, health care at the local level and citizen participation. The demand from the field that became apparent includes short courses, continued medical education, coaching of local health systems and hospitals. The challenges for this collaboration include testing models of health services organisation, progressive participation in local policymaking, strengthening the sustainability of ISP and making study grants available for MPH students. Though these activities evolved during a relatively short time-span, the ISP was strongly represented in the local public health arena, while the specificity of its approach was acknowledged.
ITM promoter: J.P. Unger
ITM collaborators: G. Van Heusden, J. Van der Vennet, P. Daveloose,R. Meloni, M. Van Dormael
External collaborators: BTC/CTB, APS project; Instituto Ecuatoriano de Seguridad Social; Ministerio de Salud Publica del Ecuador; Municipio de Quito; NGOs and hospitals
Support : ITM-DGDC Framework Agreement

Macas, Ecuador: One of the many private health centres that are startingup all over the country.

Integration and disease control

A system approach to optimising diagnosis of smear-negative tuberculosis in high and low prevalence countries of South America
Smear-negative pulmonary tuberculosis (SNPTB) is a problem for both clinicians and tuberculosis programme managers. This research project approaches SNPTB from three different perspectives: (1) the laboratory perspective, by testing the feasibility of more valid and efficient methods for quality assurance of smear microscopy, (2) the clinical perspective, by testing the clinical audit cycle as a method to improve the quality management of smear-negative tuberculosis suspects and the validity of diagnostic work-up, and (3) the health services organisation perspective in relation to (de)centralisation of different elements of the diagnosis of smear-negative tuberculosis. This 4-year project will contrast high and low incidence, centralised and decentralised, urban and rural settings. HIV-related aspects will be examined. Special emphasis will be given to the operationalisation and dissemination of study findings. The project officially began in October 2002. The first international meeting brought together all partners involved in Lima, Peru, in December 2002.
ITM promoter: P. Van der Stuyft
ITM collaborators: M.L. Lambert, M. Boelaert
External collaborators: Nuffield Institute for Health, Leeds, UK; Instituto Pedro Kourí, La Habana, Cuba; Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru; Universidad Mayor de San Simon, IIBISMED, Cochabamba, Bolivia
Support: European Union

Diagnosis of visceral leishmaniasis: a novel and global approach to validation research through Latent Class Analysis
As Visceral Leishmaniasis (VL) is widespread in the Terai plains of Nepal, with 7500 cases being reported over the period 1994-1999, the introduction of sound diagnostic/therapeutic algorithms in the first and second line of the health services is of paramount importance for achieving control of the disease. The feasibility of parasitological examination of tissue aspirates in district laboratories is currently low, but some of the newer serological tests could be valid alternatives for parasitology.
Given the high case fatality rate of VL on the one hand and the relative toxicity and the cost of current chemotherapy on the other, such a test should be extremely sensitive and of acceptable specificity. However, validation of those tests is obstructed by the lack of a gold standard for VL. Moreover, such a test should be reproducible, simple and cheap. The aim of this study is to improve the evidence-based diagnosis and treatment of Visceral Leishmaniasis by introducing a sound and unbiased approach to the validation of new tests. At a more theoretical level, this study hopes to form a contribution to methodological advance in biomedical validation research through the exploration of Latent Class Analysis. This study will evaluate the validity of direct microscopic examination, PCR, DAT, formol/gel test, RK39 dipstick test, DAT, IFAT, and the LST in a group of 300 clinical VL suspects recruited at the BPKIHS hospital in Dhahran, Nepal. Through the use of a mathematical modelling technique, Latent Class Analysis, estimates of sensitivity and specificity will be provided for each test. The study will moreover contribute to the technological advancement of the PCR technique, and will also shed light on how the use of Latent Class Analysis in diagnostic test evaluation can be generalised. Ultimately, this study should contribute to improved VL control in the study area, as its results will be used to propose a cost-effective test-treatment strategy for clinicians working in district hospitals.
ITM promoter: P. Van der Stuyft, M. Boelaert
ITM collaborators: D. Le Ray
External collaborators: S. Rijal, et al. (B.P. Koirala Institute of Health Sciences, Dharan, Nepal); P. Desjeux (World Health Organisation, Geneva, Switzerland); F. Chappuis, et al. (Geneva University Hospital, Switzerland)
Support: Fund for Scientific Research – Flanders (FWO)

HIV surveillance in Cochabamba, Bolivia
The goal of this research project was 1) to set up a rational laboratory-based HIV surveillance network, and 2) to strengthen the laboratory capacity for HIV diagnosis and monitoring of clinical AIDS cases in the Department of Cochabamba, Bolivia. Special laboratory equipment has been purchased (FACSCount). Surveillance complied with the latest UNAIDS/WHO technical and ethical recommendations in low HIV prevalence countries. Pregnant women were tested in an anonymous and unlinked way, using samples taken for another purpose. High-risk groups were selected according to their accessibility and willingness to participate; in these groups testing was voluntary, pre- and post-test counselling was provided. Seroprevalence in pregnant women was 0.1 % (2/2 000). A total of 2 440 tests were done in high risk groups, of which 16 were confirmed positive. Seroprevalence in commercial sex workers was 0.8% (4/532); in homeless persons 2% (11/547); in inmates 0.1% (1/932); in truck drivers 0 % (0/429). The prevalence in blood donors during the same period in 2002 was 0.01% (1/4 833). This project has shown that HIV-seroprevalence was very low in Cochabamba, even in high-risk groups.
ITM promoter: P. Van der Stuyft
ITM collaborators: M.L. Lambert
External collaborators: F. Torrico (Instituto de Investigaciones Biomédicas “IIBISMED”); C. Billot (Centro Universitario de Medicina Tropical (CUMETROP) of the School of Medicine) of San Simón University, Cochabamba, Bolivia
Support: DGDC, AIDS Impulse Programme

