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Learning from evidence: Advice-seeking behaviour among Primary Health Care physicians in Pakistan.

Author(s) Asmat Malik1, Cameron Willis2, Saima Hamid3, Anar Ulikpan 4, Peter Hill 5.
Affiliation(s) 1Department of Research and Development, Integrated Health Services, Islamabad, Pakistan, 2School of Population and Public Health, University of British Columbia, Vancouver, Canada, 3Department of Maternal and Reproductive Health, Health Services Academy, Islamabad, Pakistan, 4School of Population Health, The University of Queensland, Brisbane, Australia, 5School of Population Health, The University of Queensland, Brisbane, Australia.
Country - ies of focus Pakistan
Relevant to the conference tracks Health Systems
Summary Access to information is critical for creating and maintaining high performing Primary Health Care (PHC) systems. Among multiple sources of information, advice-seeking from humans possesses significant importance for the physicians in their clinical settings because they are looking for readily available answers to their questions. We used Tuberculosis and measles as a lens for analyzing the advice-seeking behavior of PHC physicians in Pakistan. The study concludes that the heath care providers are falling prey to stagnant system behaviour. There is a need to better understand system behaviors and to identify system principles such as information flows and feedback loops.
Background The available studies provide some insights into how physicians seek information while working in PHC settings. However, as this literature is largely confined to developed countries, there is relatively little known about how physicians in low-middle income countries access or use information when faced with difficult to diagnose conditions. In these settings, where access to electronic information sources is often scarce, understanding advice seeking behaviors from human sources becomes particularly important. Using methods grounded in systems science, this study examines the advice seeking behaviour of PHC physicians in a rural district of Pakistan, analyzes the degree to which the existing PHC system supports their access to advice, and explores ways this system might be strengthened to better meet provider needs.
Objectives Tuberculosis (TB) and measles are currently providing major challenges to PHC physicians in Pakistan. We used these two conditions as a lens for analyzing the advice-seeking behavior of PHC physicans in Pakistan. The specific research questions of this study were:
• To what degree does the existing structure of the PHC system in Pakistan support physicians in accessing advice on difficult to diagnose cases of tuberculosis and measles?
• To what degree are physicians satisfied with their current access to advice on difficult to diagnose cases of tuberculosis and measles?
• What changes, if any, do physicians recommend to improve their access to advice on difficult to diagnose cases of tuberculosis and measles?
In order to answer these research questions, this study has the following specific research objectives:
• To document the flow of information on diagnosing TB and measles cases in the PHC system of Pakistan;
• To describe the advice seeking behaviour of physicians in situations of difficult to diagnose cases of TB and measles;
• To explore physicians’ satisfaction with their access to advice in difficult to diagnose cases of TB and measles;
• To identify and describe possible changes, if any, that physicians recommend to improve their access to advice in difficult to diagnose cases of TB and measles.
Methodology This study was conducted at the district level in Pakistan from January 2013 to August 2013. The organization of health services at a district level is similar across Pakistan. With a cross-sectional study design we employed three research methods comprising:
1. Mapping of formal system of flow of information for diagnosing TB and measles.
Through documentary review and targeted key informant interviews with five district health administrators and line-managers of vertical health programs, we mapped the existing system of the flow of information for assisting physicians in diagnosing TB and measles cases. Illustrations of formal information dissemination systems were developed in the form of flow charts showing the direction of flow of information and roles and responsibilities for providing information/feedback at various hierarchical levels.
2. Survey for social network analysis of physician advice seeking behaviour.
A semi-structured questionnaire was used to conduct a survey for mapping professional networks. The key questions were structured to identify whom each physician had contacted for advice whenever faced a difficult to diagnose cases of TB and measles. Out of the 61 BHUs in district Attock, only those with an appointed physician (n=49) were invited to participate. The compiled data was imported in UCINET software for generating sociograms.
3. Key stakeholder interviews.
Based on the analysis of the findings from Sociograms, the BHU physicians were divided into three groups:
• Physicians who sought advice from a designated person (formally notified by the health department)
• Physicians who sought advice from someone other than a designated person
• Physicians who did not seek advice from any other person
This grouping provided the basis for selecting 11 study respondents for in-depth interviews. All study participants agreed to one-on-one interviews and consented to audio recording. Three separate interview guides were used during these semi-structured in-depth interviews among the three groups of study respondents. The average interview time was 20 minutes. The researchers using an inductive process identified categories, sub-themes and themes. The research team then compared their findings to optimize the data conformity. The final themes were presented after the research team’s consensus on the analysis process.
Results The present configuration of the primary health care system in Pakistan is largely a result of the push for universal health coverage and Health for All under the declaration of Alma Ata Conference on PHC in 1978. Under the influence of this global movement, an extensive network of PHC clinics (5449 Basic Health Units and 579 Rural Health Centers) has been established as the first point of contact for those seeking healthcare across all districts in Pakistan.
Early detection of both TB and measles is critical to decrease morbidity and mortality rates. There are multiple sources of information available to assist physicians in diagnosing cases of TB and measles including clinical guidelines, case definitions and case detection protocols. While these information sources are largely provided through government agencies, the precise channels used for their distribution and the ways in which physicians make use of these channels have not been made explicit. Mostly they use their personal social networks in order to seek guidance in clinical care from their friends, peers, and other disease-specific experts.
With a systems approach, the thematic analysis has been categorized under four key areas. Firstly, the health leadership designs health programs and interventions without placing competent experts and a pathway to seek information on difficult cases (system organizing). Referral systems are not functional and there is no feedback on the patients’ from whom advice is being taken. As a consequence, patients are lost to the private sector. Secondly, PHC clinics do not have functional linkages with tertiary care hospitals (system network). In addition, no needs assessment for refresher trainings is conducted by the health department. Thirdly, the PHC physicians are not provided any feedback on patients sent to higher level centers (system dynamics). There exists no formal system of communication and dissemination through which the latest research or related materials are shared. In addition, there exist no opportunities where PHC physicians can be placed at secondary or tertiary care hospital on a rotation basis. Lastly, the focus of the health managers and administrators is more on administrative running of programs and meeting targets (system knowledge). Consequently, capacity building in clinical management has become a neglected priority.
Conclusion The analysis of the PHC system in Pakistan clearly demonstrates that the problems in the health sector are deeply rooted and complex in nature. The evidence from this study demonstrates that in situations where PHC physicians require further advice in diagnosing potential cases of TB or measles, it is unclear from whom this advice is being sought, or the degree to which the current PHC system enables physicians to seek this advice.
PHC level acts as a driver for healthcare delivery system whereas human resources are the main driving force behind a functional health system because they provide a human link that connects the system building blocks. However, in Pakistan, the heath care providers are falling prey to  stagnant system behaviour. The solutions require a systems’ thinking that views public health problems as a part of a wider and dynamic system, with a focus on in-depth understanding of the linkages, relationships, interactions and behaviors among the sub-system components that characterize the entire system. It is imperative to better understand system behaviors and to identify system principles such as information flows and feedback loops.

