This study evaluated hospital demographics, staffing, pharmacy variables, health care outcomes measures (severity of illness-adjusted mortality rates, drug costs, total cost of care, and length of stay) and medication errors. A database was constructed from the 1992 American Hospital Association's Abridged Guide to the Health Care Field, the 1992 National Clinical Pharmacy Services database, and 1992 mortality data from the Health Care Financing Administration. Simple statistical tests and a severity of illness-adjusted multiple regression analysis were employed. The study population consisted of 1116 hospitals that reported information on medication errors and 913 hospitals that reported information on medication errors that adversely affected patient care outcomes. We evaluated factors associated with the 430,586 medication errors and 17,338 medication errors that adversely affected patient care outcomes. Medication errors occurred in 5.07% of the patients admitted each year to these hospitals. Each hospital experienced a medication error every 22.7 hours (every 19.73 admissions). Medication errors that adversely affected patient care outcomes occurred in 0.25% of all patients admitted to these hospitals/year. Each hospital experienced a medication error that adversely affected patient care outcomes every 19.23 days (or every 401 admissions). The following factors were associated with increased medication errors/occupied bed/year: lack of pharmacy teaching affiliation (slope = 0.8875, p=0.0416), centralized pharmacists (slope = 1.0942, p=0.0001), number of registered nurses/occupied bed (slope = 1.624, p=0.032), number of registered pharmacists/occupied bed (slope = 25.0573, p=0.0001), hospital mortality rate (slope = 2.8017, p=0.0192), and total cost of care/occupied bed/year (slope = 0.01432, p=0.0091). Factors associated with decreased medication errors were location in the Mid-Atlantic census region (slope = -1.5182, p=0.03), affiliation with a pharmacy teaching program (slope = -1.0252, p=0.0349), decentralized pharmacists (slope = -0.9843, p=0.0037), and number of medical residents/occupied bed (slope = -1.478, p=0.0014). There was a 45% decrease in medication errors (1.81-fold decrease) in hospitals that had decentralized pharmacists, compared with hospitals that had centralized pharmacists. In addition, there was a 94% decrease in medication errors that adversely affected patient care outcomes (16.88-fold decrease) in hospitals that had decentralized pharmacists compared with hospitals that had only centralized pharmacists. Based on previous field studies and our findings in 1116 hospitals, it appears that one of the most effective ways to prevent or reduce medication errors is to decentralize pharmacists to patient care areas. The results of this study should help hospitals reduce the number of medication errors that occur each year.
This paper discusses urban services finance in the Latin American context of rapid urbanization, severe fiscal constraints and democratization of administrative systems. Analyzing the situation in thirteen different countries, it draws several conclusions which may be helpful in the design of new lending operations. The report's main theme is that the World Bank's approach to the urban sector needs to be re-directed. The structure of the report is as follows: first it reviews the rising demand for urban services, noting the positive correlations of rapid urban growth with national development, but also the corresponding, incremental fiscal pressures. The macro-economic constraints to urban expenditures are summarized and the adverse circumstances limiting new capital formation and service provision in Latin American cities is mentioned. The report also discusses whether Latin American governments are truly decentralizing and reviews the strategies to relieve the fiscal gap of subnational governments, including changes in the existing systems of revenue sharing, reassignment of public service functions, pricing adjustments, deregulation or privatization of certain services, technical assistance, and restructuring of institutional credit. The main findings and recommendations are organized according to three main groups: country concerns; theoretical concerns; and operational concerns. The text is accompanied by three case studies in Argentina, Brazil and Mexico.
The paper provides a brief overview of the problems of physical agricultural marketing infrastructure in Africa, with particular reference to rural roads and marketing facilities, such as storage, processing and market centres. In order to overcome these constraints, it is necessav to strengthen macro policy changes, with particular reference to commodity marketing, rural finance and government decentralization policies with the obiective of providing more incentives to marketing enterprises and local authorities to promote infrastructure development. Changes in macro policies have to be supported by adequate training programmes, support to institution building and adjustment of aid strategies to encourage self-help in developing marketing infrastructure.
