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Training Management Information System as a Tool for Addressing Public Health Workforce needs and rational deployment in India.

Author(s) Nidhi Chaudhary1, Srilekha Chakrabarty2, Gaurav Sharma3, Linh Cu Le4, Dineke Venekamp5.
Affiliation(s) 1ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, Chandigarh, India, 2ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India, 3Centre for Health Informatics, National Institute of Health and Family Welfare, New Delhi, India, 4ITS Project, KIT, Netherlands, New Delhi,India, 5ITS Project, Center for Integrated Services and Program Science, Futures Group International India Pvt Ltd, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Health Workforce
Summary Skills based training of health personnel and task shifting have been two strategies under NRHM to address the shortfall of human resources in health in India. Training Management Information system, a web based “single window” software application was developed to create a nationwide database for health personnel that can be updated in real time at the training centres. The TMIS software pilot, launched in five states, helps collate individual level training information about each health personnel as well as health facility level information about the availability of trained health personnel. The TMIS facilitates monitoring and decision making for the policy makers and program managers.
What challenges does your project address and why is it of importance? India finds itself ranked 52 of the 57 countries facing a Human Resources for Health (HRH) crisis. India’s major limitation has been in the production and distribution of human resources across multiple levels of care. As of March 2010, the overall HRH shortfalls range from 63% for specialists to 10% for allopathic doctors, and 9% for Auxiliary Nurse Midwives (ANMs), respectively.
Health curricula in the country have not kept pace with the changing dynamics of public health, health policies and demographics. The ANM and General Nursing & Midwifery (GNM) curricula have only twice been revised in the past 40 years. Current medical and nursing graduates in the country, trained in urban environments, are ill-prepared and unmotivated to practice in rural settings.
The health reforms under National Rural Health Mission (NRHM), include a focus on skills based training of existing health staff and task shifting to meet the shortfall for the health workforce. However, there are challenges in terms of identifying appropriate candidates for trainings, incomplete database on training status of health personnel, equity in professional development opportunities, rational posting of trained personnel and post training performance follow up of trained personnel.
How have you addressed these challenges? Do you see a solution? The National Institute of Health and Family Welfare is the nodal agency for conducting, coordinating and monitoring performance of various trainings conducted under NRHM. The EU supported Institutional and Technical Support Project (ITS) is providing technical assistance for institutional capacity strengthening of the National and eight State Institutes of Health and Family Welfare (NIHFW, SIHFWs). The Ministry of Health and Family Welfare (MoHFW) identified quality assurance of trainings as one of the expected outputs under the ITS project which would strengthen the NIHFW and SIHFWs.
The Training Management Information System (TMIS) is a web based software application, developed by the ITS project, for nationwide database of skilled human resource to strengthen the public sector health delivery system. The TMIS will help to plan and manage RCH trainings under NRHM, rationalise deployment of trained personnel in different health facilities and strengthen monitoring of quality of training.
The web based TMIS software help collate individual personnel level training information as well as health facility level information about availability of trained health personnel. The TMIS software has two parts - dynamic and static. The dynamic section automates the data related to human resource, trainers, participants, training centres, health facilities and type of training. The real time trainings’ data is captured, updated and generates district, state and national level training reports. It integrates sms alerts to trainers and participants. The static section includes all the documents related to trainings like training guidelines, training manuals, course content, training calendars, circulars and other relevant online material.
TMIS addresses the problem of the re-entry of existing HR and training data collected over the years in excel format by bulk uploading the same into TMIS software. The TMIS facilitates monitoring and decision making for the policy makers and program managers at all levels. It will help to recommend corrective actions based on the analysis of the human resource skills gap.
In the long run, TMIS will facilitate tracking of the resource pool of trainers and of the trained personnel through GIS mapping facilitating monitoring, better planning and resource optimization. The report generated through the software will help in monitoring and evaluating the achievement in reaching MDGs.
How do you know whether you have made a difference? The user training and pilot launch of TMIS has been done in five states – Odisha, Haryana, Uttar Pradesh, Karnataka and Andhra Pradesh from April to June 2013. The SIHFWs are the nodal agencies for TMIS management at the state level. In total, 443 district and state level data entry operators were trained on the use of the TMIS software, data preparation, data cleaning and online-entry. The database software built on SQL server platform (using .NET framework) using key variables such as: trainees, trainers, training courses at different levels of health system in India which is available on the NIHFW website. To date, basic human resources data of at least 77 districts from 5 pilot states has been collected by the district data entry operators and centrally uploaded on the software by the team at NIHFW. This uploading of the human resource data is a one time activity which will be followed by online real time updates on personnel trainings. Draft user manuals and technical training documents for TMIS software have been developed. A help desk has been set up centrally at NIHFW for answering queries of the state. The help desk has received on average at least 40 queries per month from 5 states in the last 3 months. The TMIS software has been demonstrated to all national program managers at MoHFW and has been modified to meet the needs of both national and state level authorities.
In the select districts which have started using TMIS, the health department is able to nominate appropriate candidates, facilitate post training placements and name based tracking of health professionals. The sms alerts to the trainers and participants before the trainings and the instant online certificate generation through TMIS has already streamlined the training process and has overcome the limitations of manual compilation of training data in the country. The detailed pilot data report on utilisation and application of TMIS will be available by December 2013 and will be presented in the conference. However, to date all the health authorities at pilot states have shown great enthusiasm and provided positive feedback about the practicability and effectiveness of this application.
Have you or the project mobilized others and if so, who, why and how? Through the ITS project we have mobilised the resources at the NIHFW and SIHFWs for implementing the TMIS application. The existing staff at NIHFW and SIHFW have been trained as master trainers for training further district data entry operators. Two staff at NIHFW have been identified to act as a help desk for states and support the TMIS tasks of bulk uploading of human resource data. Similarly SIHFW’s nodal officers for TMIS have been identified and state data entry operators have been trained to address minor issues that the district level operators may encounter. The NIHFW and SIHFW infrastructure was leveraged for conducting trainings. With the TMIS deployed at state and district levels, the health authority would be equipped with a useful tool to manage training activities on-site. Further use of TMIS and integration with existing human resources for health database can speed up better manpower management and utilisation.
When your donor funding runs out how will your idea continue to live? The sustainability plan for TMIS has been developed for 10 years and presented to NIHFW and MOHFW for formal approval. The TMIS sustainability plan specifically aims to: build up a TMIS team in the NIHFW to maintain a national/country wide database of skilled and trained human resources; assist decision makers and stakeholders to perform gap analysis of trained human resource in public health sector delivery system; maintain a Government to Government (G2G) web based application for monitoring and planning of skilled and trained health care providers and create a foundation (if required) to make TMIS cell at NIHFW to become a “centre of excellence” in Health Information Systems. The involvement of policy makers at the national level through regular interaction to exchange inputs into TMIS design, meeting with different program divisions, and the implementation of health facility hierarchy of established ministry level software Health Management Information System (HMIS) into TMIS indicate that TMIS is viewed as useful tool by MoHFW. The MoHFW has expressed their commitment in scaling the application to a national level after the pilots. The Steering Committee meeting, chaired by the Joint Secretaries of MoHFW responsible for training, and NRHM will be allocating financial resources from the next financial year.
Based on the request from MoHFW, ITS team visited a non ITS intervention state of Tamil Nadu to explore the integration of TMIS with existing Human Resource Management Information System. It is planned that further customisation of TMIS at national and state level may even enable the users to get routine statistics on training activities going on at each level, to generate automatic reports as well as get better overview of training needs and relevant demands at each geographic regions. The TMIS would certainly help human resource development and management in India in the long run.