Exploring Primary Care: System Dynamics in USA and Romania.

Author(s) Andrada Tomoaia-Cotisel1, Karl Blanchet2, Zaid Chalabi3, Samuel Allen 4, Victor Olsavsky 5, Cassandra Butu6, Michael Magill7, Bernd Rechel8
Affiliation(s) 1Health Services Research & Policy, London School of Hygiene and Tropical Medicine, Cluj-Napoca, United States, 2Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom, 3Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom, 4Utah Medical Education Council, Utah Medical Education Council, Salt Lake City, United States, 5WHO Country Office Romania, WHO Country Office Romania, Bucharest, Romania, 6WHO Country Office Romania, WHO Country Office Romania, Bucharest, Romania, 7Department of Family & Preventive Medicine, University of Utah, Salt Lake City, United States, 8Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
Country - ies of focus Romania, United States
Relevant to the conference tracks Health Systems
Summary Policy-makers are better able to identify and implement effective health system strengthening (HSS) efforts when they have an accurate understanding of the dynamic, emergent behavior of the system they are attempting to strengthen. Achieving such an understanding is difficult. Yet, without it, decisions can easily result in unintended consequences or policy resistance. This paper describes system dynamics methodologies employed in the context of a HSS effort in Utah, USA and explores ways of applying them in LMICs, based on a case study in Romania. We present differences in data needs, availability and quality; and discuss how methods can be modified in view of these constraints.
Background Policy-makers are better able to identify and implement effective health system strengthening (HSS) efforts when they have an accurate understanding of the dynamic, emergent behavior of the system they are attempting to strengthen. Achieving such an understanding is difficult. Yet, without it, decisions can easily result in unintended consequences or policy resistance. In high-income countries, such understanding is increasingly obtained through the use of complex system modeling and detailed statistical analysis using large datasets. However, in low- and middle-income countries (LMICs) the data available are more limited, introducing higher levels of uncertainty in health system parameters. Despite this uncertainty, systems thinking and system dynamics supplies decision-makers with information needed in HSS efforts.“Systems thinking” provides a comprehensive framework for capturing, from diverse perspectives, how health systems function and how complex changes occur. System dynamics takes this approach to the next level by developing quantitative computer-based simulation models that can analyze system behavior and simulate how systems respond to policy measures and other changes over time.
Objectives To describe system dynamics methodologies employed in the context of a HSS effort in Utah, USA. Methodologies used are explained and ways of applying them in low and middle income countries are explored, based on a case study in Romania. The World Health Organization projects the burden of non-communicable diseases (NCDs) in LMICs to grow from half of total disability-adjusted life years in 2004 to three quarters by 2030. As LMIC health systems are already strained, this awareness necessitates that LMIC policy-makers anticipate and prepare for the consequences of this shift. As many NCDs are best managed in primary care settings, many HSS efforts aim to enhance primary care. System dynamics provides methods for creating custom-tailored tools to do this.HSS efforts in Romania, as in other former communist countries, focus on overcoming a previous neglect of primary health care, while redesigning the provision and financing of primary care at the same time. The goal being to facilitate patient centered care with a whole person orientation, providing all key elements of primary care.
Methodology System dynamics methodology will be presented as used in a high-income country setting and as modified for implementation in a middle-income country setting. In both contexts, the core methodology progresses as follows: 1) develop a conceptual model of the health system, 2) transpose the conceptual model to a dynamic quantitative model of the system, 3) develop and run scenarios simulating the policies and interventions under consideration. This methodology is couched within a participatory action research approach. Methodological tools employed included: Causal Loop Diagrams (CLDs) identifying key system structures such as feedback loops and time delays; statistical analyses and literature review identifying relationships among system variables; model validation techniques and key informant discussions with a diverse set of stakeholders. Decision-makers are involved throughout the project, participating in model development and critique, providing key informant expertise, designing scenarios to be tested, and discussing scenario results.We present differences in high and middle income country data needs, availability and quality. We also discuss how methods can be modified in view of these data constraints. These modifications impact the model produced and the lessons obtained from it. Strengths and limitations of these modifications are discussed.
Results We found that applying a SD methodology in LMICs is possible, but that the level of uncertainty in the model developed depends on the type and amount of available data. CLDs can be developed on the basis of interviews with key stakeholders, as well as using information in the literature. Quantifying the relationship between the identified system variables should ideally use context-specific data to increase model validity. However, model validation techniques can be performed using less data, for example via key informant discussions to elucidate a relationship’s potential behaviour. A health system model can be operationalized using less than ideal datasets. Existing data sources include qualitative and quantitative data on primary care in Romania and nationwide hospital diagnosis-related groups (DRGs) data. Additional low-cost resources would be required to conduct key stakeholder interviews to verify model structure and to design policy scenarios.
Conclusion Applying system dynamics in HSS requires the creative use of mixed methods within the constraints of data availability, transdisciplinary research teams and multi-level stakeholder involvement (of patients, providers, administrators and policy-makers). In particular, in LMICs’ HSS efforts, policy-makers need to know how to adapt innovations to their specific context and health system. System dynamics methodology promises to allow for this kind of tailoring; it also provides a framework for conceptualizing and simulating system behavior. Its design, tools and required parameterization can draw on experiences from elsewhere, while at the same time be adapted to local contexts.