Marburg haemorrhagic fever in the Democratic Republic of Congo
In 2000, a major outbreak of Ebola haemorrhagic fever (EHF) occurred in Gulu, Masindi and Mbarara in Uganda. The ITM was part of the international response team in Mbarara. Following a single introduction of the Ebola virus from Gulu into the Masindi district, the virus rapidly spread within the extended family of the first case and to some extent also among health workers, despite barrier nursing being in place. The outbreak provided an unexpected but interesting opportunity to perform comparative studies on epidemics of both filoviruses, and the original scope of the project was therefore expanded. The follow-up research in Masindi consisted of: (1) Establishment and revision of transmission chains, to describe the outbreak as precisely as possible; (2) Serosurvey among family and community contacts of EHF cases, to discover hitherto undetected EHF cases; (3) Serosurvey among health worker contacts of EHF cases, with the same objective as above; (4) Clinical and serological follow-up of survivors, to document frequency and type of clinical sequelae and patterns of antibody waning; (5) Interview survey among health workers on their experience with barrier nursing and observations on breaches, to identify ways to improve protection of local health staff against transmission of Marburg virus; (6) T-cell study in Ebola haemorrhagic fever survivors and a control group, to better understand the role of the cellular immune response to the Ebola virus.
With the exception of the follow-up of survivors, supposed to continue in the following years on an annual basis, data collection was completed at the end of 2002.
ITM promoter: P. Van der Stuyft
ITM collaborator: M. Borchert
External collaborators: Institut National de Recherche Biomédicale, Kinshasa (DRC); Watsa Health Authority (DRC); National Institute of Virology, Johannesburg (South Africa); Uganda Virus Research Institute, Entebbe; Masindi Health Authority (Uganda); Bernhard Nocht Institute of Tropical Medicine, Hamburg (Germany)
Support: Fund for Scientific Research – Flanders (FWO)

Marburg haemorrhagic fever in Watsa/DRC
The epidemic in Watsa (East Congo) in 1998-2000 is the first and only outbreak of Marburg haemorrhagic fever (MHF) in the virus’ natural environment ever documented. The number of cases is estimated at about 100, with a case fatality proportion of 75%. It appears that Gorumbwa gold mine was the environment where the repeated transmission of the virus from the as yet unidentified reservoir to man occurred. Diseased gold diggers then transmitted the virus to care-giving family members and/or health workers. ITM had been part of the international response team in 1999. Armed conflicts delayed the start of scientific follow-up, but from mid-2001 onwards, the following field activities could be undertaken: (1) Establishment and revision of transmission chains; (2) Serosurvey among family and community contacts of MHF cases, to discover hitherto undetected MHF cases; (3) Serosurvey among health worker contacts of MHF cases, with the same objective; (4) Clinical and serological follow-up of survivors, to document frequency and type of clinical sequelae and patterns of antibody waning; (5) Serosurvey in the pygmy population of the Watsa health zone, to determine whether this hunter population, having intimate contact with the local wildlife, has an increased prevalence for antibodies specific for Marburg and other viral haemorrhagic fevers. With the exception of the follow-up of survivors, which will continue in the following years on an annual basis, data collection was completed at the end of 2002.
ITM promoter: Van der Stuyft
ITM collaborator: M. Borchert
External collaborators: Institut National de Recherche Biomédicale, Kinshasa (DRC); Watsa Health Authority (DRC); National Institute of Virology, Johannesburg (South Africa)
Support: ITM-DGDC Framework Agreement

Watsa, D.R. Congo. A survivor of Marburg haemorrhagic fever enrolled in a long term follow-up study.


Health Policy

Unmet Obstetric Needs (UON)
Major, life-saving medico-surgical interventions for maternal indications need to be performed in a minimum proportion of deliveries in order to avoid maternal death or major disability. As it is relatively easy to trace these major interventions in a health care delivery system, observed numbers of interventions can be compared to this minimum, calculated on the basis of expected deliveries in a given population, and a possible deficit can be derived, called ‘unmet obstetric need’. In the UON approach, this exercise is carried out with local field actors in a wide variety of countries in the South, and the findings are shared with other health system protagonists. The central research question and outcome is under what kind of conditions such quantification of unmet obstetric need triggers reflection and effective action in order to improve the situation, thereby extending the field of enquiry to issues of health system policies and management, including mechanisms of solidarity in the communities. The results have been published extensively in several books (available on request).
ITM promoter: V. De Brouwere
ITM collaborator: D. Dubourg
External collaborators: Ministry of Health (Benin, Burkina-Faso, Haiti, Mali, Niger, Tanzania, Pakistan); Centre for Health and Population Research (ex-ICDDR, B); Bangladesh Health Service Academy; GTZ; WHO; UNFPA; UNICEF; DGDC; University of Heidelberg, Germany
Support: ITM-DGDC Framework Agreement, European Union

Filing data collected for the Unmet Obstetric Need study in Matlab, Bangladesh.