Strengthening the competencies and skills of nurses in mental health: Experiences from Bosnia and Herzegovina

Author(s) Selma Kukic1, Zvjezdana Stjepanovic2.
Affiliation(s) Mental health, Mental health Project in BH, Sarajevo, Bosnia and Herzegovina, Mental Health, Mental Health Project in BH, Banja Luka, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Health Workforce
Summary The mental health reform in BiH was launched in 1996 focusing on community-based care and so far has made significant progress in the development of a large network of community mental health centers. In the centers multidisciplinary teams operate, however nurses are the largest and least skilled professional category of professionals and have the highest fluctuation rate within health system. The reform project in BiH (Mental Health Project in Bosnia and Herzegovina) is focused on the informal education of nursing staff with the objective of professional development, empowering and providing networking as a first steps toward a systematic re-profiling of nurses in mental health.
What challenges does your project address and why is it of importance? In 2008/09 the survey "Situation analysis and assessment of community-based mental health services in Bosnia-Herzegovina“ (Mental Health in SEE Project 2009) was undertaken. The findings of the 2008/09 survey were used as the baseline for the Mental Health Project in BiH to monitor changes and improvements made with the project's support. A self-assessment of the middle-level nursing staff in this survey revealed that the staff believed they were under-trained. 46% of nurses believed they had not received enough training to work in a mental health centre, and the MHC team members believed that the work of the nursing staff was not recognised by other health professionals and that there were prejudices caused by vaguely defined job descriptions for the nursing staff working in a MHC team. A new concept of nursing, as well as the empowerment of nurses within the system of community mental health, requires well trained nurses, whose knowledge is closely linked to psychological, sociological, philosophical, educational, medical and expert training. This would improve the ability of nurses to assume new tasks. This can be achieved through formal education, non-formal education, continuing professional education, as well as initiative and creativity in the field of nursing.
How have you addressed these challenges? Do you see a solution? The adequate re-profiling of nurses in mental health is optimally achieved through formal education. This project presented informal education as the first step to a systematic aproach. Education has garnered excellent results in terms of narrowing the gap of professional training, but the benefits of education are more reflected in the development of contacts, exchange of experiences and formal networking of these professional groups that did not previously exist in the form of professional associations. The results indicate that associated advocacy for the development of nursing legislation on education and employment in mental health is required.
How do you know whether you have made a difference? The results of the performance evaluation of the Conducted Educations suggested key improvements in the work of this professional group. 96 % of respondents felt that the education contributed to providing quality services to patients and their families through individual or team work. Particular emphasis was upon the acquisition and use of new knowledge, skills and techniques in work (88%), the rights and obligations of medical professionals and patients (66%) and combating the stigma of mentally ill patients in society (32%). 90 % of respondents observed changes in the area of respect for the professional attitudes of mental health nurses by other team members. Particular emphasis was on the experience exchanges among colleagues (65%), the level of self- confidence in the process of presenting opinions to their superiors (64%) and an additional level of competence to work within a multidisciplinary team (53%). With continous collaboration with mental health staff in MHCs there is greater viability for the initiatives taken by nurses to process their difficulties in work.
Have you or the project mobilized others and if so, who, why and how? The key project holders and implementers were the Ministries of Health, and their key responsibility was to make the entire process a success by ensuring the participation of nursing stuff and relevant experts and key stakeholders in the implementation of activities, as well as to provide further support to the continuing education of nursing staff.
When your donor funding runs out how will your idea continue to live? Sustainability is ensured through cooperation with other projects whose main goal is to work on legislation that would provide a legal framework for the employment of nurses in mental health, including formal education, by providing needed information and support.

Securing WHO FCTC Article 11 Compliance Through Legislative Advocacy: the Philippines

Author(s) Patricia Miranda1, Diana Cecilia Trivino2, Karla Mae Rocas3, Evita Mariz Ricafort4.
Affiliation(s) 1Legal Team, HealthJustice Philippines, Antipolo City, Philippines, 2Legal Team, HealthJustice, Quezon City, Philippines, 3Legal Team, HealthJustice Philippines, Quezon City, Philippines, 4Legal Team, HealthJustice Philippines, Quezon City,Philippines.
Country - ies of focus Philippines
Relevant to the conference tracks Governance and Policies
Summary Under the WHO FCTC, the Philippines obligated itself to require effective health warnings on cigarette packs by 2008. That deadline has long passed. Thus, HealthJustice Philippines (HJ) and Social Weather Stations (SWS) conducted a nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco" to gauge the behavioral response of Filipino youth towards graphic health information (GHI) on cigarette packages. The results show, among others, that 82% of current smokers believe that GHI shall be effective in preventing the increase of smokers. The survey is one of the launching points of HJ's legislative advocacy to ensure the passage of a GHI law in the 16th Congress.
What challenges does your project address and why is it of importance? The biggest challenge to the GHI legislative advocacy plan is the strong pro-tobacco lobby of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. The NLA has been known to deliver a "solid vote" against tobacco control measures in the Philippines. Currently, the Philippines is implementing Republic Act No. 9211, otherwise known as the Tobacco Regulation Act of 2003 (RA 9211), which provides for text-only warnings at the bottom portion of only one side of the pack. The contents of the warnings have not changed since the enactment of RA 9211 in 2003. Notably, RA 9211 does not comply with Philippine obligations under the WHO FCTC. Under this treaty, the Philippines is obligated enact effective measures requiring the placement of GHI on tobacco product packages by 2008. Thus, the Philippines has breached its international obligations when it missed its deadline to comply with the WHO FCTC. As a member of the family of nations, the Philippines agreed to be bound by generally accepted rules for the conduct of its international relations.
How have you addressed these challenges? Do you see a solution? It is urgent and necessary that Congress pass a law or laws guaranteeing that all our policies are in compliance with the WHO FCTC. One such legislative measure is the passage of a law requiring the placement of graphic health GHI on tobacco product packages, and banning the use of misleading descriptors thereon.HJ is currently with individual lawmakers and lawmaking bodies to gain support for GHI. As part of its legislative advocacy plan, HJ has prepared the following documents:
(a) brief on implementing Article 11 of the WHO FCTC in the Philippines;
(b) draft model bill incorporating the requirements of the WHO FCTC and its Implementing Guidelines;
(c) legislator's toolkit containing reports, surveys and studies relating to the effectivity of GHI in other countries; and
(d) presentation containing data which includes the results of the HJ-SWS nationwide survey entitled "Usage and Attitudes of Filipino Youth Towards Tobacco."At the time of this writing, there are currently seven Graphic Health Information bills. In the Senate, there are two bills filed by Senate President Franklin Drilon and Senator Pia Cayetano. In the House of Representatives, there are currently five bills on GHI, filed by Representatives Marcelino Teodoro of Marikina City, Niel Tupas of Iloilo, Joseph Violago of Nueva Ecija, Leah Paquiz of Ang Nars Party List, and Eric Singson of Ilocos Sur. All of these bills have been read on First Reading and are pending in their respective committees on health and/or trade. It should be noted that Eric Singson is a member of the Northern Luzon Alliance (NLA), a legislative bloc composed mostly of representatives of tobacco-growing districts in Northern Luzon. This may prove to be a sign that there is public clamor for more health promotive policies, particularly one requiring the placement of graphic health GHI on tobacco product packages. Hence, the solution lies in pushing for the passage of a law requiring GHI, particularly because of the presence and commitment of dedicated champions, the recent re-filing of the bills in both Houses of Congress, and the filing of a bill from a member of the NLA.
How do you know whether you have made a difference? One can only hope to make a difference, since the passage of any tobacco control measure in the Philippines entails coordination and teamwork between public health advocates. This is because the Philippines has the strongest tobacco lobby in Asia. Thus, one crucial gauge to determine if tobacco control advocates have made a difference in pushing for WHO FCTC compliant measures is to determine the number of tobacco control measures passed.
Have you or the project mobilized others and if so, who, why and how? The HJ Project Team is still currently mobilizing legislators and government agencies. Hence, the results of the "Usage and Attitudes of Filipino Youth Towards Tobacco," as well as the contents of the draft WHO FCTC-compliant bill, is being made available to the public.
When your donor funding runs out how will your idea continue to live? While donor funding may have been useful in drafting the documents submitted to the legislators in the Senate and Congress, these documents are also made available to the public. Hence, even if donor funding runs out, the documents meant to promote standardized tobacco product packaging and labeling in accordance with the Article 11 Guidelines would still be available to other tobacco control advocates, both public and private partners, to use and disseminate as they fit. The end goal would be amending RA 9211 to ensure its compliance with the WHO FCTC. The Department of Health, the Civil Service Commission, and the Metropolitan Manila Development Authority are government agency partners of HJ. These agencies have shown a strong support for the implementation of tobacco control policies in the Philippines.

