Geneva Health Forum Archive

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Performance of Community Health Workers in Community Case Management: Uganda.

Author(s) Agnes Nanyonjo1, Edmound Kertho2, Seyi Soremekun3, Karin Källander 4, inSCAlE Studygroup 5.
Affiliation(s) 1Techinical, Malaria Consortium, Kampala, Uganda, 2Technical, Malaria Consortium, Kampala, Uganda, 3Department of Population Health, London School of Tropical Medicine and Hygiene, London, United Kingdom, 4Technical, Malaria Consortium, Kampala, Uganda, 5Technical, Malaria Consortium, London, United Kingdom.
Country - ies of focus Uganda
Relevant to the conference tracks Advocacy and Communication
Summary Integrated community case management is a key child survival strategy in resource poor settings. There is a paucity of data on the performance of community health workers and how this performance can be assessed. We report on a study that assessed the performance of community health workers using various case vignettes.
Background Integrated community case management for malaria, pneumonia and diarrhoea (iCCM) is one of the key interventions tailored towards curbing child mortality in low income countries. In iCCM, lay community health workers (CHWs) use a given algorithm provided as a job aid to ask about illness symptoms, assess signs, classify and treat disease or refer severely ill children. They treat malaria with artemether lumefantrine combination, pneumonia with amoxycillin and diarrhoea with oral rehydration salts (ORS) and zinc. They are also required to offer health education regarding disease prevention. Although measurement of performance in itself poses key challenges in terms of the method of choice, assessment and understanding of the performance of CHWs is crucial to ensure high quality care of the sick children.
Objectives The objective of the study was to assess the performance of CHWs while managing children with solitary disease such as malaria alone or mixed infections such as malaria and pneumonia by using case vignettes.
Methodology The study was conducted among a sample of 360 CHWs who had been practicing iCCM for at least three to eight months in eight districts in Midwestern Uganda. CHWs were given three case vignettes; one after the other. Using probing questions the CHWs were asked to describe the actions they would take from the time they encountered the sick child and his/her caregiver, to the time they finished the consultation. The CHWs were allowed to use their job aid during the evaluation. One case vignette emulated a 6 months old child with an uncomplicated malaria classification presenting with fever, poor appetite and no danger signs; requiring a malaria rapid diagnostic test, malaria treatment and health education. Another vignette depicted a 3 year old child with diarrhoea and no blood in stool; requiring zinc, ORS and health education. The third vignette was about a child with both cough and fever and a history of stiff feet depicting a child with complicated malaria and pneumonia requiring referral and pre-referral treatment due to the danger signs. The last case was about a child with fever and cough essentially with uncomplicated malaria but no pneumonia. Each appropriate action based on the guidelines (i.e. questions the CHW should have asked, tests the CHW should have performed and treatment and health education CHW should have given) was assigned a weight of one. The average performance score for each CHW was generated on a scale of 0-100. Scores were also sub-analyzed per case managed, as well as for association with socio-demographic factors, such as sex, literacy and district of the CHWs.
Results Out of all actions that should have been taken for each case, the overall mean performance score of the CHWs was 41.5 (SD 8.6). The mean performance score based on case scenarios was 46.6 (SD 16.3) for uncomplicated malaria cases, 59.3 (SD 15.6) for the cases of uncomplicated malaria with cough, 36.5 (SD 13.6) for the diarrhoea cases, and 23.5 (SD 14.4) for the cases with complicated malaria and pneumonia. Overall, CHW's ability to state the correct treatment and dose for the simulated cases was high, with 93.3% stating the correct treatment for a child with malaria alone, 94.4% stating the appropriate treatment for a case with diarrhoea, and 84.4% being able to refer a case with a history of danger signs. However, the problematic areas in the management algorithm that appeared to decrease the overall mean performance score included: a) failure to ask about dangers signs and symptoms that are not mentioned by the caregiver. Overall only 1% of the CHWs remembered to probe for the presence of any danger signs and other symptoms not automatically volunteered by the care taker in at least one of the case scenarios; b) Failure to assess for key illness symptoms. In the complicated malaria and pneumonia case only 22.7% of CHWs mentioned that they would assess the respiratory rate of the child; c) Failure to give pre-referral treatment. Only 28.1% and 9.7% CHWs mentioned that they would give pre-referral treatment for malaria and pneumonia respectively; d) Failure to give instructions on how to administer the drug, especially in the diarrhoea case scenario where only 40% mentioned at least one instruction they would give to the caretaker regarding how to mix and give ORS; e) Failure to provide general health education and information on when to take the child to the health facility for further treatment. Twenty percent of CHWs did not give caretakers any of the recommended advice. Performance levels were positively associated with the district of the CHWs (p<0.001) and to the increasing number of patients the CHW had seen in the last week (p=0.015).
Conclusion If the case scenarios were a reflection of a real life situation, our data suggests that the majority of children seen by CHWs would get the appropriate curative treatment or action required. However they would not be able to benefit optimally from their visit to CHWs due to omitted actions, such as provision of pre-referral treatment, health education, counselling and demonstration to caregivers on how to give the first dose. Supportive supervision and refresher training of CHWs, which emphasizes strict adherence to treatment algorithms, and which offers strengthening of interpersonal communication skills, should be implemented.

Inclusive decision-making and community empowerment for health and well-being: The Health Promotion and System Strengthening Project in Tanzania

