Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Using Technology and Community Empowerment to Treat Tuberculosis.

Author(s) Shelly Batra1.
Affiliation(s) 1Senior Management, Operation ASHA, New Delhi, India.
Country - ies of focus India
Relevant to the conference tracks Infectious Diseases
Summary TB is has been declared a health emergency by WHO. Over 9 million people are newly infected with TB and 1.4 million die annually. Incomplete TB treatment has led to an alarming rise in DR-TB (Drug Resistant TB), a man-made epidemic. MDR-TB (Multi Drug-Resistant TB), if not fully treated, leads to the dreaded XDR-TB (Extremely Drug-Resistant TB), causing greater suffering and economic loss. Operation ASHA’s innovative idea is a combination of our comprehensive model and high leverage of low-cost biometric technology, eCompliance. We monitor every dose taken by MDR-TB patients to prevent XDR, because MDR-TB treatment is often left incomplete due to long duration and debilitating side effects.
What challenges does your project address and why is it of importance? TB is an airborne infectious disease, which transcends all socio-economic, cultural and physical barriers. India carries 26% of the worldwide TB burden. Patients are extremely poor, malnourished, living in cramped, ill-ventilated homes. Poor quality coal for cooking creates smoke, choking the lungs, thus making them susceptible to TB. They live on less than $1.25 a day (World Bank) and cannot afford to lose work and wages to access TB care. Although Government provides free diagnostics & medicines, treatment centres are few and far between. Patients find it impossible to adhere to the regimen, which requires 60 centres-visits over 6 months. Even if they start treatment, once they feel better they tend to stop for fear of losing jobs or of discrimination. This leads to various DR-TB strains, which are near to impossible to treat. Each patient infects 10-15 others, increasing the number of DR-TB cases exponentially. Social stigma, fear and misconceptions all explain poor adherence. Out of 600,000 MDR-TB patients globally, 100,000 are in India. XDR-TB is rampant. Mumbai recently reported 12 cases of TDR-TB (Totally Drug-Resistant TB), which has no treatment. DR-TB is serious socio-economic issue causing tremendous economic loss. Thus, treating MDR-TB fully will prevent XDR & TDR-TB.
How have you addressed these challenges? Do you see a solution? Operation ASHA’ (OpASHA) model and eCompliance effectively tackle lingering problems in TB treatment: patient identity fraud, missed doses, data fudging and high treatment cost. OpASHA fosters community empowerment and employs TB treatment providers who are locals from the communities we serve. With their knowledge of the local language and geography it is far easier for the treatment to reach disadvantaged people. Providers gain the community’s trust and help destigmatise TB through comprehensive education. They assure no patient loses their job or is ostracised by their family. We effectively utilise religious and social leaders to ensure patients adhere to their regimen. OpASHA establishes DOT (Directly Observed Treatment) centres within disadvantaged communities that are accessible and open at convenient times so no patient has to miss work and wages. One DOTS centre serves a population within 1.5km radius. To ensure each dose is taken we use eCompliance, which has a fingerprint reader attached to a netbook computer (or android phone). To register in our centre, new patients must provide fingerprints. Afterwards, every time they come for their free TB treatment they provide fingerprints to verify their identity. To decrease missed doses we rely on our providers and eCompliance for follow up. If a patient misses a dose, eCompliance sends an SMS immediately to the Programme Manager & Treatment Provider. Providers must follow up within 48hrs, find the patient, repeat TB education, administer TB medicine and obtain a fingerprint as proof of visit. If patients experience side-effects, providers either treat them or, if severe, refer them to the hospital.eCompliance eliminates data fudging because we use fingerprints for registering patients, rather than rely on manual data entry. The back end EMR (Electronic Medical Record) generates a set of 100% accurate reports, which previously was a time consuming task as our staff did it manually and with errors. eCompliance saves 30% of provider’s time which is now spent on valuable Active Case Finding and Patient Counselling.We recently upgraded eCompliance to follow MDR-TB treatment, thus preventing XDR-TB. We are also installing eCompliance on android phones. This substantially reduced our terminal costs by 40% and the cost of treatment per patient to less than $3. LGT Venture Philanthropy found that “OpASHA’s cost for treating each patient in India is approximately 19 times lower than the nearest other provider."
How do you know whether you have made a difference? OpASHA believes in a measurable impact, thus generating far more detailed reports than the Government. The following shows our achievement thus far:• We serve 6.1 million disadvantaged people in India and Cambodia
• 31,150+ TB patients treated in more than 3,000 rural areas and urban slums
• We have successfully reduced default rates from as high as 36% to as low as 1.5 %, thus minimising the risk of MDR-
• Treating over 70 MDR patients; supporting 2 XDR patients and one TDR patient with medicines and protein supplements.
• Distributed 570,000 painkillers, 780,000 antacid tablets, 315,000 antiemetic tablets, 240,000 iron tablets, 45,000 calcium tablets, 30,000 condoms, 12,000 sachets of Oral Rehydration Salt, 3,500 packets of protein supplements, 5 tons of food and 4000 blankets.