Initiative for Maternal Mortality Programme Assessment (IMMPACT)
Decision-makers in developing countries today are forced to allocate scarce resources to intervention strategies of uncertain benefit in terms of reducing maternal mortality and severe morbidity. IMMPACT is a seven-year global initiative to determine efficacious and cost-effective strategies and their implications for equity and sustainability. To help generate this new knowledge and ensure its use by policymakers and programme managers, IMMPACT will enhance the methods for assessing maternal mortality and other relevant health outcomes, and strengthen capacity for evidence-based decision-making and rigorous evaluation. Applied research activities will be conducted through a collaborative network of country and technical partners, with a focus on eight developing countries across Africa, Asia and Latin America. Activities started in 2002. The Department of Public Health is responsible, firstly, for scientific support to Centre Muraz, the Country Technical Partner in Burkina Faso, and for co-ordination of the work programme activities based in this centre. The second responsibility is capacity development for research, evidence-based decision-making and evaluation.
ITM promoter: V. De Brouwere
ITM collaborators: B. Marchal, H. Buttiëns
External collaborators: W. Graham (Programme promoter, Director of Dugald Baird Centre for Research on Women’s Health, University of Aberdeen, U.K.); C. Ronsmans (London School of Hygiene and Tropical Medicine, UK); T. Ensor (University of York, UK); M. Koblinsky (Johns Hopkins University, Bloomberg School of Public Health); E.L. Achadi (Centre of Family Welfare, Indonesia); D. Ofori-Adjei, M. Armar-Klemesu (Noguchi Memorial Institute of Medical Research, Ghana); N. Meda (Centre Muraz, Burkina Faso)
Support: Bill and Melinda Gates Foundation; UNFPA; WHO; World Bank

Dr. Conombo (Director Family Health), Prof. Dr. Vincent De Brouwere (ITM) and Dr. Marion Hall (University of Aberdeen) during a press conference for the launch of IMMPACT in Burkina Faso.

Improving Access and Quality of Emergency Obstetric Care (‘Programme d’Amélioration de la Qualité et de l’Accès aux Soins Obstétricaux d’Urgence dans les Pays en Voie de Développement’ - AQUASOU)
In the interest of developing effective strategies for reducing maternal mortality and morbidity through improved access to good-quality obstetric care, understanding the advantage of a systemic approach is deemed to be crucial. In this approach, systemic elements are first identified and then acted upon comprehensively and simultaneously, rather than developing a phased series of separate interventions. The research aims to find out to what extent such a comprehensive systemic approach is more effective than the sum of its individual components.
ITM promoter: V. de Brouwere
ITM collaborator: F. Richard
External collaborators: A. Prual, project promoter (Centre Hospitalier de Montluçon, France); Société Africaine de Gynécologie Obstétrique (SAGO); Ecole de Santé Publique, ULB, Brussels; Equilibre et Population (E&P); University of Toulouse; Institut National de la Santé et de la Recherche Médicale (INSERM); Institut de Recherche pour le Développement (IRD)
Support: Ministry of Foreign Affairs (France)

Rural Public Hospitals in Change in Transitional Asia: Institutional Influences on Performance (Hospitals in Change)
This project is the first systematic study of the impact on rural hospital performance of institutional arrangements associated with China’s and Cambodia’s transition to a market economy. Hospital costs have risen sharply in China, and the quality of service is variable. In both countries, the performance of public hospitals varies a great deal. This is partly due to issues of funding, but our hypothesis is that ownership structures, mechanisms of governance and accountability, incentives and formal and informal behavioural norms are also important. The project was started up in 2002 and consists of detailed hospital case studies that explore the influence of these factors on objective measures of performance. The aim is to contribute to the formulation of realistic strategies for reform of hospital management and government regulation.
ITM promoters: B. Criel, B. Meessen
ITM collaborators: W. Van Damme, G. Kegels
External collaborators: Institute of Development Studies (Brighton, UK); Chinese Health Economics Institute (Beijing, China); National Institute of Public Health (Phnom Penh, Cambodia)
Support: European Union – INCO-DC

Rural Hospital, China.

European and Developing Countries Clinical Trial Programme (EDCTP), Accompanying Measure, Work Package 14
In 2003, a new initiative for the promotion of clinical research in AIDS, malaria and tuberculosis will be launched under the 6th Framework Programme of the European Union: the European and Developing Countries Clinical Trials Platform (EDCTP). ITM is a partner in the project (EDCTP Accompanying Measure (AM)) which is preparing for this new structure. One of the major concerns of our African partners, health systems and operational intervention research, is not in the mandate of the future EDCTP, and should be addressed under other EU programmes for international collaboration. Nevertheless, priority-setting within EDCTP should be guided by the chance which products have of being effectively introduced in DC’s health services. This project, known as Work Package 14 of the AM, documents how and why the introduction of therapeutic and other innovation in DC’s health systems are hindered or delayed, focusing on recent experiences in AIDS, malaria and TB. This analysis will lead to recommendations to EDCTP on how to guide the selection of projects with regard to compatibility with health services and systems. The WP will also formulate a proposal to the EU on how health systems and operation intervention research should be continued and reinforced through other EU support mechanisms and how this could optimally link up with EDCTP. The methods include a modified Delfi process for consultation of African key experts, as well as other qualitative methods. Final recommendations will be reported by May 2003. A set of criteria will be proposed which might guide EDCTP in its project selection process. Moreover, a specific proposal will be made to the EU identifying priority involvement in research, policy development, capacity building and advocacy for channelling effective technical innovations into DC’s health care systems.
ITM promoter: M. Boelaert
ITM collaborator: F. Matthys
External collaborators: T. Trilla (Hospital Clinico Barcelona) and other EU partners
Support: European Union