Princeton’s University Global Health Program: Research and teaching at the nexus of science, policy and social science

Author(s) Kristina Graff1, Peter Locke2
Affiliation(s) 1Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 2Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, United States, 3.
Country - ies of focus Global
Relevant to the conference tracks Education and Research
Summary Princeton University’s Global Health Research and Teaching Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
What challenges does your project address and why is it of importance? Global health challenges go far beyond clinical issues. These problems are rooted in economic, social and political forces, geographical and logistical hurdles as well as the dynamic impacts of globalization and governance. Solutions to global health problems demand an interdisciplinary response –one that integrates the expertise and perspectives of a range of sectors and specialties. A holistic approach to global health looks beyond what medicine alone can achieve and addresses all the elements that contribute to improved wellbeing, ranging from population and system-based interventions to an understanding of how broad public health initiatives affect individual lives.
Princeton University’s Global Health Program is anchored in the philosophy that complex problems demand a comprehensive and integrated approach, in which players from a range of academic and technical areas collaborate to analyze global health problems and explore innovative solutions. Princeton’s Global Health Program generates the scholarship fundamental to health improvements at the nexus of science, policy and social science, and educates students who will become leaders in these fields. Its defining elements are a cross-disciplinary approach, hands-on field research and a focus on the policy dimensions of global health.
How have you addressed these challenges? Do you see a solution? Princeton’s Global Health Program operates integrated research and teaching initiatives that span the breadth of faculty expertise. The global health program supports a multi-disciplinary research agenda and curriculum bridging engineering, the humanities, and the social and natural sciences.The University sponsors innovative and exploratory research, which is scaled up to draw external grants. Faculty lead projects that engage undergraduates, graduates and postdoctoral researchers. They extend into the classroom and into students’ research and internships.The global health program also supports students’ internships and research in laboratories and field sites around the globe, academic and public events, and student participation in external conferences. This program model simultaneously fuels research and teaching in key areas of global health.A key program focus is on high-quality, hands-on learning. Students conduct research and internships in 20+ countries, based at research centers, NGOs and grassroots organizations, academic institutions, hospitals and clinics. Junior researchers mentor many student projects, providing training in topics such as technical methods for research and analysis, to the ethics and principles of sound and responsible global health research. These field experiences are life changing for many students and form the basis of their future pursuits in domestic and global health.A final critical factor in the success of Princeton’s global health program is a strong and longstanding partnership with the institutions where students and faculty conduct research. Solid institutional relationships allow for regular exchanges, high-quality research, expanded opportunities for collaborative projects and more efficient administration. Two key governing principles for the program’s collaborations are reciprocity and on-site advising by Princeton researchers based in the field. Princeton hosts faculty members and graduate students from partner institutions for varying periods of time. Postdoctoral fellows have proven highly effective as on-site research coordinators and advisors.

By centering its research and teaching activities on interdisciplinary and integrated principles, Princeton’s global health program facilitates cross-departmental engagement of faculty and prepares students to address the increasingly complex slate of global health challenges.