• 24 Female TB patients were provided vocational training to prevent them from being abandoned by families.
• $150/year increased income through reinstated productivity from TB, equivalent to an annuity of $1,877; treated patients have benefited by $56 million, $13,150 saved by economy for each person treated (Annual TB Report 2011: Govt. of India).
• 190 disadvantaged persons provided dignified sustainable full-time work.
• Income of 178 micro-entrepreneurs in disadvantaged localities (Community Partners) enhanced substantially.
• Social return on investment (SROI) of 3217% i.e. for every dollar invested, the society and the economy benefit by $49.3.Apart from the above, we also regularly measure, collate and analyse the following parameters
• User satisfaction metrics
• Access/ utilisation metrics: Detection as a percentage of prevalence; target is 100%
• Cost and sustainability metrics: Monthly expenses, Cost per patient & Cost per
Treatment / DOTS centre
• Achievement of positive health outcomes: Increase in body weight during the treatment.OpASHA has partnered with J-PAL, MIT in USA, which has conducted an RCT (randomised control trial) to assess the impact of OpASHA’s incentive-based salaries. We have received funding from USAID for the second RCT to assess the benefit of eCompliance. This is helping impact policy in India and abroad.
Have you or the project mobilized others and if so, who, why and how? The overarching principle of OpASHA is providing free, quality TB treatment to the doorsteps of the disadvantaged, while at the same time mobilising them to take self-initiative to improve their health as well as their socio-economic lifestyle. We believe OpASHA’s localised model is an efficient way of generating that mobilisation. For instance, in Cambodia all of our employees are locals, except for the Country Director. 80% of our budget is used to generate jobs for the disadvantaged in India and Cambodia. Within 6 years OpASHA became the 3rd largest TB treatment provider worldwide & the biggest in India by using a high-impact/low-cost, scalable & replicable model. In 2012 The Millennium Villages Project & Columbia University replicated our model and eCompliance in Uganda with “staggering improvement” in results. It took only 8 hours of Skype calls to train the master trainer in Uganda, who then trained their local providers. All technology, training and troubleshooting was done remotely from our office in India. Columbia University is now replicating eCompliance in the Dominican Republic.TB is not only a serious medical issue but it also has serious gender-related consequences. In India 100,000 female TB patients are thrown out of their homes each year by their families, left to die of disease and starvation. 300,000 children have to leave school because of TB either as a result of the infection, or because the parents have TB, in which case the child has to work to support the family (Government of India). OpASHA regularly employs women as TB treatment providers, thus reducing gender disparity. In return, not only do they generate income to support their families but they also gain great respect from the communities who treat them as doctors. In addition, at the end of each quarterly report we reward the provider with the most successful rate of active TB case finding.OpASHA’s delivery of effective TB treatment to women and girls, and in general to the “poorest of the poor”, remote and marginalised tribal communities in India, alleviate the adverse medical, social, economic and gender-based effects of TB, both on the individuals and their communities. This will, in turn, improve productivity, raise income, prevent economic loss, provide skills, training and employment for semi-literate providers in those communities, and enable access to services for the deeply marginalised tribes.
When your donor funding runs out how will your idea continue to live? OpASHA’s collaboration with the Indian Government increased our leverage by more than 4 times. They provide us with free TB and MDR-TB diagnostics, physician consultations and medicines for the communities we serve. The government also gives a grant per patient, which we receive 2 years after starting patient’s treatment. At the moment the government grant covers our entire field costs, i.e. cost of operations, thus our fieldwork is sustainable. Nevertheless, the grant still comes 2 years late. This means that in the meantime we need donor funds to help establish and operate those same centres for 2 years, as well as cover administrative expenses. This makes the government grant currently inadequate. As the eradication of TB is one of the Millennium Development Goals and due to rapid proliferation of DR-TB cases, the Indian government is focused more than ever on TB eradication, which has become a priority for politicians and policy makers. Hence, the Government has declared a plan to increase funds for TB treatment by at least 4 times and also to keep pace with the inflation by steadily increasing the funds. It has been decided that the money will also be given upfront to NGOs rather than being delayed for 2 years. Because of that we can use this grant to establish and operate our centres and continue treating patients year after year. Once the new plans come into place our entire programme will truly become self-sustaining and we will no longer be dependent on donor funds at all.The eCompliance initiative comes at a cost of $3 per patient, which is more than offset by increased productivity of our providers and office staff so it does not add to the per patient cost. eCompliance is therefore, self-sustaining from the very beginning.

