Despite the popularity of quality improvement collaboratives (QICs) in different healthcare settings, relatively little is known about the implementation process. The objective of the current study is to learn more about relations between relevant conditions for successful implementation of QICs, applied changes, perceived successes, and actual outcomes.Twenty-four Dutch hospitals participated in a dissemination programme based on QICs. A questionnaire was sent to 237 leaders of teams who joined 18 different QICs to measure changes in working methods and activities, overall perceived success, team organisation, and supportive conditions. Actual outcomes were extracted from a database with team performance indicator data. Multi-level analyses were conducted to test a number of hypothesised relations within the cross-classified hierarchical structure in which teams are nested within QICs and hospitals.Organisational and external change agent support is related positively to the number of changed working methods and activities that, if increased, lead to higher perceived success and indicator outcomes scores. Direct and indirect positive relations between conditions and perceived success could be confirmed. Relations between conditions and actual outcomes are weak. Multi-level analyses reveal significant differences in organisational support between hospitals. The relation between perceived successes and actual outcomes is present at QIC level but not at team level.Several of the expected relations between conditions, applied changes and outcomes, and perceived successes could be verified. However, because QICs vary in topic, approach, complexity, and promised advantages, further research is required: first, to understand why some QIC innovations fit better within the context of the units where they are implemented; second, to assess the influence of perceived success and actual outcomes on the further dissemination of projects over new patient groups. QICs bring together 'groups of practitioners from different healthcare organisations to work in a structured way to improve one aspect of the quality of their service. It involves them in a series of meetings to learn about best practices in the area chosen, about quality methods and change ideas, and to share experiences of making changes in their own local setting' . Anotherentation .The current study intends to contribute to a better understanding of the processes and outcomes of QIC implementation in the context of a change programme for 24 Dutch hospitals based on 18 QICs. This programme--a multi-level quality collaborative--is aimed at organisational development and the dissemination of healthcare innovations . It is tThis study aims to answer two questions: to what extent do expected relationships between conditions, applied changes, and outcomes of QIC-implementation exist; and can differences in conditions and outcomes be explained by the fact that the teams belong to different QICs and hospitals?This study focuses on relations between relevant conditions for successful QIC implementation, on changes in working methods and activities, and on patient-related outcomes. In opposite order, the outcomes involve perceived project successes and actual progress made in the area of patient safety and logistics. Changes in working methods and activities have to do with all the new or intensified efforts taken by the teams on behalf of their project. The literature on the implementation and dissemination of innovations in health service organisations contains many descriptions of success conditions, linked to the tasks and responsibilities of the actors involved in QIC efforts ,16. An ie.g., business unit or corporation), and who manage their relationships across organisational boundaries' [This affects the teams joining a QIC. Cohen and Bailey defined a team as 'a collection of individuals who are interdependent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems  the number of applied changes is hypothesised to be influenced by the presence of the right conditions and (B) an increase in the number of applied changes has a positive effect on the outcomes, it is logical that (C) the presence of the conditions is expected to be positively related to the outcomes of the implementation:Hypothesis C: a positive relation exists between conditions and outcomes.A final assumption has to do with the relation between perceived and actual project outcomes. If an outcome indicator shows that a project's main topic is improved, a project leader is more likely to be positive about the success of the project. Or conversely, if the team leader has a tendency to think more positively about the result, this may have influenced his or her behaviour in such a way that it actually contributed to a higher level of improvement.Hypothesis D: a positive relation exists between perceived and actual outcomes.The total study population consists of 168 teams from 24 hospitals and 18 QICs. Project teams from three hospital groups started, one group after the other, in October 2004, October 2005, and October 2006, with the implementation of the six types of QIC projects as described in Table Two data sources were accessed to gain information on six variables that were used for the purpose of statistical modelling. The QIC team leaders served as a first data source. In January 2006, 2007, and 2008, the team leaders received a questionnaire at the end of the first year of implementation and were asked to rate the overall success of their project on a scale from zero (min) to ten (max). Other questions reflected relevant conditions for successful implementation. Principal component analysis showed that several of the items measured with the questionnaire  cluster together into three constructs, resembling the categories described in the introduction: organisational support, team organisation, and external change agent support  that the data collection burden for participating hospital staff was to be minimised. Therefore, the central database was the sole source for team performance indicators. Spreadsheet files with team monitoring data were provided three times by the change agency approximately six months after the end of the first implementation year . These data were used in the analyses that are described later. Project indicators were: prevalence of pressure ulcers (pressure ulcers), prevalence of wound infections (postoperative wound infections), access time for outpatient appointments in days (waiting lists), throughput time for diagnostics and treatment in days (process redesign), and percentage of allocated time actually used (operating theatre productivity). Three types of medication-safety projects had their own indicators: percentage of unnecessary blood transfusions, intravenous antibiotics, or patients with a pain score above four. Medication-safety scores were calculated using the first and last 20 patients treated. Pressure ulcers, operating theatre productivity, and waiting-list project results were based on the change between the scores of the first and last two months. In the case of process redesign and postoperative wound infections, the project period was compared to an identical period in the past.e.g., breakthrough--is based on feedback [The change percentages in this study were converted into a three-point scale: 1) at least 10% worse than before, (2) neutral, and (3) improved by at least 10%. Compared to goals such as 30%, 40 to 90% and 50% improvement , one due to differences between QICs (level two), and one due to differences between hospitals (level three). In the model, the hypotheses were tested in a three-level cross-classified structure as depicted in Figure All analyses were performed using MLwiN software version 2.02. Estimation method was iterated generalised least squares (IGLS) .A total of 168 team leaders, belonging to 23 hospitals  and 18 QICs, filled out the questionnaire (71% response rate). Table The information presented in Table As well as the average changes in activities, the percentage of teams (with data available) experiencing an improvement in the performance indicator by at least 10% also differs between the six project types. This criterion is met by 70% of the pressure ulcer teams (reduction of pressure ulcers), 100% of the medication safety teams, 12% of the operating theatre teams , 56% of the wound infections teams, 83% of the process redesign teams (throughput times for diagnostics and treatment), and 46% of the waiting list teams (access time).To learn more about the process and outcomes of QIC implementation, the four hypotheses were tested using multi-level analyses. In Table Hypothesis A concerns the relation between the three conditions and the number of changes teams applied. The association between organisational support and external change agent support and the number of applied changes is confirmed to be significant (p < 0.001). An increase in organisational support or external change agent support is accompanied by an increase in the number of applied changes. The relation between team organisation and the number of applied changes is insignificant. The multi-level model reveals that organisational support differs significantly between hospitals: 18% of the variance is situated at hospital level. Hypothesis B concerns the effect of applied changes on project outcomes. An increase in the number of applied changes is verified to have a positive effect on perceived success (p < 0.001) and indicator outcomes (p < 0.05). Hypothesis C involves the direct relation between conditions and outcomes. In the case of organisational support and perceived success, and team organisation and perceived success, a positive correlation was found of 0.29 (p < 0.001) and 0.30 (p < 0.001), respectively. The relation between external change agent support and perceived success is not significant (p > 0.05), similar to the relation between the three conditions and actual outcome (p > 0.05). In addition to these test results, a two-tailed Sobel Test was conducted to determine whether the relation between the support conditions and both outcomes is mediated by the number of applied changes . PartialIn this article, a model was tested to gain a better understanding of the QIC black box. The study objective was to answer two questions.The analysis resulted in several findings, contributing to a better understanding of the implementation process that took place in the context of the multi-level quality collaborative.First, when a team leader is more positive about organisational and external change agent support, this has a positive effect on the number of intensified or new working methods applied by the team. Second, a higher number of applied changes has a positive influence on the degree of perceived success and actual outcomes. Third, positive relations between perceived success and organisational support and team organisation could be confirmed. The direct connection between actual outcomes and the three conditions is insignificant. Moreover, the relation between perceived success and organisational support and external change support is partly mediated by the number of applied changes. With regard to the degree of actual success, a similar mediation effect could be verified with 90% certainty.Finally, the association between actual outcome and perceived success is insignificant at team level but strong at QIC level. The high correlation between perceived and actual success at QIC level indicates that teams who joined a QIC, in which the perceived success ratings of team leaders are high, have also relatively high performance indicator scores.The multi-level model adds an important dimension that would have been overlooked in a single-level approach. Judgements on external change agent support and team organisation and actual outcomes do not seem to differ between hospitals, but organisational support does. Not one of the conditions differs at QIC level. In the case of external change support, this is particularly interesting because this condition represents the core of the QIC. Apparently, there are no differences in external change agent support between QICs, while at the same time QICs do differ in the level of perceived and actual success. Nevertheless, the finding that an increase in external change agent support is accompanied by an increase in the number of applied changes confirms the relevance of external change agents within QICs as a mechanism for best practice transfer.A priori expectations and beliefs are confirmed, while evidence that does not support the effectiveness of the QIC method is underweighted or discounted [It was mentioned in the introduction that the evidence on QIC effectiveness is mixed but positive. Mittman explained how subjective ratings provided by collaborative participants and leaders are