How do you know whether you have made a difference? The Princeton Global Health Program tracks the impact of its research and teaching programs over time, and it also devotes ongoing attention to ensuring that its international partnerships are mutually beneficial. For research we monitor how the work is scaled up into larger programs, published in academic and other journals, and translated into policy and practice changes. We do this through reporting by recipients of internal grants and through tracking global health faculty member’s work.For teaching we follow the threads of students’ academic progress over multiple years and then track their career trajectories once they graduate. We do this through a combination of quantitative measures (number and proportion of global health students who pursue related graduate study and careers) and qualitative data (asking students over time how their experience in Princeton’s global health program shaped their understanding of global health issues and the evolution of their careers). We also link current students to program alumni, in order to create an informal network for advising and guidance.For international partnerships we work with our collaborating institutions to identify mutually beneficial projects at the start of our cooperative efforts. We also commit to a true exchange, whereby our partner institutions can send faculty or graduate students to Princeton for periods of research or study. We communicate frequently to keep things running smoothly, set agreements about use of data and publications resulting from the collaboration, send as many field-based researchers to our partner sites as possible, and conduct periodic site visits for monitoring and relationship management.
Have you or the project mobilized others and if so, who, why and how? The international partnerships have resulted in a range of studies, projects and grants to address global health challenges around the world. Some of these have been the result of student projects that were designed to address pressing issues facing a particular partner institution. Princeton’s participants were called upon to address the economic, social, cultural and logistical factors affecting health care access and overall wellbeing. One example is Princeton’s global health program partnership with Wellbody Alliance, a community-based healthcare organization in rural Sierra Leone. Under the supervision of a global health program postdoctoral fellow, Princeton students conduct summer field research focused on helping Wellbody to better understand community needs and evaluate the impact of its services.Based on a student’s project analyzing barriers to tuberculosis (TB) treatment adherence, Wellbody applied for and received a grant from the World Health Organization’s STOP-TB Partnership to implement an innovative district-wide home-based TB screening and treatment system. As part of this project, Wellbody Alliance has hired and trained 150 community health workers, upgraded laboratory and administrative capacity, and secured additional medication needed to treat hundreds of new TB patients. All patients diagnosed with TB in Kono District are now assigned a Wellbody Alliance community health worker who visits patients in their homes to administer medication and evaluate their progress. Additionally, community health workers offer early testing and treatment to high-risk individuals, saving lives and preventing others from becoming infected.In the summer of 2013, students returned to support and evaluate the implementation of the program by accompanying supervisors and health workers as they carried out their duties in the community. Their findings will be essential to identifying and overcoming unexpected challenges in the field and to facilitating the renewal of the WHO grant beyond the first year.
When your donor funding runs out how will your idea continue to live? In the research dimension, the University’s initial investment in global health research is being translated into support from external donors whose primary agenda is to further these lines of inquiry. The research projects will then ultimately become a self-sustaining entity. The program also maintains endowed funds so that there will always be avenues to seed innovative ideas and projects until they can be scaled up for broader external funding. In the teaching dimension, the philosophy of Princeton’s global health program is present in the University’s core educational curriculum. Therefore the program and its guiding principles will remain at the center of all pedagogical initiatives as ongoing and standard academic offerings.In its international collaborations, these costs will ultimately be moved from the category of “special initiatives” over to a standard part of normal program operations, so that they become part and parcel of global health partnerships – both at Princeton and within its partner institutions. When the partnerships prove to be mutually beneficial they can then merit a spot as an essential element of both collaborators’ regular operating budgets.

New Model of Formative Supervision to Improve Health Outcomes in Ukraine

Author(s) Martin Raab1, Nataliia Riabtseva2
Affiliation(s) 1Health Technology & Telemedicine Unit, Swiss Center for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Swiss Center for International Health, Swiss Tropical and Public Health Institute, Kyiv, Ukraine.
Country - ies of focus Ukraine
Relevant to the conference tracks Health Systems
Summary Swiss-Ukrainian Mother & Child Health Programmes aim to improve the quality of MCH care in Ukraine. One of the tools is formative supervision: regular structured visits to hospitals. The visits are provided by a trained team according to developed guideline. The following results are observed: improved clinical skills and practices of personnel, more comfortable, friendly & safe conditions for patients, enhanced collaboration with local authorities, etc. The approach is evaluated highly by regional management who provide logistical & financial support for the team.
What challenges does your project address and why is it of importance? The overall objective of the programme is to reform perinatal health services in the Ukraine. Historically, health services staff are hierarchically governed and directed by decrees and narrow guidelines. This human resources management scheme had been impeding continuous education based on evidence based knowledge. At the same time, health care administrations had inadequate access to information about factors leading to positive or negative health services outcomes, while the rates of maternal and infant mortality and morbidity in the country are 2-3 times higher comparing to EU averages.
How have you addressed these challenges? Do you see a solution? The special focus is on antenatal, delivery and postnatal care provision in antenatal clinics and maternity hospitals.
Key interventions are regular, structured visits to health facilities and round table discussions with managerial and service personnel. Supervisors (obstetricians, neonatologists, managerial officers) had been trained and are guided by a manual elaborated by the programme. The supervision guideline is composed of a methodology section and by assessment tools ensuring the information and data capture according to a unified format. This allows the evaluation of field information and thus allows the comparison of data across different services regions and across time. On the basis of the information obtained, gaps analysis is performed and further improvement interventions are planned and implemented.
The formative supervision is based on principles of peer support and the identification and dissemination of good practice encountered in different Ukrainian regions and facilities. Personnel of particular service regions have been assessed by supervision teams from other regions (peer exchange approach). The overall supervision approach developed for Ukraine contains key findings and elements from the WHO and leading international professional associations.
The manual for formative supervision is actively promoted throughout the country and is available under the following address:
http://motherandchild.org.ua/eng/resource/245
How do you know whether you have made a difference? The development of the perinatal health services are monitored by an M&E information system which collects quantitative and qualitative information. Special interviews with personnel in the frame of the M&E scheme provide information on central changes targeted by the programme (e.g. the availability of an adequate building and devices infrastructure according to a set standard or the diagnosis and treatment according to new evidence based guidelines, etc.). Qualitative evaluation revealed an increased staff satisfaction and motivation as a result of the supervision interventions.
Concrete improvement outcomes: successful reorganization of obstetric and neonatal services according to perinatal concepts, renovations to assure thermo stability for women and newborns, improved psycho-social conditions for women and partners, the improvement of clinical skills (e.g., urgent care for woman with pre-eclampsia, correct assessment of newborn’s status, breathing support for newborn), better collaboration with local authorities for financial and policy support and improved contact with mass media to deliver health promotion messages.
Have you or the project mobilized others and if so, who, why and how? The Project mobilized:
1) Regional authorities: via regular meetings and reporting on the results – to assure their ‘political goodwill’ and support for the teams;
2) Regional team: via trainings, provision and training of manual, supervision from national consultants – so they actually perform the visits and ‘keep an eye’ on what’s going on in their regions and what is to be improved.
3) Chief / Head doctors of the partner hospitals: via special training “Why monitoring / supervision is needed? How could it be useful for managers?” – to assure their support and performance of the recommendations which occurs as a result of the visits.
When your donor funding runs out how will your idea continue to live? The regional authorities and teams will continue this activity as the positive outcome is palpable and widely promoted through national events. For this reason, authorities provide additional financial and logistical support (e.g. assuring the transportation for the team to the hospital).

MOTHER: A Mobile-Based Voice Health Alert Tool to Create Awareness on Young Child Feeding Habits.