Immunization status of young people attending a youth clinic in Geneva, Switzerland

Author(s) Anne Meynard1, Emilien Jeannot2, Lydia Markham3, Claire-Anne Lazarevic 4, Bernard Cerutti 5, Francoise Narring6
Affiliation(s) 1Department of Pediatrics, Geneca University Hospitals, Geneva, Switzerland, 2Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Institute of social and preventive medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland, 3Private general practice, Private general practice and school health service, Nyon, Switzerland, 4School Health Service , Department of Public instruction Geneva, Geneva, Switzerland, 5Faculty of medicine University of Geneva, Faculty of medicine University of Geneva, Geneva, Switzerland, 6Department of Pediatrics, University hospitals Geneva, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Advocacy and Communication
Summary This study aims to describe immunization status at first visit in a collective of young people coming to an academic youth clinic. Results confirm our hypothesis that many young immigrants have had adequate childhood vaccination especially for tetanus but  are missing Hepatitis B and HPV. Collaboration between nurses in the youth clinic and school health services allows, not only detection of under-vaccinated youth, but quick and effective vaccination .
Background Adolescents are under-vaccinated and have limited access to effective care or preventive services in many regions of the world. Data on immunization status of adolescents or young adults in Switzerland are scarce and little is known about barriers to adequate coverage. Swiss vaccination coverage data shows that children of foreign origin are usually better immunized, but that this difference is lost in adolescence, where the most important factor of adequate vaccination is the presence of a school health vaccination program.
Objectives The objective is to describe the immunization status at first visit and differences in immunization status according to duration of stay in Switzerland and nationality of young people coming to a mulitdisicplinary youth clinic in Geneva
Methodology Immunization status at first visit (medical file, immunization booklets or school health database) was collected retrospectively between January 2010 and June 2011 in all patients coming for a first visit at Geneva University hospital’s multidisicplinary youth clinic. The main outcomes were Tetanus antibody titers one month after a booster of tetanus containing regimen and immunization status at first visit and the comparing of rates between young people of Swiss or foreign origin and for foreigners according to duration of stay in Switzerland.
Results 89% of patients tested for tetanus antibodies had values above 1000 U/l indicating adequate childhood immunization with 29% above 10’000 U/l putting them at risk of hyperimmunization if given usual adult catch up regimens (3 dosis). On the contrary Hepatitis B serology was often negative among the same population in our sample. Finding written information about immunization is significantely higher in youth born in Switzerland regardless of sex and nationality for all vaccines studied (tetanus, measles, hepatitis B and HPV) but is inferior to Swiss vaccination coverage data. Collection of information was highly facilitated by collaboration between academic youth clinic and school health services.
Conclusion In the absence of data, many young people immunized against tetanus or measles might in fact already be well immunized for childhood vaccinations. Effective collaboration between school-health services, primary health care facilities and youth clinics is highly effective in improving adolescent vaccine coverage especially with the help of public heath policies. School health services are usually very well informed about vaccination strategies in countries of immigration and the WHO database can also help to adapt recommendations to migratory flows.  However, they might miss young people at higher risk of being under or over immunized for example those with no booklet, absent from school on the day of immunization campaign, or with no permanent address. In Switzerland, parental consent is required for Hepatitis B or HPV immunization for young people under 16 years of age.Individually adapted catch-up immunization plans for adolescents and young adults regardless of origin or gender can avoid unnecessary and unsafe vaccination, and bring attention to barriers to adolescent vaccination as well as other adolescent health issues. Individual counseling allows targeted screening for silent infectious diseases (STI’s, Hepatitis, Chagas disease or common parasitic infections) but should mainly focus on assessment of protective and risk factors for healthy development of young people.