Sylos: development of local health systems
The quality of and access to health care increasingly require integration between care providers and actors representing different sectors and institutions. This kind of co-ordination is much easier to achieve in local health systems. The Sylos project started in 1997 in Belgium, where the health system was characterised by the absence of formal co-ordinating agencies – a feature also shared by numerous developing countries. This project aims to test strategies designed to create functioning local health systems. Small groups of health care providers, working in hospital and general practice settings, were set up, with technical assistance from ITM. Using action-research, these groups identified and tested possible organisational and vocational solutions to problems encountered by local actors. Besides improvement in the health system’s response to users’ health problems, the project also aimed to develop a managerial know-how used in providing technical assistance to health systems in developing countries. As a by-product, the Sylos project seems to be offering a positive benefit to the Belgian health care organisation policy.
ITM promoter: J.P. Unger
ITM collaborators: E. Hesse, J. Van der Vennet, B. Criel, S. Dugas,P. Daveloose, R. Meloni
External collaborators: Sint Vicentius Ziekenhuis, Antwerp; Hôpital Molière Longchamps, Brussels; Clinique Reine Astrid, Malmédy; Local General Practitioner Organisations; CERISSP.
Support: Belgian Ministry of Social Affairs

Jordan: in-service development of family medicine
In 2002, an ITM public health team provided technical guidance to the Jordan Primary Health Care Initiatives (PHCI) project. This five-year project assists the Jordanian Ministry of Health in implementing a primary health care and reproductive health programme aimed at improving access to and quality of care throughout the country. Its components include training (continuing medical education); quality assurance; management information systems; research; evaluation; and clinic renovations. ITM coaching helped local staff develop key management systems and human resource schemes as a means of introducing family medical practice into public health centres. It created an opportunity to scale up nation-wide and apply a technology designed for the introduction of family medicine and patient-centred care into publicly-oriented health services, with appropriate management, supervision and in-service training.
ITM promoter: J.-P. Unger,
ITM collaborator: P. Daveloose
External collaboration: Jordanian Ministry of Health; Abt Associates
Support: USAID

Nutritional Transition: Epidemiological Transition And Health Impact in North Africa (TAHINA)
The objectives of the interdisciplinary research on the epidemiological transition in two North African countries (Tunisia and Algeria) is to characterise the present nutritional transition stage; to assess its consequences on the disease burden; to identify the underlying individual and social determinants; and to help design adapted, feasible and cost-effective intersectoral strategies to face this new reality over the middle-to-long term. Key features of the research include: a precise assessment of the actual burden of lifestyle-related non-communicable chronic diseases with an in-depth analysis of the environmental and lifestyle risk factors at population level; an investigation of the attitudes and practices of different actors (population, health personnel, decision-makers), towards the changing epidemiological situation; a risk approach methodology taking both epidemiological evidence and public opinion into account to design jointly, with decision-makers, sectoral and multisectoral intervention strategies to improve health care and promote healthy lifestyles relevant to the context.
ITM promoter: P. Kolsteren
ITM collaborators: P. Lefèvre, T. Hoerée, A. Pérez-Cueto
External collaborators: B. Maire (project promoter), F. Delpeuch,G. Le Bihan, M. Holdsworth, P. Traissac (Institute de Recherche pour le Développement, Montpellier, France); M. Padilla (Institut Agronomique Mediterranéen, Montpellier, France); J. Elati (Institut National de Nutrition et de Technologie Alimentaire, Tunis, Tunisia); H. Ben Rohmdhane,N. Achour (Institut National de Santé Publique, Tunis, Tunisia); Faculté de Médecine, Université d’Oran, Algeria L. Houti; A. Ouchfoun, M. Atek (National Public Health Institute, Alger, Algeria)
Support: European Commission – INCOMED.

Prevention of intrauterine growth retardation in Hounde district, Burkina Faso
Intrauterine Growth Retardation (IUGR) is an important determinant of mortality and morbidity in the neonatal period, and of nutritional status, health and development in childhood. Evidence points to the potential role played by combined micronutrient deficiencies during pregnancy. The aim of this project is to study ways to improve children’s health by preventing intrauterine growth retardation through the provision of an improved package of prenatal care, including multivitamin-mineral supplements. In 2002 a pilot phase started during which socio-anthropological, nutritional and epidemiological aspects of IUGR will be assessed via qualitative and epidemiological methods. Later, a double-blind, randomised, placebo-controlled trial is planned, including 1215 pregnant women, testing 3 hypotheses: supplementing pregnant women with a multivitamin-minerals mix will improve foetal growth; improved foetal growth will have a positive effect on health and growth during infancy; covering nutritional needs of lactating women with a multivitamin-minerals mix during 3 months after delivery will improve health and growth of infants. The trial is planned in Hounde District, Burkina Faso, in collaboration with Centre Muraz.
ITM promoter: P. Kolsteren
ITM collaborators: U. d’Alessandro; V. De Brouwere; D. Roberfroid; S. Gies
External collaborators: N. Meda, I. Sombie (HIV, AIDS, and reproductive health department, Centre MURAZ, Bobo-Dioulasso, Burkina Faso); C. Ronsmans (LSHTM, London, United Kingdom); F. Delpeuch (Tropical Nutrition Unit, IRD, Montpellier, France); J. Kusin (KIT, Amsterdam, The Netherlands); J. Van Camp (University of Ghent, Department of Nutrition and Food Sciences, Faculty of Agronomy, Belgium)
Support: Nutrition Tiers Monde, ITM/DGDC Framework Agreement

Burkina Faso: Moto-ambulances at the Houndé district hospital.