subject to unintentional and unrecognised biases generated by common human decision and judgment heuristics. In that respect, he exemplified how a combination of expectation biases and belief perseverance produces systematic overweighting of evidence and observations. scounted . This stThe study confirms the association between organisational and external change agent support and the number of changes realised by QIC teams. Hospital managers, project teams, external change agents, and public stakeholders may benefit from the survey instrument, because it potentially provides tangible information, applicable for real-time adjustments or intake procedures.et al. found many studies addressing adoption, implementation, and diffusion, but only a limited number of studies dealing with sustainability [Researchers are in a situation where relevant questions remain unanswered. Generally, the advice to adopt hierarchical models in future research should be taken as seriously, as are recommendations for more experimental , narratinability .The multi-level approach is one of the strengths of this study. Other strengths are that the conditions were measured using a validated and reliable instrument, and perceptions were linked to outcome data. The dependence on data provided by the teams is a limitation. Despite the high response rate, the use of self-reported perceptions always involves a risk of overestimation or social desirability. Outcome indicators could be linked to questionnaire data in 61% of all teams in the study sample. It is very likely that the positive results are overrepresented, particularly because the absence of monitoring data may very well be caused by the fact that teams were incapable of implementing the project (and the required measurements) as planned. In that sense, actual outcomes presented in this article do not entirely represent the overall level of success of the programme.While the vast majority of the projects had a planned length of one year, operation theatre, process redesign, and postoperative wound infections were in fact two-year projects. Because the team questionnaires were administered at a fixed moment by the end of the first year, second-year data on conditions, perceived success, and applied changes are unfortunately unavailable. Hence, for practical reasons, the analyses described in this article are based entirely on first-year data. A potential limitation is that the success level of two-year projects was determined without the project being finished. At first glance, it is reasonable to assume that the improvement rate of those projects is likely to be more positive after two years. A recent evaluation, however, illustrates that the level of improvement has remained the same . An addiFinally, the number of applied changes was modelled without taking into account the influence of individual and key interventions or specific combinations. In reality, some interventions are more time-consuming and complex than others, and some may not even be suited for application within a collaborative .By examining 18 QICs, part of a quality improvement programme for hospitals, several expected relationships could be verified. Organisational and external change agent support had a positive influence on the number of changes applied by QIC teams during the implementation. The number of applied changes had a positive effect on perceived success as well as on actual outcomes. By taking into account the fact that teams are nested in hospitals and in QICs, it became clear that some hospitals are better than others in providing organisational support. Project outcomes differ between QICs. One should be cautious when accepting perceived successes as a proxy for the actual success of individual teams.The authors declare that they have no competing interests.MLAD was responsible for designing the study, acquiring, analyzing and interpreting the data, and drafting the manuscript. PS assisted with the analyses and interpretation of the data. As research manager of the independent evaluation study of the hospital improvement programme, CW was responsible for designing the study. CW and PPG assisted in interpreting the results and revising the manuscript for intellectual content. All authors have read and approved the final manuscript.The purpose of the first pillar was to create awareness and provide room for new paradigms by having authoritative experts from other fields of service delivery and industry communicate appealing approaches and ideas about how to deal with issues of safety, logistics, and accountability in healthcare. Focus was added to national and local discussions on necessary changes.Transparency is thought to guide purchasing decisions and improvement efforts. The second pillar is considered an important step in generating comparative data on healthcare quality. A national set of standardised quality indicators for hospital care has been developed and maintained by the Healthcare Inspectorate .A national programme to stimulate transparency, efficiency, and quality of care was implemented in three groups of eight hospitals between 2004 and 2008, covering approximately a quarter of all hospitals in the Netherlands. This multi-level quality collaborative combined interventions at the bottom and the top of member organisations.At bottom level, physicians, nursing staff, and managers were encouraged to participate in quality improvement collaboratives to continuously improve the quality of their work by trying out interventions using a breakthrough model while being supported by their institution and by external change agents Table .At top level, hospital executives participated in a special collaborative leadership programme . An internal programme organisation was established to monitor the progress of the various programmes. The strategic management was expected to encourage active staff participation  and to s


The aim of this study was to investigate in members of the Chinese community in Melbourne the impact of Mental Health First Aid (MHFA) training on knowledge about mental disorders and on attitudes to people with mental illness. The hypotheses were that at the end of the training participants would have increased knowledge of mental disorders and related treatments, and decreased negative attitudes towards people with mental disorders.Respondents were 108 participants of three MHFA training workshops for the Chinese community in Melbourne conducted by a qualified MHFA trainer. Participants completed the research questionnaire prior to the commencement of the training (pre-test) and at its completion (post-test). The questionnaires assessed participants' ability to recognize a mental disorder (depression and schizophrenia) described in the vignettes, knowledge about the professional help and treatment, and negative attitudes towards people with mental illness.Between pre- and post-test there was significant improvement in the recognition of mental disorders, beliefs about treatment became more concordant with health professionals, and negative attitudes reduced.The MHFA training course for general members of the Chinese community in Melbourne produced significant positive change in the level of mental health literacy and reductions in stigmatizing attitudes. The evidence from this study, together with the accumulated evidence of the benefits of MHFA training in the general Australian community, suggests that this approach should be scaled up to a level where it can have an impact on the whole of the Chinese community in Australia. General community members often have some knowledge about handling common physical health problems, whereas knowledge about mental health problems is much less well developed . The pre"Mental health literacy" refers to knowledge and beliefs about mental disorders which aid their recognition, management or prevention. It includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking . NationaAustralia is a culturally diverse nation - 43% of Australians were born overseas or have at least one parent who was born overseas . In addiPeople of Chinese-speaking background make up 3.4%  of the total Australian population. Overseas and Australian scholars have found that Asians, including Chinese, have a low rate of utilization of mental health services ,13. Factet al [Only a few studies have explored the mental health literacy of Chinese-speaking people. In studies conducted by Parker and colleagues of Chinese-speaking Australians, the researchers found that (1) Chinese tended to deny depression or express it somatically ; (2) Chiet al  supportset al. [et al. [There are also fewer studies exploring the schizophrenia literacy of Chinese-speaking Australian. Klimidis et al.  found th [et al.  found thIn response to the inadequate mental health literacy in Chinese community in Australia, a suitable training program is required for improving the necessary confidence and skills to provide basic help. Mental Health First Aid (MHFA) training is such a program. It was developed on the basis that people with mental health problems can potentially be assisted by those in their social network ,26. The 1) Assess risk of suicide or harm2) Listen non-judgmentally3) Give reassurance and information4) Encourage the person to get appropriate professional help5) Encourage self-help strategiesThe initial letters of these actions constitute the mnemonic ALGEE. The MHFA program has more than 750 instructors delivering training across Australia and there are organizations in 14 countries that have adapted the MHFA Australia program for local use. The training course has been evaluated in various settings, with different samples using a range of methods, including randomized controlled trials, uncontrolled trials and qualitative studies. A review of evaluations of MHFA training has highlighted consistent positive benefits in knowledge, behavior, intentions and attitudes of participants .The benefits of MHFA have been demonstrated in several studies with the general Australian community. However, there has been limited evaluation with immigrant communities. The only study to date has been an evaluation with Vietnamese Australians, which showed improvements in knowledge about mental disorders and reductions in stigmatizing attitudes . There hThe evaluation involved an uncontrolled pre-test post-test design with three training groups. This study was carried out between November 2008 and January 2009.The participants were recruited through a convenience cluster sampling method in three major areas in metropolitan Melbourne where many Cantonese- and Mandarin-speaking Chinese people live: Box Hill and Doncaster, Monash, and Preston. The recruitment was carried out through social services organizations serving the Chinese population in these three areas. Posters in both traditional and simplified Chinese introducing the research were put up on the notice boards of these organizations. Interested potential participants approached the organizations to register for the program, which was delivered free of charge. Selection criteria included: being (1) aged 18 or above, (2) immigrants of Chinese-speaking background who were living in Melbourne, Australia, and (3) able to read and write basic Chinese.The participants were asked to complete a questionnaire on their own at the beginning of the program. Oral consent from participants was obtained prior to filling out the questionnaire, after the participants were made aware that participation in the study was voluntary and would not pose any barriers for them to join the program.This questionnaire covered two categories of information: (1) mental health literacy regarding depression and schizophrenia, and (2) the sociodemographic characteristics of the respondents.et al., [This instrument was adapted from that used by Jorm et al.,  for the The participants were asked, "From the information given, what, if anything, is wrong with Mary/John?" (open-ended question) and "Do you think Mary/John needs professional help?" (yes/no). These questions were followed by lists of professionals, treatments and actions that the person in the vignette might use, and participants were asked to rate each of the items as likely to be "Helpful" or "Harmful." "Neither" was also given as a response option.For depression, there is a professional consensus that GPs, psychiatrists, clinical psychologists, antidepressants, counseling and cognitive behavior therapy are helpful, while for schizophrenia there is a professional consensus that GPs, psychiatrists, clinical psychologists, antipsychotics and admission to a ward are helpful . Thus, fThe questionnaire next assessed stigmatizing attitudes using a social distance scale. Social distance was measured by asking how willing the participant would be to: Move next door to Mary/John; Spend an evening