Author(s) Kate Molesworth1, Ally-Kebby Abdallah2
Affiliation(s) 1Swiss Centre for International Health (SCIH), Swiss Tropical and Public Health Institute, Zürich, Switzerland, 2Health Promotion and System Strengthening Project (HPSS) Field Office, Swiss Tropical and Public Health Institute, Dodoma, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary This presentation aims to show how participatory techniques can be effectively embedded within government health and community development structures to successfully support community action for health and well-being and at the same time contribute to broader positive social change and equitable access to health services.
By using participatory techniques and at the same time mainstreaming gender, HIV and social equity, within the project itself, as well as at the community and government levels, the Health Promotion and System Strengthening Project (HPSS) takes a broad human rights, equity and inclusive approach, to improve the health and well-being of all members of the community.
What challenges does your project address and why is it of importance? The HPSS Project aims to improve the health status and well-being of all members of a community through innovative approaches, with a particular emphasis on the support of vulnerable people, such as women, children, elderly and socially disadvantaged. A special focus is to ensure that all aspects of project implementation and information will maximize the potential to include all sectors of society in community health promotion and address existing inequalities. However, most often communities - and in particular vulnerable groups - do not have an arena in which to raise their voice and address their health concerns, while the possibility of involvement is low.
The project therefore aims to empower communities and their members to identify and express their health needs and demand equitable access to appropriate health care and social services. By addressing local needs and supporting community action for health, the projects aims to establish sustainable community mechanisms and strongly link them with government and non-government structures for sustainable results that contribute to improve health and well-being of all people in the region.
How have you addressed these challenges? Do you see a solution? This presentation will demonstrate how the project translates the Ottawa Charter onto the ground in the context of Dodoma Region and report on early operational research outcomes of the Regional pilot for health reform.
In adapting the health and community development systems to strengthen health promotion, the project has negotiated adapted terms of reference and trained-as-trainers Community Health and Development Officers (CHOs and CDOs) as well as School Health Coordinators (SHC) in community participatory techniques and cutting edge health promotion approaches. As master trainers, with support of HPSS District Coordinators, these government cadres have rolled out a tailored training packages to their assistants, Non-Governmental Organizations (NGOs), Faith Based Organisations (FBO), Community Based Organizations (CBOs) and communities themselves. Following consultative workshops, regional governments agreed to expanded health promotion roles of the Region’s 152 CDOs and their assistants. They work together with Health Officers to support communities, through participatory methods, to identify local health concerns, as well as resources and to plan solutions. In this process the trained government CHOs and CDOs and SHCs facilitate communities to identify their health concerns and solutions in a participatory meeting of peer groups - disaggregated by sex and age as well as by concern groups – such as the disabled. After initial community-led discussions, facilitators showed discussion groups how to quantify their priorities and the group subsequently voted for their primary health concerns. The results of the sub-groups were then presented by the facilitators to the whole community in a final meeting, emphasising the very different priorities of men and women, and different age groups in the same community. This usually resulted in a direct community discussion and debate concerning different perceptions on health and well-being issues within the community. Following this, the community as a whole, facilitated by their trained CDO, prepared a community health promotion plan for presentation to local councils for inclusion within and funding with the Council Comprehensive Health Plans.
How do you know whether you have made a difference? In the process Regional authorities have raised the importance and profile of inclusive, participatory approaches by adding these duties to government staff terms of reference. The strengthening of health promotion, gender and social inclusion approaches within community led-processes has not only improved grass-roots level dialogue and action on local health and social concerns but strengthened the capacity and networking of community-based organisations. This has also set in motion means by which communities can not only take action to address issues in the local context, but access existing funding lines for community health activities. The Participatory Rural Appraisal (PRA) process has been rolled-out to all communities in the 7 districts of Dodoma region. Even at this early stage of the project, PRA outcomes resulted in community health action plans, which have been inclusively developed in more than 200 villages. A total of 220 health promotion action plans have been developed by communities in this way, reflecting 16 priority health-related themes.
By taking an inclusive approach that sensitises government and non-government facilitators, the solidarity and empowerment of traditionally marginalised and stigmatised groups including women, the poor, people living with HIV and affected by AIDS and people living with disabilities has also been strengthened.
Have you or the project mobilized others and if so, who, why and how? Approaches chosen within the HPSS Project have mobilized people on several different levels. Primarily, government CHOs, CDOs and SHCs were trained-as-trainers in facilitating community participatory techniques and cutting edge health promotion approaches. This has led to their expanded health promotion roles in accordance with the regional governments. The master-trainers have rolled out these techniques to all government staff and community organisations in the region. Applying a bottom-up approach, government officers facilitate communities to identify their health concerns and solutions in a participatory manner.
When your donor funding runs out how will your idea continue to live? The HPSS Project, implemented by the Swiss Centre for International Health (SCIH)/Swiss Tropical and Public Health Institute (Swiss TPH) on behalf of the Swiss Development Cooperation Agency (SDC), is subdivided into three project phases, namely a pilot implementation phase from the year of 2011-2014, a consolidation and scaling-up phase between 2015 and 2017 and the completion of a nationwide scale-up in the years of 2018-2020.
By training a cadre of master trainers within government and non-government structures in the first phase of the project in Dodoma region, novel inclusive approaches have been rapidly cascaded to the communities for complete geographical coverage. The inclusive, participatory techniques used effectively advocate for the different health priorities of various groups within community’s debates, inclusive action planning and ensure that these actions are funded and realised.
As approaches have been embedded in the skills and responsibilities of government staff, this allows the direct involvement of community members, in particular giving voice to vulnerable groups. These inclusive, participatory techniques are likely to be sustained and replicated as a nationwide scaling-up of the HPSS approaches and activities in subsequent phases. Furthermore, the project has developed and launched a short course (in June 2012) on participatory techniques for inclusive community action for health promotion at the Zonal Training Centre. This will contribute to sustainability by providing focussed training of development and health staff in the coming years and act as regional resource centre for these activities.

Knowledge and Access to Health by Tuberculosis Patients in India.

Author(s) Hemmavathy M.T.Valluvan1, Karuna Sagili2, Srinath S3, Sarabjit S Chadha 4, Nevin C Wilson 5.
Affiliation(s) 1 Medical School, Monash University, Melbourne, Australia, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India, The Union South-East Asia Office, International Union Against Tuberculosis and Lung Disease (The Union), Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary India is one among the 22 highest TB burden countries contributing a large proportion of the global TB cases. To increase awareness on the issue of TB, India’s RNTCP uses several forms of media to communicate TB related information to the general population. As part of Project Akshya, a baseline Knowledge, Attitude and Practices (KAP) study was conducted in 30 districts of India to gather baseline information from specific target groups on TB. The following study analyses the KAP and describes the media behaviour of TB affected individuals in India, with a focus on their key sources of general health related and TB related information, and identifies the most trusted source of information.
Background Infectious diseases are one of the key contributors to the mortality of people around the world. Globally, of the 57 million deaths that occurred in 2011, 21 million deaths were caused by infectious diseases (WHO, 2012b). Of the infectious diseases Tuberculosis (TB) persists to be one of the leading causes of mortality since the 1800s (Houston, 1999). An estimated 8.7 million new cases of TB occurred in 2011 globally and a total of 1.4 million people died from TB (WHO, 2012a). India is the highest TB burden country accounting for 26% of global cases (WHO, 2012a).
India’s National Tuberculosis Programme-RNTCP (Revised National Tuberculosis Control Programme) uses several forms of media to communicate TB related information to the general population and TB affected individuals. These range from street plays to radio commercials (Mehrotra, 1998). A similar study was done in Chandigarh (Hemlata, 2011). The other studies that were conducted in Delhi targeted specific populations such as homemakers (R.Malhotra, 2002), and the rural population (Sharma and Sharma, 2007). However these studies  are localised and focused upon limited target groups within the general population.
Objectives In 2010, Project Axshya ACSM (Advocacy, Communication and Social Mobilisation) project was initiated in India as part of the Global Funded Round 9 India TB programme. It is being implemented in 374 districts across 23 states covering a population of approximately 75 million people. The main objective of Project Axshya is to empower the community and each individual through education/awareness on TB with various resources and knowledge that would enable India to reach the ultimate goal of reducing the mortality and morbidity caused by TB. The baseline KAP (Knowledge, Attitude and Practices) study was conducted in 30 districts of India as part of Project Axshya, which aimed to gather baseline information from specific target groups (the general population, TB patients, health service providers, NGO’s and opinion leaders) on their knowledge, attitude and practices on TB. The survey tool designed for TB patients had specific questions on their sources of information about general health and TB. By comparing the different characteristics of the TB patients and the media source through which they gained the information, we would locate the media forms currently being accessed by TB affected individuals. This will also inform future planning of the health information dissemination programs.
In this study we aim to describe the types of mass media used by TB patients to gain information on general health related, TB and DOTS and to describe the most preferred and trusted sources of mass media from the patient’s perspective and then relate it to various patient characteristics.
Methodology Study Design.
A cross sectional community based survey was conducted in 30 districts out of the 374 districts under Project Axshya. These districts were selected using stratified cluster sampling method. These districts were further divided into primary sampling (PSUs). Depending on the number of households, in each PSU a minimum of 250 households were line listed with an estimated population of 1000. 10 PSUs were randomly selected from each district. Trained field investigators from the social research organisation GfK MODE visited these selected PSU’s and conducted the survey during the months of January - March 2011 using pretested semi-structured questionnaires.
To address the study objectives, the data collected from ‘Media and Information Sources’ section of the questionnaire for TB patients in KAP has been used for analysis.Data Entry and Analysis.
The data collected was recorded in a pre-structured data-entry form in Fox Pro (version 2.6). The data was analysed and tables generated using Epidata Analysis software.

