- Email: [email protected]
BCG vaccination in Spain
377
threefold to KSh 300 000 per hospital for the third quarter of 1992. Current monthly FIF revenue represents an increase of 45 % over the non-staff, non-drug operating budget for the hospitals, and substantial funds are being generated for primary health care. All FIF revenue remains at the local level to improve the quality of existing services: 75% is retained by the facility itself and 25% is for primary health care (PHC) activities. Facility funds have been used for items such as restoration of operating theatres to service, over
renovation of inpatient wards, redecoration of outpatient areas, and keeping radiography units functioning. PHC funds have been used for activities such as maintaining the vaccine cold chain, combatting local disease outbreaks, and district training programmes. Contrary to published assertions,3 user fee revenue has not reduced central government allocations. Actual Ministry of Health recurrent expenditures have risen each year, increasing from 112 million Kenya pounds (currently about US$64 million) in 1988/89 to an estimated 146 million Kenya pounds in 1991/92. PHC expenditures have risen by 30% over this period. Ministry expenditures as a percentage of Government of Kenya expenditures have risen from 7-6%
to over
annual decrease in incidence of 8%.5 Prospective data for all paediatric hospitals show a steady reduction in the incidence of tuberculous meningitis in children aged 0-4 years-from 21 cases in 1977 (5-09 per 100 000) to only 2 cases in 1991 (1-12 per 100 000). We found a close correlation between the observed incidence of tuberculosis meningitis and mean ARI (r=0-9156, p<00001). The relation between drop in tuberculous meningitis and BCG vaccination cover suggests that BCG suppression has not substantially changed the risk of tuberculous meningitis in children under 5 years of age in Barcelona. BCG vaccination does not greatly modify the epidemiology of tuberculosis; by contrast, correct administration of chemotherapy does do so.6 The problem of tuberculosis in Spain results from incorrect chemotherapy over the past 30 years. At present antituberculous treatment has been put in general practitioners’ hands, most of whom have little experience of this treatment. Dispensario
de Enfermedades del Torax,
C/Torres Amat, 1, 08001 Barcelona, Spain
P.
DE
MARCH-AYUELA
8-5%.
Thus, Kenya’s user fee programme has developed operating strategies which include 100% local retention of revenue; additivity of funds to Treasury allocations; graduated fees to encourage cost-effective utilisation; vigorous pursuit of insurance reimbursement; a functional waiver and exemption system; and a performance-oriented approach to management. Phased introduction of fee changes and strengthening of FIF management has led to a striking increase in revenue and steady progress. Importantly, the programme now enjoys general acceptance and credibility among patients, health staff, and the general public. Development of the FIF has been facilitated by the financial and policy support of USAID, the World Bank, and other donors and by the technical support of Management Sciences for Health and African Development and Economic Consultants. Ministry of Health, Nairobi, Kenya
D. M. MBITI F. A. MWORIA I. M. HUSSEIN
1. Government of Kenya. Kenya National Development Plan, 1989-1993. Chapter 10, section 10.3, the health system; and section 10.4 health objectives and strategies. Nairobi: Government of Kenya, 1993. 2. Moses S, Marji F, Bradley JE, Nagelkerta NJD, Malisa MA, Plummer FA. Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet 1992; 340: 463-66. 3. Epstein PR, Coultas L, Kenya: cost-recovery programme. Lancet 1991; 337: 1467-68. 4. Health Care Financing Secretariat. Facility improvement funds status report. Nairobi: Ministry of Health. April 15, 1992.