Case Management in Mental Health Settings in Bosnia and Herzegovina.

Author(s) Darko Paranos1, Biljana Lakić2, Tatjana Popović3, Dženita Hrelja Hasečić 4.
Affiliation(s) 1Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina, 2Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 3Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Banja Luka, Bosnia and Herzegovina, 4Mental Health Project in Bosnia and Herzegovina, Mental Health Project in Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina.
Country - ies of focus Bosnia and Herzegovina
Relevant to the conference tracks Chronic Diseases
Summary Within scope of the Mental Health Project in Bosnia and Herzegovina (BIH) the Case Management in Mental Health was introduced across the country with the aim of improving the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs. In order to achieve planned objectives an integrated set of activities was conducted compromising of teaching materials development, continuous education activities targeting Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives and (Peer) Support to Mental Health institutions in applying Case Management. Initial findings indicate the significant increase in the number of CMHCs which successfully started with the application of the Case Management in their institutions.
Background Activities were conducted within the scope of the Mental Health Project (MHP) in Bosnia and Herzegovina (BIH). The Mental Health Project in BIH is a result of continuous commitment of the health ministries to continue the mental health reform in BIH. The mental health reform was launched in 1996 focusing on community-based care as a contrast to the traditional model that was mainly oriented towards hospital treatment of persons with mental disorders. The overall goal of the Mental Health Project in BIH, in the period June 2010 - December 2013, was to improve the general mental health of the population and enhance the capacities of policy makers and competent institutions for complying with European standards in mental health care in BIH. Since 2011 the Mental Health Project in Bosnia and Herzegovina was involved in trainings of Community Mental Health Centres staff in the field of Case Management with the aim to improve the quality of provided care focusing on increasing access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs.
Objectives The objectives of the Mental Health in BiH Project in the period June 2010 to December 2013 were as follows: 1. Improved administrative and legislative frameworks to enable efficient operations and processes in mental health care in both BiH entities, Federation of Bosnia and Herzegovina and Republika Srpska.
2. Persons with mental problems to have access to improved and better quality services of mental health care at the community level.
3. Provision of high-quality mental health services at the community level is supported as a priority of the reform process by the management structures in Community Health Centres.
4. Capacities to fight against stigmatisation and discrimination related to mental disorders are strengthened. Within the objective 2, the specific objectives include: a) Competencies and skills of the multidisciplinary teams of the Community Centres for Mental Health to be enhanced, b) Independence and responsibility of the nurses in provision of the mental health services and direct work with clients to be enhanced.In order to achieve planned objectives the integrated set of activities were conducted:
• Teaching materials development -
o The Case Management continuing education Curriculum and Manual development
• The continuous education -
o A Training of Trainers (ToT) course in Case Management
o The health professionals continuous education of Community Mental Health Centres multidisciplinary teams and
psychiatric hospitals/clinics/departments representatives
• (Peer) Support to Mental Health institutions in applying Case Management -
o Mentoring and support to Community Mental Health Centres and psychiatric
hospitals/clinics/departments in applying Case Management.
Methodology The case management is a collaborative process which connects users with services and available resources aimed at ensuring provision of optimal care. The approach involves the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders, and often reluctant to come into contact with mental health services. It is activated by establishing contact with customers in the community, a comprehensive needs assessment, developing individual "tailored" packages of care and effective coordination of services and treatments in a variety of services which increases the user's potential for recovery. The process of introducing the Case Management principles across Mental Health Settings in Bosnia and Herzegovina is based on a set of integrated activities. The Development of Teaching materials sets the fundamentals for the continuous education of multidisciplinary teams employed by Community Mental Health Centres and psychiatric hospitals/clinics/departments representatives. The core materials are the Case Management in Mental Health Curriculum and Manual which are organised into seven modules: I - Introduction to Case Management - concepts, principles, practices and theories; II – User Involvement and needs assessment; III - Assessment and Risk Management; IV - Planning of care, implementation of treatment and use of resources in the community; V - The Case Management at the first psychotic episode, early intervention and prevention of relapse; VI - Team Approach to Mental Health; VII - Gender and Mental Health. The Mental Health Professional continuous education was organised in two phases. The first step was to identify, recruit and train group of mental health professionals as a part of Case Management Training of Trainers course. The next step was to deploy trainers in training of Community Mental Health Centres multidisciplinary teams and psychiatric hospitals/clinics/departments representatives.Applying the Care Coordination model across the country began after the completion of the trainings. The Peer support to Mental Health Institutions across the country is organised Systematic (peer) support to application principles in Mental Health Settings will be conducted in between September- December 2013 with aim of ensuring increased access to a range of complementary health, social, educational and other public services for service users with severe mental health disorders and multiple needs is secured.
Results The Mental Health Case Management Curriculum and Manual were developed setting the basis for continuous education of Mental Health Professionals in Bosnia and Herzegovina. Training for trainers was completed in 4 training cycles with total duration of 9 days. As an education result, 21 mental health professionals have been certificated and formally appointed as future trainers by entity MoHs. Training of CMHC multidisciplinary teams was organised involving 625 mental health professionals from 67 CMHCs and 15 psychiatric hospitals/clinics/departments. 565 professionals (or 90%) passed the final exam, and successfully completed the training. After completion of the trainings the application of Case Management across the Mental Health care institutions started. Initial findings indicate that the 54% CMHCs (37 out of 69) successfully started the application of the Case Management in their institutions. As such this data indicates the significant increase in number of institutions applying the Case Management compared with 4 CMHCs from the baseline conducted in 2008. (Peer) Support to Mental Health institutions will provide not only support to the institutions in applying Case Management in standardised manner, but will provide insight in terms of effectiveness in changing the practice of those institutions. The key indicators to measure success of the process (in the short term) are the percentage of CMHCs appointing the Case Managers, number of appointed Case managers per CMHC (segregated by profession, particular focus on nurses) and percentage of service users involved in care plan development. A particular focus will be on measuring the service users involved in Case Management satisfaction.
Conclusion CMHCs capacities to involve the service users with complex, multiple needs, which are at high risk and / or suffering from severe mental disorders are improved when compared to the initial survey. The significant increase in the number of CMHCs applying Case Management in their institutions is observed. The Case Management is recognised by the revised service nomenclature, an organised and officially recognised classification/ registry of the health services endorsed by entity/cantonal Health Insurance Funds. As only those services officially recognised in the nomenclature can be performed by health institutions and charged to HIFs, a long term sustainability of Case Management is supported. Initial findings emphasise the issues of a large number of patients covered by the coordinated care, lack of staff and other resources required for adequate Case Management application in their institutions. In addition, another obstacle in the implementation of the Case Management observed is weak cooperation among agencies and institutions involved in the Case Management process.