Ethical Considerations.
Baseline KAP study was approved by the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease. Permission to conduct this study was given by the Central TB Division, Ministry of Health and Family Welfare, Government of India. Informed consent was obtained from each respondent and, where possible, written consent was obtained. Confidentiality of the data was assured.

Results The general profile of TB affected individuals interviewed in this survey in relation to their access to services informs that 67% of them have access to electricity, 14% have a radio set at their houses, 36% have television sets at their homes and 52% have mobile phones. 56% of the total TB affected individuals interviewed had BPL (Below Poverty Line) identity cards. The source of information for 65% of TB patients on any health related information was via interpersonal communication (Table 1). Likewise, interpersonal communication was the leading source of information for TB (74%)(Table 1). With regards to information on DOTS, 61% of the TB patients did not receive any information on DOTS (Table 1). 56% of those who are exposed to interpersonal communication as their source of information received information on TB from that source (Table 2). Among these 56% there was a significant difference among the low and high income households (p=0.0000), rural and urban setting (p=0.0000), among the zones such as North (p=0.0000,OR:2.87,CI:1.89-4.35), South (p=0.0000,OR:0.25,CI: 0.16-0.39), East (p=0.0000,OR:3.07,CI:2.17-4.33) and West (p=0.0000,OR:0.16,CI:0.10-0.26). Of the 220 who had a television (TV) 67% indicated TV as their source of information for general health, 60% for TB related information and 41% for information on DOTS. Of the 85 people who had a radio set at their homes, 33% indicated radio as their source of information for general health, 35% for TB related information and 14% for DOTS related information. There was also a significant difference for those who used TV as their source of information for TB between the low and high income households (p=0.000), between the rural and urban settings (p=0.000), among the zones such as North (p=0.0006), South (p=0.0000) and East (p=0.0001) and education levels (p=0.0000). 43% of TB patients chose government health staff as their choice of trusted information source, followed by 15% of the TB patients trusting the private health workers. Among the 43% of TB patients who trust government health staff, there was a significant difference among the age of 25-34 years old (p=0.0288, OR:0.61, CI:0.39-0.95) and 35-44years old (p=0.0069,OR:1.70,CI:1.15-2.50), and students (p= 0.0049,OR:0.40,CI:0.21-0.77) and lastly, among the zones such as North (p=0.00573,OR:1.44,CI: 0.99-2.09), East (p=0.0000,OR:0.48,CI:0.34-0.67) and West (p=0.0000,OR:2.62,CI:1.69-4.06) had significant differences.
Conclusion From the KAP survey of TB patients, it was observed that 74% of TB patients received their TB related information from interpersonal communication which could partly be attributed to the people they had come into contact with in order to be diagnosed with TB. However, a separate analysis on where TB patients had received health related information found that 65% responded as the source being interpersonal communication followed by 34% receiving it from television. As such, interpersonal communication is an important medium through which a large portion of the TB patients received information. On further analysis, it was found that 56% of those exposed to interpersonal communications as their source of information received information on TB from that source. Household income played a significant role as possessing a television as the source of media for TB information. 20% of those with less than Rs.4000 received their TB information from TV while 46% of those with more than Rs.4000 did so. This could be due to the higher income group having the ability to afford a television, the added increase in electricity bill and a house that accommodates it. The geographical zones of the TB patients also played a role on their source of TB information. The key source of TB information for the North was word of mouth (74%), while that of South and West was Television (53% and 29% respectively). This is an important finding as it shows that different zones have different media behaviour which could be due its varied cultural behaviours or social structure. Hence when planning IEC activities, these factors should be considered in order to utilise the most accessed resources of the target population.There are three key findings from this analysis; different income groups/settings have different sources of media exposure, the choice of media exposure differs among the different zones and the population's trusted source of information. It is important to understand that the fundamental expectation of any media aspect of a health policy is to increase awareness on a health issue and due to increased knowledge, eventually see a decrease in the overall incidence in the condition. However, before waiting at the finishing line for this result, it is crucial to make sure that the information reaches the population effectively and efficiently. Further developments to this study would include a qualitative study to assess the knowledge level of TB patients and its relation to media exposure.