socializing with Mary/John; Make friends with Mary/John; Have Mary/John start working closely with you on a job; Have Mary/John marry into your family. Each question was rated on the following scale: 1. Definitely willing, 2. Probably willing, 3. Probably unwilling, 4. Definitely unwilling. The post-test questionnaire was identical except that the socio-demographic information was excluded. The English version of the scale was translated into Chinese and back translated into English by an experienced professional translator.The training was delivered by a qualified MHFA instructor, who is a mental health professional . The instructor was from Hong Kong and had 4 years experience in teaching MHFA there. The adapted MHFA manual was translated into Chinese by a Chinese psychologist. The training program was conducted in Cantonese and was instantaneously translated into Mandarin.The McNemar test was used for analyzing change in the ability to recognize the disorder and in agreement that the person in each of the vignettes needs professional help. Answers to questions about the helpfulness of various types of intervention and about social distance were scored as scales and changes were evaluated by paired sample t-tests. Statistical data management and analyses of the data were carried out using Statistical Package for Social Sciences (SPSS 18.0 for Windows)Table p < .001 for depression and p = .029 for schizophrenia). Nevertheless, the percentages correctly recognizing the vignettes were far below the results for the Australian population [Some of the respondents did not return the post-course questionnaire and thus there were only 84 responses available for pre-post analysis. The percentage correctly recognizing the disorders in the vignettes are shown in Table pulation .Table Table Table This is the first evaluation of MHFA training with an immigrant group in a Chinese language. Although the results should be regarded as preliminary, they are encouraging. The study found a number of benefits from MHFA training. The training increased participants' ability to recognize depression and schizophrenia in a vignette, altered beliefs about the helpfulness of treatments for mental health problems and decreased stigmatizing attitudes as measured by social distance.et al [At pre-test, it appeared that mental health literacy among the Chinese was low, consistent with the findings of Wong et al ,25. It wDian, which is a psychotic condition without excitation, and Kuang, which is a psychotic condition with excitation [Kuang in particular denoting a sense of unpredictability, dangerousness and bizarre and uncontrollable behaviour. Chinese people perceive schizophrenia very negatively and it is not uncommon for Chinese to deny the existence of psychotic illness and to use alternative more socially acceptable labels to describe a condition [There are some possible reasons for this. First, there is a great deal of personal and social stigma attached to the schizophrenia label in the Chinese community . In Chincitation . These tondition ,32. Thisondition  and limiThese points raise important concerns for the teaching of MHFA and its evaluation in Chinese communities and in other cultural groups. As a training program that originated in English, it is important to play attention to the contextual and cultural differences when adapting the program to another country or culture. Given the negative connotations of traditional Chinese labels for psychotic disorders, particular attention needs to be given to reducing the stigma of these disorders, e.g. by promoting personal contact with a person who has recovered from a psychotic disorder, since contact is known to reduce stigma . In addiThe present study found that MHFA training can improve mental health literacy, which is consistent with the conclusions drawn from a review of evaluation studies on the immediate impact of MHFA training ,29. HoweTo allow comparison across studies, it is important to use the same evaluation questionnaires as used in the earlier studies with English-speaking Australians. However, there are potential limitations to the cultural and language transportability of questionnaires. Subtleties of meaning and cultural factors may have influenced the results of the present study, and thus their interpretation when filling a translated questionnaire.Another limitation is the sample selection, which was chosen for convenience and may not be representative of the broader Australian Chinese community.Finally, the present study was uncontrolled, so we do not know to what extent any changes are due to the passage of time or re-testing with the questionnaires. A randomized controlled study would be the next step, as has been done in the mainstream Australian community.For the Chinese community in Melbourne, MHFA training has been shown to be effective in improving recognition of mental disorders, in reducing negative stigmatizing attitudes and in changing beliefs about the helpfulness of treatment. The evidence from this study, together with the accumulated evidences of the benefits of MHFA training in the general Australian community, suggest that this approach should be scaled up to a level where it can have an impact on the whole of the Chinese community in Australia. Such a scaled up population mental health program should be evaluated over time.The second author was the developer of the Mental Health First Aid course.AYKL co-designed the study and the translation of the evaluation questionnaire, analyzed the data, taught the Mental Health First Aid courses, and wrote the final version of the paper. AFJ designed the English evaluation questionnaire, and co-wrote the manuscript and contributed to the data analysis. DFKW co-designed the study and the translation of the evaluation questionnaire, and contributed to the data analysis. All authors read and approved the final manuscript.


Due to demographic changes and an un-equal distribution of physicians, regional analyses of service utilization of elderly patients are crucial, especially for diseases with an impact like dementia. This paper focuses on dementia patients. The aim of the study is to identify differences in service utilization of incident dementia patients in urban and rural areas.Basis for the analysis were all insured persons of a German Health Insurance fund (the GEK) aged 65 years and older living in rural and urban areas. We focussed on physician contacts in the outpatient sector during the first year after an incidence diagnosis of dementia. Special attention was given to contacts with primary care physicians and neurologists/psychiatrists. The dementia cohort was analyzed together with a non-dementia control group drawn according to age, gender and amount of physician contacts. Uni- and bivariate as well as multivariate analysis were performed to estimate the influences on service utilization.Results show that the provision of primary care seems to be equally given in urban and rural areas. For specialists contacts however, rural patients are less likely to consult neurologists or psychiatrists. This trend can already be seen before the incident diagnosis of dementia. All consultations rise in the quarter of the incident dementia diagnosis compared to the control group. The results were also tested in a linear and a logistic regression, showing a higher chance for persons living in urban areas to visit a specialist and an overall higher rate in service utilization for dementia patients.Because of a probable increase in the number of dementia patients, service provision has to be accessible even in rural areas. Due to this and the fact that demographic change is happening at different paces in different regions, regional variations have to be considered to ensure the future service provision. Accessibility to health services, especially for persons with a disease with such an impact as dementia, is important in order to ensure guideline-orientated diagnosis and optimal therapy.Dementia is a disease with a major impact on patients, relatives and society; and its importance will grow in the future due to demographic changes. In Germany, the population aged 65 years and older consisted of over 15 million persons in the year 2005 . Based on the statistic assumptions, this number will increase to between 21 and 25 million persons  in the year 2050 [Access to physicians is a widely discussed topic. Important barriers to access primary care in Europe were analyzed by Schoen et al., who identified costs for medication and waiting times to see a specialists as well as the time a physician spends with a patients as major influencing factors . Also, tIn Germany, the physician atlas states that general practitioners are found throughout most areas. Regionally, Germany can be subcategorized in federal states (Länder), those in administrative districts (Bezirke), those into counties (Kreise) and those into municipalities (Gemeinden). Counties often include a county seat and a surrounding rural area. On a county level, the service supply is sufficiently given; only in some areas in the north-east an under-supply is noticeable on county level. However, it has to be considered that counties are rather large areas combining more urbanized and more rurally influenced regions with differences in population density and infrastructure. Therefore, it cannot be assumed that the density of general practitioners is equally distributed in a county .The situation regarding specialist care is different. In this publication we focus on neurologists and psychiatrists. While, according o the physician atlas, in most areas there seems to be an oversupply on a county-level, there is region in the federal state Saxony-Anhalt that has an undersupply regarding neurologists and psychiatrists (NPs) . For speDifferences in service utilization for persons living in urban or rural areas have been described, even though studies concerning health care utilization by elderly patients in rural areas, especially by dementia patients, are scarce. One way to determine poor service provision or utilization is to analyze hospital admissions for ambulatory care sensitive conditions (ACSC). The hypothesis is that those admissions could be prevented in a sufficient ambulatory care system. Mobley et al. analyzed all ACSCs in the US, showing that if the degree of poverty for elderly is high in rural areas, those persons tend to have a higher admission rate for ACSCs than their urban counterparts . LaditkaThat service supply is not only a question of the crude distance but also a question of social space is discussed in Castleden et al. study on geographic differences in rural palliative care, identifying a complex combination of distance, location, aesthetics and sites of care in Canada. The authors conclude that the growing elderly population in rural areas leads to difficulties in formal and informal service provision at the end of live, since the modes of transportation and condition of transportation possibilities can differ widely .There is few research published focussing especially on service utilization by patients with dementia. Morgan et al. describe a rural and remote memory clinic for Canada, after reviewing existing studies showing limited access availability for services, problems concerning transportations and distances . In anotEspecially for elderly and patients with dementia, regional differences in nursing care availability are also of importance. Rothgang et al. found various differences in the supply of nursing facilities (ambulatory as well as stationary) between federal states and rural and urban areas in Germany . This clWhen evaluating health behaviour in rural areas, one faces the problem of defining "urban" and "rural". While this is already a difficult task for one specific region or country, it is hardly possible to find a common international standard; i.e. a rural area in Germany has to be discussed differently than rural areas in larger countries like the USA, Canada or Australia.Castleden et al. describe in their introduction the geographic point of view, identifying rurality as a socially and culturally constructed phenomenon, and list a number of studies focus on inequalities in services provision, health behaviour and rural lifestyles ,18.Other than the theoretical side of "urban" and "rural", it is crucial to find an empirical definition for analysis. Various factors can be considered, such as population density, absolute number of inhabitants, distance to nearest agglomerated area, infrastructure of transportation, etc. This problem has been pointed out before .In this paper, we use the municipality types defined by the Federal Institute for Research on Building, Urban Affairs and Spatial Development (BBR) (see methods section).To interpret the utilization patterns of the patients, information on the