Integrating Community Participation in Maternal and Newborn Health Services: Burkina Faso

Author(s) Janet Perkins1, Cecilia Capello2, Aminata Bargo3
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Geneva, Switzerland, 3Health Department, Fondation pour le Développement Communautaire/Burkina Faso , Ouagadougou, Burkina Faso.4
Country - ies of focus Burkina Faso
Relevant to the conference tracks Social Determinants and Human Rights
Summary Improving maternal and newborn health (MNH) in regions where women and newborns suffer most requires a rights-based approach which identifies and addresses the broader social determinants of health. In Burkina Faso, we are implementing a health promotion component within the national MNH strategy. A central feature is the institutionalization of community participation in the identification of priority MNH needs as well as the design of interventions. The result is a system in which data related to social determinants of health are collected and used within the health sector. This allows the health sector to participate in addressing these determinants and promotes the rights of community members.
What challenges does your project address and why is it of importance? Despite progress over the past two decades, women and newborns in Burkina Faso continue to face elevated risks related to pregnancy and childbirth. With a maternal mortality ratio of 300/100,000, a woman in Burkina Faso faces a 1 in 55 lifetime risk of death due to maternal causes. Thirty-eight of every 1,000 newborns fail to survive the first month of life. Effectively addressing MNH demands a rights-based approach to health programming that focuses on rooting out inequities and addressing social determinants of health.
Central to a rights-based approach is the promotion of meaningful participation of individuals and communities in the development and implementation of actions designed for their benefit. Participation is both an ends in and of itself, as participation is defined as a right, as well as a means of contributing to a process of empowerment. One of the aims of our program is to integrate participatory processes into health programming. This contributes to assisting the health services in becoming aware of and designing appropriate and tailored interventions to address challenges in MNH, including social determinants, as well as to give a voice to community members and ensure that they are able to participate and are empowered in the process.
How have you addressed these challenges? Do you see a solution? Since 2006, Enfants du Monde, a Swiss NGO, in collaboration with the local NGO Fondation pour le Développement Communautaire/Burkina Faso (FDC/BF), has been supporting Ministry of Health (MoH) in implementing a programme based on the World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy, as it does in the Burkina Faso national strategy. One of the principal aims is to empower women, men, families and communities to improve MNH. A central component of the empowerment process is institutionalizing participatory processes in health planning.Notably, participatory community assessments (PCA) are conducted at the outset of district-level implementation. These assessments provide a platform for community members, with an emphasis on marginalized groups, to discuss MNH needs in the community and develop tailored interventions. During the PCAs, participants explore the broad array of factors, including social determinants that contribute to poor MNH. The ensuing results of these assessments are planned interventions which are appropriate and specific to the context as well as the initiation of the empowerment of community members as they assume influence in improving the health of their community.While participatory planning processes are not new in health programming, the IFC framework institutionalizes these processes within the broader health system to make community voices systematically represented and to allow for the systematic collection of information related to social determinants of MNH. With the endorsement of the national MoH, actors from within the sub-national MoH have been trained to conduct PCAs in collaboration with other actors working within MNH at the regional and district level. In this position, they have been able to assume the responsibility of listening to the voices of community members and of taking direct action in response to their participation. This process has created a mechanism by which community participation has been integrated within the health sector. This contributes to promoting participation, and thereby rights, of community members, and increases accountability and transparency in the health services. It allows for health inequities and socioeconomic determinants of health to be identified and addressed within the public health sector.
How do you know whether you have made a difference? To date, PCAs have been conducted in seven districts (Tenkodogo, Zabré, Kongoussi, Ouragaye, Barsalogho, and Sindou) over three regions. These assessments have effectively identified challenges related to MNH, many related to rights and socioeconomic determinants, that did not surface through more traditional, non-participatory situation analyses. These include: lack of knowledge of health behaviors during and following pregnancy; lack of awareness of danger signs during and following pregnancy; lack of planning for birth or potential complications; women’s inability to make the decision to seek health services autonomously or use family resources to pay for services due to low socioeconomic status; financial and transportation barriers to reaching health facilities; and lack of satisfaction in interactions with health care providers.