A more global approach to child health (Bolivia, Peru)
The project was conceived in order to develop and apply a global and integrated approach to promoting child health with the participation of the health services, the parents and other actors of the community. Measures to alleviate growth monitoring were to be taken into consideration in the framework of health care delivery from the viewpoint of the health sector and the caretakers. In Bolivia, the research was conducted in the urban periphery of Cochabamba and in the Amazonian region of Chapare. In Peru, the activities took place in the outskirts of the city of Lima. A socio-anthropological component studied: (i) the logics and comprehension of child health, growth and development as perceived by caretakers and health personnel; (ii) the relationships between these groups around child care; (iii) activities considered necessary to support child growth and development; (iv) the factors explaining the differences of knowledge, perceptions and practices relating to growth and development of children between caretakers and health personnel; (v) feeding and socialisation process of children; (vi) the perception and utilisation of the growth chart (and understanding of growth and development) by the health personnel. The public health component comprised (i) an analysis of universal and local risks faced by the children under five with the aim of prioritising activities, (ii) an analysis of currently used preventive packages and their performance and (iii) an analysis of the functioning of the front-line health services in the context of current national health policies of both countries. Knowledge was generated concerning local risks faced by the children, prevailing lay perceptions of child growth, development and health, main health problems faced by children, strategies of the caretakers within the local health system, relationships between caretakers and health personnel and the practical consequences thereof, weaknesses of routine growth and development monitoring, universal risks faced by children under six. More important, it has been demonstrated that alternative strategies do exist and can be designed and implemented successfully. Through the implementation process, parental participation increased and competence and communicative behaviours of the health personnel in answer to the children’s caretakers improved. The gap between actors was partially diminished, leading to improved child rearing practices. Although the project concluded in December 2001, the valorisation process continued in 2002. In addition, numerous linkages and relationships with various organisations at field, national and international level have been established. These will form the basis for organising a formal network of institutions interested in conducting further research on growth and development of children.
ITM promoter: P. Kolsteren
ITM collaborators: T. Hoerée, P. Lefèvre, D. Roberfroid
External collaborators: E. Sejas, E. Ardúz, D. Illanes, J. Zambrana (Instituto de Investigaciones Biomédicas y Sociales (IIBISMED), Equipo de Nutrición, Facultad de Medicina de la Universidad Mayor de San Simón de Cochabamba (UMSS), Bolivia); B. Maire, C.E. de Suremain (Unité de Recherche 106 “Nutrition, Alimentation, Sociétés” (NAS), Institut de Recherche pour le Développement (IRD), Montpellier, France); I. Pecho, E. Rubín de Celis, E. Vidal (Unidad de Nutrición, Facultad de Salud Pública y Administración, Universidad Peruana Cayetano Heredia (UPCH), Lima, Peru)
Support: European Union INCO-DC

Strengthening Public Health Policies in Health Sector Reforms in Latin America
Health sector reforms in Latin America (as elsewhere in the world) are, it is claimed, designed for achieving more equitable, effective, efficient (i.e. cost-effective) and accessible (economically, geographically and culturally) health services of a reasonable quality despite the increasing economic restrictions occurring almost everywhere on the sub-continent. The question of how to improve health and health care for the poor in a cost-effective way is closely related to successfully achieving the provision of essential health care. Based on the hypothesis that health sector reforms have a deep and often negative impact on the provision of adequate (effective, efficient, accessible and equitable) essential health care for the control of communicable and non-communicable diseases in Latin America, this research project compares the health policies in several Latin American countries, with the objective of strengthening policies and policy implementation of cost-effective and equitable public health care. Therefore, the project analyses health policies related to the delivery of public health care (“essential health care packages”) in Latin America and the actual implementation of these policies, and develops indicators for monitoring policies related to public health care in the general population, particularly for the poor, and their implementation and impact. It seeks to identify alternatives for improved public health policies and to design guidelines for policymakers which help to ensure that particularly the poor population strata are covered by adequate public health care, and to compare the Latin American experiences of public health services and health sector reform for European countries.
ITM promoter: P. Van der Stuyft
ITM collaborator: P. De Vos
Support: European Union


