The quality movement is gaining momentum worldwide in the field of health care. Initiated in industrialized countries, it steadily grows in Africa. However, there is no evidence that approaches designed to address issues in a given organizational context have the same effect in another one where issues present differently. Along the epistemological paradigm of realistic evaluation proposed by Pawson and Tilley, we use Mintzberg's organizational models to compare the configurations of European and African health care organizations and the trends followed by the quality management movement in both contexts. We illustrate how European health systems traditionally emphasize professional autonomy while African health systems are structured as command and control hierarchical systems. We illustrate how the quality movement in Europe emphasizes standardization of procedures, a characteristic of a mechanistic organization, while excessive standardization is part of the quality problem in Africa. We suggest that instilling professionalism may be a way forward for the quality movement in Africa to improve patient focus and responsiveness of responsible professionals. We also suggest that our interpretation of broad trends and contrasts may be used as a useful departure point to study the wide contextual diversity of the African experience with quality management.

BackgroundCoping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely – and possibly irreversibly – disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems.MethodsThis study is based on a self-administered questionnaire addressed to a convenience sample of health workers in Mozambique and in Cape Verde.ResultsThe study confirms that misuse of access to pharmaceuticals has become a key element in the coping strategies health personnel develop to deal with difficult living conditions. Different professional groups (mis)use their privileged access in different ways, but doctors diversify most. The study identifies the reasons given for misusing access to drugs, shows how the problem is perceived by the health workers, and discusses the implications for finding solutions to the problem.Our findings reflect, from the health workers themselves, a conflict between their self image of what it means to be an honest civil servant who wants to do a decent job, and the brute facts of life that make them betray that image. The manifest unease that this provokes is an important observation as such.ConclusionOur findings suggest that, even in the difficult circumstances observed in many countries, behaviours that depart from traditional civil servant deontology have not been interiorised as a norm. This ambiguity indicates that interventions to mitigate the erosion of proper conduct would be welcome. The time to act is now, before small-scale individual coping grows into large-scale, well-organized crime.

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In this study, we evaluate the potential involvement of collagenase--3 (MMP13), a matrix metalloproteinase (MMP) family member, in the exudative form of age--related macular degeneration (AMD) characterized by a neovascularisation into the choroid. RT--PCR analysis revealed that human neovascular membranes issued from patients with DMLA expressed high levels of Mmp13. The contribution of MMP13 in choroidal neovascularization (CNV) formation was explored by using a murine model of laser--induced CNV and applying it to wild type mice (WT) and Mmp13--deficient mice (Mmp13 --/--mice). Angiogenic and inflammatory reactions were explored by immunohistochemistry. The implication of bone marrow (BM)--derived cells was determined by BM engraftment into irradiated mice and by injecting mesenchymal stem cells (MSC) isolated from WT BM. The deficiency of Mmp13 impaired CNV formation which was fully restored by WT BM engraftment and partially rescued by several injections of WT MSC. The present study sheds light on a novel function of MMP13 during BM--dependent choroidal vascularization and provides evidence for a role for MSC in the pathogenesis of CNV. Keywords: CNV, MMP13, angiogenesis, bone marrow, mesenchymal stem cells. Non--standard abbreviations used: AMD: age--related macular degeneration; BM: bone marrow ; CAM: choroiallantoic membrane ; CNV: choroidal neovascularisation ; MSC: mesenchymal stem cells ; RPE: retinal pigmented epithelium ; TIMP: tissue inhibitor of metalloprotease. 3 INTRODUCTIONAge--related macular degeneration (AMD) is one of the most common irreversible causes of blindness among people over 50 years [1]. Ninety percents of all vision loss due to AMD occurs in the exudative form which is characterized by choroidal neovascularization (CNV). The newly formed blood vessels arising from choriocapillaries are directed to the subretinal macular region with subsequent bleeding and/or fluid leakage into the subretinal space, local retinal detachment and retinal photoreceptor damage [2]. The pathophysiology of AMD is complex and age--related changes that induce pathologic neovascularization are incompletely understood. In combination with the rapidly growing knowledge on basic mechanisms in angiogenesis, new evidence in pathogenesis of macular disease have led to novel developments in therapeutic strategies. Indeed, angiogenic factors such as VEGF play an important role in choroidal neovascular formation [3--5] and anti--VEGF molecules represent a substantial tool against AMD [6]. In the process of CNV, the vascular overgrowth is coupled with a localized proteolysis, extracellular remodelling and cell migration involving different proteolytic systems among which the matrix metalloproteinases (MMPs) are key players [7--9].An involvement of MMPs in the progression of retinal and choroidal neovascularization is supported by both experimental and clinical data. A mutation of Timp--3 gene (tissue inhibitor of metalloproteinase--3) is the cause of a rare familial form of macular dystrophy associated with ...