Strengthening health systems to achieve access to essential medicines

Author(s) Alessandra Ferrario1, Rita Seicas2, Nina Sautenkova3, Jarno Habicht4
Affiliation(s) 1LSE Health, London School of Economics and Political Science, London, United Kingdom, 2Centre for Health Policies and Studies, Chisinau, Moldova, 3World Health Organization, Regional Office for Europe, Copenhagen, 4World Health Organization, Country Office, Republic of Moldova
Country - ies of focus Moldova
Relevant to the conference tracks Health systems
Summary This presentation aims to generate debate on issues affecting access to medicines in low- and middle income countries, discuss how they can be tackled through a coordinated health system response by proposing simple and actionable recommendations and to encourage participants to share their own countries’ experience.
Background Despite continuous scientific progress and the existence of several life-saving medicines, one third of the world’s population still lacks of access to essential medicines.
Achieving access to essential medicines requires much more than an increase in funding for medicines reimbursement. As outlined by the World Health Organization (WHO) in 2004, access to medicines encompasses rational selection and use, affordability, sustainable financing and reliable health and supply systems. Although the WHO health system building blocks model depicts medicines almost as an independent component of the health system, improving access to essential medicines is dependent on the strengthening of all other building blocks. Trained human resources are necessary to develop a national essential medicines list and treatment guidelines, to educate patients on how to take their medications and follow them up to ensure compliance. Facilities equipped with the necessary diagnostic tools are needed to diagnose patients. Policies need to be in place to promote price competition and use of generics. Efforts to achieve universal health coverage need to be sustained and quality of medicines needs to be ensured through a reliable and efficient regulatory system.
Objectives To show the need for integrated action across different health systems dimensions to improve access to medicines using as an example the recent reforms introduced in the pharmaceutical sector in the Republic of Moldova.
Methodology Analysis of expenditure, use and reimbursement data together with a review of policy documents in Moldova.
Results Between 2005 and 2012, reimbursement for outpatient medicines increased from Lei 7,404 thousands (Euro 434 thousands) to Lei 166,244 thousands (Euro 10,490 thousands). The increased budget translated in a greater number of medicines reimbursed over time, from 8 medicines (with different active ingredient) in 2005 to 81 medicines in 2013. In parallel, the number of reimbursed prescriptions and the proportion of total prescription value reimbursed have also increased.
A similar pattern was highlighted for inpatient medicines whose spending increased from Lei 94,234 thousands (Euro 5,550 thousands) in 2007 to Lei 357,766 thousands (Euro 22,575 thousands) in 2012 and was accompanied by an increase in the number of medicines available.
Another positive development was the inclusion of insulin in the 2013 reimbursement list. Before insulin used to be procured through a vertical programme and although patients could access insulin for free, stock-outs problems were reported due to gaps in the distribution system and the lack of accurate data on the number of insulin patients.
After a previous attempt to introduce generic prescribing, in October 2012, thanks to Government support, it was finally possible to introduce generic prescribing. This is expected to reduce spending for both the national insurance company and for patients.
Until 2013 compliance with good manufacturing practices (GMP) was not enforced. With release of the new reimbursement list medicines registered in either the European Union, the US, Canada, Australia, or Japan and therefore compliant with GMP are given preferred supplier status. This is expected to provide a strong incentive, particularly to the local manufacturing industry, to improve their manufacturing practices according to international accepted standards of good quality.
Areas were more efforts are needed include covering the insured population, expanding the breadth and depth of medicines coverage while promoting rational selection and use of medicines, strengthening post-marketing quality control and pharmacovigilance activities.
Conclusion Although presented as a building block on its own, achieving access to essential medicines requires integrated action across all health systems building blocks.
In Moldova, increased coverage of medicines was possible due to increased funding. Political support enabled to overcome initial resistance and to introduce generic prescribing. However, several challenges remain to achieve universal access to quality essential medicines. These include, but are not limited to, achieving universal health coverage, obtaining better prices for medicine, reduce waste by promoting rational selection and use of essential medicines, strengthening post-marketing quality control systems and pharmacovigilance.

Improving governance and local level planning through community mobilisation: lessons learnt from Bangladesh

Author(s) Rumana Huque1
Affiliation(s) 1Department of Economics, University of Dhaka, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Advocacy and Communication
Summary Poor governance in the health sector is negatively influencing service delivery mechanisms in Bangladesh, which in turn results in low utilization of public facilities. Although the principle of strengthening effectiveness and accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups (CG) in rural Bangladesh, reviews to date have shown very slow progress in this area. The current project strengthened capacity of CGs through providing skilled based training. This enhanced the voice of citizens which inturn improved governance at CCs.
What challenges does your project address and why is it of importance? Poor governance in the health sector is negatively influencing service delivery mechanism in Bangladesh, which in turn results in low utilization of public facilities. Non-availability of drugs and commodities, imposition of unofficial fees, lack of trained providers and weak referral, feedback and monitoring systems contribute to low use of public facilities in Bangladesh. A number of other factors also adversely influence the service delivery mechanism. One such challenge is the inadequate participation of civil society in decision making processes. Evidence suggests that closed decision making processes in unequal societies can result in priorities that are biased towards elite interests and not adapted to the needs and priorities of the poor, which may have a negative impact on equity and social justice. Although the principle of strengthening effectiveness and the accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups in rural Bangladesh, reviews to date have shown very slow progress in this area. Out of 13000 Community Groups very few are functional, leading to inadequate participation of the poor in local level planning or initiating accountability.
How have you addressed these challenges? Do you see a solution? The project has strengthened the Community Groups through providing skilled based training to its members in four upazilas in two districts. It provided relevant information and data including potential sources of funding and information on changes in rules and regulations to CG members. The process contributed to developing self confidence among people in discussing and analysing issues, identifying a problem, visualizing disparities, understanding their entitlements, identifying their duty bearers, articulating issues, developing plans as a team to address their problems, and communicating this properly to the appropriate forum/platform. The project has created a better referral linkage of Community Clinics with Upazila Health Complex (UHC). The patients they refer get special attention and preference at UHC. Due to the monitoring of CG, CC remains open from 9 am to 3 pm six days a week. The greatest success the development of coordination between health care providers and clients, people now conceive as public health care facilities as being their property, the reputation of the CG members in the community has gone up and the utilisation of services and respect for providers at CC has also increased.
How do you know whether you have made a difference? Clearly this project created opportunities for capacity strengthening of the local political leaders as well as community representatives so that they become better informed on health issues. It contributed to facilitating the relationships of citizens with health providers and governments. This in turn has given a platform to improve the quality of information available to citizens and to raise their voices. The project has created a sense of ownership among the citizens in functioning CG's. Interaction between service providers and patients became informal which increased access to services. It reduced the ‘illegal’ operations such as absenteeism and misuse of drugs.
Have you or the project mobilized others and if so, who, why and how? The project has created a link between Community Clinics, which is under Ministry of Health and Union Council members, who are under Local government. Union Council Members now attends the monthly meetings of the CG and monitor their functioning.
When your donor funding runs out how will your idea continue to live? The project will be sustainability even if donor funding is withdrawn, as the community group members are adequately trained and have been empowered to conduct the activities without third party facilitation. A mechanism to generate fund through community mobilisation to meet some expenses as also been created.

Improving Global Health by Leveraging Corporate Value Chains.