To address these priority concerns, community members, leaders and the health sector worked together to develop interventions. These interventions vary by district, but include health education activities (theatrical performances, culinary demonstrations, radio game shows, etc.), birth preparedness and complication readiness, mobilization of men and the broader community to increase their awareness of MNH rights and needs and enlist their participation in MNH actions, building maternity waiting homes and training health workers to build their capacities to interact with women.Preliminary results to date suggest the success of the processes and interventions. Notably, the IFC interventions have been directly integrated into the MNH action plans of each district. This mechanism has assured the institutionalization of community members’ participation in the planning of activities designed to benefit them. This has not only contributed to the promotion of their rights, but has also provided a way for the health sector to gather data and become involved in addressing the broader determinants of health, including social determinants. Where interventions have been implemented, health care providers have created links for exchanging information with communities. Male partners are accompanying women when receiving MNH services in greater numbers and health information system data has revealed an increase in utilization of MNH services. A current evaluation is assessing the degree to which the activities have contributed to change in MNH knowledge, attitudes and practices in these initial sites of implementation.
Have you or the project mobilized others and if so, who, why and how? We initiated the project based on the assumption that improving MNH cannot effectively be accomplished in a vacuum and requires the mobilization and action of a myriad of actors. As such we have mobilized a variety of agencies and sectors acting at the national, sub-national and district level. This process began with the introduction of the IFC framework at national level. Workshops were held with MoH, Ministry of Education, international organizations and others working on MNH at this level. These workshops were designed to help these actors understand the critical nature of working with and empowering individuals, families and communities and institutionalising mechanisms that allowed them to participate in reaching the goals laid out in the national MNH strategy and ultimately fulfill women’s maternal health rights. Actors from within MoH to be responsible for the IFC component at the national level were identified and their capacities built to lead these efforts.
At the same time, IFC committees, operating under MNH bodies, at sub-national and district level were formed. This structure of IFC committees has created a mechanism allowing for both horizontal and vertical communication. This has reinforced the institutionalization of community participation in MNH as actors at both the national and sub-national levels become aware of the specific needs expressed by community members as well as the social determinants of maternal and newborn health in play at the local level. They are then able to respond with centralized action when necessary and appropriate.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Notably, health care providers have created linkages for working with communities and for the exchange of information. They have contacted and begun working with community leaders, male partners, community health workers and village birth attendants. Through these links, actors in the community have become engaged in encouraging women to attend MNH services. They also transmit information from the health services to the community and gather information on an on-going basis in the community and relaying it back to the health services. This contributes to the realization of rights, including promoting community members’ rights to information and education and through ensuring accountability and transparency. It also provides a mechanism for continued community participation within the health sector.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision. To begin with, the IFC framework and its related interventions have been directly integrated into the national MNH strategy, as the health promotion component and fifth pillar of the national Plan for Reducing Maternal and Newborn Mortality: A Road Map. This has assured that it has never been implemented as a standalone, vertical program. In addition, the component is being implemented directly by MoH, with the support of outside actors, including NGOs and UNFPA. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. Moreover, while the program is still financially supported primarily by exogenous actors (i.e. UNFPA, EdM), MoH understands that this funding will ultimately expire and has identified and begun implementing strategies for resource mobilization internally.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in regional offices. Likewise, FDC/BF is a local NGO, based and operating in Burkina Faso. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country actors prevents an over-reliance on outside actors and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate in identifying their needs and designing methods to address these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is equipped with the capacity to integrate and promote community participation.