German health insurance system is necessary. In Germany, next to the hospital sector there is an independent outpatient/ambulatory system. Physicians in the hospital sector are not working in ambulatory care and vice versa. The ambulatory sector consists of physicians working alone or in group offices. Usually, the primary care physician is the person first contacted by patients, but he does not have a gate-keeper function, all patients can contact physicians of any specialization at any time. A fee of 10 Euros has to be paid for each quarter for ambulatory care; to avoid paying this fee at each consultation, a referral is needed.Based on this background, this study aims to evaluate the actual ambulatory medical services utilization of dementia patients in the German Statutory Health Insurance in the year before and after the diagnosis of dementia in rural and urban areas. Since studies in this area are scarce, especially in Germany, our study tries to fill this gap. We assume that the service utilization, mainly for specialists care, is lower in rural areas. An overall analysis of the service utilization with no geographic focus has already been made with these data .The analyses are based on the population of the GEK, a German nationwide health insurance fond insuring about 1.7 million people in 2007). We selected all persons who were at least 65 years old and were continuously insured in the GEK from 2004 to 2006. To ensure incident cases of dementia, a person must not have a diagnosis of dementia in at least all four quarters of 2004 and must have three diagnoses in following four consecutive quarters. The observational period covers the incidence quarter and the year before and after. To ensure that a consultation was made due to the dementia diagnosis, a control group was formed with a 4:1 matching with the criteria age, sex, and number of contacts with physicians four quarters before the Q5 (incidence quarter for the dementia patients). The selection of patients and controls has been described more extensively elsewhere [07. We seTo identify possible rural and urban differences in service utilization, therapy, morbidity or mortality we created a regional variable. Due to data protection policies, the current living address of the insured persons is not part of the data. We therefore used the "Siedlungsstrukturellen Gemeindetypen" . Through datasets offered by the German Post office and the Federal Statistical Office we created an assignment table that enables to match postal codes with the municipality types. This data was processed by the GEK to maintain the anonymity of each person so that eventually every person was categorized into a municipality type . The 17 categories are sub-categorized into the three groups "agglomerated area", "urbanized area" and "rural areas, though an ordinal scale is not given. We re-classified them into rural and urban; the categories 1 through 7, 9 and 10 were classified as being urban, 8 and 11 through 17 were classified as being rural.To determine the utilization of health services, we included all contacts the persons had in ambulatory care in the year before and after the first diagnosis of dementia for the dementia group and the corresponding 8 quarters for the control group, respectively. We analyzed visits to a) all physicians, b) primary care physicians (PCP) and c) neurologists and psychiatrists . A contact is defined as a consultation of one physician, if that specific physician was contacted more than once during the quarter, every visit was counted. To evaluate how many different physicians were contacted, we also included the number of contacted physicians in our analysis. To analyze the effects on health care utilization, we also adjusted for other individual characteristics in multivariate linear and logistic models.Local ethical committees approved the study. All statistical analyses were performed with SAS (Version 9.2) and R.Table Figure th quarter (approx. one year after diagnosis). Without reaching the level of statistical significance, this tendency demonstrates that persons living in and rural environment could not consult physicians as often as patients in urban areas. This effect is not observable for the control group.No significant differences were found between patients with dementia in rural or urban setting, even though the differences between the two groups grow until the 8Subsequently, we analyzed the utilization in a more detailed way; focussing on the number of contacts with PCPs and NPs Figure .While the same rise in consultations of PCPs by dementia patients in Q5 and before is visible similar to the amount of physician contacts, there is no significant difference between the urban and the rural population. In fact, persons living in a rural environment seem to visit a PCP a little bit more frequently than their urban counterparts. A very different tendency can be found concerning the visits to NPs Figure . There tIn a next step we further analyzed how many different physicians were contacted by the insured persons (not shown as a figure). In this analysis, it does not matter how often one specific physician was seen during the quarter. These physicians again include all PCPs as well as all specialists, serving as an indicator of the persons overall health care utilization; i.e. if regular general check-ups, eye-exams, orthopaedic or urologic/gynaecologic visitations are made. Here the familiar increase in Q5 in the dementia group is also noticeable. The people living in urban areas visit more different physicians than people living in rural environments. In the dementia group, this difference is strongly visible in the quarters after diagnosis; however, it is not statistically significant. For the control group, significant differences between urban and rural persons are noticeable throughout the whole observational period.To control for individual factors, we performed multivariate regressions. For the number of physician contacts a linear regression (response variable: number of contacts) and the consultation of a NP a logistic regression (response variable: person visited a NP: yes/no). The control variables in both regressions were: age, sex, nursing care dependency, community setting and dementia yes/no. Both regressions refer to the Q5 and the Q7. In the Q5, the service utilization differed a lot from the quarters before, so we chose to analyze the Q7 which gives information on service utilizations after the "impact" of the first diagnosis. The Q7 therefore shows a more "regular" service utilization for the patients with dementia already visible in the graphs shown before. Table It can be seen that the major influences on the number of consultations are nursing care dependency, being responsible for 3.7 additional visits within the incidence quarter, and the diagnosis of dementia with 2.5 additional visits, respectively. All other parameters show statistical significance due to the high number of persons in the sample, but do not show a major influence on the number of consultations. The results do not differ between the diagnosis quarter and half a year after diagnosis in most variables. The only factor that is not significant in the incidence quarter but half a year after is the community setting, although compared to the values of dementia and nursing care dependency, the estimate is rather low.Table The largest influence on a NP consultation is the dementia diagnosis in the quarter of the first diagnosis. Those patients have a 8.4fold chance to visit a NP compared to the control group. While age reaches the level of statistical significance, it does not influence the NP visit noticeably, overall the younger patients have a greater chance to visit a NP. Other than in the linear regression on all physician contacts, the regional variable is important for the NP visits even under the control of other factors. Persons living in urban surroundings have a significantly higher chance (of about 43%) to visit an NP compared with their rural counterparts in the incidence quarter this chance persists over the following quarters.Our analysis identified differences in utilization of ambulatory medical services between urban and rural dementia patients. While urban patients visit more NPs in the year before and after the first dementia diagnosis, rural patients tend to contact their PCP more often but less NPs. Even after controlling for age, sex and the existence of nursing care dependency, the chance to visit an NP is much lower in the rural population than in urban persons. These finding are not in line with the results of Donath et al., who did not find major visit frequency differences between rural and urban dementia patients besides the use of imaging techniques of the diagnosis, which were more often applied for urban dementia patients. They analyzed the referrals to specialists, and did not find any differences between the urban and rural population . An explThe lower utilization in rural areas can have various reasons we can only speculate about. Several factors have been identified in the literature. First of all, the distance to the service provider can be far and the transportation difficult for patients as for carers . IndividAnother reason for different service utilization can be a different lifestyle and beliefs in rural areas, including a stronger sense of community which could result in more personal assistance and less professional consultations. Also, social stigmatization of mental diseases has to be taken into account. This might lead to less service utilization because a patient might not want to address mental problems. It can also lead to a later diagnosis or no diagnosis at all, since physicians might not be comfortable to address existing problems ,21. StilRemarkably, half of the incident cases with contact to a NP had several contacts in the year after the incidence quarter . For these continuous utilizers, the NP is obviously taking over permanent care and co-treatment function, a phenomenon not found in the control sample. These continuous utilizers are more often urban inhabitants. Only 57.3% of all rural patients visiting an NP in the quarter of incidence still visit a NP four quarters later (compared to 72.9% in the urban sample). This can partly explain the growing decrease in utilization between urban and rural regions as seen in Figure Our study identified differences in urban and rural service utilization in dementia patients in specialist consultations, not for primary care. It is based on a secondary data analysis of health insurance claims data and therefore has some limitations. Due to data validity, we included only dementia patients insured over the whole study period which might lead to the exclusion of some patients, especially those who died within the year after the first diagnosis of dementia. Also, the regional differentiation of residence is only possible according to rural and urban, an exact position of the patient on the map is not possible because of data privacy. An analysis of variations between different urban or different rural areas is therefore not possible. Also, the data is collected for financial purposes and therefore does not include more variables on the socio-economic background of the insured persons. I.e., some studies in the US found racial differences in service provision ,22. Yet,Regional variations between urban and rural persons with dementia do exist, especially concerning specialists treatment after the incident diagnosis of dementia. In further research, the focus should lie on the consequences - it has to be addressed if less resource utilization leads to a lack of treatment and a worse course of disease or if the PCPs in rural areas compensate the lack of specialists. So the question if more service also leads to more health needs to be addressed. Another question would be the closer analysis of the influence of the socioeconomic and cultural background on service utilization. All this could help health services research, local policy makers and communities to inform about and help accessing an optimal health care for dementia patients.GG received funding to analyse data of several health insurance companies, for instance the GEK. All other authors declare that they have no competing interest.DK performed statistical analysis and wrote the main body of the text; ME contributed to the study design and revised the article, HK contributed to the interpretation, GS performed statistical analysis and revised the paper, SS contributed in data management and statistical analysis, BW contributed in the conception of the cohort and statistical analysis, GG was responsible for the acquisition of data and study conception and HvdB contributed to study design, writing text and interpretation. All authors have read and approved the final manuscript.


