الفهرس 
AcknowledgementOnly 14 pages are availabe for public view
 |  | from | 219 |  |  |
| | | from | 219 | | |
Abstract
The aim of this work was to study the pattern of utilization of medical services in Mogadishu. The study covered one general hospital, one specialized hospital and four outpatient clinics. To study the utilization of hospitals information were collected from patients records for the year 1983. Information include: inpatients characteristics (age and sex), medic~l data (diagnosis, investigations, treat¬ment ~d outcome), and hospital beds utilization (occup¬ ancy rate, average length of stay and turnover interval). I. Utilization of the General Hospital in Mogadishu : The hospital contains 458 beds distributed in 15 departments, five of them for medical specialities and 10 departments for surgical specialities for both sexes. Four departments, two for males and two for females are supervized by the School of Medicine for training the students. The hospital contains laboratories, x-ray department, operating rooms and a pharmacy which meet the needs of the patients. 1) Distribution of discharges by age and sex: The total discharges in 1983 were 4200,(62 ) of them were males and (38 ) were females. In the medical departments males constituted (58.5 ) and in the surg¬ical departments they constituted (63.2 ), the rest were females. In regard to age, (46.2 ) of all discharges were in the age group 20-49 years, (38.8 ) were 50 years and above while (15 ) were below 20 years of age. There were no pediatric departments in the hospital. The mean age for males was about 41 years while the mean age for females was about 34 years, in the medical departments. In surg¬ ical departments patients were little younger (mean age for males about 38 years and for females about 32 years). 2.Average length of stay and Turnover Interval : All hospital discharges in 1983 exhausted (113137) hospital days of care i.e. mean (26.9) days per patient. The average stay in general hospitals which is accepted by majority of workers is about 12 days. The shortest ALS was recorded in ENT and Ophth. Depts (19.7) days, and the longest stay was recorded in Traumatology Dept (58.4) days. The long stay of patients can be attributed to several reasons: inefficient administration of the hospital and lack of defined policy for admission and discharge of patients - bottlenecks in laboratories and x-ray departments whose results are needed to reach a diagnosis and prescribe the course of treatment - sched¬ uling of the operating rooms. On the patients side some of them. were chronic cases; some of them were poor and have nobody to care for them; some patients had complica¬tions. The most frequent diagnosis was ’Cataract’ and cases composed 20 of the total discharges and exhausted(14.2) of all hospital days. Next to it was ’fracture lower limb (3.5 and 9.5 respectively). These were followed by ’prostate hyperplasia’, ’glaucoma’, stricture of ure¬ thra’, ’otitis media’, and others. The average leJgth of stay was studied for cases of the same diagnosis in the general departments and in the university supervized departments. In some diagnoses there was no difference or slight difference, in some others there was a significant difference. Examples of the latter group were: (1) Diabetes - ALS in university dept.(32.8) days and in general dept.(15.8) days and the difference was sig¬nificant (t = 2.930). (2) Heart Failure - (31.6) days and (11.9) days respect¬ ively and t = 2.226. (3) Adenoma of Breast - (14.3) days and (23.8) days and t = - 2.319. (4) Appendicitis -(15.1) days and (18.8) days and t = - 1.716. .In medical departments the ALS in general was longer in university departments than in general departments. Vfuile in surgical departments the ALS was generally slightly longer in general departments than in university departments. ALS was also studied for the cases operated in the hospital. It was noticed that the average preoperative stay was usually long - about seven days - the longest stay was 25 days for cases of osteomyelitis, 8 days for adenoma of breast, 7 days for anal fistula and 5 days for appendicitis. This ’ong preoperative stay could be att¬ ributed to the admission policy. Patients are admitted without prior investigation (there is no outpatient de¬partment) then they have to stay in hospital for some days for investigation and consultation. Then they are prepared for the operation and have to wait for their turn on the schedule of the operating room. . The post-operative stay was also studied for operat¬ ed cases in general and university departments. The longest post operative stay was longest (39.8) days for ’tumour of bone’ and shortest (8.2) days for lipoma. Generally speaking postoperative stay was slightly long¬ er in general surgery departments than in university departments. The reasons for this long stay could be the chronic nature of the disease, development of ,In. medical departments the ALS in general was longer