Report from GHF2012

The challenge from the Geneva Health Forum 2012 is to summarise what was an amazing few days of presentations, discussions and meetings of frontliners in health. 246 oral presentations including issues such as child obesity in Tunisia, innovative approaches of managing diabetes in Mali, how urbanisation is impacting people in Bangladesh, how atmospheric contamination is leading to increased hospitalisations in Barcelona, the challenges of over and under nutrition coexisting in the same societies and how noncommunicable diseases also exist in refugee and migrant populations, the challenge of access to medicines and the financial burden this means for many of the world’s poorest people and how the issues of justice and equity need to be included in the debate in how we address chronic conditions.

A total of 895 participants from 70 countries including policy makers, health professionals, academics and NGO frontliners all shared their view points and experiences and the sessions emphasised how complex the issue of chronic diseases is to address and that there is no magic bullet. Is it Youth empowerment or the use of new technologies? Is it redesigning health systems or putting more of an emphasis on primary health care? Is it addressing the way we all are living in a more sedentary and unhealthy environment or tackling the challenge in those who are most at risk? So many questions still remain after the Forum, but some key lessons:

  • Research and its role to sometimes highlight the obvious, but to be used as an effective tool for project implementation, monitoring and evaluation and policy change
  • Innovative approaches that are adapted to the context we work in, that are sustainable and scalable, but that technology should not drive the answer, but be one of many tools used
  • We need a multi-discipline and multi-disciplinary approach and this will require changing the way we think about chronic diseases, how we teach medical and nursing students about chronic diseases and how we move the issue of chronic diseases from being something purely dealt with by the health sector to truly a whole of government and society approach
  • The health systems clinicians work in, whether in Switzerland or Uganda need to be reorganised to address chronic diseases. This will require in some cases decentralisation of care to the primary health care level, development of new roles for health professionals, avoiding verticalisation and a disease based approach and integration of different aspects of the health system
  • The role partnerships will play in addressing this challenge is necessary, however we need to address issues of conflict of interest and trust, but these can be overcome

Hearing from people with chronic diseases, innovators, philosophers, health system specialists, researchers, health professionals or policy makers the common theme was putting the individual with the chronic condition, the beneficiary of our actions and activities at the centre for what we do. We are all working as was stated by Sridhar Venkatapuram for the noble cause of improving health, in addressing chronic conditions we must not forget that we are working to ensure that children in Nepal do not develop cardiovascular risk factors, that people with sickle cell disease receive the treatments they need, when they need them, and that the health system should work for and with the person for improved health and not be a barrier to this.

In the session on innovation Mahad Ibrahim argued that space for innovation is necessary and the aim of this edition of the Forum was to provide such a space. With the issues addressed during the Forum it was not only innovative work that was presented, but also the approach to learning and sharing ideas at the Forum and not letting individual’s expertise get in the way of new ideas.

After the session on health systems Andy Williamson said he felt encouraged after having heard from a policy maker, an academic, someone working for an NGO and a clinician in a hospital. The challenge is great, but the inspiring and innovative approaches presented at the Forum show us what can be done and that the lessons presented will help in addressing chronic diseases in different settings and make a change to the lives of people living with chronic diseases throughout the world.