Author(s) Suneetha Sapur1, Kathiresan Chinnusamy2, Girija Vadlamudi3
Affiliation(s) 1Nutrition, AkkshayaFoundation Society, Hyderabad, India, 2Indian Development Gateway, Center for Development of Advanced Computing, Hyderabad, India, 3Health, Health Management Reaserch Institute, Hyderabad, India, 4
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary Background: Malnutrition in Children is extensively prevalent in India. Poor feeding practices may lead to the burden of malnutrition, infant and child mortality.Objectives: To create awareness and demand generation in the community of government health services for infant and child feeding practices with the help of Information Communication Technology (ICT)Methods: Centre for Development of Advanced Computing and the Ministry of Communications and Information has developed the ‘MOTHER’ tool to capitalize the mobile phone’s core utility of ‘voice calls’ to create health awareness among the illiterate rural community. The project was taken up where the 80% of the population owned mobile phones.
What challenges does your project address and why is it of importance? •Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. Our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal Headquarters.• Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system. To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registration.
•In many families, mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team. As part of MOTHER project, we organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
•Compared to SMS, voice calls are costlier.
How have you addressed these challenges? Do you see a solution? Challenge: Registration and updating of the beneficiary records in the ‘MOTHER’ system directly from remote locations was a big challenge owing to poor internet connectivity. The solution was that our field workers started collecting the beneficiary details manually in the prescribed registration forms and in the evening, records were updated online from the Mandal HeadquartersChallenge: Voice alerts are being pushed from the system to the beneficiary mobiles and it is unilateral communication (Push Method). Beneficiary can’t call back and interact with the system.Solution: To facilitate the beneficiaries queries the phone numbers of health officials of the PHCs have been circulated to the beneficiaries during registrationChallenge: In many families mobile phones are only with husbands who receive the voice alerts. Most of the husbands are not interested in knowing about the basic support that can be provided to women during pregnancy and child care. They feel that it is the duty of the women. Sensitizing the husbands was one of the major challenges faced by our team.
Solution: We organized village level awareness meetings to sensitize the men to listen to the voice alerts and pass the information to their wives.
Challenge: Compared to SMS, voice calls are costlier. Moreover, service providers charge based on call duration and number of calls made per month.
Solution: We designed the voice alerts such a way that each call will be less than one minute and each alert will be sent two times in a day. Only critical alerts (such as expected date of delivery) will be repeated more than 3 times.
How do you know whether you have made a difference? Who were targeted:
• pregnant women, husbands of beneficiaries, fathers of children, health care providers,
Why:
• To create demand for the health services in the community, better utilization of health services by the beneficiaries and timely monitoring by the health officials.
How was this delivered:
• Apart from better infant and child feeding practices as presented in the abstract we observed positive changes after implementations of the project.
• Repeated voice calls sensitized the family members, particularly husbands, to understand the importance of pregnancy and the care to be taken at critical stages. Improved participation of husbands and fathers in health care activities was observed.
Have you or the project mobilized others and if so, who, why and how? The project mobilized community participation and awareness created by the project helped to create demand for health services, especially for immunization as the Mother call voice alert reaches the beneficiary (pregnant women, Mother's of below 18 months) on the days of immunisation schedule as well as nutritional supplementation through the Integrated Child development Surveillance program. Beneficiaries were demanding the village health workers for immunization and the food supplements such as Egg, fruit and calorie and protein mix.It also helped to improve health workers participation as it increased the responsibility of Health workers to follow-up with registered members. The number of visits by health workers to the beneficiary house reduced, in turn helping them to effectively utilize their time in other productive works. As to corruption, beneficiaries were sensitized about the entitlements and monetary benefits from health department along with voice health alerts. The better utilization of health as well as monetary benefits was observed.There was online monitoring of the beneficiaries details by higher government health authorities especially about high risk cases of pregnancy.
When your donor funding runs out how will your idea continue to live? In spite of a few limitations and challenges faced by the Mother tool implementation, the Mother project is a successful program that creates awareness on infant and child feeding habits. The Mother pilot project has been initiated with the goal of being integrated into the national level health services, so the pilot has been implemented by involving State National Rural health Mission and the antenatal and child data collection formats used in mother project were also of National Rural health Mission (NRHM) as these formats are common across the country. The NRHM people were involved at each step of the implementation program which helped the Mother project to be taken up by the state NRHM. The scale up of the Mother project to state level has been assisted by the NRHM officials involved witnessing the effectiveness of this innovative tool to create awareness across community, in particular to rural illiterate women. At the National level NRHM is considering a scale up to entire nation in a phased manner. Considering the level of mobile penetration in India and literacy level among rural women, voice calls (MOTHER) is the best model to reach-out towards the target beneficiaries directly at an affordable cost.  The projected has been scaled up to the state level and National Rural Health Mission is adopting this tool and scaling up to the different states in phases at national level. This project has been awarded "eIndia 2012’ Public Choice Award under Health category.

