DEPARTMENT OF PUBLIC HEALTH   CONTENT 1. Introduction 2. Focus on PROJECTS Publications in international peer-reviewed journals Other publications and abstracts

	1. Introduction The Department of Public Health strives to contribute to the world-wide development of effective and efficient health care systems, assuring equity, quality, participation and sustainability. To achieve this the Department has adopted an integrated strategy in which teaching, research and technical assistance mutually interact. Each of the three units, Nutrition and Child Health, Public Health, Epidemiology and Disease Control, embodies specific technical expertise, particularly with respect to teaching. The research of the Department, however, is managed in task-oriented groups involving one or more units, and other departments from within or outside the ITM. Research priorities are primarily based on the relevance for health care systems in the developing world, the objectives and values contained in our mission statement, and the pursuit of added value or innovation in international health policies. Oriente, Ecuador: Discussion between a doctor of the health centre and a scientific research team. The scientific audit in 2001 showed the high relevance and quality of our teaching, but we are determined not to become complacent. Our teaching cannot be separated from research, capacity strengthening and international policy development, but remains (certainly when measured in terms of time) our primary task. More information can be found in the general chapter on Education. Local and institutional capacity strengthening are also essential components in all our projects, which always involve national institutes or organisations. This perspective is described in the chapter on Development Co-operation. The research and services of our department were evaluated as “good” overall, but the Scientific Advisory Board formulated valuable recommendations to enhance our focus, coherence and international visibility. Over the past year, we have further concentrated our research along four, partially overlapping lines: accessibility, quality, disease control and health policies. Clearly, all activities of the department have policy-oriented objectives and include to some extent the three other elements as well. A major challenge for the coming years is to strengthen our research matrix in such a way that local, national and international activities become seamlessly integrated and mutually reinforcing. In any case, our impact on international health policies will remain deeply rooted in the realities of the field and the true needs of the populations. Surveying data collected for the Unmet Obstetric Need study in Matlab, Bangladesh. Access to Care Lack of accessibility is perhaps the most fundamental health care problem in developing countries. There are multiple, often combined causes for this: services are too far apart or physically unreachable; for many people, they are unaffordable due to extreme poverty; social and cultural factors may restrict their attractiveness; often, the offer is of such poor quality that people opt for other channels. In 2002, the departmental research in this field concentrated primarily on the financial accessibility of health services at the primary and secondary levels. A main collaborative action-research line concerns mutualist health financing systems in sub-Saharan Africa, including Guinea Conakry, Mali, D.R. Congo, Uganda and Senegal. This work examines the conditions under which mutualist insurance and financing systems can be harmoniously developed, and what resistance such processes encounter. We are also developing a growing network with other researchers and institutions working on this issue. Together with several Belgian university groups, we initiated a new “Belgian Platform on Accessibility to Health Care”. A broad international network makes it possible to formulate, refine and test research hypotheses about mutualist systems in the field. International IMMPACT Team on the occasion of the inauguration of the IMMPACT project in Burkina Faso. With a project on “Health Equity Funds”, we started a second major research line on financial accessibility. These funds finance health care for the poorest citizens, comparable to the social safety nets in industrialised countries. Among other efforts, the Department supports the conceptualisation and monitoring of this strategy in a promising experiment being conducted by regional health services and Médecins sans Frontières in Cambodia. Together with other partners, we are investigating the perspectives of similar initiatives elsewhere, including Africa. Quality and Human Resources Advertisement for Mutual Health Organisations – Bobo-Dioulasso,Burkina Faso. Quality and Human Resources Health care must be available and accessible, but it must also be of adequate quality. Quality of care requires sound technical, clinical, managerial and operational standards, but also – and perhaps most importantly – well-trained and motivated staff. Insufficient and unequally distributed human resources, inadequate training and support, low salaries and poor motivation are crucial factors in the failure of many health care systems to respond to the needs of the population. Ecuador: Meeting between the mayor of an Indian community and those in charge of the Macas district health. Quality management techniques are not easy to apply in the health sector, particularly under such conditions. Joint