Author(s) Asher Hasan1
Affiliation(s) 1Executive, NAYA JEEVAN, Karachi, Pakistan.
Country - ies of focus Global
Relevant to the conference tracks Advocacy and Communication
Summary NAYA JEEVAN collaborates with MNCs such as UNILEVER to cascade its "global health plan for the marginalized" up and down their Corporate Value Chain (CVCs), enrolling low-income stakeholders (suppliers, distributors, micro-retailers, informal domestic workers such as maids, drivers, etc) in a market-based retail incentive/loyalty program that can potentially serve the needs of 660 million lives globally.
What challenges does your project address and why is it of importance? In Pakistan and India, at least 800 million earn less than $3 a day. Like other developing nations, South Asian governments spend just 1.7%-3% of GDP on an under-resourced and overwhelmed public health sector. Consequently, 97% of all health care expenditures occur out-of-pocket and ‘catastrophic’ medical expenses (e.g. for heart attacks, pregnancy complications, etc) are a major precipitant of generational poverty. The three priority issues that low-income, marginalized populations have to contend with are: (i) Access, (ii) Affordability and (iii) Quality.
How have you addressed these challenges? Do you see a solution? NAYA JEEVAN’s accessible, affordable, quality healthcare plan for underserved communities has been cascaded by UNILEVER to over 2500 sales distributors nationwide and 400 microretailers (ice-cream wallahs) who lie at the end of UNILEVER's supply chain. UNILEVER has financed the annual health insurance program costs ($30/life/year) of these microretailers and their dependents in a tiered loyalty/incentive program in which the corporation pays a contribution for health insurance that is prorated to the performance of the retailer. This model can be replicated globally with a varying degree of Corporate co-financing/subsidy which is contingent on: (i) the strategic value of these supply chain partnerships (ii) the cost of the health plan in that specific market and (iii) the impact on their bottom line – i.e increased revenue/sales per dollar invested in this loyalty program. NAYA JEEVAN’s accessible, affordable, quality healthcare plan for underserved communities has been cascaded by Kansai Paints (a Japanese industrial/residential paint company) to over 200 small business painters who lie at the end of Kansai’s supply chain. Kansai has financed the annual health insurance program costs ($30/life/year) of these painters and their dependents in a tiered loyalty/incentive program in which the corporation has fully subsidized the health insurance plan of their loyal customers. This model can be replicated globally with a varying degree of Corporate co-financing/subsidy which is contingent on: (i) the strategic value of these supply chain partnerships (ii) the cost of the health plan in that specific market and (iii) the impact on their bottom line – i.e increased revenue/sales per dollar invested in this loyalty programNAYA JEEVAN’s health insurance plan includes:• Annual medical check-up, which promote the early detection of disease
• A 24-hour telemedicine helpline managed by doctors and available to all beneficiaries to handle any concerns or emergencies that may arise.
• A Health Rescue Fund, which assists beneficiaries for uninsurable conditions or when their hospital management/health care exceeds the maximum annual insurance coverage.
• Preventive Health workshops that detail the causes, symptoms, treatments and prevention against most common maladies to allow individuals to be better able to protect themselves and their families. Our workshops include: Healthy Heart – Keep your Heart Happy & Nutrition – How to Eat Right.
How do you know whether you have made a difference? NAYA JEEVAN has successfully enrolled over 23,000 low-income workers across more than 20 corporations into this incentive program. We have already enabled over 200 critical, life-saving interventions and over 5000 urgent medical consultations by mobile phone that would ordinarily have led to hospitalisation (the aversion of hospitalization has a major impact on worker productivity and health system costs that are saved.In addition to the above, we have conducted a baseline health risk assessment and are monitoring our members for the following outcomes:• Poverty alleviation – by reducing the financial impact of catastrophic medical expenses
• Reduction in Maternal/Child Mortality - through timely intervention and 24/7 access to ambulances, medical doctors, ERs, trauma centers, etc.
• Improvement in Primary Health Outcomes - through preventive health education and behavioral change workshops

• Mitigation of Child Labor/Sexual/Physical Abuse

Have you or the project mobilized others and if so, who, why and how? NAYA JEEVAN has engaged more than 5000 volunteers and stakeholders across the Corporate sector to sponsor the healthcare of children from NGO schools. Over 250,000 residents in an urban slum (Sultanabad, Karachi) have been mobilized to take preventive health measures (nutrition, child immunization, antenatal care) by visiting our Community Health Center.Over 200 secondary/tertiary care centers have been integrated into our nationwide provider network on a cashless basis.
When your donor funding runs out how will your idea continue to live? Naya Jeevan negotiates a basic inpatient (hospitalization) group health insurance plan from various underwriters (for example Allianz-EFU, Pak-Qatar Takaful, IGI Insurance, Saudi-Pak Insurance etc.) at below-market, discounted rates of about USD $16/person/year. By expanding access to a previously untapped low income working population, Naya Jeevan is creating significant value for insurance underwriters who are able to save substantial resources in associated sales/marketing/business development expenses while leveraging Naya Jeevan’s service delivery platform to provide value-added services (VAS) uniquely tailored towards this customer segment. Consequently, insurance underwriters are able to offer Naya Jeevan the health insurance plan at highly discounted group health plan rates of USD $16/person/year.2. Naya Jeevan forms partnerships with various clients including both international and local corporations and businesses such as: Unilever, Espresso, Cafe Flo, Sanofi, Philips, Haque Academy Group, Deutsche Bank, Haji Group, PICT, etc. The supply chains of these clients include a large number of low-income employees from the service industry and informal sector who do not have access to health insurance at all. As discussed, the ‘missing middle’ population forms the target market for Naya Jeevan and clients like local companies/MNCs in Pakistan form the most efficient distribution channel to tap into these masses. Naya Jeevan sells the health insurance plans to clients at ~ US$30/person/year, representing 1.28 – 4.26% of the employee’s monthly payroll (of USD $50-150 per month).Naya Jeevan currently has 70+ clients through which health insurance is being distributed to its low-income members.

3. As part of their respective corporate and business programs, clients finance on average $24 (80%) of the annual $30 health plan cost, with the remaining $6 (20%) paid by the low-income workers directly through payroll.

The clients see this program as a channel to encourage worker productivity/loyalty among their employees and as part of their corporate social responsibility.

Naya Jeevan has witnessed steady growth in its business model, validating proof-of-concept of its sustainability.

GRIP’s Pentagonal Framework for a Global Change in Antibiotic Resistance.