Publications in international peer-reviewed journals

Beghin I, Maire B, Kolsteren P, Delpeuch F. La surveillance nutritionnelle: 25 ans après. Cah Santé 2002; 12: 112-116.
Boelaert M, Le Ray D, Van der Stuyft P. How better drugs could change kala-azar control; lessons from a cost-effectiveness analysis. Trop Med Int Health 2002; 7: 955-959.
Boelaert M, Lynen L, Van Damme W, Colebunders R. Do patents prevent access to drugs for HIV in developing countries? [letter]. JAMA 2002; 287: 840-841.
Boelaert M, Van Damme W, Meessen B, Van der Stuyft P. The AIDS crisis, cost-effectiveness and academic activism [editorial]. Trop Med Int Health 2002; 7: 1001-1002.
Borchert M, Muyembe-Tamfum JJ, Colebunders R, Libande M, Sabue M, Van der Stuyft P. A clus-ter of Marburg virus disease involving an infant. Trop Med Int Health 2002; 7: 902-906.
Bossyns P, Miyé H, Van Lerberghe W. Supply-level measures to increase uptake of family plan-ning services in Niger: the effectiveness of improving responsiveness. Trop Med Int Health 2002; 7: 383-390.
Colebunders R, Lambert ML. Management of co-infection with HIV and TB [editorial]. Br Med J 2002; 324: 802-803.
Colebunders R, Van Esbroeck M, Moreau M, Borchert M. Imported viral haemorrhagic fever with a potential for person-to-person transmission: review and recommendations for initial management of a suspected case in Belgium. Acta Clin Belg 2002; 57: 233-240.
De Brouwere V, Dubourg D, Richard F, Van Lerberghe W. Need for caesarean sections in west Africa [letter]. Lancet 2002; 359: 974-975.
Getahun H, Lambein F, Van der Stuyft P. ABO blood groups, grass pea preparation, and neurolathyrism in Ethiopia. Trans R Soc Trop Med Hyg 2002; 96: 700-703.
Getahun H, Lambein F, Vanhoorne M, Van der Stuyft P. Pattern and associated factors of the neurolathyrism epidemic in Ethiopia. Trop Med Int Health 2002; 7: 118-124.
Guerin PJ, Oliaro P, Sundar S, Boelaert M, Croft SL, Desjeux P, Wasunna MK, Bryceson ADM. Visceral leishmaniasis: current status of control, diagnosis, and treatment, and a proposed research and development agenda. Lancet Infect Dis 2002; 2: 494-501.
Hoerée T, Kolsteren P, Roberfroid D. La prise en charge de la malnutrition chez les enfants pré-scolaires: le rôle des services de santé locaux. Cah Santé 2002; 12: 94-99.
Kroeger A, Falkenberg T, Tomson G, Sen K, Diesfeld HJ, Dujardin B, Tang S, Van der Stuyft P. Does Brussels listen? European health systems research in developing countries at the edge of extinction [editorial]. Trop Med Int Health 2002; 7: 101-103.
Lambert ML, Van der Stuyft P. Global Health Fund or Global Fund to fight AIDS, tuberculosis, and malaria? [editorial]. Trop Med Int Health 2002; 7: 557-558.
Lefèvre P, de Suremain CE. Les contributions de la socio-anthropologie à la nutrition publique: pourquoi, comment et à quelles conditions? Cah Santé 2002; 12: 77-85.
Mbithi-Mwikya S, Van Camp J, Mamiro PRS, Ooghe W, Kolsteren P, Huyghebaert A. Evaluation of the nutritional characteristics of a finger millet based complementary food. J Agric Food Chem 2002; 50: 3030-3036.
Orach CG, Kolsteren P. Outpatient care for severely malnourished children [commentary]. Lancet 2002; 360: 1800-1801.
Ronsmans C, Van Damme W, Filippi V, Pittrof R. Need for caesarean sections in west Africa [letter]. Lancet 2002; 359: 974.
Schrooten W, Dreezen C, Borleffs J, Dijkgraaf M, Borchert M, De Graeve D, Hemmer R, Fleerackers Y, Colebunders R, Eurosupport Study Group. Financial situation of people living with HIV in Europe. Int J STD AIDS 2002; 13: 698-701.
Unger JP, Van Dormael M, Criel B, Van der Vennet J, De Munck P. A plea for an initiative to strengthen family medicine in public health care services of developing countries. Int J Health Serv 2002; 32: 799-815.
Van Damme W, Boelaert M. Therapeutic feeding centres for severe malnutrition [letter]. Lancet 2002; 359: 260-261.
Van Damme W, Van Lerberghe W, Boelaert M. Primary health care vs. emergency medical assistance: a conceptual framework. Health Pol Plann 2002; 17: 49-60.
Van Dormael M, Unger JP. The global response to mental illness [letter]. Br Med J 2002; 325: 967.
Van Lerberghe W, Adams O, Ferrinho P. Human resources impact assessment [editorial]. Bull World Health Organ 2002; 80: 525.
Van Lerberghe W, Conceiçao C, Van Damme W, Ferrinho P. When staff is underpaid: dealing with individual coping strategies of health personnel. Bull World Health Organ 2002; 80: 581-584.
Van Lerberghe W, Conceiçao C, Van Damme W, Ferrinho P. When staff is underpaid: dealing with individual coping strategies of health personnel. World Hosp Health Serv 2002; 38(2): 11-14.
Van Lerberghe W, Ferrinho P. From human resource planning to human resource impact assessment: changing trends in health workforce strategies. Cah Sociol Démogr Méd 2002; 42: 167-178.