research on the impact of organisational culture on quality management in Niger, Zimbabwe, Guinea and Morocco identified a number of critical problems and factors. For improving efficiency and acceptance, a professional and flexible approach appears to generate better results than “bureaucratic” methods with standardised procedures. Another research line attempts to identify the conditions under which “family medicine”, emphasising professional quality of care, can give a new impetus to primary health care concepts, with case studies in Cuba, Mali, South Africa and Thailand. Advertisement for condoms on the road Ouagadougou – Bobo-Dioulasso, Burkina Faso. Quality of care is also addressed in relation to specific target groups. A research project on “Prevention of mother-to-child HIV transmission and care of HIV-infected children” deals with the operational effectiveness and problems of short-course antiretroviral therapy in services in South Africa, Tanzania and Mozambique, and explores the implications for human resource management. A research project on “Near-Miss Audits” studies the operational handling of severe obstetrical problems through investigations of the survivors, and develops this method for identifying bottlenecks and potential quality improvements in maternal health care. Capacity building at all levels of the health system is an ever greater necessity, compounded by the AIDS epidemic and to some extent even the international responses to it. A study of strategies on stewardship and capacity building (“Strengthening capacities and new challenges in public health”) began in 2002 with a literature review and the documentation of capacity building mechanisms in a number of developing countries. Bolivian women preparing the village fête. Integration and Disease Control In this research field we concentrate on tuberculosis, TB-HIV co-infection, “neglected diseases” and interventions with micro-nutrients as well as on strengthening partner institutions in the South. The Department renewed its research efforts on the epidemiology and control of tuberculosis. A collaborative study was completed on the role of independent pharmacists in tuberculosis treatment in Cochabamba, Bolivia. We are working on a literature study on the frequency of re-infection versus relapse as a cause of TB recidivism, in particular in HIV-seropositive persons. The Department also started an ambitious network project on quality assurance in tuberculosis care at the clinical, laboratory and organisational levels, in collaboration with partners in Peru, Bolivia, Cuba and England. Together with the University of Cape Town and Médecins sans Frontières, we set up a study on integrated control and care of AIDS and tuberculosis in South Africa. In Bolivia, we provided support to the development of a laboratory network for HIV surveillance. TB ward in Sotnikum hospital, Cambodia. Responding to the scientific audits in 2001, and to increasing internal demand, the institute analysed the priorities of its research on sleeping sickness, leishmaniasis and other neglected diseases. One outcome is that the Department will expand its operational research on the control of these diseases within the interdepartmental working group “Neglected Diseases´ (see Focus on and the chapter “Department of Parasitology”). We have already started a retrospective study of urban sleeping sickness and a case-control study of risk factors in Kinshasa, D.R. Congo. In collaboration with the World Health Organisation, we have initiated comparative cost-effectiveness studies of different control strategies. In Nepal we completed a research project on leishmaniasis, focusing on the validation and comparison of existing and new diagnostic tests. Follow-up research on recent epidemics of Viral Haemorrhagic Fevers (Marburg virus in Watsa, D.R. Congo and Ebola virus in Masindi, Uganda) concentrated on the clinical and serological evolution of survivors. Water transport, rural Thailand. In our nutritional research, we successfully concluded two controlled clinical studies on micro-nutrients in Cochabamba, Bolivia (in collaboration with the University of San Simon) and in Lima, Peru (with the University Cayetano Heredia). In Tanzania, we compared the impact on the bio-availability of iron and zinc in children with an optimised supplementary diet and those with a normal diet. Other research looked into the impact of the mother’s pre-natal nutritional status on the post-natal development of the child. The departmental and institutional focus on comprehensive care and disease control culminated in the International Colloquium “Integration and Disease Control” (see Focus on), which updated the debate about integration within an international context of “neo-verticalism”. Transport of suger cane, Cambodia. Health policies As recommended by the Scientific Advisory Board, we are increasingly seeking to valorise our local work on the international level. The Antwerp Institute strongly advocates the development of accessible, efficient health care systems as a universal right and as the basis for sustainable disease control. Together with many partners, we will raise our voice in the current international context of targeted disease control, guided by economic and political arguments. Our international congresses “Health Care for All” (2001) and “Integration and Disease Control” (2002) made it clear that many health workers, scientists and authorities in developing countries share this view, but often