BCG vaccination in
Spain
SIR,-Dr Martinez (Dec 12, p 1475) disagrees with the view of the national consensus for the control of tuberculosis in Spain that routine BCG vaccination is not justified.l He says that the overall annual incidence for respiratory tuberculosis was 21per 100 000 for 1991, which is higher than in previous years, and believes that the Spanish authorities should not have discontinued BCG vaccination. Martinez does not indicate that the last notification from the Spanish health authorities to the WHO in 1974 of 3131 patients with respiratory tuberculosis (rate 8-8 per 100 000) was regarded as unreliable.2 Since then notification has become more accurate and in 1986 an increased rate of 35was recorded. Nevertheless, the actual incidence in Spain is much higher, as demonstrated by the rates of 40 per 100 000 in 1991 detected by the Sociedad Espanola de Patologia Respiratoria and 67in the city of Barcelona.3 Much more important is the fact that the highest percentages of tuberculosis of 24-7% (90 per 100 000) and 27.4% (124-6 per 100 000) have been recorded in the 25-34 year age group in Spain and Barcelona, respectively. BCG efficacy varies between 0 and 80%,4 and the vaccine has no protective effect against tuberculosis infection. Our results differ from those of Dr Schwoebel and colleagues (Sept 5, p 611) in France. In Barcelona province BCG vaccination was stopped in March, 1974. The annual risk of infection (ARI) could be calculated, and had fallen to 0 113% by 1991, with an
1.
2.
3.
4.
5. 6.
de Trabajo sobre Tuberculosis Consenso Nacional para el Control de la Tuberculosis en España. Med Clin (Barc) 1992; 98: 24-31. Bulla A. Revision de la morbilidad y de la mortalidid por tuberculosis en el mundo (1967-1971-1977) basada en las informaciones officiales. Bull Int Un Tuberc 1981; 5693: 121-27. Cailà JA, Jansà JM, Iglesias B, Plàsencia A, Diez E. Programa de prevenciòn y control de la tuberculosis de Barcelona: resultados del año 1991. Barcelona: Institut Municipal de la Salud, 1992. Fine PEM, Rodrigues LC. Mycobacterial diseases. Lancet 1990; 335: 1016-20. March-Ayuela P de. Choosing an appropriate criterion for true or false conversion in serial tuberculin testing. Am Rev Respir Dis 1990; 141: 815-20. Styblo K. Overview and epidemiologic assessment of the current global tuberculosis situation: with an emphasis on control in developing countries. Bull Int Un Tuberc Lung Dis 1988; 63: 39-44.
Grupo
Maasai diet SIR,-Professor McCormick and Dr Elmore-Meegan (Oct 24, p 1042) imply that there has been no relevant research on the Maasai diet. This is
not so. As I noted previously,! data are available. Of special importance is the report by Bekure et al.2Our own research on rangeland productivity3 shows that maizemeal has been a steadily increasing component of the Maasai diet in Kajiado district since at least the 1960s. There is about an 8/1calorie gain: selling a kilogram of liveweight beef, netting about 1000 calories, will purchase 8000 calories of maizemeal. The group ranch areas of Kenya in Kajiado (excluding towns) contain more than twice the population that can be supported by the traditional milk-based diet
(meat and, in caloric terms, blood
were
never
substantial
proportions). The areas of Southern Narok district (Loita) are less densely populated. Tanzania, with ten times the rainfall per caput of Kenya, will be under much less pressure to change, although the situation near the border must be similar to neighbouring areas of Kenya. It would be helpful to know the meaning of "main items of diet" in McCormick and Elmore-Meegan’s survey. Is this list generated from responses to a general question, or has it been ranked in terms of, for example, calorie intake? Without that information, the data they provide are not very useful. In the group ranches of Kajiado more than half the calories in the average Maasai diet come from starch (mainly maize). It will be somewhat less than that in less densely populated areas (Kajiado group ranch areas have about 10 people per square km; Southern Narok about 6). Further research would certainly be useful, but should be quantified more than McCormick and Elmore-Meegan suggest. If their raw survey data can be studied to infer calorie intake, and if it indicates location (so that population density can be estimated), I would like to analyse the original data. PO Box 42493, Nairobi, Kenya
GORDON W. BROWN
1. Brown GW. Community care in Kenya. Lancet 1991; 338: 1212-13. 2. Bekure S, De Leeuw PN, Grandin BE. Maasai herding: an investigation of pastoral production on group ranches in Kenya. International Livestock Centre for Africa, July 1987. 3. Brown GW. "Rangeland Productivity", CORAT AFRICA, 1991. (A modified version will also be published under the title "An Approach to Development of the Arid and Semi-Arid Areas" in the volume I of the Range Management Handbook of the Ministry of Livestock Development of Kenya).