Vedas. It seems to have been the world view of its time, although subsequently the world view of this knowledge base shrank to India alone and India remained its sole custodian till the end of the 20th century. Because of its unique pro-nature vision, Ayurveda once again is gaining global relevance. This new upsurge of interest in Ayurveda and its rapidly increasing public use has given rise to many newer issues and challenges. The public in general, as well as the scientific and professional community, seems to be largely convinced with the rationality and possible scientific validity of the principles and approaches of Ayurveda as a logical life science and as a healing modality. But simultaneously the demand for new scientific evidence for the efficacy, safety and quality of its medications is gaining momentum. Such a demand has motivated a large number of investigators to launch ambitious research and development activities. This is definitely a welcome development.Ayurveda represents the most ancient and classical knowledge base pertaining to life science, health and cure, its antiquity going back to the However, it cannot be overemphasized that ongoing research and development activities do not seem to be based on sound footings. Most of the current R and D programs in this field are still based on the conventional reductionist methodology, which is often applied by molesting the holistic theories of Ayurveda. There is a need to develop new appropriate research methodology for Ayurvedic research through intense interface between Ayurveda and conventional science. It is because of lack of such an appropriate research methodology that Ayurvedic research has not succeeded in yielding any breakthrough in recent years. It cannot be overemphasized that in any research exercise the goal of research should not be compromised to suit the convenience of researching methods.The overall spectrum of contemporary Ayurvedic research seems to include (1) Literary and conceptual research; (2) Clinical and therapeutic research; (3) Drug development research, including standardization of in-use drugs and development of new drugs. In my perception, the only successful component of Ayurvedic research activity during the last five decades has been the literary research conducted by scholars of Ayurveda, including the scholarly works and translations and critical commentaries on Ayurvedic classics in modern languages which made the classical knowledge base accessible to the present generation of scholars and scientists, thereby opening newer vistas of research and development.Science Initiative in Ayurveda.As a matter of fact, now Ayurveda requires two-pronged research enterprise, namely, (1) Research in the science of Ayurveda and (2) Research in the therapeutics of Ayurveda. Till now, the entire effort seems to have been focused on therapeutic research, that too in a halfhearted manner, borrowing abridged methodology without any genuine attempt to develop appropriate new methods specific to the Ayurvedic approach. As a result, the research so done has not proved really rewarding. The former sector, i.e., the research in science of Ayurveda, has remained largely unexplored, although now there is a gradual paradigm shift, which can be visualized in Dr. Valiathan's project on Pratyaksha pramana (direct observation), (2) Anumana pramana , (3) Aptopadesa  and (4) Yukti pramana . This fourfold battery of testing new knowledge is classical of ancient Indian scientific tradition, which seems to be highly contemporary.On the other hand, one should not go with the impression that classical Ayurveda has no evidence base. In fact, Ayurveda has always been evidence conscious, and most of the principles and treatment modalities seem to have been critically tested and validated for the conditions existing in their own time frame. The ancient concept of evidence is based on fourfold testing, viz., (1) The evidence base of contemporary Ayurveda is to be visualized in several forms, including (1) Textual evidence and folklore claims, (2) Experience-based evidence, (3) Longstanding traditional use, (4) Mass acceptability and (5) New scientific evidence. It cannot be overemphasized that in spite of all the strengths of primary evidence, one cannot deny the need to develop new supportive scientific evidence without which contemporary Ayurveda cannot attain the status of a real global science accessible for the larger benefit of humanity at large. WHO also holds a similar view. However, it must be emphasized that fruitful strategies for developing new scientific evidence cannot succeed if traditional primary evidence is ignored. New research is to be planned on the foundations of existing textual and experience-based evidence. The frequently used term "evidence" essentially means a relevant and reasonable proof for a fact or truth; such a proof need not be necessarily in words or terms of today's science alone.The technology for developing new scientific evidence for the validity of a classical fact or concept will have to be created afresh precisely to test the original knowledge without distorting the same to suit the application of the new methodology. Any undue compromise in this regard is unwarranted because Ayurvedic biology and therapeutics are fundamentally different than the contemporary sciences, hence routine modern research methods will prove futile. I personally feel that at present there is more a need of research in developing an appropriate research methodology for Ayurvedic research than actual clinical or therapeutic research in Ayurveda.panchakarma therapy. Panchakarma is the therapeutic technology of samsodhana, while samsodhana is the fundamental therapeutic principle of Ayurveda. According to Ayurveda, the living human body is comprised of innumerable channels, i.e., srotamsi — "srotomayam hi sariram," which functions as a quantized inner transport system of the living body, both gross and subtle, biologic and energetic, as well as tangible and intangible. Because of the ongoing life processes, pollution and breakdown, the srotamsi are inherently prone to lose their integrity and need to be periodically cleansed with the help of appropriate therapeutic technology such as panchakarma. Any research in panchakarma therapy and samsodhana in contemporary perspective needs to develop an appropriate research methodology which may directly throw light on the integrity of srotas function. I wonder if any such study could be done at the level of membrane biology as known in contemporary life science. Whether a samsodhana treatment really improves the integrity of membrane function at the visceral and cellular level will be of real interest. This is important in view of the fact that most of the chronic diseases, including inflammatory and immunological diseases, involve membrane pathology leading to cellular and visceral failure; and in all such cases, samsodhana karma may prove crucial.I would like to illustrate the point through an example of research in rasayana therapy of Ayurveda is primarily linked with molecular nutrition. Ayurvedic rasayana remedies, including achara rasayana, ajasrika rasayana and ausadhi rasayana, seem to work through nutrition dynamics, improving the molecular health (dhatu samya), leading in turn to rejuvenation and positive health (swasthya). In view of such facts, a research programme in rasayana therapy should focus on mechanism studies before proceeding to parametric assessment of the secondary effects, which could be the mixed effect of many associated factors. It cannot be overemphasized that only basic studies may succeed to validate the basic principles of Ayurveda, which would open newer vistas of original research. The secondary therapeutic studies will limit the scope to mere treatment validation, with temporary impact.Similarly tanmatra, tridosa, saptadhatu, ojas, ojabala, baladosa, agni, agnibala, ama, srotas, etc., besides the concept of rasa, guna, virya, vipaka, prabhava of drugs, which projects unique holistic pharmacology and pharmacodynamics of the drugs used in Ayurveda. Such attempts are likely to help developing a new positive approach to drug research, introducing new traits of medications and revolutionizing the entire field of medicine and medical care.On similar lines, urgent action is needed to study the unique concepts of


The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear.We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel , the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018.With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels. The human resources for health (HRH) shortage is estimated at more than 4 million workers globally . The shoSeveral factors contribute to this shortage of health workers. In some countries, underinvestment in training institutions has led to an inadequate supply of professional health graduates -7. MeanwPolicies to reduce HRH shortages include expanding training institutions and providing incentives to improve retention ,15. SuchThe Republic of Zambia is among the countries currently facing an acute HRH shortage. According to the Government of the Republic of Zambia Ministry of Health (MOH), the country is operating with fewer than half the health workforce necessary to deliver basic health services, with even higher vacancy rates in rural areas . Staff-tIn 2005, the MOH initiated a policy reform process to address this critical shortage in the public sector . The ZamOther modelling efforts have been developed to establish optimal HRH staffing levels for planning purposes. As reviewed elsewhere, models are often needs-based, utilization-based, service-target based, adjusted-service-to-target, or health workforce-to-population-based estimates . Models We built an HRH projection model to estimate the size of the government health workforce in 2018. We focused our analysis on four key cadres: doctors, clinical officers, nurses, and midwives. These cadres account for 80% of