A shift towards decentralization in many low-income countries has meant more skills are demanded of primary health care managers, including data and information handling at all levels of the health care system. Ministries of Health are changing their central reporting health information systems to health management information systems with emphasis on managers utilizing information at the point of collection. This paper reports on a research study to investigate the introduction of new information management strategies intended to promote an informational approach to management at the operational health service level in low-income countries. It aims to understand the process taking place when externally developed training materials (PHC MAP), which are intended to strengthen health management information systems, are introduced to potential users in an east African country. A case study has been undertaken and this research has demonstrated that the dynamic equilibrium approach to organizational change is applicable to the introduction of new information management strategies and management approaches in low-income countries. Although PHC MAP developers envisaged a technical innovation needing implementation, potential users saw the situation as one of organizational change. Contributions to theory have been made and many implications for introducing new information systems or the informational approach to management are identified. This theoretical framework could also facilitate the introduction of future information management innovations and would allow practitioners to perceive the introduction of information management innovations as one of organizational change that needs to be managed. Consequently, issues that may facilitate or inhibit adoption could be identified in advance.
Non-mydriatic Polaroid photography in screening for diabetic retinopathy SIR,-I have been using a non-mydriatic camera in a district general hospital diabetic clinic for the past three years and think that the finding by Dr D Jones and colleagues (9 April, p 1029) that one in five Polaroid photographs are uninterpretable is a remarkably high figure; in our experience failures are fewer than 1 in 10.The age distribution of patients in their study is not mentioned; problems caused by constricted pupils and lens opacities rise progressively over the age of 65. If both eyes are photographed at the same clinic visit we have found that the second photograph is invariably of poorer quality than the first, and our practice now is to photograph the contralateral eye at the next clinic visit.We have been screening all patients under 65 attending the diabetic clinic. Those with visual symptoms and those known to have retinopathy who were already under review by an ophthalmologist were excluded. The patients' mean age was 42-8 years (range 16-65) and mean duration of diabetes 9-8 years (range 0-47); 63% had type 1 diabetes. A total of 1166 retinas were examined with a Canon CR2-NM camera and Polaroid 779 film. Retinopathy (maculopathy, cotton wool spots, new vessels, and intraretinal microvascular abnormalities) was identified in 54 retinas (4 6%).In an ideal world diabetic patients would undergo annual fluorescein angiography or be examined through dilated pupils by a consultant ophthalmologist (although many of my patients would be unwilling to submit repeatedly to either of these experiences). This utopian situation is unlikely to occur in most district general hospital diabetic clinics and the non-mydriatic camera should not be dismissed without further evaluation. In the late 1960s and 1970s comprehensive reviews of the value of screening for a variety of conditions and the criteria to be observed before introducing screening were published.`3 Furthermore, the Department of Health funded a major controlled trial of the value of multiphasic screening in middle age.4 In suggesting that health checks might be of value the authors of the white paper do not appear to have taken into account the results of these studies (funded by the Department of Health and Social Security).In view of the correct insistence by the present government on the improvement of efficiency and effectiveness in the National Health Service, it is disappointing to find its own white paper wanting to perpetuate ineffective and inefficient procedures.W W HOLLAND
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