Reporting at the Geneva Health Forum also took an innovative and participative approach. Different participants contributed not only in terms of feedback on the sessions on content and quality, but were also able to give their perspectives on the content presented. Students from Boston University for example prepared presentations on their experience and what they learnt at the Forum. Students from the University of Geneva’s Institute of media, communication and journalism also attended some sessions and provided insight into how experts in the field of health communicate on certain issues. Travel grantees and other key participants reported on the sessions they attended by adding their view to the issues addressed. All this material is presented in the final report from the 2012 edition and the issues raised in this report will shape the discussions and content of the Geneva Health Forum in 2014.

Enhancing Access and Quality of Care in Developing Countries through Integrated Provider Empowerment and Environmental Safety

Author(s): E. I. Okechukwu*1, A. C. Onyenwenyi2, G. F. Upham3, B. M. Kady4
Affiliation(s): 1Action Family Foundation, 2Institute of Child Health & Primary Care, Lagos, Nigeria, 3Safe Observer Int’l, France, 4Society for Women and AIDS in Africa, Kinshasa, Democratic Republic of the Congo
Keywords: Healthcare, safety, stigma, waste management, provider confidence

The weak healthcare in developing countries engenders chaotic management of medical wastes, thereby exposing care providers and patients to risk of injuries and infections by deadly blood-borne pathogens aside environmental degradation. Millions of women as healthcare personnel, domestic care providers or pregnant mothers and babies on immunization or children at play are primary casualties of unsafe healthcare practices especially improper handling of medicare wastes. In the absence of safety nets among health providers, the fear of contracting infections at the workplace compromises the quality of services rendered to patients especially those infected or affected by HIV/AIDS. WHO estimates that in developing countries, over 60% of injections are unsafe, and 10% of the global workforce are at risk of needle stick injuries capable of transmitting blood-borne pathogens. A survey of five West African countries (including Nigeria) revealed that public containers meant for household refuse receive more than 50% of medical wastes. There are anarchical practices at the collection, sorting and stocking, transport and elimination phases.


In 2005, Action Family Foundation, civil society groups, Safe Observer International and academics from the Institute of Child Health and Primary Care of the Lagos University Teaching Hospital initiated interventions to mainstream proper healthcare waste management in Nigeria through capacity building, community mobilization and practical medical waste handling services. We developed survey instruments and obtained baseline data on the knowledge, attitude and practices of stakeholders; co-hosted with the state agency two annual medical waste management summits and raised community awareness to the hazards of unsafe medicare waste practices as well as organized sensitization sessions for different professional groups. We are engaging in the project as an intervention research work to build the local capacity, conduct research and generate data to inform scaling up and replication to other regions.


Presently, about 15% of the over 3000 healthcare facilities are being covered. Generators are sorting waste at source, and are expected to budget for waste disposal while the government Waste Management Authority supplies consumables and carts waste regularly. The public is more aware and empowered, including holding their care providers accountable for medicare waste.

Lessons learned:

The advocacy and community mobilization expertise of civil society groups when matched with political will of public service organs can reconstruct people’s attitudes and enforce desired practices with modest investments. Our initiative brought together patients, practitioners, consumer groups along with persons living with, or affected by nasocomial pathogens. The presentation will draw on work in process in Nigeria, Uganda, India and globally. We shall share the locally applied strategies, challenges and success stories of Action Family Foundation’s pioneering work in mainstreaming integrated medical waste management.

How to Access and Partner with Migrant Populations for Health Intervention

Author(s): D. P. Williams1
Affiliation(s): 1Microbiology, Howard University School of Medicine, Washington, DC, USA
Keywords: Migrant community-based participatory research

The Marshallese migrant population in the United States has adverse health conditions and disparities that are mainly attributed to their pre-migration health status. Little is known about the perceived and real barriers Marshallese experience in accessing and utilizing health services in the United States. Additionally, because health service providers are not cognizant of these barriers, they cannot efficiently meet their health needs.


To access a hard-to-reach migrant population, principles of Community-Based Participatory Research (CBPR) were used to form a collaborative partnership between community members, healthcare workers, and the research team and to obtain culturally relevant data to design an intervention.  Results: CBPR was used to access a migrant Marshallese community and to develop partnerships between the community and local health clinics. Quantitative and qualitative methods, using an ethnographic approach, including participant observation, group discussions, and the development of a questionnaire, were used to obtain formative data to identify perceived and real barriers to existing health services.