threefold to KSh 300 000 per hospital for the third quarter of 1992. Current monthly FIF revenue represents an increase of 45 % over the non-staff, non-drug operating budget for the hospitals, and substantial funds are being generated for primary health care. All FIF revenue remains at the local level to improve the quality of existing services: 75% is retained by the facility itself and 25% is for primary health care (PHC) activities. Facility funds have been used for items such as restoration of operating theatres to service, over
renovation of inpatient wards, redecoration of outpatient areas, and keeping radiography units functioning. PHC funds have been used for activities such as maintaining the vaccine cold chain, combatting local disease outbreaks, and district training programmes. Contrary to published assertions,3 user fee revenue has not reduced central government allocations. Actual Ministry of Health recurrent expenditures have risen each year, increasing from 112 million Kenya pounds (currently about US$64 million) in 1988/89 to an estimated 146 million Kenya pounds in 1991/92. PHC expenditures have risen by 30% over this period. Ministry expenditures as a percentage of Government of Kenya expenditures have risen from 7-6%
to over
annual decrease in incidence of 8%.5 Prospective data for all paediatric hospitals show a steady reduction in the incidence of tuberculous meningitis in children aged 0-4 years-from 21 cases in 1977 (5-09 per 100 000) to only 2 cases in 1991 (1-12 per 100 000). We found a close correlation between the observed incidence of tuberculosis meningitis and mean ARI (r=0-9156, p<00001). The relation between drop in tuberculous meningitis and BCG vaccination cover suggests that BCG suppression has not substantially changed the risk of tuberculous meningitis in children under 5 years of age in Barcelona. BCG vaccination does not greatly modify the epidemiology of tuberculosis; by contrast, correct administration of chemotherapy does do so.6 The problem of tuberculosis in Spain results from incorrect chemotherapy over the past 30 years. At present antituberculous treatment has been put in general practitioners’ hands, most of whom have little experience of this treatment. Dispensario
de Enfermedades del Torax,
C/Torres Amat, 1, 08001 Barcelona, Spain
P.
DE
MARCH-AYUELA
8-5%.
Thus, Kenya’s user fee programme has developed operating strategies which include 100% local retention of revenue; additivity of funds to Treasury allocations; graduated fees to encourage cost-effective utilisation; vigorous pursuit of insurance reimbursement; a functional waiver and exemption system; and a performance-oriented approach to management. Phased introduction of fee changes and strengthening of FIF management has led to a striking increase in revenue and steady progress. Importantly, the programme now enjoys general acceptance and credibility among patients, health staff, and the general public. Development of the FIF has been facilitated by the financial and policy support of USAID, the World Bank, and other donors and by the technical support of Management Sciences for Health and African Development and Economic Consultants. Ministry of Health, Nairobi, Kenya
D. M. MBITI F. A. MWORIA I. M. HUSSEIN
1. Government of Kenya. Kenya National Development Plan, 1989-1993. Chapter 10, section 10.3, the health system; and section 10.4 health objectives and strategies. Nairobi: Government of Kenya, 1993. 2. Moses S, Marji F, Bradley JE, Nagelkerta NJD, Malisa MA, Plummer FA. Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet 1992; 340: 463-66. 3. Epstein PR, Coultas L, Kenya: cost-recovery programme. Lancet 1991; 337: 1467-68. 4. Health Care Financing Secretariat. Facility improvement funds status report. Nairobi: Ministry of Health. April 15, 1992.