current clinical staff and 75% of employment targets. We forecasted HRH supply under current conditions and then estimated the effect on the size of the government health workforce by modelling changes in training enrolment, graduation rates, public sector entry rates of graduates, and attrition rates.Our HRH projection model uses Excel  to forecast the annual number of health workers in the public sector workforce for each cadre based on the annual inflows and outflows of each cadre in the public sector health workforce. The annual number of staff leaving the workforce includes the number of health workers going back to school as well as those lost to attrition. Annual attrition is calculated by measuring the size of each cadre before new hires multiplied by the workforce attrition rates for each cadre. The annual inflow of staff is equal to the sum of new hires from training institutions and from abroad. To calculate the number of hires from training institutions in a year, the model multiplies together the number of training institution students in their final year of study from the prior year, the graduation rate for the prior year, and the rate that graduates entered the public sector workforce in the previous year:To avoid overproduction of health workers, the model does not allow the number of health workers in the public sector to exceed the target number for each cadre. If a cadre is expected to reach its target level, the model reduces the number of training enrolment slots in advance of that point so the workforce will meet but not exceed the target number.The model allows the user to establish attrition rates, immigration inflow, training enrolment, graduation rates, and public sector entry rates for each year. We assume that training institution enrolment slots can always be filled with qualified students.Baseline estimates for key staff  come from Ministry of Health payroll data from September 2008 Table  24,25].,25.24,25Training parameter estimates were derived from a 2008 joint Ministry of Health and Clinton Foundation assessment of all 39 medical training institutions in Zambia. The assessment determined graduation rates to be 90-97%, based on available data and interviews with school staff .The same assessment determined that enrolled and registered midwifery training programs require all their students to have nursing professional health diplomas and prior work experience. Additionally, it found 15% of students in the registered nursing program to be former enrolled nurses who left the workforce for further schooling. We use this information to determine the number of nurses who leave the workforce annually to go back to school.For simplicity, we assumed graduates are hired into the public sector and begin working within one calendar year after their graduation year for all cadres. To estimate the proportion of new graduates who enter the public sector, we divided the aggregate number of new hires during the period of January 2007 to February 2008 by the number of graduates from training institutions during the same time period . In ZambWe conducted what-if analyses to estimate the effects of changes in training, hiring, and attrition conditions on the supply of HRH over time. We assumed all changes would take effect by 2010.Under current conditions, the number of doctors, clinical officers, nurses, and midwives in the public sector is expected to increase from 10 679 in 2008 to 14 402 in 2018, or from 44% to 59% of minimum necessary staff--far short of the 24 319 recommended by the government  or because they graduate but will seek employment elsewhere (3054) .We projected the number of key healthcare workers in the public sector under several single-variable (one-at-a-time) intervention scenarios that would take effect by 2010. These included increasing the graduation rate to 100%, increasing the public workforce entry rate to 100%, decreasing voluntary attrition to 0%, doubling training enrolment, and tripling training enrolment Table . By itseHowever, each type of intervention has a different effect on each cadre. For example, decreasing voluntary attrition to 0% has the same impact by 2018 on the number of doctors--who have the highest annual voluntary attrition rate at 3.14%--as tripling training enrolment. Increases in training enrolment have the largest effects for clinical officers, nurses, and midwives who each require only up to three years to train, compared to doctors who require 7 years to train in Zambia.Under the single-variable intervention scenarios, increases in training enrolment were the only interventions with enough potential power to reach public sector staffing targets by 2018. To reach the combined cadre target of 24 319 staff by 2018, training enrolment must grow by a factor of thirteen for medical doctors (from 74 to 960 per year), quadruple for clinical officers (from 155 to 623 per year), triple for nurses (from 1083 to 2924 per year), and grow by a quarter for midwives by 2010 (from 483 to 589 per year). However, in the scenario of only increasing training enrolment, the Government of Zambia could significantly reduce training enrolment from these higher new enrolment levels after it reaches its staffing targets. Once a scale-up of the workforce to staffing targets is completed by 2018 under the training enrolment scenario, the number of new hires only has to equal the number of new exits from the workforce. The equilibrium level of training enrolment necessary to sustain the workforce at the target level once it has been reached is 201 for medical doctors (172% increase over baseline), 204 for clinical officers (32% increase over baseline), 275 for nurses (18% increase over baseline), and 285 for midwives (41% decrease of baseline), assuming no changes to the current hiring and attrition rates.We conducted a four-way what-if analysis to determine which combinations of changes in training enrolment, the graduation rate, the public sector entry rate, and attrition would enable the MOH to reach its staffing targets by 2018. The analysis determined that staffing targets could be reached by 2018 for each rate of attrition, graduation, and public sector entry rate achieved by 2010, as long as there is a large enough accompanying increase in training enrolment by 2010 . However, if attrition is reduced to 0% and graduation and public sector entry is increased to 100% by 2010, the increase in training enrolment required falls to a factor of three (3×) for doctors. As a mid-range scenario, decreasing attrition by five percentage points for doctors could change the necessary training enrolment increase from thirteen times to ten times current levels. Alternatively, the same benefits could be achieved by increasing the combined graduation and public sector entry rate by twenty percentage points.Reducing attrition and increasing graduation and public sector entry rate by 2010 for clinical officers, nurses, and midwives does not have as significant an effect on the required increase in the size of the training enrolment increase as it does for doctors. At current levels of attrition, training enrolment must be increased by a factor of four (4×) for clinical officers, three (3×) for nurses, and two (2×) for midwives by 2010 in order to reach targets by 2018. If attrition is reduced to 0% and graduation and public sector entry is increased to 100% by 2010, the increase in training enrolment required only falls to a factor of three (3×) for clinical officers, two (2×) for nurses, and one (1×) for midwives. In the case of midwives, however, reducing attrition by two percentage points or increasing graduation and public sector entry by fifteen percentage points from current levels by 2010 will enable the MOH to meet midwives staffing targets by 2018 without an increase in training enrolment (1×).If attrition rates were to increase or the graduation and public sector entry rate were to fall over time, it would make reaching doctor targets by 2018 even more difficult. For every increase in the attrition rate by two percentage points or for every drop in the graduation and public sector entry rate by ten percentage points, current doctor training enrolment would have to increase by an additional one hundred to two hundred percentage points to reach staffing targets by 2018. The level by which clinical officer and nurse training enrolment must increase to reach staffing goals by 2018 is also sensitive to increases in the attrition rate or decreases in the graduation and public sector entry rate, but much less so than it is for doctors. Roughly, for every increase in the attrition rate by four percentage points or for every decrease in the graduation and public sector entry rate by fifteen percentage points, there would have to be a one hundred percentage point increase in training enrolment to reach staffing targets by 2018 for both clinical officers and nurses. Increases in attrition or decreases in the graduation and public sector entry rate do not significantly affect the training enrolment needs for midwives to reach staffing goals by 2018.We projected the supply of HRH in the public sector in Zambia from 2008 to 2018 under a number of scenarios. Zambia will not reach target levels for health workers in the next ten years at current levels of training institution enrolment, attrition, and graduation and public sector entry rates, thereby threatening the country's ability to provide adequate and equitable health care delivery to meet its MDGs.Our analysis identified several optimal combinations of changes in training institution enrolment, attrition, graduation rates, and public sector entry rates to enable Zambia to employ its required number of health workers for the public sector by 2018. In any scenario, a significant increase in training institution enrolment is critical for all cadres but midwives; doubling, tripling or even expanding by up to 13 times the current levels of training enrolment is required for doctors, clinical