in university departments ~han in general departments. While in surgical departm~nts the ALS was generally slightly longer in general departments than in university departments. ALS was also studied for the cases operated in the hospital. It was noticed that the average preoperative stay was usually long - about seven days - the longest stay was 25 days for cases of osteomyelitis, 8 days for adenoma of breast, 7 days for anal fistula and 5 days for appendicitis. This long preoperative stay could be att¬ ributed to the admission policy. Patients are admitted without prior investigation (there is no outpatient de¬partment) then they have to stay in hospital for some days for investigation and consultation. Then they are prepared for the operation and have to wait for their turn on the schedule of the operating room. The post-operative stay was also studied for operat¬ ed cases in general and university departments. The longest post operative stay was longest (39.8) days for , ’tumour of bone’ and shortest (8.2) days for lipoma. Generally speaking postoperative stay was slightly long¬ er in general surgery departments than in university departments. The reasons for this long stay could be the chronic nature of the disease, development of complicbtions, poor housing condition of the p~tient bnd no one to care for him duringconvblescence. In regard to turnover intervbl the mean for the whole hospitbl was (12.9) days. It WbS longest in Trbumbtology (36.7) blld shortest (6~2) in university male surgery. 3)Use of laboratory and x-ray services : The total laborbtory tests alone done in the hospitbl during the yebr 1983 were 2543 tests or about one test per pbtient. Total x-rbY eXbmination blone done in the same period were (60), bnd the total combined (laboratory ~nd x-ray) were 1183. It was noticed that (34.5 ) of all laborbtory tests ~lone bnd (24.8) of all combined tests were ordered by the Ophthalmology Dept. About (8.5 ) of the tests were ordered by each of general surgery and general medicine departments, very few tests were ordered by traumbtology, neurosurgery blld stombto1ogy and none were ordered by ENT department. 4) Hospital Mortality Rate: During 1983 the hospital mortality was 3.6 Mortb1ity was highest (9.2 ) in male medical departments and about (7 ) in female medicbl departments. In surgicb1 depart¬ ments mortality was highest (6.6 ) in urology then (5.9) in neurosurgery bnd female general surgery departments. . No debths occurred in ophthalmology department. 5)Bed occupancy : Bed occupancy rate expresses the average percent of occupied beds during a specified period and it is used as a measure of the efficiency of hospital administration 80 OCCUPbncy is accepted by mhnY workers as the optimum level of occupancy. Some workers believe that general hospitals, for economic reasons, can operate ~t a higher rate e.g.(90 ) or more. The mean occupancy rate of the General Hospital in Mogadishu in 1983 was (68 ); for all medical departments (64 ) ~d for all surgical departments (71 ), which is below the accepted average. Analysis of occupancy rate by month showed marked fluctuations. It was lowest in. December (47 ) and high¬ est in November (87 ). The occupancy curved showed tWo peaks; one in April, May and June (about 80 occupancy) and the second peak was in November (87 bnd the wide rbnge of fluctu¬ations are dependent on hospital’s policy for admission and discharges. The low mean occupancy rate could be attributed to the high proportion of emergency ~dmissions. H~ncock et ~1.(1978) reported that in most cases the Gver~ge occupancy is observed to increase as the percent of emergency admissions decreases. II. Utilization of Benadir Hospital; This is a specialized hospital for Maternity and Pediatrics. It includes 300 beds; 120 for children and 180 beds for women. Some of the departments are super¬ vized by the Medical School and are used for training the students.. The study includes ~ll discharges in 1983 and information was collected from patients records (retros¬pective). 1) !: During 1983 there were 4764 discharges, 2925 (61.4 ) were women and 1839 (38.6 ) were children. Among children 58.5 were boys and 41.5 were girls. 2) ; ALS w~s differen~ in different departments. It was longest (32 days) in pediatric surgery, (23 days) in gyna¬ cology, (17-18 days) in pediatric medicine,(5 days) in abortion dep~rtment, and shortest (3 days) in obstetrics department. ALS for all pediatric departments waS (19.6) days and for all maternity departments (6 days). The turnover Interv~l was l~rgest (14 d~ys) in gyna¬ cology and shortest (2 days) in pediatric surgery. The long stay of patients in hospital c~n be attributed to ¬ several reasons which are closely related to the hospital’s policy in admission and discharge, the flow of services in laboratory bnd x-ray departments, the staffing pattern including number ~nd qualifications, space, equipment,the n~ture of the disease and the socio cultur~l characteris¬ tics of the patients. The pattern of medical practice, free and excessive consultations and also use of same patients for teaching and training the medical students are factors affecting the length of stay and turnover in¬ terval. Study of ALS of certain diagnoses treated ’in general departments bnd university departments revealed signifi¬ cant differences. Examples: Mal&ria (32.1 d~ys) in university department and (16.2 days) in general dep&rt¬ment (t = 1.213) - pneumonia (21.8 days) and (11.2 days) and t = 1.569 - Anemia (11.1 days) and (22.1 days) and t = 1.78. ALS was also studied for operated cases, &nd it r&nged between (34.5 days) in cases of ’Vesico-vaginal fistula’ and (1.6 days) in ’Ruptured Uterus’. 