The Future: Research and Information Needs
A few fundamental and urgent needs must be met as a prerequisite to improving understanding of district hospitals in low-and middle-income countries, although tackling these issues may be far from simple:
developing and accepting meaningful performance indicators in conjunction with developing appropriate standards of care
collecting higher-quality routine data from district hospitals
improving understanding of the costs and health consequences of different, evidence-based, service provision portfolios proposed for district hospitals and improving understanding of the marginal benefits of incremental additions and their implications for planning infrastructure and estimating human resources and technology needs.
A solution to the first issue would perhaps pave the way for and enhance the value of further focused research in a number of areas.
Implications of a Changing Disease Spectrum
In many middle-income and some low-income countries, the demographic transition to noncommunicable diseases—notably cardiovascular, smoking-related, and malignant diseases—will have considerable implications for the hospital sector. Thus, hospital costs likely will rise as older patients with chronic diseases become an increasing proportion of inpatients (Barnum and Kutzin 1993). In some cases, the relative cost-effectiveness of hospital care will improve compared with further expansion of primary or preventive services that incur increasing marginal costs (Barnum and Kutzin 1993).
More immediately, in low-income countries in Africa, the massive impact of the HIV pandemic is most easily seen in the continent's hospitals. Bed occupancy is rising, and hospital stays appear to be lengthening, as an increasing proportion of hospital admissions, now over 50 percent in some countries' medical wards, have HIV-related disease (Mpundu 2000). Those diseases associated with HIV infection, notably tuberculosis, and changing demands for care, such as the need for palliation, may change not only the workload but also the nature of the demands placed on the service. The advent of antiretroviral therapy, which might ameliorate some of these problems, will itself place great demands on the hospital service provision mechanisms. With or without new drugs, HIV will continue to tax both planners, who have to respond to a rapid change in needs, and health care financing. Research that permits hospitals to tackle these new challenges and develop efficient and cost-effective strategies to provide care for HIV-related disease while preventing a decline in care standards for HIV-uninfected patients is a high priority.
Accounting for Case Mix and Case Severity When Measuring Hospital Performance
Overall inpatient-fatality rates and case-fatality rates of different common diseases are often included in district hospital performance measures. These are crude measures unless some adjustment is made for case mix when describing inpatient fatality and for severity of illness when describing case fatality. Alternatively, hospital outcomes should perhaps be replaced as key indicators of performance by carefully chosen process indicators, which are likely to be more generalizable tools of performance monitoring that offer the advantage of specifically identifying areas that require improvement (Lilford and others 2004).
Implications of Emerging and Existing Technologies
Technology has had an enormous effect on the amount of information available to clinicians and managers in industrial countries, from new rapid diagnostic tests to automated stock-checking and ordering procedures. A particularly exciting potential in developing countries may be the ability to undertake and interpret many diagnostic tests remotely, thereby enabling district hospitals to operate without a skilled diagnostic staff on site. It also seems probable that appropriately targeted technology could have a major effect, not least in the generation, communication, and analysis of hospital use, cost, and outcome data, without which the health system cannot identify and respond to needs.
Interventions That Improve Performance
Interventions aimed at improving hospital administration and clinical management at the district hospital level warrant investigation. For clinical management, interventions such as clinical guidelines, supervision, and feedback; audit and continuing professional development; quality improvement strategies and accreditation; and improvements in referral and integration with PHC may improve district hospital performance and be relatively cost-effective. Such interventions deserve attention, along with more traditional research aimed at optimizing treatment of specific diseases.