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.

Dual practice in Uganda: the evolution and management of a complex phenomenon.

Author(s) Ligia Paina Bergman1, Freddie Ssengooba2, David Peters3.
Affiliation(s) 1Department of International Health, Johns Hopkins University School of Public Health, Washington, United States, 2Health Policy Planning and Management, Makerere University School of Public Health, Kampala, Uganda, 3Department of International Health, Johns Hopkins University School of Public Health, Baltimore, United States.
Country - ies of focus Uganda
Relevant to the conference tracks Health Systems
Summary Dual practice is widespread in developing countries, yet it is seldom accounted for in health workforce policies. A systems lens guided the development of a qualitative research design to describe how dual practice evolved and how it is currently managed in urban Uganda. We found that dual practice is deeply embedded in the Ugandan health system. In the absence of formal policies, the local, informal management and coping strategies provide learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of dual practice is essential for health workforce policy and planning in countries where this phenomenon occurs.
Background Dual practice, when government health providers also work in the private health sector, is widespread in developing countries, particularly in settings with rapidly developing private sectors. However, it is seldom accounted for in health workforce policy and planning. Uganda has an active private sector and a high proportion of health providers working multiple jobs, particularly in the capital region. An informal, unenforced ban on dual practice in a system where high demand for patient services is constrained by low supply of health professionals creates complexity and unanticipated dynamics over time. Informal management of dual practice, or local responses to complexity, have not been previously documented and could inform health workforce policy and planning in Uganda and similar settings.
Objectives Acknowledging that the health system is a complex adaptive system, this study applied a systems lens to describe how dual practice evolved and how this phenomenon is currently managed in urban Uganda.
Methodology A qualitative research design, supplemented by a review of historical and policy documents was used to develop five case studies of government health facilities, capturing the perspective of both health providers and health managers through semi-structured in-depth interviews. This is one of the few studies examining both doctors and nurses’ perspectives on dual practice. Additionally, interviews with policy stakeholders allowed the exploration of dual practice from multiple angles, from government to private sector. A causal loop diagram was constructed using the qualitative data in order to illustrate the influence of various health system actors, as well as interactions and feedback.
Results Dual practice in Uganda is rooted in the history surrounding the professionalization of medicine, the development of the private sector, and political and economic turmoil. Private practice, and dual practice, started as a privilege for African doctors seeking autonomy and professional status. Feedback from the economic decline and the deterioration of government infrastructure, transformed dual practice into a coping mechanism for health providers who did not migrate. Over time, the government’s skepticism and resistance to dual practice increased, although enforcing a ban has consistently been met with threats from providers leaving. Most respondents believed that the majority of health providers engaged in dual practice informally. Doctors and nurses enter dual practice through a variety of mechanisms – from direct recruitment, to informal networking. Internal labor markets have emerged around major facilities, where parallel institutions conduct well-funded research and service provision, usually related to infectious diseases. Informal management approaches at the facility level vary. In smaller facilities, nurses and doctors self-organize to ensure their shifts are covered. The facility in-charges’ emphasis is on performance and coverage during government hours, although those who had done dual practice in the past apply a personalized approach. In larger facilities, specialists organize their public and private activities depending on the type of service provided, at times in coordination with colleagues and supervisors.
Conclusion The systems lens fostered an approach to capture the perspectives of multiple health system actors, historically and across various levels of the Ugandan health system. The findings confirmed that, in the absence of formal policies, health providers adopt informal approaches to coping with and managing dual practice. Health managers emphasize the government job as a primary duty, while at the same time recognizing the reality that there are advantages to dual practice, from both the individual and the societal perspectives. Doctors and nurses have each developed unique coping mechanisms. The local management and coping strategies are learning opportunities which can inform the development of a formal policy on dual practice in Uganda. An in-depth understanding of how dual practice evolves and how it is managed in a system is essential for health workforce policy and planning.

