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Aims Observational assessment of the change in number and type of admissions after an increase in fees at Trinity Hospital in rural, Southern Malawi. Methods Trinity Hospital is a (not for profit) Mission hospital. The local population are mainly subsistence farmers. It is 70 km from the nearest free government hospital. For 60 years the medical care has been subsidised by a small Christian charity. By 2011, the charity had been unable to provide funding for over a year. Government support for under five care was withdrawn. From February 2011 fees were increased to cover costs. The number of patients admitted for the six months from February, and their final diagnosis were recorded and compared to the previous 3 years. Analysis was done using MS Excel 2010. Results There was a 54% fall in paediatric admissions, compared with a one-third decrease in adult admissions and outpatient attendance. This was despite an increase in admissions for meningitis (117%) and malnutrition (29%). The results are summarised in the table 1 below. Table 1 Malaria Pneumonia Gastroenteritis Malnutrition Meningitis Trauma Neonatal Sepsis Other Total 2008-2010 Feb-July Average number of admissions 864 246 87 24 6 31 27 190 1625 2011 February- July average number of admissions 396 165 29 31 13 25 2 86 747 % reduction 54.2 32.9 66.7 −29.2* −116.7* 19.4 92.6 54.7 54 *Represents an increase in admissions. In-hospital mortality fell during the same period. Conclusion Increased cost of admission and treatment made the hospital financially inaccessible, particularly for children. Although clinical management changes made during this period would account for some of the fall in admissions, the increase in the number of patients with malnutrition and meningitis implies that there was a delay in seeking medical attention. The disproportionate fall in paediatric admissions compared with adult admissions, suggests children were affected more than adults. This shows that the cost of providing basic medical care to the rural population of Malawi is too great to be funded by individual families in rural areas, and extra support is required. The management and governors of the hospital have been made aware of the fall in admissions and are seeking ways to increase funding. The current global economic situation could result in similar problems at other small hospitals in the developing world.

Aims Oxygen therapy is often refused by patients in rural Southern Malawi. The aim of this study was to assess the impact of a twofold brief education intervention on the use of oxygen therapy at a rural hospital in Southern Malawi. Methods The use and uptake of oxygen was assessed by a retrospective review of paediatric case notes during the months of December 2010, January 2011 and February 2011. The results were discussed with the clinical officers and primary health care team based at Trinity Hospital. The superintendent clinical officer organised a teaching session on the use of oxygen concentrator. The primary health care team did a community education session (a talk to guardians attending outreach clinics) on oxygen at the four nearest villages during the month of March 2011. A review of notes from April, May and June then assessed the impact of the oxygen therapy. The results were analysed using Microsoft Excel 2010. Results During December, January and February there were 506 admissions of which 62 were for acute respiratory infections (ARI). 20 patients in total (4% of total) were counselled for oxygen therapy of which 15 patients had ARI, 6 of these (40%) refused oxygen, 4 (27%) died whilst on oxygen and 5 (33%) survived. During April, May, and June there were 352 admissions, of which 120 were for ARI. 53 patients in total (15% of total) were counselled for oxygen therapy of which 35 had ARI. 13 (37%) refused oxygen, 1 (3%) died on oxygen and 22 (63%) survived. Conclusion After a brief education session, clinicians and nurses were more willing to counsel patients regarding oxygen therapy. More patients are given oxygen therapy and more survive with oxygen therapy. Community education by the primary health care team had no effect on changing the opinions of patients and guardians as to whether or not they would accept oxygen therapy. Further research is needed into why patients refuse oxygen therapy.