Health care delivery in resource limited settings

Elizabeth Molyneux · Forfar & Arneil 7th Edition | Primary health care · IMCI · Human resources · Essential drugs · HIV/AIDS · TB · Malnutrition · ETAT
📌 Key facts: 10 million child deaths/year, 60% preventable with existing interventions. Human resources crisis: Africa needs 1 million more health workers. IMCI, ETAT, EPI, ART, ready-to-use therapeutic food save lives.

📖 Core concepts: delivering child health where resources are scarce

🏥 Human resources crisis
Ratio health workers 10x higher in Europe vs Africa. 1 million additional workers needed in Africa. Task shifting: clinical officers, CHWs, nurses take on doctor roles.
📋 IMCI strategy
Integrated Management of Childhood Illness: improve case management, health systems, family/community practices. Reduces costs and improves outcomes.
⚡ ETAT (Emergency Triage & Treatment)
WHO ETAT reduces inpatient mortality from 11-18% to 6-8% using triage (P: pneumonia, D: dehydration, S: shock, etc.).
💊 Essential interventions
Immunization (EPI, GAVI), vitamin A, zinc, co-trimoxazole prophylaxis for HIV, ART, insecticide-treated nets, ready-to-use therapeutic food (RUTF).
🌍 Sector-wide approach (SWAp)
Donor basket funding to Ministry of Health. TEHIP Tanzania: 40% reduction under-5 mortality ($1 per person).
⚠️ Major killers: Pneumonia (19%), diarrhea (18%), preterm (10%), asphyxia (8%), neonatal sepsis (10%). Undernutrition underlies >50% deaths.

🔍 Health systems approach for resource-limited settings

1
Assess the health system level – Village health post (CHW), health center (nurse/clinical officer), district hospital (first referral), tertiary hospital (specialist).
2
Use syndromic management where labs unavailable – IMCI flowcharts for pneumonia, diarrhea, malaria, malnutrition, measles. No need for chest X-ray or blood culture.
3
Prioritize high-impact, low-cost interventions – Oral rehydration, exclusive breastfeeding, vitamin A, immunization, ITNs, co-trimoxazole for HIV-exposed infants.
4
Implement emergency triage (ETAT) – Identify emergency signs (obstructed breathing, shock, coma, convulsing, severe dehydration) and treat immediately.
5
Address human resources creatively – Task shifting: train community health workers for malaria rapid tests, family planning, pneumonia antibiotics.
6
Strengthen supply chain – Essential medicines list (WHO), avoid donations of unknown drugs, revolving drug funds, GAVI/Global Fund support.
📌 Clinical pearl: In a child with cough and fast breathing, treat as pneumonia with oral amoxicillin. No need for chest X-ray. Fast breathing threshold: ≥50/min (2-12 months) or ≥40/min (1-5 years).

📋 Stepwise clinical & public health management in low-resource settings

1
Triage (ETAT) – Airway, breathing, circulation. Emergency signs: cyanosis, severe respiratory distress, shock, coma, severe malnutrition with shock.
2
Treat main presenting illness using IMCI – Classify as pink (urgent referral), yellow (specific treatment), green (home care).
3
Severe acute malnutrition – F-75 then F-100 or RUTF (plumpy'nut). Manage hypothermia, hypoglycemia, infection, electrolyte imbalance. WHO 10 steps.
4
HIV care – Co-trimoxazole prophylaxis for all HIV-exposed infants from 6 weeks; early infant diagnosis (PCR); ART when eligible (CD4 or clinical stage).
5
Malaria – RDT if available; artemisinin combination therapy (ACT) for uncomplicated; IV artesunate or quinine for severe.
6
Neonatal care – Kangaroo mother care for preterm/low birth weight, chlorhexidine cord care, antibiotics for possible serious bacterial infection.
7
Prevention – Vaccination (EPI schedule: BCG, DTP, HepB, Hib, PCV, rotavirus, measles). Vitamin A supplementation (6-59 months).
⚠️ Key ETAT emergency signs: obstructed breathing, severe respiratory distress, shock (cold hands, prolonged capillary refill, weak pulse), coma, convulsing, signs of severe dehydration.

🧠 Reflex prompts: practicing in resource-limited settings

🏥 A child presents with lethargy, fast breathing, and chest indrawing. IMCI classification?
Severe pneumonia (pink classification) → urgent referral, first dose antibiotic, treat for hypoxia if possible.
💊 What is RUTF and why is it revolutionary?
Ready-to-use therapeutic food (plumpy'nut) – peanut-based, high-energy, no water needed, home-based therapy for severe malnutrition. High recovery rates.
🩸 A 9-month-old with severe anemia (Hb 3 g/dL) and malaria. Immediate steps?
Check for shock, transfuse blood if unstable, IV artesunate, screen for heart failure. Malaria endemic area → assume malaria.
👶 HIV-exposed infant, 6 weeks old. What prophylaxis is recommended?
Co-trimoxazole started at 6 weeks to prevent PCP and bacterial infections. Also early infant diagnosis (PCR).
📉 What is the 90/10 divide in research?
Only 10% of research funding goes to low-income countries where 90% of preventable child deaths occur.
🚑 A child with severe dehydration (sunken eyes, slow skin pinch). Immediate management?
IV Ringer’s lactate or normal saline 100 ml/kg, half over 6 hours. If able to drink, ORS by mouth.
🌍 Why do user fees in health care harm the poor?
User fees are a barrier to care (inverse care law). WHO recommends tax-based financing or social insurance; many countries have abolished fees.
💉 EPI vaccines – which are pentavalent?
DPT-HepB-Hib (diphtheria, pertussis, tetanus, hepatitis B, Hib). Cost 10x higher than DPT; GAVI supports financing.