The ESTHER European Alliance: a decade of hospital partnerships assessed

Author(s) MEZGER Nathalie1.
Affiliation(s) 1Service de Medecine Tropicale et Humnanitaire, Hôpital Cantonal Universitaire de Genève, Genève, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Health Systems
Summary To evaluate a decade of activities, better define the current environment and its future, the ESTHER European Alliance, an initiative based on hospital/institutional partnerships with low resources countries, requested an external, qualitative assessment. Results showed that added value of these partnerships and of the EEA were well perceived. EEA seems in line with the current development cooperation landscape, helping to tackle the health human resources crisis and adapted to face the new health challenges. Nevertheless to better contribute and improve, there was a need to better demonstrate EEA's contribution to the health system strengthening and review its strategy.
Background The ESTHER Alliance (Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau - EEA), a French initiative composed currently by 12 European member states (France, Italy, Luxembourg, Spain Germany, Austria, Belgium, Portugal, Greece, Norway, Switzerland, Ireland) and 1 observer (UK), was launched in 2002 to strengthen, through hospital partnerships, the capacities of low income countries to face the HIV/AIDS emergency and related diseases. Each ESTHER national entity is different from each other, but all signed a ministerial declaration of engagement to develop the initiative and are linked by a joint charter of principles.
In 2012 the Alliance members were active in 41 countries and involved in a wide range of training activities including collaboration with civil society organisations. As the last 10 years has seen a change in the worlds health needs and cooperation landscapes, ESTHER evolved and broadened its scope, scale and type of activities to include other health priorities that contribute to meet the Millennium Development Goals 4-5-6 and strengthen health systems to improve health outcomes.
In 2013, an external study was ordered by the Alliance to qualitatively assess the achievements and challenges faced by the EEA over its decade of existence.
Objectives This external qualitative evaluation of the ESTHER initiative, at European and country implementation level, aimed to capture the EEA’s achievements and challenges, draw lessons and clarify the EEA position in the current, evolving, development cooperation and health landscape in order to better define its future. This work was made on request of the EEA.
It focused on identifying the added value of the institutional partnerships for health, on identifying and analyzing the added value that the Alliance brings as a European platform for development cooperation in health, identifying commonalities and challenges for Alliance member bilateral partnership programs, evaluating contributions that partners have made to Health Systems Strengthening (HSS) and presenting future option to move forward.
Methodology Capacity Development International won the EEA international tender after each ESTHER national entity ranked the different candidate’s proposals for this qualitative evaluation.
Two investigators ran it. In all stages of the assessment they included the priority countries that have an active bilateral program (France, Germany, Spain, Italy, Norway and Ireland). Switzerland, Luxembourg, Greece and UK were involved in the first stage of this evaluation. Belgium, Portugal and Austria did not participate.
An extensive review of documents and literature provided by the EEA secretariat, the national coordinating bodies and the technical implementing partners, was performed. It was completed by an international literature review guided by key informants related to development cooperation, health partnerships, capacity development, human resources for health and health system strengthening.
The first stage of interviews focused on the ESTHER model, its achievement, its added value, the challenge and future. They reached the EEA secretariat, 10 northern governments, 13 national coordinating bodies and 2 experts working in the institutional partnerships.
Best practice demonstrating projects were selected by the interviewed national coordinating bodies to be included for the second type of interviews, which focused on the added value of hospital partnerships. Enablers, challenges, lessons learned and contribution to health system strengthening were reviewed. Nine northern implementing partners, 11 southern implementing partners and 3 southern government representatives were interviewed.
Results were analyzed at 4 different levels (added value of institutional partnerships for health, EEA level, National Secretariat level and partnership/project (case studies and lessons learned)) using the OECD/DAC framework (relevance, efficiency, effectiveness, sustainability) to draw out the main themes. Results were synthesised in the perspective of current thinking and EEA objectives and guidelines. Case studies concretely illustrated the evaluation, highlighted innovations, lessons learned and challenges in contributing to HSS.