Author(s) Sabiha Essack1, GRIP (Global Respiratory Infection Partnership)2, Laura Noonan 3
Affiliation(s) 1Health Sciences, University of KwaZulu-Natal, Durban, South Africa, 2Various, Various, Various, United Kingdom, General Practitioner, Bellview Clinic, Mullingar, Co Westmeath, Edgeworthstown, Ireland.
Country - ies of focus South Africa
Relevant to the conference tracks Advocacy and Communication
Summary Antibiotic resistance has become a critical health issue on a global scale, with much of the problem resulting from inappropriate use of antibiotics in primary care. To change this practice, the Global Respiratory Infection Partnership (GRIP) has formulated a pentagonal (5 P) framework for the non-antibiotic management of upper respiratory tract infections (URTIs) to promote antibiotic stewardship in primary care. The framework focuses on five key areas to bring about change: policy, prevention, prescribers, pharmacy and patients. It is a flexible framework that can be adapted across countries to create a consistent global approach to change behaviour.
What challenges does your project address and why is it of importance? Antibiotic resistance has become a critical health issue on a global scale [1]. Much of the problem results from the inappropriate use of antibiotics in primary care [2]. URTI symptoms are the most common reason patients to seek medical attention in primary care and account for a large proportion of the antibiotics prescribed in primary care [3].
However, the majority of throat infections are of viral origin and resolve without antibiotic treatment. Despite this, antibiotic use for sore throat infections remains high, partly because it is difficult to determine when antibiotics may be useful, on the basis of physical findings alone [4]. Patient expectations and patient pressure are also important drivers of antibiotic use [5]. To address these issues, a behavioural change is required to improve communication between primary healthcare providers and patients.
How have you addressed these challenges? Do you see a solution? To facilitate a change toward prudent use of antibiotics for the treatment of URTIs, members of the GRIP have developed an international pentagonal (5 P) framework for the non-antibiotic management of such infections (Figure 1) [6]. The principles are then applied to the management of sore throat (as an example of a common symptom of URTIs) offering practical advice to primary care teams on how to implement the guidance in their daily practice. Doctors, nurses and pharmacy staff, working in primary care or in the community, will be provided with a structured approach to management, with the aim of educating and empowering patients to self-manage their condition. The first component of this approach involves identifying and addressing patients’ expectations and concerns with regards to their sore throat and eliciting their opinion on antibiotics. The second part is dedicated to a pragmatic assessment of the severity of the condition, with attention to red-flag symptoms and risk factors for serious complications. Rather than just focusing on the cause (bacterial or viral) of the URTIs as a rationale for antibiotic use, healthcare providers should instead consider the severity of the patient’s condition and whether they are at high risk of complications. The third part involves counselling patients on effective self-management options and providing information on the expected clinical course.
Such a structured approach to management, using empathetic, non-paternalistic language, combined with written patient information, will help to drive patient confidence in self-care and encourage them to accept the self-limiting character of the illness—important steps towards improving antibiotic stewardship in URTIs.This framework has been shared with and reviewed by healthcare professionals from Australia, Austria, Brazil, Germany, Hungary, India, Ireland, Israel, Italy, The Netherlands, Romania, Russia, Singapore, South Africa, Spain, Thailand, the United Kingdom, and the United States of America. The global framework is strengthened through a collaborative approach by input from multiple primary healthcare provider specialties and is applicable across countries and continents. It is envisaged as a prototype that can be adapted to other infections in the long term.
How do you know whether you have made a difference? GRIP identified acute URTIs (with the exception of the more severe infections, such as pneumonia) as being appropriate for a pilot for the development of such an integrated approach because the treatment of URTIs is currently characterised by the overuse of antibiotics in the primary care sector. Antibiotics are often an ineffective and unnecessary treatment option for the majority of patients when alternative symptomatic relief options are available. Once a coherent international approach has been developed to promote a change in the prescribing and use of antibiotics for the treatment of URTIs, this could serve as a model for change in other infections. Spending time with the patient and providing information and reassurance are strongly linked to patient satisfaction. At the individual level, a successful intervention may mean that the patient will be able to self-manage sore throat symptoms in the future. Directing patients to effective self-care and providing information on the expected duration of symptoms reduces re-consultation rates. Applying a structured approach to patient consultations will help all healthcare providers to fulfil these roles in a time-efficient manner.
Have you or the project mobilized others and if so, who, why and how? The GRIP project aims to involve all levels of healthcare professionals and institutions, including doctors, nurses, patients, pharmacists, as well as professional bodies/associations, clinical communities of practice and local experts and national and local Ministries of Health. In 2013 the GRIP hosted an educational conference, with international delegates to discuss and validate the elements of their 5 P framework and their Global campaign with other healthcare professionals. The group also shared their 1,2,3 Toolkit for appropriate respiratory infection management in primary care. The multidisciplinary, educational resources in the toolkit include a CPD module, patient leaflets, patient poster, GP tear-off pad, Pharmacy educational booklet and a conversation guide with an infographic to use in discussions with patients about appropriate RTI management. This toolkit is being adapted for use in multiple countries whilst maintaining consistency of GRIP’s approach. Implementation of national policies by primary care providers will be further enhanced by incorporating the principles into clinical decision-making and by gaining support and endorsement from local experts. For example, leading figures in antibiotic resistance from national societies could be actively involved in the development of guidelines. The role of pharmacy staff is important and diverse. They tend to see patients who have already chosen the self-management route. They can thus offer reassurance and advice on appropriate treatment to increase the chances of optimum symptomatic relief and patient satisfaction while having the knowledge for patient-centred advice on when to consult another healthcare provider. Pharmacy staff are ideally placed to provide reassurance to patients by offering more detailed advice on symptomatic treatment options in line with the patient preferences.To move towards a culture where non-antibiotic management of URTIs is the norm, it is important to mobilise the public and the patient as proponents of non-antibiotic treatment for self-limiting conditions. Educating the public is an important step to nurture change, with potential measures including media campaigns and educational projects in schools and universities, to raise awareness early in the education cycle.
When your donor funding runs out how will your idea continue to live? GRIP’s initiative is multifaceted and supports a unified approach to primary care. With the threat to public health posed by antibiotic resistance continuing to increase, the need for robust and consistent antibiotic stewardship initiatives on a global level will continue to grow. GRIP’s framework aims to provide a memorable and immediately actionable campaign to support changes in practice as well as at a policy level by way of a simple pentagonal framework. A globally consistent and locally adaptable campaign will disseminate a unified message to address a global problem. Once the initiative has rolled out across relevant healthcare professions and the public both globally and locally, the level of education achieved will have increased and overuse of antibiotics will be reduced accordingly. Successful results can be used to support the adaptation of the framework to other infections and be integrated into the policies of other countries facing similar challenges.References
1. World Health Organization. The evolving threat of antimicrobial resistance. Options for action, 2012. Available online: http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf. (accessed on 12 September 2013).
2. NHS Choices. Available online: http://www.nhs.uk/NHSEngland/ARC/Pages/AboutARC.aspx (accessed on 30 September 2013).
3. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ. 2009; 339: b2885.
4. Van der Velden A, Bell J, Sessa A, Duerden M, Altiner A. Sore throat: Effective communication delivers improved diagnosis, enhanced self-care and more rational use of antibiotics. International Journal Clinical Practice, in press.
5. van Driel ML, De Sutter A, Deveugele M, Peersman W, Butler CC, De Meyere M et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006; 4: 494–9.
6. Essack S, Pignatari AC. A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance. International Journal Clinical Practice, in press.

Social media in health information and communication: a content analysis of Facebook groups related to hypertension.