go unheard in the North. Together we will try to steer “global initiatives” towards the strengthening of primary health care. At the request of the Belgian Ministry of Development Co-operation we began a critical study on the recent proliferation of international “public-private partnerships” and related decision-making processes. Our health policy research also focuses on a number of specific themes and target groups. A collaborative programme on “Safe Motherhood” seeks effective strategies to reduce maternal mortality and severe obstetric morbidity, effectively relating research results to policymaking. Other studies relate to the “nutritional transition” problem, as developing countries are increasingly confronted with changing disease patterns due to changing diets. In child health, we are searching for new policies for monitoring and improving development in young children, capitalising on our successful 2001 Colloquium “Growth and development in under-fives”. Several health policy projects are closely related to changing socio-economic circumstances. In Cambodia and China, we started investigating the evolution of hospital management during the transition from a centrally planned to a market economy. Comparable work is being done on the impact of economic liberalisation on health systems in Latin America and, in another context, on increasing efficiency in the public health system of Cuba. In Jordan and other countries we are attempting to study and improve the relation between the health sector and the government. Finally, the Belgian Ministry of Social Affairs is also using our international expertise in the establishment of locally co-ordinated health care systems in our own country. Thus, we come full circle: the principles and values of accessible, efficient quality health care are indeed universal. The IMMPACT Team.
	2. FOCUS ON: International Colloquium « INTEGRATION AND DISEASE CONTROL » Antwerp 26-28 November 2002 Our annual colloquium was held from 26 to 28 November 2002 at the Fortis Bank in Antwerp and attended by 193 participants, 40% of whom came from developing countries. The theme was ´Integration and Disease Control´, with emphasis on the role DC health services play in disease control. During the academic session, a number of representatives from major organisations (WHO, GAVI, The Global Alliance for TB Drug Development) explained how and to what extent they contribute to strengthening health systems. The Director of the ITM pointed out that vertical programmes frequently fail because they do not make any structural contribution to the development of health care systems. The representative of Secretary of State Boutmans (Belgian Development Cooperation) also indicated that an integrated disease control policy is a conditio sine qua non. The WHO pleaded for a more pragmatic approach to the entire problem. Instead of emphasising ideological differences between horizontalists and verticalists, we must find structural solutions to achieve an integrated control policy. The ´Global Alliance for TB Drug Development´ stressed the importance of ´public-private partnerships´. During the colloquium, a conceptual framework presented by the Department of Public Health was further elaborated on. The guiding principle for integrating disease control must be the improvement of quality and accessibility of care. Much more than complete programmes, we must integrate activities into the basic health system, but only when it is right to do so. However, relatively well-functioning health services have to be in place before they can cope with the integration of activities. Taking the context into account, as well as adopting a pragmatic approach, always remains necessary. Integration also implies that it must be possible to make decisions at more peripheral levels, something which is not always acceptable to programme managers at central level. Prof. G. Kegels, chairman of the meeting. Health economists should not be allowed to decide independently about the nature and desirability of a health programme. Their contribution lies more in estimating the cost of interventions. Given the current emphasis on fighting malaria (resistance), AIDS (antiretroviral drugs) and TB (multidrug resistance), it is clear that much more money is needed than has been made available thus far. We must therefore abandon the customary and implicit rule of thumb that 3 US$ per capita is the maximum that can be spent on health care. And so the key question remains: how can we ensure that funds keep coming in? Another discussion topic was evaluation. Previously the emphasis was on impact and cost-effectiveness. Currently the focus is on the process of strengthening health services, on the one hand, and output measurement, on the other. We urgently need indicators which accurately reflect the ´performance´ of basic health services. The ultimate objective however must be: how can we objectively demonstrate that health services work properly? Finally, access was also discussed during this colloquium. Besides the fact that more money is needed, several speakers pointed out that the patient now generally pays for his essential health care, which leads to financial exclusion in some countries. If there is no access to health care, how can the ideal of ´Health Care for All´ be realised? And if for some ´Health for All´ remains the objective, everybody agrees that you cannot achieve one without the other. 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.