Other publications and abstracts

Afifi Soweid R, Nakkash R, Nehlawi M, Khogali M, Alam S, Hoerée T, Najjar N, Razum O, Salti I. Together for heart health; an initiative for community-based cardiovascular disease risk factor prevention and control, Beirut, Lebanon, September 1998 - March 2002. Beirut: American University of Beirut, 2002: 112 pp.
Apers L, Kegels G. Chloroquine-sulfadoxine/pyrimethamine sensitivity surveillance in Zimbabwe; where vertical experts and horizontal structures happily meet [abstract]. In: Integration and disease control; international colloquium, Antwerp, 26-27-28 November 2002; abstract book. Antwerp: Institute of Tropical Medicine, 2002: 48.
Blaise P. Des expériences de management de la qualité dans les systèmes de santé en Afrique; entre programme vertical et stratégie de changement, des espoirs déçus et des contraintes mal maîtrisées. In: Qualité et accès aux soins en milieu urbain; séminaire conjoint UNICEF, Coopération française, GTZ, Dakar 18, 19, 20 juin 2002. [s.l.]: [s.n.], 2002.
Blaise P. Le management de la qualité dans les systèmes de santé en Afrique; entre programme vertical et stratégie de changement, des espoirs déçus et des contraintes mal maîtrisées [mémoire]. Bruxelles: Université Libre de Bruxelles, Ecole de Santé Publique, 2002: 18 pp.
Blaise P. A mental health care programme as entry point to improve the quality of primary care services [abstract]. In: Integration and disease control; international colloquium, Antwerp, 26-27-28 November 2002; abstract book. Antwerp: Institute of Tropical Medicine, 2002: 27.
Blaise P, Kegels G. Les différentes approches de management de la qualité des soins: le potentiel et les limites de la mise en oeuvre des programmes d’assurance qualité; études de cas en Afrique subsaharienne. In: 10èmes Journées Nationales de Santé Publique; Table Ronde sur l’Assurance de Qualité, Nabeul, Tunisie, 24-25 octobre 2002. [s.l.]: [s.n.], 2002.
Blaise P, Kegels G. Quality management in health care systems in Africa: one concept, many faces, contrasted results; an analysis of three case studies from Africa. In: Quality in higher education, health care, local government; 5th ‘Toulon-Verona’ conference, Lisbon, 19-20 September 2002. [s.l.]: [s.n.], 2002.
Blaise P, Kegels G, Criel B. Child-centred care in African health care systems: why is there so little of it? and what can be done? In: Kolsteren P, Hoerée T, Perez-Cueto EA, edi-tors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 200-221.
Borchert M, Sabue M, Grade M, Burt F, Emmerich P, Luwaga H, Kulidri A, Lutwama J, Rwaguma E, Muyembe Tamfum JJ, Schmitz H, Swanepoel R, Van der Stuyft P. Serosurvey among contacts of Marburg and Ebola haemorrhagic fever patients in Durba/Watsa (DR Congo) and Masindi (Uganda): preliminary results [abstract]. Acta Trop 2002; 83(Suppl.1): S107, Abstract Nr.WeSy001; S180, Abstract Nr. P194.
Criel B. A framework to analyse the relationship between integrated health care and vertical programmes [abstract]. In: Integration and disease control; international colloquium, Antwerp, 26-27-28 November 2002; abstract book. Antwerp: Institute of Tropical Medicine, 2002: 7.
Criel B, Noumou Barry A, von Roenne F, Eds. Le projet PRIMA en Guinée Conakry; une expérience d’organisation de mutuelles de santé en Afrique rurale. Brussels: Medicus Mundi Belgium, 2002: 255 pp.
da Silva-Santana SC, da Silva Diniz A, de Feitas Lóla MM, Santana de Oliveira R, Silva SMM, de Oliveira SF, Kolsteren P. Parameters of evaluation of zinc nutritional status: comparison between zinc hair rates and serum alkaline phosphatase in preschoolers of the Municipality of Joao Pessoa, Paraíba. Rev Bras Saúde Matern Infant 2002; 2: 275-282.
De Brouwere V. Qui veut devenir le prochain directeur de l’OMS? Lett RIAC 2002; 7(14): 6-7.
De Brouwere V. Who wants to become the next director-general of the WHO? INFI Newsl 2002; 7(14): 6-7.
de Suremain CE, Lefèvre P. Santé de l’enfant: le volet socio-anthropologique du projet INCO: Health sector reform: towards a more global approach of child health (Bolivie, Pérou). Bull Amades 2002; 39: 4-6.
de Suremain CE, Lefèvre P, Maire B, Kolsteren P. Local perceptions of child’s health, growth and development among Bolivian mothers. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 87-95.
De Vos P. Cuba’s geneeskunde voor het volk; een nationale gezondheidsdienst in een socialistische maatschappij. In: Globalisering en gezondheid; een alternatief voor commer-cialisering en privatisering. Berchem: EPO, 2002: 81-102. (Gounet T, Cottenier J, Vandenbroucke D, Lerouge H, Rosa-Rosso N, editors. Marxistische Studies; 58).
De Vos P. Cuba: une médecine pour le peuple; un service national de santé dans une société socialiste. In: Globalisation et santé; une alternative à la commercialisation et à la privatisation. Berchem: EPO, 2002: 83-105. (Gounet T, Cottenier J, Vandenbroucke D, Lerouge H, Rosa-Rosso N, editors. Etudes Marxistes; 58).
De Vos P. Hoe gezond is de Europese gezondheidspolitiek? In: Globalisering en gezondheid; een alternatief voor commercialisering en privatisering. Berchem: EPO, 2002: 15-56. (Gounet T, Cottenier J, Vandenbroucke D, Lerouge H, Rosa-Rosso N, editors. Marxistische Studies; 58).
De Vos P. Saine, la politique de santé européenne? In: Globalisation et santé; une alternative à la commercialisation et à la privatisation. Berchem: EPO, 2002: 15-58. (Gounet T, Cottenier J, Vandenbroucke D, Lerouge H, Rosa-Rosso N, editors. Etudes Marxistes; 58).
De Vos P, Pérez R, Espinoza E, Salazar G, Barten F, Ricarte G, Méndez C, Elías MA, Utrera J, Van der Stuyft P. The role and place of local health initiatives in the changing health environment of post-war Central America [abstract]. Acta Trop 2002; 83(Suppl.1): S94, Abstract Nr.WEPS064.
Hoerée T, Kolsteren P, Roberfroid D. Missed opportunities in the battle against malnutrition of pre-school children: analysis of recommendations of three WHO programmes. INFI Newsl 2002; 7(13): 47-51.
Hoerée T, Kolsteren P, Roberfroid D. Les occasions manquées pour une meilleure prise en charge de la malnutrition chez l’enfant préscolaire: analyse des recommandations de trois programmes de l’OMS. Lett RIAC 2002; 7(13): 47-51.