BCG vaccination in
Spain
SIR,-Dr Martinez (Dec 12, p 1475) disagrees with the view of the national consensus for the control of tuberculosis in Spain that routine BCG vaccination is not justified.l He says that the overall annual incidence for respiratory tuberculosis was 21per 100 000 for 1991, which is higher than in previous years, and believes that the Spanish authorities should not have discontinued BCG vaccination. Martinez does not indicate that the last notification from the Spanish health authorities to the WHO in 1974 of 3131 patients with respiratory tuberculosis (rate 8-8 per 100 000) was regarded as unreliable.2 Since then notification has become more accurate and in 1986 an increased rate of 35was recorded. Nevertheless, the actual incidence in Spain is much higher, as demonstrated by the rates of 40 per 100 000 in 1991 detected by the Sociedad Espanola de Patologia Respiratoria and 67in the city of Barcelona.3 Much more important is the fact that the highest percentages of tuberculosis of 24-7% (90 per 100 000) and 27.4% (124-6 per 100 000) have been recorded in the 25-34 year age group in Spain and Barcelona, respectively. BCG efficacy varies between 0 and 80%,4 and the vaccine has no protective effect against tuberculosis infection. Our results differ from those of Dr Schwoebel and colleagues (Sept 5, p 611) in France. In Barcelona province BCG vaccination was stopped in March, 1974. The annual risk of infection (ARI) could be calculated, and had fallen to 0 113% by 1991, with an
1.
2.
3.
4.
5. 6.
de Trabajo sobre Tuberculosis Consenso Nacional para el Control de la Tuberculosis en España. Med Clin (Barc) 1992; 98: 24-31. Bulla A. Revision de la morbilidad y de la mortalidid por tuberculosis en el mundo (1967-1971-1977) basada en las informaciones officiales. Bull Int Un Tuberc 1981; 5693: 121-27. Cailà JA, Jansà JM, Iglesias B, Plàsencia A, Diez E. Programa de prevenciòn y control de la tuberculosis de Barcelona: resultados del año 1991. Barcelona: Institut Municipal de la Salud, 1992. Fine PEM, Rodrigues LC. Mycobacterial diseases. Lancet 1990; 335: 1016-20. March-Ayuela P de. Choosing an appropriate criterion for true or false conversion in serial tuberculin testing. Am Rev Respir Dis 1990; 141: 815-20. Styblo K. Overview and epidemiologic assessment of the current global tuberculosis situation: with an emphasis on control in developing countries. Bull Int Un Tuberc Lung Dis 1988; 63: 39-44.
Grupo
Maasai diet SIR,-Professor McCormick and Dr Elmore-Meegan (Oct 24, p 1042) imply that there has been no relevant research on the Maasai diet. This is
not so. As I noted previously,! data are available. Of special importance is the report by Bekure et al.2Our own research on rangeland productivity3 shows that maizemeal has been a steadily increasing component of the Maasai diet in Kajiado district since at least the 1960s. There is about an 8/1calorie gain: selling a kilogram of liveweight beef, netting about 1000 calories, will purchase 8000 calories of maizemeal. The group ranch areas of Kenya in Kajiado (excluding towns) contain more than twice the population that can be supported by the traditional milk-based diet
(meat and, in caloric terms, blood
were
never
substantial
proportions). The areas of Southern Narok district (Loita) are less densely populated. Tanzania, with ten times the rainfall per caput of Kenya, will be under much less pressure to change, although the situation near the border must be similar to neighbouring areas of Kenya. It would be helpful to know the meaning of "main items of diet" in McCormick and Elmore-Meegan’s survey. Is this list generated from responses to a general question, or has it been ranked in terms of, for example, calorie intake? Without that information, the data they provide are not very useful. In the group ranches of Kajiado more than half the calories in the average Maasai diet come from starch (mainly maize). It will be somewhat less than that in less densely populated areas (Kajiado group ranch areas have about 10 people per square km; Southern Narok about 6). Further research would certainly be useful, but should be quantified more than McCormick and Elmore-Meegan suggest. If their raw survey data can be studied to infer calorie intake, and if it indicates location (so that population density can be estimated), I would like to analyse the original data. PO Box 42493, Nairobi, Kenya
GORDON W. BROWN
1. Brown GW. Community care in Kenya. Lancet 1991; 338: 1212-13. 2. Bekure S, De Leeuw PN, Grandin BE. Maasai herding: an investigation of pastoral production on group ranches in Kenya. International Livestock Centre for Africa, July 1987. 3. Brown GW. "Rangeland Productivity", CORAT AFRICA, 1991. (A modified version will also be published under the title "An Approach to Development of the Arid and Semi-Arid Areas" in the volume I of the Range Management Handbook of the Ministry of Livestock Development of Kenya).