Lessons learned: CBPR can be a successful and efficient strategy to access and partner with migrant community members to design culturally relevant interventions. Focusing on the strengths of the community and utilizing a culturally-sensitive communication approach can enhance empowerment, promote dialogue, and foster trust. Understanding that immigrants may have diverse ethnomedical models and explanatory models of disease; these models may not complement western biomedical models…; acculturative stress, anxiety, language, isolation, fear of unknown, navigating social, employment, and health systems. Because health and illness are culturally defined, an understanding of a population’s explanatory model of health and illness is fundamental to ameliorating health disparities in diverse populations.

A Malaria Knowledge Gap

Author(s): J. Ehmer1
Affiliation(s): 1SolidarMed, Luzern, Switzerland
Keywords: Community perception; malaria; bed nets

Malaria is a main factor contributing to the high child mortality (172/1000) in Mozambique. For this reason, the Swiss organization SolidarMed has started a catch-up bed net distribution campaign in collaboration with local authorities in 2006 : Long lasting impregnated bed nets were distributed for a symbolic prize of 1 USD to children < 5y and pregnant women. In February 2007, a sharp MoH - policy swift has determined that the 1 USD - contribution per net had to be abandoned and brought the campaign to a halt. The new Mozambican public health directive was to give out bed nets for free. Reluctant to do so and before starting with free distribution, an interim-evaluation was conducted in 9 villages of Chiure District (Cabo Delgado Province). 316 of the households which had bought bed nets were interviewed randomly.


The objectives of the evaluation were to understand if the households used the nets correctly, to evaluate if the framing IEC activities were successful or had to be modified and to learn more about local community perceptions about malaria.


62% of the persons interrogated were mothers and 22% of the households reported three or more children <5y, who - in a majority of 52% - slept at night with their mothers in the same bed. 39% of households reported more than 3 malaria attacks in their children <5y during the preceding year. 13% of the households had at least one pregnant family member and 81% of the households reported to take their sick children to the nearest health post by foot. In 68% of the households, it was the father who took the decision to buy the net. In 54% of the households, the father also earned the living for the family. Two findings were striking:
1 – Only 26% of the households had the nets installed, and only 18% of the households reported to make use of the nets every night. 46% of the households reported to use the nets in the rainy season mainly.
2 – Whereas 87% of the interrogated reported a correct knowledge about malaria signs and symptoms and 80 % knew how to correctly prevent malaria, 67% of the interrogated did not know how malaria is transmitted.
These results show, that:
1 – Whereas mothers deliver immediate care for their children, fathers have an important economic responsibility and play an important role in decision making, also related to the health of their children.
2 – Use and usefulness of bed nets seemed to not have been fully understood by the population. Malaria was not perceived as endemic condition throughout the year, but as periodically peaking disease. Nets were reportedly seen as status symbol, correct and consistent use was low.
3 – Good knowledge about signs and symptoms may result from malaria being a common disease in this endemic area and the local concept of ‘etecussa’ (designation for malaria-linked fever in the local language Macwa) being a common concept. However a knowledge gap was identified: People knew the signs and symptoms of malaria but did not understand how the disease is transmitted. The poor knowledge about Malaria transmission may contribute as key factor to the inconsistent use of the nets, despite good reported knowledge about malaria prevention.

Lessons learned:

This example shows, that in the provision of healthcare services it is not sufficient to provide access to technical means of disease prevention (such as bed nets), but that communities must be empowered to understand basic concepts of common diseases in order to make correct and consistent use of these means. Information, education and communication must target both men and women and cover all main areas such as disease transmission, prevention, signs and symptoms, home treatment, help seeking and vulnerability. Messages should be provided in a culturally adapted way, taking into account the local concepts of disease. Health promotion and community empowerment should be an integral part of health service provision.