Making profession of family doctors attractive for future doctors: Kyrgyzstan

Author(s) Salima Sydykova1, Nurlan Brimkulov2.
Affiliation(s) 1Hospitral Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan, 2Department of Hospital Therapy, Kyrgyz State Medical Academy I.K. Akhunbaev, Bishkek, Kyrgyzstan.
Country - ies of focus Kyrgyzstan
Relevant to the conference tracks Education and Research
Summary One of the main current healthcare problems is a shortage of family doctors/general practitioners, especially in rural areas. Medical students are not motivated to choose the specialty of family medicine because they don't find it prestigious. The community also has disrespectful and discriminating feelings about this specialty.
The Kyrgyz State Medical Academy has the very challenging task of re-orienting the training in order to find a training approach that would change this situation. This abstract is about one of the new teaching modules, “Human, Society and Health”. Its primary goal is to set a positive “pro-family medicine” attitude from the beginning of the undergraduate training.
What challenges does your project address and why is it of importance? The burning problem of health education and the healthcare system is a dramatic lack of general practitioners/family doctors in the field, particularly in rural areas. Many villages do not have even a single medical professional however it is considered that  the number of medical students in Kyrgyzstan is sufficient. Another figure is the low number of students who have their post-graduate education in family medicine as opposed to the giant number of residents who do their post-graduate education in the field of surgery, gynecology, cardiology and other narrow specialties. The major reason why students are not motivated to become a general practitioner/family doctor is a negative and disrespectful image of this specialty in the eyes of the community as undertrained and poorly qualified doctors.
Kyrgyz traditional health education system, both at undergraduate and post-graduate levels, is based on a curriculum with longitudinal disciplines that are taught separately and in isolation. The teachers of different departments are used to focusing on the narrow competencies of their discipline without knowing the general goal of the curriculum.
How have you addressed these challenges? Do you see a solution? KSMA is the largest medical educational institution that provides undergraduate and post-graduate and continuous medical education. To meet the needs of the healthcare system and to help to overcome the crisis in family medicine, the KSMA started working actively to change the curriculum and to change the whole approach to teaching the curriculum. The working groups of KSMA realized that the current curriculum needs one main goal that would connect and link all teaching units. The main task and challenge was to introduce the integration principle, so called vertical and horizontal integration, and build the curriculum around the core competencies to provide the country with well-prepared and motivated general practitioners.
After setting the main teaching goal as producing well-prepared General Practitioners/Family Doctors, the Department of the training, organizational and methodic work (DTOMW) has assigned working groups consisting of the representatives of each teaching Department/Chair to revise the existing modules and training programs.
Current modules were revised and some new integrated modules were developed in place of the longitudinal isolated disciplines.
One of the new modules was module “Human, Society and Health” for the 1st year of medical study. It involves the following disciplines: public health, psychology, philosophy, anatomy and physiology, biology and physics and clinical component. The revolutionary piece of the module is bringing the students to a real clinical environment, in the setting of a family medicine at a primary health organization. The module has a dual goal: the first is technical and the second is “ideological”. All the disciplines of the module built their teaching around these two goals. The first goal is to introduce a new medical student into the specialty of General Practice/Family Medicine, to orient medical students towards the specialty of general practice/family medicine and make them comfortable and aware about the goals of the undergraduate training. The second goal is to set a positive attitude towards the specialty of family medicine and help students understand the challenges and advantages of this specialty. The module explains the most important yet challenging role of the family doctors especially in neglected rural areas and the key role of primary health professionals in sustaining the health of the nation.
How do you know whether you have made a difference? Students are trained in the module “Human, Society and Health” in the beginning of their 1st year of study. To test the effectiveness of the module and our success in achieving our “ideological” goal each student was asked to make a visual presentation in any format to describe his vision and feelings about being a family doctor. Different formats were proposed: Power Point presentation, video, illustrated personal story, poster. Students were encouraged to work in groups. The idea behind the group work was to facilitate discussions and enhance creativity.
At the end of the module we conducted an anonymous survey among the students to assess the organizational and methodological aspects of the new module.
The students worked really hard on their projects and created motivational presentations and videos describing the challenging but fascinating work of a family doctor. All of them acknowledged that it is one of the most difficult jobs and admitted that their vision about the image and perspectives of a family doctor has been changed in the process of the training.
The anonymous survey of 221 first year medical students showed that 96% of the students found visiting doctor’s office interesting and helpful. 88% of the students found it the most interesting and motivational part of the training which allowed them to understand this profession better.
At the first meeting with students, each student was informally asked about future career plans and very few students had plans to become a family doctor, which was very shocking. A question about the choice of the profession was included into the survey.
25% of students responded that they “would like to work as family doctors in future”, 48% - “don’t know yet”, 27% - “would not like to work as family doctor” (explaining that they would like to become narrow specialists such as neurosurgeons, cardiologists, gynecologists, etc.).
48% of students who don’t know yet whether they would become a family doctor illustrates the possibility of using the 6-year training process to further encourage family doctor as a career choice. All the teachers of the KSMA have to be dedicated to the idea behind all the teaching units which is to build a positive and respectful attitude towards family medicine in our future doctors.
Our module allows us to understand the feelings and career plans of our future doctors, orient them into family medicine, and form positive attitudes to the primary healthcare professions.
Have you or the project mobilized others and if so, who, why and how? The disciplines were mobilized to form the working group and elaborate the training plan for the module “Human, Society and Health”. The most difficult part of the work was to re-orient the teaching staff into the integration mode. Traditionally every department would teach the discipline in isolation with its own competencies not being linked with the core global competencies of the whole master curriculum. Teachers of various departments had difficulty discussing the general training plan of the module and finding links to their discipline. They would tend to develop their part of the module without considering integration and interrelation with the other parts of the module. The coordinator of the module (the author of this abstract) took over the role of ensuring the integrity of the module and interconnection of the various disciplines and maintaining regular communication between the departments.
Now that the module is developed it is important to motivate the departments to continue collaboration and monitor the effectiveness of the new module in order to provide dynamic development and yearly improvement of the module.
If considered successful by the Main Training and Methodic Committee of KSMA, this module will be recommended to other medical schools in Kyrgyzstan.
When your donor funding runs out how will your idea continue to live? Our activity is not funded externally or internally. It is an internal initiative within the frames of the current health education reform which was started several years ago to meet the needs of the Kyrgyz health care system. To help with the revisions of the overall health education strategy and re-shaping the curriculum the KSMA has been granted funding for technical support by the health education experts of the Faculty of Medicine of Geneva University. They have provided field trainings for the KSMA leaders and faculty about the integration principles, competencies-based teaching and teamwork.
The reform at the KSMA is impeded by the lack of motivation of the faculty staff because their extra work is not funded and the only motivation to change is professional interest.
We need to discover other opportunities to motivate the faculty staff to improve their performance, to be engaged actively in this challenging but fascinating process in order to improve the training of future doctors!

Making heathcare affordable to poorest communities through acupuncture: India

Author(s) Walter Fischer1
Affiliation(s) 1Barefoot Acupuncturists, Barefoot Acupuncturists, Mumbai, India.
Country - ies of focus India
Relevant to the conference tracks Health Systems
Summary Barefoot Acupuncturists is a non-profit organisation registered in Belgium and founded by acupuncturist Walter Fischer in 2009. We run acupuncture clinics in slums of Mumbai and villages in Tamil Nadu (south of India), and also train local acupuncturists in order to encourage autonomy.Our services have been developed to give the poorest communities access to affordable and efficient healthcare, limited mainly to pathologies for which acupuncture has been recognised and proven (among others by the WHO) to be an effective treatment.
Our range of action covers chronic or acute pain, paralysis and stroke recovery, digestive disorders, fatigue, gynaecological issues and hypertension.
What challenges does your project address and why is it of importance? In India the healthcare sector, which is highly privatised, urged around 39 million people to fall into poverty in 2004-2005 because of out-of-pocket expenditures for their treatments.
India is the country with the largest number of poor people in the world and also has one of the most privatized healthcare systems.
It was estimated in 2010 that in India there was a shortfall of 100.000 doctors and 1000.000 nurses.High absenteeism and corruption amongst health workers discourage the poor to access public facilities. Surveys have pointed out that even when the poor try to seek medical assistance in the public sector, richer people have a greater share of public services.The challenge we are trying to address with Barefoot Acupuncturists is the great disparity between rich and poor, between public and private health systems, in which the poorest:
- choose to be treated in private sector at a high cost that puts them at even higher risk in terms of financial insecurity and social instability.
- often choose low quality publics services with the risk of not being taken care of properly and with the threat of developing more chronic diseases, which in the long term might negatively impact their future.

In both cases, the poor become poorer.

How have you addressed these challenges? Do you see a solution? We have been trying to address that great disparity between rich and poor in healthcare by providing efficient and affordable health services to the poorest through low-cost acupuncture clinics and offering acupuncture training to local communities.
Acupuncture is a unique tool not only for social health practitioners as it is cheap, effective and easy to teach. It treats pain and illness without harmful side effects. A healthcare system provided by local «barefoot doctors» who offer first-line services is a simple solution to ensure much-needed healthcare in slums or rural areas where there is little or sometimes no access to medical facilities.Why is acupuncture a unique tool against poverty:
Acupuncture from an economic perspective:
• Allows treatment at a low cost (acupuncture equipment is cheap).
• Is highly adaptable to different environments due to its simplicity and portability.
• Provides an alternative to expensive and sophisticated treatments.
Acupuncture from a healthcare perspective:
• Offers a proven and effective solution to health related issues.
• Can offer help in cases that have not been successful with conventional medicine.
• Can reduce the excessive use of chemical drugs and their potential side effects.85% of our patients consult for pain related to musculoskeletal disorders.
Coolies, farmers, workers, housewives, drivers, and maids are the majority of people at the lowest economic level who earn their living through physical works. Those are our patients.
Because their body is overused, often misused, and because of poor living conditions, this group will suffer more than others from physical pain. At the same time, they cannot afford to remain inactive without wages. Acupuncture (well known for and particularly effective against pain) allows them to recover faster and better.
The well-known efficiency of acupuncture against pain has not only been an observation through our practice in India, but globally in our acupuncture clinics around the world. In 2002 The World Health Organisation (WHO) issued a detailed report about acupuncture and a list of diseases for which through controlled clinical trails acupuncture has been proven to be an effective treatment.