Limitations were due to the limited time and geographical constraints. Data objective verification was beyond the scope of the study. Best practice projects were selected by the national secretariat and may be subject to bias. Descriptions were dependent on the completeness of information provided.
Results The added value of institutional partnerships (IP) for health based on capacity building and sustainable improvement was clearly perceived. Benefits were: institutional strengthening, responsiveness to needs, ownership, long term building of trust and capacity, peer to peer multidisciplinary exchanges, solidarity, innovation, ability to fund unusual interventions for development cooperation, opportunities to learn how to manage in deprived conditions and cultural sensitivity. IP was felt to go well beyond traditional assistance which is centered on short term filling of capacity gaps and was considered to be a complement to the classical development cooperation.
If hospitals, often neglected in the development, should remain central to ESTHER, inclusion of other organizations or levels was valued.
Concerns expressed the IP potential contribution to the aid fragmentation/proliferation, unintended harms, the creation of pockets of excellence and their real capacity to strengthen the health system.
Recognition, objectification, better definition of the EEA contribution to the HSS were felt to be improved, as the conceptualization of the IP added value to the gaining of knowledge, evidence and ease and the conceptualisation of costs.
The EEA added value was recognized (networking, information sharing), but much of its potential is not fully realized (joint projects, joint working, coordination).
Political mandate and release of resources not straightforward. Weight given to EEA validation and mandate varies. Political commitment was sometimes seen as a mere weight to back-up “ESTHER”, an IP quality brand. Consequently the quest for external funds becomes vital. This would be eased by a better demonstration of the EEA added value beyond members’ programs. The ESTHER diversity, a wealthy fishpond cemented by valuable charter of principles, makes knowledge generation and joint work challenging. If key, knowledge management will have to be balanced as resources are restricted.
In the changing global health agenda ESTHER seems well adapted to address issues such as the non-communicable diseases or the horizontal and integrated approaches. By building capacity, contributing to medical education and continued professional development EEA clearly addresses the human resource crisis.
There is momentum to revisit the EEA vision, strategy and objectives to better adapt to the on-going changes in economy, health and development cooperation.
Conclusion This qualitative study outlines that the EEA, which is based among others on institutional/hospital partnerships, capacity building, local ownership, is needs driven, has long term involvement, respects the Paris Declaration (enshrined in its shared charter of principles), is well aligned with the current thinking and best practices in development cooperation for health. It especially helps in tackling the health human resources crisis.
These principles and ESTHER multidisciplinary identity are clearly of value in the post MDG landscape. Initially focused on the HIV/AIDS crisis, a thematic which was already broadened to include the MDG4-5-6, the EEA has the potential to evolve and contribute to the new emergent health themes.
Added values of IP and of the EEA are well perceived by members, even if it is felt that there is still unveiled potential. The perceived addition of the work in partnerships over other forms of technical cooperation and of the EEA is nevertheless difficult to measure and demonstrate. Creation of enabling, inspiring environments by partnerships does not fully guarantee results. Approaches that address knowledge and capacity gaps through empowerment, leadership by the beneficiary and use of country systems are quite recent and lack rigorous evaluation material to assess their impact. Therefore, efforts should be made to develop material and evaluate processes and projects, but in a light and bearable manner. This could contribute to developing evidence on how to make a quality partnership that brings added value, a matter in which the Alliance could play a role.
Worldwide, little agreement exists on the effective strategy to strengthen the health system, one of the ultimate EEA goals. Operational research could help to clarify how partnership work can contribute to HSS at different levels. The EEA projects/programs diversity is a rich field to work on. This will require the Alliance members to better define and share a common understanding of the HSS.
This knowledge generation would serve EEA to better demonstrate its impact/contribution and increase donors and key stakeholders’ interest. Balance between operational research, monitoring/evaluation and service delivery will have to be found, especially when resources are scarce.
To take advantage of this momentum, clarification and re-definition of the Alliance strategy and structural improvement seem to be needed. A motivating challenge !