In Burundi, the intestinal parasite, Schistosoma mansoni, inhabits the waters of the Rusizi Plain (1 of the worst affected areas), the Capital Bujumbura, the Imbo-Sud, and around Lake Cohoha. It continues to cause illness in these regions. In 1985, the Lutte Contre la Schistosomiase project implemented a control program in these regions, chiefly involving chemotherapy. In addition, the European Development Fund had financed integration of safe water supply and environmental sanitation efforts into the program. To further reduce the incidence of schistosomiasis, the control program has introduced a training program for auxiliary health workers and health education campaigns. These efforts assist the program in decentralizing schistosomiasis control to health services and communities. Auxiliary health workers in primary schools, health centers, and subcommittees for sociosanitary development are responsible for educating the public about schistosomiasis. Program workers have developed educational material which allows the educators to address consistent messages to all audiences yet also allows for flexibility. The material consists of posters demonstrating how the disease is transmitted and other preventive measures, a film on schistosomiasis control, and a flip chart. Eventually health centers will be responsible for epidemiological surveillance of schistosomiasis. Communal subcommittees for sociosanitary development play an important role in informing local authorities of needed actions to control the disease and in setting priorities.
A complete proof is given of global convergence to zero of the prediction error and asymptotic optimality for a direct adaptive controller is established based on multistep quadratic cost minimization with a receding horizon philosophy. The only substantial assumptions are that the controller designed when the parameters are known, stabilizes the plant and the exact knowledge of the first N y (N y -optimization horizon) impulse response coefficients of the plant. The technical hurdles for the development of a comprehensive convergence theory of this type of controller are also highlighted.
Abstract The different forms of privatization all imply some diminution of the state's role in the provision, financing or regulation of welfare. Privatisation does not simply mean the sale of public assets and greater reliance on private enterprise and competitive markets; it also means the transfer of welfare responsibilities from the state to the voluntary and informal sectors. This is partly an ideological issue, concerning the state's relationship with individual citizens and social groups, and partly a matter of practicalities. Welfare pluralism implies a less dominant role for the state in the provision (as opposed to the financing and regulation) of welfare services: its major themes are decentralization and participation. Some doubt is cast on the capacity and the desirability of the informal and voluntary sectors substituting for the state in social service provision. The family is undergoing substantial changes which may reduce its capacity to provide care and, at the same time, the number of dependents is increasing. The voluntary sector is beset with problems of uneven and incomplete coverage, equity, fragmentation and accountability. The chief consequence of welfare pluralism has been the rapid development of the commercial sector.
Abstract Thailand's public health system is in transition, reflecting the economic status of the country. The decentralized system has made great strides in improving the health of its people. But paradoxes exist. While some urban areas have an oversupply of CT Scanners, rural villages still cope with hygiene‐related illnesses. Malaria and Yellow Fever no longer dominate health resources. Now AIDs, heart disease and accidents top the problem list. Like other countries, Thailand also struggles with health financing to address the unmet needs.
Abstract The public sector in Latin America has been characterized by the proliferation of national semi‐autonomous bodies known as ‘decentralized agencies’. This article focuses on such agencies in Colombia from the 1960s onwards. Attention will be paid to their institutional proliferation and how this affected local government, particularly in the fields of water and sanitation. Such changes in state organization have not been problem free. The growth of ‘decentralized agencies’ has been associated with problems of inefficiency, administrative confusion and problems of social and political unrest. Indeed, such contradictions have resulted in the issue of decentralization being placed on the political agenda and the development of innovative and administrative reforms that could breathe new life into local government.
Evaluating decentralization in terms of three economic criteria - social efficiency, technical efficiency, and equity - the paper argues that some decisionmaking (about finance and teacher recruitment) should be provided for at the local level, and some (about school organization and curriculum) at the regional level. A system of central government grants should be used to correct problems of equity and inefficiency inherent in a decentralized system. Little is known about the economic and educational consequences of decentralization, despite a wide variety of country experiences. The effects of decentralization are difficult to isolate, so scholars have focused instead on issues of implementation.