- In 5 years, we have treated more than 3.500 patients, both in slums and villages.
- Today we offer 10.000 treatments every year.
- We are employing a team of 20 local people, including 7 acupuncturists.
- We are preparing to organise acupuncture trainings at a larger scale.

How do you know whether you have made a difference? We are presently making a difference at a very local level, in the slums and the villages where our clinics operate. Our clinics are busy due to our reputation spreading in the community by patients who have been encouraged to consult us by relatives or neighbours who were treated by our barefoot acupuncturists and found relief and solutions to their health problems.
A medical survey and various testimonies have shown and explained the impact and the level of satisfaction among slums dwellers and villagers.
Although our impact is clear upon surrounding poor communities, it is true that we lack scientific data to support our field experience and to quantify that impact.
We plan to hire specialised external skills to enable us to build our practises and communication.In order to expend our impact to other areas, others states in India and later in different countries, Barefoot Acupuncturists is developing an acupuncture training program. This program is aimed at the staff of local NGO’s that will fully manage their own acupuncture clinics, based on their own network and financial resources. This will allow an exponential growth of low-cost clinics, independently of Barefoot Acupuncturists’ human and financial resources. By bringing all the knowledge and tools into the hands of local communities, we hope to create more sustainable growth and functioning.
Have you or the project mobilized others and if so, who, why and how? - Founders: private founders in Europe and India have supported us financially and made it possible for our project to develop during these 6 years.
- Around 30 experienced acupuncturists and medical doctors from all over the world have joined us to work and teach in our Indian clinics.
- In 2012 we signed a collaboration with the "World Federation of Chinese Medicine Societies", an important group of Chinese doctors and professors in Beijing (China) to work on the elaboration of an acupuncture training manual.
- The Foundation Frédéric et Jean Maurice in Switzerland has offered us financial and technical support.
- The association "Humanitarian Acupuncture Project" was created in 2012 in the United-States by American acupuncturists to support our work in India with funding and volunteer acupuncturists.
- Two Indian organisations, UnLtd India and Toolbox, have been advising and coaching us for the year to help us strategise our goals and grow more efficiently.
- Professionals from various fields share their skills continuously with us: graphic designers, photographers, web designers, professional development coaches, accountants, lawyers, film makers…
When your donor funding runs out how will your idea continue to live? Today Barefoot Acupuncturists fully manages and finances all its activities. If funds run out, clinics close and all our patients lose the benefit of our services. This is the main reason (added to the need of a better cost-efficiency ratio) why in the following two years we are preparing to become an organisation offering acupuncture training to local NGO’s and communities, making possible not only an exponential growth but also sustainable structures that will function independently from Barefoot Acupuncturists resources.

Lessons from the Commercial Sector: How Integration Can Transform Public Health Supply Chains

Author(s) Carmit Keddem1, Nadia Olson2, Carolyn Hart3, Joseph McCord4.
Affiliation(s) 1Center for Health Logistics, John Snow, Inc., Boston, United States, 2USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC, United States, 3Center for Health Logistics, John Snow, Inc., Washington, DC, United States, 4USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC,United States.
Country - ies of focus Global
Relevant to the conference tracks Health Systems
Summary Successful health programs require an uninterrupted supply of health products provided by a well-designed, well-operated and well maintained supply chain. By applying a new approach to end-to-end integration, adapted from the commercial sector, health managers can ensure that public health supply chains deliver an adequate supply of essential health commodities to the clients who need them.
What challenges does your project address and why is it of importance? Health programs can succeed only if people have access to the essential health products they need. Although many countries have strengthened their public health supply chains and, thus, improved product availability in recent years, they continuously face new challenges. Countries are under increasing pressure to deliver a rising volume of products to support expanding health programs and respond to greater demand from donors for accountability and sustainability. New technology and commercial sector approaches can help countries build dynamic supply chains that respond to these changes and yield health and development benefits.
How have you addressed these challenges? Do you see a solution? JSI has researched and applied commercial sector approaches to public health supply chains, including supply chain integration, and has seen significant results. While public health systems in resource-limited settings are very different than private companies, public health supply chain managers face many of the same challenges as commercial supply chain managers did many years ago. Over the past few decades, commercial sector supply chains of major corporations, including Apple, Proctor & Gamble, Wal-Mart, and Dell, have undergone a major transformation to become cost-effective, agile, and responsive to consumer needs. This occurred in an environment where consumers were expecting wider choice and better service from retailers, and increasing globalization encouraged companies to build international, outsourced supply chains with increased management complexity. With the right approach, integration can be as transformative for public health as it has been in the commercial sector – leading to more cost-effective and reliable supply chains that effectively deliver health products to clients and contribute to better health outcomes.When adapted for public health, supply chain integration involves linking the actors managing health products from the top to the bottom of the supply chain, or from end-to-end, into one cohesive organization, which oversees all supply chain functions, levels, and partners, ensuring an adequate supply of products to clients. Lessons from the commercial sector teach us that integration is more than merging health program supply chains - for example putting malaria and HIV and AIDS products on the same truck. JSI has worked to design and strengthen various public health supply chains according to the principles of supply chain integration by better linking people, information, and activities from where products are made to the people who need them.
How do you know whether you have made a difference? In Zimbabwe, after applying supply chain integration principles to integrate key products into a well-functioning family planning supply chain, stockout rates for nevirapine tablets decreased from 33 percent to 2 percent and supply chain costs were reduced. This, ultimately, resulted in 35 percent more mothers treated to prevent mother-to-child transmission of HIV.
Have you or the project mobilized others and if so, who, why and how? JSI, through various supply chain projects, works with government, civil society, academic and funder organizations to strengthen public health supply chains worldwide. We have incorporated supply chain integration concepts into our system strengthening approaches in various countries – from a supply chain orientation of animal health specialists in Indonesia, to pre-service training in Tanzania, to guiding the supply chain system design process for essential medicines in Nigeria.
When your donor funding runs out how will your idea continue to live? Strengthening supply chain systems requires significant investment and resources, but can reap significant long-term benefits for health programs and the broader health system. While supply chains required sustained investment, designing public health supply chains according to the principles of supply chain integration will improve their efficiency and effectiveness in the long-term, protecting the investment in commodities and the supply chain system and leading to more sustainable health solutions.