Hoerée T, Van Haegenborgh T, Colebunders R, Avonts D, Van Verseveld N, Engels R. Integrating HIV care: networking with family doctors and AIDS specialists; lessons learned from a pilot project in Flanders [abstract]. In: Integration and disease control; international colloquium, Antwerp, 26-27-28 November 2002; abstract book. Antwerp: Institute of Tropical Medicine, 2002: 56.
Hoerée T, Zambrana E, Sejas E. Health promotion practice of rural health workers in Bolivia; a qualitative exploration. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 72-79.
Hutse V, Abdellati S, De Doncker S, Rijal S, Karki BMS, Campinho L, Jacquet D, Boelaert M, Dujardin JC. Development and evaluation of a simple and cheap PCR-ELISA assay for diagnosis of visceral leishmaniasis [abstract]. Acta Trop 2002; 83(Suppl.1): S57, Abstract Nr.TUPS021.
Kadima Ebeja A, Lutumba P, Molisho D, Kegels G, Miaka Mia Bilenge C, Boelaert M. Sleeping sickness outbreak in Kinshasa, DRC: more than an urban legend [abstract]. Acta Trop 2002; 83(Suppl.1): S49, Abstract Nr.MOPS042.
Kegels G. Some issues in ensuring access to necessary pharmaceuticals. Med Mundi Int Newsl 2002; 68: 21-28.
Kolsteren P. Croissance du jeune enfant; la fin des idées simples. Sci Sud 2002; 14: 5.
Kolsteren P, Hoerée T, Roberfroid D. Growth monitoring and promoting growth and develop-ment; synthesis of the colloquium. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 3-13.
Lambert ML, Boelaert M, Van der Stuyft P. Are strong general health care systems needed to reach tuberculosis control targets? In: International conference: “Health care for all”, Antwerp, Belgium, 25-26 October 2001. [s.l.]: [s.n.], 2001: 13 pp.
Lambert ML, Delgado R, Pardo H, Fernandez C, Vols A, Aguirre AM, Michaux G, Van der Stuyft P. Collaboration between private pharmacies and national tuberculosis programme in Bolivia [abstract]. Acta Trop 2002; 83(Suppl.1): S64, Abstract Nr.TUPS037.
Lefèvre P, de Suremain CE, Hoerée T, Arduz E, Pecho I. De la investigación a la investigación-acción participativa: las lecciones de una experiencia multidisciplinaria sobre el desarollo y el crecimiento del niño en Bolivia y en Perú. Bolivian Res Rev 2002; 2(1): 36-53.
Lefèvre P, Hoerée T, Sejas E, de Suremain CE, Zambrana E. Appropriation of the growth chart by mothers of under fives in Bolivia. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 96-102.
Marlet M, Wuillaume F, Boelaert M. Visceral leishmaniasis in Bakool, a recently identified endemic area in the south of Somalia [abstract]. Acta Trop 2002; 83(Suppl.1): S58, Abstract Nr.TUPS025.
Meessen B, Criel B, Kegels G. Les arrangements formels de mise en commun des risques maladie en Afrique subsaharienne: pistes de réflexion sur les obstacles rencontrés. Rev Int Sécurité Soc 2002; 55(2): 91-116.
Meessen B, Criel B, Kegels G. Formal pooling of health risks in sub-Saharan Africa: reflections on the obstacles encountered. Int Soc Security Rev 2002; 55(2): 71-93.
Meessen B, Criel B, Kegels G. Institutionelle Lösungen zur gemeinschaftlichen Risikoverteilung bei Krankheit in Afrika südlich der Sahara: Uberlegungen angesichts der vorgefundenen Hindernisse. Int Rev Soz Sicherheit 2002; 55(2): 91-119.
Meessen B, Criel B, Kegels G. Mancomunidad formal de los riesgos de salud en Africa subsahariana: reflexiones sobre los obstáculos encontrados. Rev Int Seguridad Soc 2002; 55(2): 81-104.
Meessen B, Van Damme W, Ir Por P, Van Leemput L, Hardeman W. The new deal in Cambodia: the second year; confirmed results, confirmed challenges. Phnom Penh: Médecins Sans Frontières Holland/Belgium, 2002: 57 pp.
Rijal S, Boelaert M, Karki BMS, Jacquet D, Singh R, Chance ML, Chappuis F, Hommel M, Van der Stuyft P, Le Ray D, Koirala S. Evaluation of a urinary leishmanin antigen based latex agglutination test ‘Katex’ in the diagnosis of kala-azar in eastern Nepal [abstract]. Acta Trop 2002; 83(Suppl.1): S57, Abstract Nr.TUPS022.
Robays J, Webber R, Bilenge MM, Boelaert M. How does the Card Agglutination test for trypanosomes contribute to the effectiveness of screening for trypanosomiasis? [abstract]. In: Integration and disease control; international colloquium, Antwerp, 26-27-28 November 2002; abstract book. Antwerp: Institute of Tropical Medicine, 2002: 62.
Roberfroid D, Lefèvre P, Kolsteren P, Hoerée T. Health professionals’ perceptions of growth monitoring and promotion programmes in selected developing countries. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 58-71.
Sejas E, Hoerée T, Illanes D, Mejean C, Maire B, Arduz E. Development and testing of an intervention strategy for improving participation of parents in promotion of growth and development of pre-school children in Bolivia. In: Kolsteren P, Hoerée T, Perez-Cueto EA, editors. Promoting growth and development of under fives; proceedings of the International Colloquium, Antwerp 28, 29, 30 November, 2001. Antwerp: ITGPress, 2002: 341-353.
Unger JP. Privatisation des soins de santé ou développement communautaire des services publics? Santé Conjuguée 2002; 22: 17-25.
Unger JP, El Abassi A, Traore FN. The community development of “public” services. [s.l.]: [s.n.], [2002]: 23 pp.
Van Damme W, Meessen B. Sotnikum new deal, the first year; better income for health staff, better service to the population. Phnom Penh: Médecins Sans Frontières Holland/Belgium, 2001: 64 pp.
Van der Vennet J. Community participation in Bolivia: how to transcend populism. INFI Newsl 2002; 7(13): 35-40.
Van der Vennet J. La participation populaire en Bolivie: comment dépasser le populisme? Lett RIAC 2002; 7(13): 35-40.
Van Diest E, Stoffelen E, Wydooghe L, Van Duppen D, Seuntjens L, Van der Stuyft P. Primaire cardiovasculaire preventie met statinen; grote discrepanties tussen Europese, Nederlandse en Belgische criteria. Huisarts Nu 2002; 31: 5-11.
Van Leemput L, Van Damme W. Dengue epidemic in Thmar Pouk, April-December 2001; disease and its cost in rural Cambodia. Phnom Penh: Médecins Sans Frontières Holland/Belgium, 2002: 30 pp.