Author(s) Mohammad Al Mamun1, Tanvir Chowdhury Turin2.
Affiliation(s) 1Department of Public Health , General Directorate of Health Affairs in Tabuk Region, Ministry of Health, Kingdom of Saudi Arabia, Tabuk, Saudi Arabia, 2Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada, Calgary, Canada.
Country - ies of focus Global
Relevant to the conference tracks Advocacy and Communication
Summary Studies on the utilisation of social media sites for health related information and communication are still limited. We conducted a content analysis of the Facebook groups related to hypertension by searching Facebook (www.facebook.com). We identified 187 hypertension-related Facebook groups containing a total of 8,966 members. The majority of the groups were formed to create awareness regarding hypertension-related diseases, and to provide support to the affected patients and caregivers. Facebook has a great potentiality to be utilised as a popular and useful platform for health information and communication purposes in order to build up a better global health.
Background Social media is a convenient means of communication where people create, share, and exchange information and ideas across the internet-based communities and networks throughout the world. Studies on the utilisation of social media sites for health related information and communication are still limited. Facebook (www.facebook.com) has become one of the most popular social media sites possessing more than one billion active users. Although several disease-specific information sites are available now on various social media, little is known about how Facebook groups are used for people suffering from hypertension related diseases, or how these groups contribute to creating awareness regarding hypertension among the netizen in the current context of global health.
Objectives This particular research program studied the Facebook groups related to hypertension in order to characterise their objectives, subject matters, member sizes, geographical boundaries, activeness, and user-generated contents.
Methodology We performed an intensive search in Facebook using the keywords ‘hypertension’, ‘high blood pressure’, ‘raised blood pressure’, and ‘blood pressure’. We limited our search activity within the open groups (accessible to anyone having a Facebook account) utilising the customised search options available in Facebook’s built-in search engine. Reviewing all search results we excluded the groups that contained subject matters either unrelated to hypertension or in non-English languages. Facebook pages for individual users, organisations, events, and applications were not included in the present study.
We extracted the following data from the content of each eligible group: title of the group, web address (URL), introductory description, total number of members, top-displayed most recent wall post with posting date, number of likes and comments on it, and presence or absence of photos, videos, events and attached files on the group wall. We developed a coding and categorising scheme for the whole data set by reviewing the content of the first 100 groups based on the theme present in each data.
We identified the main objective of each group derived from a content analysis of the group title, introductory description, or any message posted by the group creator or administrator. We assigned a specific code for each of the main objectives, which ultimately led to the identification of seven major categories of the hypertension groups: (a) awareness creating groups (b) support groups for patients and caregivers (c) experience sharing groups (d) fundraising groups (e) product promotion groups (f) research conducting groups (g) health professionals groups.
According to the date of the most recent wall post or comment, we categorised the Facebook groups into two categories: active (most recent wall post or comment was posted on or after 1st January 2013); and less active (most recent wall post or comment was posted before 1st January 2013). Multivariable logistic regression (backward elimination method) was used to explore the factors independently associated with the activeness of the Facebook groups related to hypertension. All variables having a univariable level of significance p.
Results Our search results yielded a total of 263 groups on Facebook. Finally 187 groups were found eligible for data extraction and analysis after applying the exclusion criteria. A total of 8,966 Facebook users were members of these eligible groups related to hypertension. Total number of members in each group ranged from 1 to 2161. Group activities were restricted to a particular geographical location for 15% of the groups, while most (85%) of the groups were global in nature. Hypertension was the general focus for majority (40.6%) of the groups, while 29.9% groups concentrated on pulmonary hypertension, 14.4% on intracranial hypertension, and the remaining 15% groups dealt with hypertension and other diseases together. Analysing the main objective of each group we found that the Facebook groups (n=187) were created for the purposes of hypertension-related awareness creation (59.9%), providing supports to patients and caregivers (11.2%), sharing disease experiences and life stories (10.7%), raising funds for relevant organisations (7.5%), promoting pertinent products or services (3.7%), conducting studies or surveys (3.7%), and networking among health professionals (3.2%).
Regarding the user-generated contents, at least one wall post was available for 87.7% groups. Among these groups (n=164), 24.4% groups had at least one ‘like’ on the most recent wall post, and 17.7% had at least one comment on that wall post. Moreover, at least one photo, video, event, or attached file was present for 51.2%, 5.5%, 1.2%, 8.5% of those groups (n=164), respectively. Top-displayed most recent wall posts (n=164) were those focused on promoting a relevant product or service (21.3%), sharing hypertension-related information (20.1%), sharing an external web address related to health (13.4%), query to members for a particular information (9.8%), greeting, wishing or thanking message (9.1%), promoting an event (8.5%), describing the group interest (7.9%), sharing disease experience or life story (6.7%), and fundraising message (3%).
Of the 187 groups analysed, 27.8% were found active, while the remaining 72.2% groups were less active. Logistic regression analyses showed that the activeness of the hypertension-related Facebook groups was independently associated with the group-size (adjusted OR=1.02, 95% CI=1.01–1.03), presence of likes on the most recent wall post (adjusted OR=3.55, 95% CI=1.41–8.92), and presence of attached files on the group wall (adjusted OR=5.01, 95% CI=1.25–20.1).
Conclusion Facebook has great potential to be used as a popular and useful platform for creating awareness among the global population about hypertension-related diseases, and also for providing supports to the affected patients and caregivers across the world. Social media sites can be utilised more widely for health information and communication purposes in order to build up a better global health.

Identifying and addressing structural quality gaps in primary health care in Tanzania