Administrative Integration of HIV Monitoring And Evaluation: A Case Study From South Africa.

Author(s) Mary Kawonga1, Sharon Fonn2, Duane Blaauw3.
Affiliation(s) 1Department of Community Health, Wits School of Public Health, Johannesburg, South Africa, 2School of Public Health, Wits School of Public Health, Johannesburg, South Africa, 3Centre for Health Policy, Wits School of Public Health, Johannesburg, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Health Systems
Summary With increasing global focus on the integration of vertical programmes within health systems, methods are needed to analyse whether general health service (horizontal) managers at district level exercise administrative authority over disease programmes (administrative integration). This study adapts "decision space" analysis to measure administrative integration of HIV programme monitoring and evaluation (M&E). The study shows that horizontal managers exercise high degrees of authority in producing HIV information but not in using it for decisions, while vertical managers use HIV information but in silos. The lack of M&E integration may undermine district health system strengthening aims.
Background In South Africa, integration is a health sector reform priority, while several vertical programmes exist, notably for HIV, tuberculosis (TB), and maternal and child health (MCH). Historically a national HIV/AIDS directorate and specialist HIV managers have vertically managed the HIV programme and HIV programme managers account for ear-marked HIV programme funding through dedicated parallel reporting mechanisms. This is at odds with current health sector decentralisation reforms that envisage integrated management of health services under the control of generalist (horizontal) managers at a decentralised district level. National health policy envisions health districts as the foundation of the national health system.
Objectives If health districts are to be the foundation of the health system as envisaged, then horizontal district managers would need to be allocated and to exercise authority over district health services, including disease-specific interventions (i.e. administrative integration). This study examines whether this is happening in the South African health system. We use the HIV programme as a case study given its traditionally vertical approach, and focus on the M&E (information) function as a tracer for analysing administrative integration. The research aims are to:
1. Describe the extent to which horizontal managers exercise authority over HIV M&E coordination.
2. Explore factors associated with exercised authority.
Methodology The research explores two hypotheses: a) vertical managers exercise higher degrees of authority than horizontal managers in administering HIV M&E; and higher management capacity and HIV M&E knowledge are associated with higher degrees of exercised authority. This cross-sectional study was conducted in two of South Africa’s nine provinces. Fifty one participants were interviewed including: a) managers primarily responsible for general health services or general health information (horizontal manager) and b) those responsible for vertical services or information (vertical manager). HIV M&E was defined as the production of HIV information (HIV data collection, collation, analysis) and use of HIV information for decisions.In the absence of existing methods for measuring 'exercised authority' over vertical programmes, Bossert's decision-space’ approach provided a useful frame. Since decision-space analysis has not been applied to either the M&E function or in the context of programme integration, it was adapted to measure ‘exercised (administrative) authority’ in this study. We defined exercised authority as a manager undertakes tasks to oversee HIV data collection, collation and analysis, and uses HIV data to review the programme and take action. To measure this, we first identified the M&E tasks that managers were expected to perform within each M&E domain (collection, collation, analysis, use) and then administered a semi-structured questionnaire to collect data on participants’ performance of these tasks. We developed four sub-scales to measure the degree of exercised authority for each M&E domain. Sub-scales comprised several items (M&E tasks), which we coded ‘no’ if a respondent did not perform the task (score zero) or ‘yes’ if s/he did. We computed an ordinal dependent variable for each HIV M&E domain and coded observed scores as ‘low’, ‘medium’, and ‘high’. We performed ordinal logistic regression to explore whether explanatory variables (actor type [horizontal or vertical], health system level, highest, qualification, duration of management experience, management capacity score, and M&E knowledge score) were predictive of higher degrees of exercised authority.
Results More than 75% of participants were female, with an undergraduate degree or higher, and had some management
training. Participant characteristics were similar between vertical and horizontal managers. Horizontal managers attained higher mean scores for HIV data collection.
Conclusion In light of the increasing focus on health system strengthening and integration, our research makes a contribution
by providing a method and scales for measuring and monitoring administrative integration. We anticipate that
these scales will be strengthened further by empirical testing on larger samples and varied settings. In applying this
method to South Africa’s public sector HIV programme, we find that HIV M&E coordination is generally not administratively integrated, characterised by horizontal managers exercising little authority in using HIV data, and vertical managers using HIV data in sub-programme silos. We argue that this programme model potentially undermines South Africa's policy aims of integrated management of district health services under the authority of horizontal general health service managers. The research also indicates that plans for integrating the HIV programme within the health system at decentralised district level should include investments in strategies to equip horizontal managers with the knowledge and skills to use programme data for decision-making.

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.

Detecting Malaria in Refugees living in Non-Endemic Area: South Africa

Author(s) Joyce Tsoka-Gwegweni1, Uchenna Okafor2.
Affiliation(s) 1Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa, 2Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary The study presents findings from a research conducted in a refugee population in South African city known to be non-endemic to malaria transmission.
Background It is reported that 64% of malaria cases in South Africa are imported. This is expected given the high influx of refugees into the cities and reports by United Nations High Commission for Refugees that South Africa carries the highest number of asylum seekers globally. Although South Africa has planned to eliminate malaria by 2018, current interventions and research only take place in malaria endemic areas, which are remote and rural.
Objectives The aim of this study is to determine prevalence of malaria infection among a refugee population living in a malaria non-endemic city of KwaZulu-Natal province, South Africa.
Methodology After obtaining relevant approvals and consent, adult refugee participants were recruited from a faith-based facility offering social services in a city of KwaZulu-Natal province. The participants were screened for malaria using rapid diagnostic tests and confirmed with microscopy. Demographic data for the participants were obtained using a closed ended questionnaire.
Results Data were obtained for 303 participants consisting of 52% females and 48% males ranging from 19 to 64 years old. Of these 303 participants, 289 originated from different African countries, mainly central Africa. Two hundred and ninety participants provided a blood sample for screening of malaria. Of these, 3.8% tested positive for rapid diagnostic test and 5.2% for microscopy. The majority of malaria infections were due to Plasmodium falciparum.
Conclusion The study confirms important findings that include the prevalence of asymptomatic malaria infections detected in a refugee population and residing in an urban area of KwaZulu-Natal province that is not endemic for malaria. These findings have important implications for both public health and malaria control in South Africa, particularly since the country has decided to eliminate malaria by 2018. To achieve this goal, South Africa needs to expand research, surveillance and elimination activities to include non-endemic areas and marginalized communities. The findings further emphasize the importance of integrating services such as malaria surveillance into other public health intervention programmes, and provide refugees with full access to public health services. Other implications of the findings and possible challenges threating the success of the malaria elimination process and health service provision in South Africa are discussed.