officers, and nurses.Doctors require the largest increase in training enrolment to meet minimum staffing needs within the decade because they have the longest training time. Clinical officers and nurses require significant but much smaller increases in training enrolment (by a factor of four and three respectively). Targets for midwives can be met with either an increase in training enrolment or an intervention that improves retention, graduation, and public sector entry rates. Interventions that improve retention, graduation, and public sector entry rates are not sufficient on their own to reach staffing targets by 2018 for doctors, clinical officers, or nurses, but they can reduce the size of the required increase in training enrolment, especially for doctors.Increasing training enrolment is the most expensive option. It takes several years for training enrolment changes to have an impact on the public workforce. This delay is equal to the length of the training and hiring pipeline for each cadre- the time that it takes for students to be trained, graduate, and enter the workforce. By cadre, the pipeline is eight years for medical doctors, four years for clinical officers, three years for enrolled nurses, four years for registered nurses, two years for registered midwives, two years for enrolled midwives, and three years for direct entry midwives. To increase the workforce in the near future, training enrolment would need to increase immediately. Nonetheless, policies to increase training levels will not address immediate staffing needs, particularly for cadres with the longest pipelines .Policy options could address the duration of the pipelines. Fast-tracked training programs could produce staff more quickly, or new cadres could be created that require less time to train. Decreasing the amount of time that it takes for the MOH to recruit and hire graduates could also reduce the overall pipeline by up to a year.Our model also identified another opportunity to reduce immediate shortages--by reducing the number of nurses who leave the workforce to go back to school to get advanced training. Removing prerequisites to advanced nursing degrees  would reduce back-to-school attrition. Zambia has introduced two such programs already: the direct-entry midwifery diploma and the direct-entry nursing bachelor's degree. The direct-entry midwifery diploma does not require students to have a nursing diploma, and it only requires two years of training compared to one year of training for the registered and enrolled midwifery diplomas. The non-direct entry nursing bachelor's degree requires students to have a nursing diploma (minimum two years training) and two years of nursing experience prior to enrolment, but the direct-entry program requires neither. The direct-entry degree only requires three years of training compared to two years of training for a non-direct entry nursing bachelors.Nurses who leave the workforce to earn higher degrees will not all re-enter the public sector workforce after graduating, as they may choose more lucrative jobs in the private sector or abroad where demand for health workers is high. The estimated rate of retaining the nurses who leave the public sector to go back to school is equal to the graduation rate multiplied by public sector entry rate of each program, currently around 73-79%.The sizes of the training scale-up necessary to reach staffing targets for doctors, clinical officers, and nurses by 2018 are likely unfeasible or prohibitively costly. Therefore, even with significant gains in improving training enrolment, retention, graduation, and public sector entry, Zambia is likely to operate with a shortage of manpower for at least the next decade unless alternative means of addressing this shortage are determined. For example, shifting some clinical tasks from doctors or clinical officers to nurses and midwives could leverage the ability of nurses and midwives to care for significantly more patients in the short run. Clerical and simple clinical work  could potentially be performed by lay health workers. Nurse- and clinical officer-centred care have resulted in good clinical outcomes in Zambia, where these two cadres provided the bulk of paediatric HIV care in a number of primary health care clinics in Lusaka . SimilarIf Zambia increases training enrolment significantly, it is unclear what Zambia would do with a large excess of training graduates once current staffing needs are met. The Philippines has experienced significant economic benefits from the remittances of nurses who emigrate to developed countries, though such a policy would have to be carried out carefully in Zambia so as to avoid the cannibalization of staff hires and the potential for increased outflows from the domestic public sector health workforce due to emigration . AnticipWhile improvements in attrition over time do not have the same benefits on the long-term health workforce as improvements in training enrolment, reductions in attrition will reduce the magnitude of needed training enrolment increases that are required to meet targets--and, conversely, any increases in attrition over time will enlarge the magnitude of needed training enrolment increases that are required to meet targets. Two new government policies have the potential to reduce attrition. Zambia currently requires students in government-supported training institutions to work in the public sector workforce for a specified number of years after graduation under a bond. Efforts to enforce or even expand the time requirement of this policy should reduce attrition of newly hired health workers. Furthermore, the MOH is piloting retention schemes that provide monetary and working environment incentives to keep staff in the public sector, especially in rural areas . ImproviThis study has several limitations. Our intent in this analysis was to suggest training, hiring, and attrition conditions under which the MOH can reach its HRH target in the next ten years. Our conclusions should be interpreted with caution since we do not analyze the feasibility and costs that are associated with each intervention. A study was commissioned by the MOH subsequent to this analysis that examined the feasibility and costs of doubling training institution enrolment for all cadres by 2012 . The finThis analysis assumes an unlimited demand for slots in training institutions. While anecdotal evidence suggests that there is currently a surplus of qualified applicants at the national training institutions, this may change if training institution enrolment were increased dramatically. Adequate preparation in primary and secondary education becomes even more crucial in the preparation of a good supply of eligible and qualified applicants. We also assume the MOH has an unlimited capacity to absorb newly-trained health workers. It is possible that the government will not be able to hire graduates of training institutions at current rates if the number of graduates grows. Historically, international monetary institutions have imposed limitations on the expansion of the public sector workforce in debtor countries . UnforesOur findings are based on a wide range of possible values for training institution enrolment, attrition, graduation rates, and public sector entry rates. Our projections assume the structure of the workforce will remain the same over time and does not incorporate potential changes in productivity such as those from task shifting and skill mix. We make a number of assumptions for the model parameters based on the best available data. As the population of Zambia continues to grow, it is likely that staffing targets will also increase given their rooting in population size; however, we do not update the staffing targets in our analysis to reflect this estimated growth but rather use the current MOH approved established targets for the health cadres. Furthermore, our analysis focused on a ten year horizon. If this time horizon is lengthened or shortened, our results would change.Finally, our analysis suggests a rapid increase in the training enrolment in the next ten years, which could be followed by a large decrease after targets are reached. This would need to be taken into consideration down the road so as to avoid an equally rapid increase in attrition from the workforce as this large group of trainees that graduate in the next ten years retires or leaves the workforce.Closing the gap between the demand and supply of health workers in Zambia requires an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling provides a valuable tool to help policy makers examine how a range of policy options would impact the supply of HRH.Following this analysis, the Government of Zambia called for an increase in current training enrolment by over 90% across all cadres. In May and June of 2008, the Government of Zambia and the Clinton Foundation assessed all 39 of Zambia's health training institutions to develop a full-cost estimate of the needs associated with meeting these expanded targets . The GovAIDS: Acquired immune deficiency syndrome; CHAI: Clinton HIV/AIDS Initiative; HIV: Human immunodeficiency virus; HR: Human Resources; HRH: Human resources for health; MDG: Millennium Development Goal; MOH: Ministry of Health; WHO: World Health Organization;The authors declare that they have no competing interests.MK and KS conceived of the study, guided the analysis, and coordinated the collection of data. AT helped to develop the model, assisted in the collection of data, assisted in the sensitivity and what-if analyses, and helped to draft the manuscript. CS performed the sensitivity analysis and helped to draft the manuscript. EM helped to conceive the design of the study, coordinated the analysis, and helped to draft the manuscript. JL and ML performed the analysis of the training institutions and assisted with the collection of data. All authors contributed to the writing of and approve the content in the final manuscript.