Author(s) Dominick Mboya1, Flora Kessy2, Christopher Mshana3, Alexander Schulze 4, Christian Lengeler 5
Affiliation(s) 1Research, Ifakara Health Institute, Dar es Salaam, Tanzania, 2Dar es Salaam Campus College, Mzumbe University, Dar es Salaam, Tanzania, 3Research, Ifakara Health Institute, Dar es Salaam, Tanzania, 4Novartis Foundation for Sustainable Development, Novartis Company, Basel, Switzerland, 5Health Interventions Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary The abstract presents the findings from assessments that used an electronic Tool to Improve Quality of Health Care (e-TIQH) within regular supportive supervision of primary health care facilities in Tanzania. The e-TIQH uses a comprehensive approach to assess the quality of primary healthcare provision at facility level, disseminates the results, and uses the results for evidence-based planning and budgeting. Improvements in some indicators are attributed both to targeted interventions after the assessments and proper planning and budgeting at district level. The tool has huge potential for scaling up by informing the planning process and making resource allocation more efficient.
Background Regular supportive supervision is a crucial element to improving the performance and quality of health facilities. To make supervision more effective, a situation analysis needs to be conducted and identified problems need to be discussed and addressed with all involved. In order to facilitate this process, an electronic Tool to Improve Quality of Health Care (e-TIQH) was introduced on a pilot basis in the Kilombero and Ulanga Districts, Morogoro Region in Tanzania. This assessment tool uses a performance based approach to identify and address the quality gaps in health facilities (mainly primary health care) in a comprehensive manner. The focus lies on primary healthcare since this is the entry point into the formal health system for most patients. Moreover, most health conditions are managed at this level. The services available at health facilities are compared with the expectations on these services, as defined by the national standards of care and community preferences. The e-TIQH approach has recently been scaled up to seven additional councils in the country (Kilosa, Gairo, Rufiji, Bagamoyo, Iringa Municipal, Mvomero and Morogoro Rural) covering 420 health facilities.
Objectives The electronic Tool to Improve Quality of Health Care (e-TIQH) was introduced with the objective of making supportive supervision of primary health care services more manageable, efficient and sustainable through reducing time and costs and by removing technical challenges in entering, cleaning and analyzing the collected data.
Methodology e-TIQH is embedded in a comprehensive approach that is to be applied in the frame of supportive supervision activities at district level. This approach is comprised of three steps:
• Assessing the quality of primary healthcare provision at facility level
• Disseminating the results of the assessments including identified quality gaps, root causes and improvements to both healthcare providers and district health authorities
• Evidence-based planning and budgeting according to the assessment findings. A comprehensive assessment of the quality of health care provision in all health facilities in the project districts is done annually. The tool assesses performance in six areas:(1) physical environment and equipment, (2) job expectations, (3) professional knowledge and skills, (4) management and administration of the facility, (5) staff motivation and (6) clients’ satisfaction. After data entry at the facility, the data are uploaded via an internet connection, and the backend of the tool generates automatically statistical reports based on predefined, standardized data analysis. This also means that the results are immediately available and easily accessible to allow for timely feedback to providers and health system managers. The following results can be viewed by health facility, district or region:
• Each of the six quality dimensions
• Disease specific care (TB, HIV/AIDS, fever (malaria) in adults, Integrated Management of Childhood Illnesses (IMCI) and maternal health
• Ownership category of health facilities (faith-based, public, private or institutional)
• Historical trends.The main results of each assessment round are disseminated among the healthcare providers and district health authorities. Moreover, they are used as a basis for evidence-based planning and budgeting of health interventions in the district through the so-called Comprehensive Council Health Plans (CCHPs).
Results At baseline, weak performance prevailed with regard to staff motivation, job expectations, and professional knowledge, skills and attitudes of health care personnel. Shortage of trained staff, lack of essential equipment and non-adherence to basic principles of infection prevention and control measures were important issues across all districts. Similarly, low performance prevailed with regard to management of TB/HIV across all districts. A comparison of the baseline and follow-up assessments in Kilombero and Ulanga Districts showed quick improvements in job expectations and professional knowledge skills and attitudes as a result of targeted on-the-job training and supply of treatment guidelines to health facilities. The results indicate that districts can reach scores of 80% or beyond. However, it seems rather hard for the districts to go higher given the limited resources at the district level and lack of qualified staff. While Kilombero and Ulanga, after 5 years of quality assessments, have reached a good level of above 75%, Kilosa/Gairo, after only two assessment rounds, still lags behind. However, the example of Kilosa/Gairo illustrates a general trend one observes in all districts so far and relatively quick improvements can be made in the quality areas of job expectations and client satisfaction. Even the most challenging dimension, staff motivation, can be improved, though on a relatively low level. Through appropriate feedback following the assessments, small changes at health facility level (e.g. provision of incentives to staff on night shift) can be rapidly initiated which results to improvement in quality of care. These changes can then lead to higher client satisfaction. Yet, most changes with regard to physical environment and staff motivation in terms of promotions and salary increment depend a lot on resources made available at district level and therefore often take more time. Professional knowledge and facility management/administration can be partially addressed through on-the-job training.In terms of disease specific care offered in the assessed primary healthcare services, results reveal that the two districts which have been benefiting from the e-TIQH exercises for a longer time have higher scores, especially for malaria/fever and TB care, but also for child and maternal healthcare. Generally, weaknesses remain with regard to HIV/AIDS and partially maternal healthcare (Rufiji, Iringa).
Conclusion e-TIQH helps to identify the major quality gaps across districts, regions and the country. For the first time it provides a realistic, structured and informed picture of the quality of health care situation, including performance in child and maternal health, malaria, HIV/AIDS and TB related care. Furthermore, it offers the opportunity for productive interactions between health system managers and health care providers. By providing immediate results and feedback to providers and health governing structures, the e-TIQH approach facilitates immediate, mid- and long term planning to address the identified gaps. Thus, it has huge potential for scaling up by informing the planning process and making resource allocation efficient in view of achieving the health-related Millennium Development Goals.

Advocacy, Communication, Superior Outcomes: A Global Model of Nursing Service Excellence

Author(s) Linda Lewis,
Affiliation(s) Magnet Recognition Program, American Nurses Credentialing Center, Silver Spring, United States.
Country - ies of focus United States
Relevant to the conference tracks Advocacy and Communication
Summary In the United States, Australia, Singapore, Lebanon, and the Kingdom of Saudi Arabia, chief nurses, nurses, hospital administrators, and other health care providers have developed innovations that support better patient outcomes through the implementation of a global model of nursing service excellence. This model incorporates high standards for nursing leadership; structural empowerment of nurses, exemplary professional practice, new knowledge, innovation and improvements, and empirical outcomes into an organization’s structure and processes to produce sustainable superior results.
Background The Magnet Model standards were first realized in 1983, as of a result of the landmark research study by the American Academy of Nursing identifying the fourteen Magnet characteristics. These characteristics were found to be the common threads within hospitals that were thrived in the early eighties and did not experience the negative impact of the nursing workforce shortage which impacted upon patient and organizational outcomes. The American Nurses Credentialing Center established the Magnet Recognition Program in 1990 based on these Magnet characteristics and developed evidenced-based standards to create the Magnet credential. Through a rigorous peer review process, organizations submit their application, demonstrating evidence that the Magnet standards are fully enculturated and superior outcomes for each of the standards are met. The prestigious credential is granted after this review of documents and a site review of peer experts determine the Magnet standards are met and the superior outcomes expected are attained and sustained. This credentialing process is repeated every four years to maintain the Magnet credential. The Magnet Model and the standards are evaluated for their relevancy every four years. The most recent scientific review was completed in 2012.
Objectives This global model of nursing service excellence emphasizes the integration of new knowledge and innovation into the practice of nursing. The model incorporates three components - structure, process, and outcomes. The model consists of meeting high evidenced-based national and international standards resulting in a credential that represents the “Gold Standard” for nursing services and patient care. The objective is to advocate and communicate for the global model of nursing services throughout the world, to enculturate the Magnet standards in healthcare organizations and sustain superior results for the patients, their families, and the communities served. Ultimately, the objective is to impact on a grand scale worldwide healthcare.
Methodology The Magnet Model consists of five major components: Transformational Leadership, Structural Empowerment, Exemplary Professional Practice, New knowledge, Innovations & Improvements, and Empirical Outcomes. Within each component are sub-sets of standards that correlate with the evidenced-based fourteen Magnet characteristics. Using scenario-based case studies, examples will be provided, demonstrating how the Magnet framework has been successfully adopted and adapted in the Magnet credentialed organizations resulting in superior outcomes with improved nursing workforce retention and development, improved clinical outcomes, including mortality and failure to rescue, as well as improved satisfaction. In addition, innovations developed due to this global model of nursing service excellence from the case studies, will also be shared.
Results Today, Magnet credentialed organizations are nearing 400 in number and 14% of these organizations have maintained their credential for over 12 years. In fact the first organization credentialed in the world in 1994 has maintained this “Gold Standard” nearing 20 years. The overall results for Magnet organizations have shown significant improvements in patient outcomes and cost savings to patients and healthcare organizations. All along this journey, there has been improved nursing service clinical practice standards, and the nursing profession’s influence on the transformation of healthcare has increased.
Conclusion The global model for nursing service provides an evidenced-based, sustainable structure for organizations to continually improve, innovate and advance the healthcare services provided to their communities. A “global” model allows for the nursing profession to expand best-practices, enhance innovations and set standards that are universal for all nurses around the world. Healthcare leaders can apply this model and framework to their individual organizations and countries to improve care and create a culture of innovation, quality improvement, safety, and affordability.