3): In 1983 the mean occupancy rate for the whole hospital was 66.5 . It showed monthly fluctuations and was also different in the different departments. Bed occupancy rate was highest in June (86.5 ) and lowest in January and December (53 and 56 )respectively. In Pediatric departments occupancy was generally high. In June, July and November the occupancy exceeded 100 . While in Maternity departments the occupancy was generally low. In Obst~trics department. occupancy ranged between (40 ) and (21.5 ). 4).;..: In 1983, (2687) laboratory tests alone were done, (6 ) X-rays alone and (508) combined laboratory and X-ray examinations. 5) : The mortality rate for the whole hospital was (2.6). The highest mortality was (11). The highest mortality was (11) and Abortion department (0.2 ). deaths recorded in gynacology department. No 111. Utilization of Outpatient Clinios : Four clinios were studied in Mogadishu, two bre operbted by the Ministry of Health ~d provide free service and the other two olinics were private. A long¬ itudinal study was ,conducted in the four clinios for three months, March - May 1984. Aspeoial questionnaire was constructed and a group of volunteers from Red Cre¬scent and Ministry of Health were trained to oolleot data from the attendants and the physicians were requested to collect the medioal data. The clinios had different specialities; general medicine was the speciality comm¬on in all. 1)Distribution of outpatients by speciality: All patients during the study period were 8268 patients; (16.6 ) attended Hodan, (28.2 ), attended El-Gab, (40 ) attended Taleh and (15.2 ) attended KOshin. The first two olinics are governmental and the other two are private. Distribution of patients by speoiality was as follows: (23 ) general medioine,(20 ) pediatrios, (18 ) gynaoo¬ logy, (9 ) in eaoh of general surgery and dermatology,8 neurology, 7 dentistry and (6 ) ophthalmology. 2)Distribution by Age and Sex: Age and sex distribution of patients differed acoord¬ing to specialities in each clinio. In Hodan 54 of the patients were males and 37 of all patients were children below (10 years) because there is a pediatric clinic. In El-Gab (55 ) of the patients were males. Majority of the patients wer~ adults and old age (96 ) because there is an ophthalmology clinic and a dental clinic and no pediatric clinic. In Taleh (65.5 ) of the patients were females because is a maternity clinic. Also (60 ) of the patients were in the age group 10-49 years and (32 ) were below 10 years because there is a pediatric clinic. In Koshin (52 ) of the patients were males,(86.5 ) were over 10 years. There was no pediatric clinic and no maternity clinic. 3)Distribution by level of education : Majority of the patients in the four clinics were illiterate or could read and write which reflect their social class. 4)Distribution by occupation: (33 ) of all patients were housewives,(19 ) children, (17 ) students, (9.5 ) labourers, (6.5 ) employees and the rest were other profession. were of modest social class. This shows that majority 5) Distribution according to diagnosis: The most frequent diagnoses among this group of pat ients were: anemia (15 ), pneumonia (15 ), gastro¬ enteritis (10.5 ), urinary tract infection (8 ), in¬testinal parasites (1 ) and pulmonary T.B. (4.5 ). These are indications of poverty, illiteracy and insani¬ tary environment. 6)Distribution according to residence, investigations and referal to hospital : (95 ) of the patients were local residents,(42 ) undergone laboratory or X-ray investigations or both and (4.5 ) were refered to hospital. This was nearly the picture in the four clinics. Recommendations: The study has revealed certain shortcomings in the Health Services System and in hospital administration 1. Hospital directors are recommended to attend a course in hospital afministration. 2. Development of patients record. 3. Development in each hospital a ’medical records’ unit. 4. Development in each hospital a ’social service’offices. 5. Organization of ambulance service with centrol administ¬ ration in Mogadishu and branches in the regions. 6. Strengthening the department of Community Medicine in the Medical School for training of community doctors. WHO assistance may be secured for providing consultants and fellowships.