Integrating neuro-psychiatric disorders at the level of primary health care centres: Guinea

Author(s) Abdoulaye SOW1, Oury SY2, Amatigui DIALLO3, Abdoulaye KOULIBALY4, Mouctar DIALLO5, Binta BAH6.
Affiliation(s) 1Mangment, Medical fraternity Guinea, Conakkry, Guinea, 2Physian, Medical fraternity Guinea, Conakry, Guinea, 3Physian, Medical fraternity Guinea, Conakry, Guinea, 4Physian, Medical fraternity Guinea, Conakry,Guinea, 5Physian, Medical fraternity Guinea, Conakry, Guinea, 6research, Medical fraternity Guinea, Conakry, Guinea.
Country - ies of focus Guinea
Relevant to the conference tracks Chronic Diseases
Summary Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease. According to the World Health Report 2000 neuropsychiatric disorders (a component of mental health) are the second cause of disability-adjusted life years (DALYs), behind the infectious and parasitic diseases. Under the theme “Stop exclusion, Dare to care”, the year 2001 was dedicated by the WHO as the "Year of mental health”. Since ancient times, epilepsy has remained a controversial subject for many world populations. This is because mental illness has been perceived as socio-anthropological for many societies.
What challenges does your project address and why is it of importance? Primary health care strategy aims to make accessible to as many people as possible healthcare according to people’s needs, at an affordable cost and taking into account a country's given resources. Equity and social justice are the basic principles of this strategy.
According to the World Health Report 2002, neuropsychiatric disorders account for 13 % of the global burden of disabilities adjusted life years (DALYs). In Guinea, while significant progress has been made in primary health care programmes, little improvement has been measured in the field of mental health. The psychiatrist ratio per capita is one of the lowest in the world. A similar gap in the number of neurologists prevails throughout the country.
In order to address this gap, the Guinea Medical Fraternity (a Guinean association of doctors) opted for the integration of neuropsychiatric consultation into the daily work of the general practioners working in its health centers.
At the opening of its health centers in the 90's, one missing element was the lack of data about the number of patients who sought consultation for mental health problems. At that time, no information was available due to the lack of qualified human resources and poor access to medicines. To tackle this challenge, Guinea Medical Fraternity initiated the project SaMoa, and used 'action research.'
How have you addressed these challenges? Do you see a solution? The model of care employed is based on the three-dimensional approach used in outpatient mental health management: medical, socio-psychological and the community. These three dimensions are combined for almost all patients in our centers, without following neither a chronological nor a hierarchical order.
For the two groups of diseases described in this abstract, epilepsy and mental health disorders, a care package is offered to the patient. This includes: identification of fixed and advanced strategy for the patient, medical treatment (with antipsychotics and/or anticonvulsants), follow-up and psychosocial support (individual interview, with family members, home visits), family and community reintegration through discussion groups and reintegration workshops (graphical expression, apprenticeships) and finally social support interventions (such as supporting the recovery of a lost job or supporting patients in rebuilding a couple in crisis).
In order to ensure continuity of care, a number of materials have been developed.
These include:
• Personal health record (first visit and follow up)
• Home visit notebook
• Reintegration notebook (describing the patient personal project)
• Group workshops notebook.
• Monthly collection sheet.
• Monthly report
Regular inter-professional encounters have been established in order to promote synergies and complementarity among caregivers and has been used to foster continuous staff training. This framework is supported by:
• A joint consultation between a generalist and a specialist (neuropsychiatrist ) at the beginning of the project
• A daily joint consultation between doctors and social workers
• A weekly team meeting between doctors, social workers and community volunteers, to discuss specific cases
• A monthly coordination meeting, which brings together the heads of unit of each health center and the officials of the NGO.
How do you know whether you have made a difference? From January 2000 to June 2013, 7079 mental health problems were diagnosed among which 47 % were psychoses, 33% were epilepsy cases and the remaining 20% represented by depression, dementia, neurosis, social problems and cerebral motor deficiencies.
Among patients put under treatment, two main molecules were used for psychosis (different forms of Haloperidol and Akineton as corrector) and for epilepsy, four essential generic drugs (carbamazepine, phenobarbital, phenytoin and sodium valproate). We found a positive impact for both patients and their families, health care providers as well as for health centres.
For the patient, the impact is assessed by how much healthcare management has improved by integrating the socio-cultural context of the patient and his/her family, how much the intervention has strengthened patient-provider relationship and contributed to better adherence and how much the intervention has facilitated patients social reintegration and has strengthened their economic capacity.
At the level of health centers and providers: the impact is felt at many levels
 Improved patient-provider relationship (beyond mentally ill patients).
Indeed, GP’s trained to adopt a more holistic bio-psycho-social approach with psychiatric patients and spontaneously applied a similar approach vis-à-vis other patients, spending more time, listening and discussing with them and paying more attention to their psychosomatic problems.
 Improved relationships between health centers and the communities they serve.
Communities started to see healthcare providers and the health centres as partners and contributed to the development of the relationship.
 Improved relationships between primary health centers and referral hospitals.
Given the fact that the care package provided by the programme is not available in district hospitals, the project has reversed the usual pattern of the health pyramid that usually sees PHC centers referring their patients to a hospital. In this case, the opposite took place, hospitals sending their patients to the lower level of care.
 Implementation of several community initiatives around the health centres.
The momentum created by the project has allowed the emergence of community-led initiatives such as economic interest groups among intervention communities, involvement of young people in the village around health promotion activities and the establishment of patient support groups.
 Health centre as a training and internships for medical students in public health and community health workers. Successful health centres are coveted by academics whose students are engaged in the internships and the development of dissertations.
Have you or the project mobilized others and if so, who, why and how? The project involved several actors in different and various socio-medical fields.
In Guinea, networking is not integrated into the system. Each association operates in isolation and tries to protect its field of competencies as a private territory. Initiatives are confined to a limited territory or to a given intervention and do not benefit neither the beneficiaries nor field social workers. To break this single thought mindset, our project has created an inter-professional approach mobilizing a supportive and dynamic network of various health workers, social workers and human rights advocates in order to improve the management of heavy neuropsychiatric disorders.
Among the objectives, this initiative attempted also to demedicalize some health problems, to push healthcare providers to pay more attention to social problems and to involve other social stakeholders in medical work.
As an illustration, health centres provide care (medical consultations, nursing services and drugs) to all populations. Social centres provide services (psycho -social support, legal support, rehabilitation, social and professional reintegration) to the same populations. The interaction of these two levels of intervention can only be beneficial for patients, providers and medical-social structures.
Our methodology involves the organization of platforms for dialogue between actors, field visits, referrals of patients or target groups and the organization of joint actions.
The platforms are organized around a theme: clinical, social, results or best practice.
Field visits take place upon request in order to assess the social and/or medical situation of an identified patient, or to meet with an association that wants to share its experience and best practices or seek advice.
Social workers refer their clients to a healthcare professional for a medical condition and the healthcare professional refers their patients to social workers in order to be more effective not only in medical care but also to delegate certain activities (counseling, search of lost to follow up) in order to deal with other aspects.
Joint actions are put in place to identify, plan and agree upon a synergic mode of implementing activities that improve the quality of services offered.
When your donor funding runs out how will your idea continue to live? The project initially depended on single funding, but since its activities are integrated into health centres, it has become routine and no longer dependent on external funding. Yet, the fact that we are in the process of replicating and scaling up the programme in several other health centres, funding will be needed in order to train staff, provide a starting stock of essential generic drugs, conduct reintegration workshops and provide supportive teaching materials.