It uses true 3-D visualization and EndoWrist®. It was approved by FDA in July 2000 for general laparoscopic surgery, in November 2002 for mitral valve repair surgery. The da Vinci robot is currently being used in various fields such as urology, general surgery, gynecology, cardio-thoracic, pediatric and ENT surgery. It provides several advantages to conventional laparoscopy such as 3D vision, motion scaling, intuitive movements, visual immersion and tremor filtration. The advent of robotics has increased the use of minimally invasive surgery among laparoscopically naïve surgeons and expanded the repertoire of experienced surgeons to include more advanced and complex reconstructions.The term “robot” was coined by the Czech playright Karel Capek in 1921 in his play Rossom's Universal Robots. The word “robot” is from the check word robota which means forced labor. The era of robots in surgery commenced in 1994 when the first AESOP (voice controlled camera holder) prototype robot was used clinically in 1993 and then marketed as the first surgical robot ever in 1994 by the US FDA. Since then many robot prototypes like the Endoassist , FIPS endoarm  have been developed to add to the functions of the robot and try and increase its utility. Integrated Surgical Systems  redesigned the SRI Green Telepresence Surgery system and created the daVinci Surgical System This has proved to be a breakthrough technology and stood the test of time since its inception.In 1997, Intuitive Surgicals Inc.  came out with their prototype robot called the da Vinci surgical robot. The instruments in laparoscopic surgery are rigid and provide only four degrees of motion as compared to the surgical robot which provides seven degrees, just like the human wrist does, in open surgery. The abdominal wall also adds to this a ‘Fulcrum effect’ which reverses movements for the surgeon in laparoscopic surgery which is eliminated in robotic surgery just a in open surgery.[Advanced laparoscopic surgery has a technically more demanding learning curve as against open surgery. The laparoscopic surgeon must view a distant monitor which provides 2-D vision, leading to a change in the normal hand-eye target axis. The 2-D  surgery. Hence, i surgery. All thes surgery.6 However surgery.–13 The sda Vinci surgical robot is developed and marketed by Intuitive Surgical Inc. . The first machine was setup in Europe in 1997 and the first surgical procedure was reported by Himpens et al in March 1997[The arch 1997 Since itarch 1997S-Type da Vinci [The robotic cart of the da Vinci  approximEach arm has a series of multiple positioning joints and a terminal pivot joint at the attachment with the port allowing easy positioning of the arms during setup and a full range of movement during the surgery. Buttons provided at each joint allow manual adjustment by acting as a clutch, releasing the button locks the arm in place. The central, camera arm is compatible with a standard 12-mm port and the camera unit. The other three arms attach to specially designed 8-mm metal ports supplied with both blunt and sharp trocars. The arms are mechanically and electronically balanced for safety and ease of use. Custom-fitted plastic drapes are available to drape the four arms to achieve sterility, thus, allowing only the sterile ports and instruments in the operating field. The camera system  has a dual lens system with two three-chip cameras and spatially separated within 12-mm casing. Hence, two complete optical systems are incorporated, representing the left and right eyes. The spatial separation of these images projected to the surgeon's eyes in the binocular viewer allows true 3-D image perception at the console. The head end of the cart is fitted with a HD monitor for the benefit of the assistant surgeon and the scrub nurse.A wide variety of instruments  availablThis consists of the binocular viewer of the Insite vision system, the instrument controllers, the system setup and control panels, and five foot control pedals . The conThis is a high resolution endoscope, as mentioned earlier, consisting of two three-chip cameras and two optical channels generating two images delivered to each human eye viewing the binocular viewer . Two ligThe surgeon is seated in an ergonomically comfortable position with the elbows resting on a padded bar. The thumb and index finger of each hand are placed in adjustable loops attached to the master controllers. Approximation of the thumb and index fingers operate the jawed instruments. The multi joint master controls move freely in all dimensions, allowing intuitive control of the instruments and the camera .There are five foot pedals. Starting from the left, the clutch pedal simply disengages the instruments from the controllers, allowing movement of the controllers to an ergonomically satisfactory position without changing the instrument position. The pedal to its right, i.e. the second one, is the camera pedal which when pressed disengages the instrument from the masters and engages the camera allowing adjustment of the camera depending on the need of the surgeon. The next foot switch adjusts focus and is used only initially before the commencement of the procedure normally to focus the telescope vision. The next foot switch is for bipolar coagulation and the fifth pedal is for monopolar cautery .Two panels on either sides of the surgeon, one on the left includes camera and endoscopic calibration and motion scaling; the other on the right hand side controls the system start control, emergency stop control and standby buttons. Pressing the emergency stop button causes the master controllers to immediately disengage. This command can only be re-engaged by pressing the fault override button. In case of need to convert to open, the system can be rapidly disengaged by placing it on standby mode and disengaging the cart after removing the instruments and releasing the arms from the ports and the cart wheeled away from the field. Trained staff can normally achieve this in a matter of approximately two to four minutes.The surgeon sits at the console with elbows resting on a padded bar, forehead placed against a padded bar with eyes comfortably viewing into the binocular viewer, the height of which is adjustable. The hand and finger positioning is as mentioned earlier. The intraocular distance can also be adjusted to suit the individual's needs. The ideal hand positions can be maintained, as the surgery progresses, by using the clutch pedal to reposition the surgeon's arms and hands.This stack has all the features of a standard laparo / endoscopic stack viz: the monitor, a CO2 insufflator, a dual high intensity light source , and a dual CCD camera unit . The features of the camera unit and light source are as already mentioned.The robotic system start up sequence includes a self test that takes approximately one minute. The arms are draped thereafter, normally by two personnel, one being the scrub nurse and the other the OR assistant, who is not scrubbed, with practice, this usually takes less than 10 minutes. Once the camera and endoscope have been connected it needs to be calibrated. The system goes in to the standby mode by default. Now the patient has to be placed in the position desired and only then can the robotic ports be placed and the arms attached to start the procedure. Any movement of the operating table after the arms are fixed to the ports are contraindicated and can be extremely dangerous.Once the arms are in place and the full range of movement of each arm is confirmed the desired instruments are placed by the scrub nurse or assistant surgeon through the ports in the operating field. The surgeon takes his position at the console and the ready button is pressed. As described earlier, the surgeon places his fingers in the adjustable loops and head in the binocular view and begins performing the surgery. An infrared sensor at the head pad engages the instruments and the camera just like pressing the ready button does.The system is also incorporated with an audio intercom system which enables the surgeon's voice to be heard in the OR loud and clear, enabling the surgeon to keep looking in to the viewer and still talking to the assistants at the patient side. The other facilities included are an endoscopic cardiac stabilizer, ultrasonic instrumentation and the Gyrus plasma kinetic dissector. Needless to say, a large operating room is essential to house the robot and its components along with the routine equipment in the present day mini/invasive OR setup.More than 1000 systems have now been setup across the globe, a majority of them being in the USA. The system was designed for use in minimally invasive surgery. However, it can be used for open surgery as well. The robot has been used until now mainly by urologists, general surgeons, cardiothoracic, gynaecologists and paediatric surgeons.It is best suited for mini-invasive surgeries, especially those which are seemingly impossible or very difficult to perform with conventional laparoscopic techniques. Procedures like cholecystectomy, Nissens' fundoplication, adrenalectomy, rectopexy, cardiomyotomy, hernia repair and bariatric surgery were developed to be performed with standard instruments with the robotic technology.–22However, it is important to identify the right indications for the use of the robot simply because of the cost factor as of today. Hence, it is prudent to classify the indications as follows,Surgeries improved with the robot- radical prostatectomy, radical cystectomy, pyeloplasty, partial nephrectomy, ureteric reimplantation, major hepatectomy, spleen preserving pancreatectomy, esophagectomy, gastric bypass, gastrectomy, nephrectomy, Heller's cardiomyotomy, pulmonary resections, rectal resection (with TME), difficult splenectomies.da vinci robotic system  - pancreatetoduodenctomies and other complex pancreatectomies, visceral artery aneurysmectomy, small sized hepatico-jejunostomy, microsutures  and complex lymphadenectomies.[Surgeries which can be performed only with the ectomies.da Vinci system is concerned. Gynaecologists, paediatric surgeons, cardio-thoracic surgeons, ENT surgeons are taking the cue and incorporating it in their respective fields and the applications of the da Vinci are increasing by the day. The learning curve for advanced abdominal minimally invasive surgeries is sustained and long but achievable at specialised centers with a high volume of cases.To conclude, robotic surgery is an already well established technology being used across the globe. Presently the urologists and general surgeons are the frontrunners as far as the Any new therapeutic innovation is critical to our future health and such an innovation will, at least initially, cost more than the previous therapy. To abandon the search for improved therapies on the basis of cost would represent enormous disservice to our patients and would distinguish attempts to improve patient care from the quest for better automobiles, audio systems, or computers, or from any area of human endeavor.


As many other domains in biology, molecular structures have proposed challenging but interesting computational problems. The unique challenge of the 3-dimensional molecular structures comes from the combination of the fundamental concepts of physics, chemistry, biology and geometry, and it is often computationally intensive to search for the correct structure. The Computational Structural Bioinformatics Workshop (CSBW) is a workshop that focuses on the fundamental computational work that is related to 3-dimensional molecular structures. This workshop aims to bring together researchers with expertise in bioinformatics, computational biology, structural biology, data mining, optimization and high performance computing to discuss recent results, new techniques, and open research problems in computational structural bioinformatics.BMC Structural Biology. Although the number of the submissions is limited, the papers often come from the research groups that have the established records in structural bioinformatics. The next CSBW is going to be at Norfolk Virginia. We will continue our effort and hold the next workshop even better.The first workshop was held on November 4, 2007 in San Jose California, in conjunction with the International Conference on Bioinformatics and Biomedicine (BIBM). The papers in this issue were selected from the third workshop that was held on November 1, 2009 at Washington D.C. We received thirty-three paper submissions in 2009. Eight were selected for an extended version for the publication on The authors declare that they have no competing interests.