The Interrelationship between Community Health Insurance and Quality of Care

Author(s): W. Soors*1, A. Boré2, O. Ouattara2, P. Ndiaye1, B. Criel1
Affiliation(s): 1Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium, 2Union Technique de la Mutualité malienne, Bamako, Mali
Keywords: Community health insurance, primary care services, quality of care, empowerment, Sub-Saharan Africa

Perceived quality of care is key to service utilisation and to community health insurance (CHI) enrolment. In Mali, both service utilisation and CHI enrolment are typically low. Whereas the possible positive effects of CHI on service utilisation are well documented, little is known on whether and how CHI might also influence quality of care.


To bridge the knowledge gap on the interrelationship between CHI and quality of care, ITM and UTM engaged in a comprehensive effort to investigate the effects of CHI on quality of care at first-line level in Mali, West Africa. The study addresses these effects through a series of case studies in urban and rural healthcare facilities where a functioning CHI scheme is present. For this purpose, ITM developed a conceptual framework, which distinguishes between favourable and adverse quality-related possible effects of CHI at both supply and demand side of healthcare. A team of sociologists and public health experts collected data during two weeks per site. Tools and methods involved comprise exit interviews and focus group discussions (with healthcare users, both CHI members and non-members), in-depth interviews (with healthcare users as well as other actors), document analysis and archival research (including analysis of pre-existing meeting records and case-mix and prescription analysis from routine data), discourse analysis and observational research (including ethnographic data collection and systematised observation of clinical consultations) and triangulation (corresponding to the complementary sources, methods and researchers). Analysis is in full process. This presentation focuses on findings and preliminary lessons from two rural case studies (Cinzana and Nongon), centred on the opinions voiced by healthcare users as a proxy for perceived quality.


In both Cinzana and Nongon, users express their dissatisfaction with waiting times, opening hours and staff attitude. CHI members have the most outspoken opinion. Demand for change in staff attitude is the most frequent topic found in the records of CHI-provider exchanges. Document analysis so far identifies changes in relational aspects of care, but no influence of CHI beyond giving voice to discontents. Users in Cinzana and Nongon have a different opinion on biomedical aspects of quality. In Cinzana, most users are satisfied with provider skills and drug prescription, but dissatisfied with drug procurement. In Nongon, users disagree on provider skills and drug prescription, but are highly satisfied with drug procurement. CHI members and non-members have no different opinion. The perception of biomedical aspects by significant parts of the communities differs strikingly from the perception of the same by public health experts. A CHI-channelled demand for change in biomedical aspects of care is not documented. None of the CHI schemes has a medical adviser at hand. Analysis so far does not identify changes in biomedical aspects of care, related to CHI as such. In Cinzana, users see CHI as lever to quality improvement, even if restricted to change in staff attitude. In Nongon, users see CHI as lever to quality improvement, gender balance and social cohesion, even in adverse economic times.

Lessons learned: The cases of Cinzana and Nongon suggest a positive but limited influence of CHI on the relational aspects of quality of care. In the given context, the lever function of CHI seems at least as related to the development of social capital as to the pooling of monetary capital. Lack of informed users might possibly explain the discrepancy between the users’ and the researchers’ perception of biomedical aspects of quality of care. A CHI support and capacity gap – as illustrated by the absence of a medical adviser – might possibly explain the lack of influence of CHI on biomedical aspects of quality of care. The latter hypotheses need further analysis.

Case-Mix Innovations in Public Hospital Systems of India: A Case of Jaipur, Rajasthan 123

Author(s): M. Balasubramanian*1, P. F. Howard2, S. Cole3
Affiliation(s): 1Research and Development Centre, Apollo Hospitals Educational and Research Foundation, The Apollo Hospital Group, Hyderabad, India, 2School of Health and Social Development, Deakin University, Burwood, Australia, 3The Information Centre, National Health Service, London, UK
Keywords: Public hospital management, case-mix innovations, human activity system, worldviews, conceptual model, patient empowerment

During the past three decades, hospital management in economically-developed countries has been transformed by the adoption of a technology innovation known as ‘case-mix’, a generic term for scientifically developed grouping mechanisms used to categorise hospital or health service patient care episodes in order to facilitate scientific planning and management of healthcare. Case-mix systems lead to efficient resource utilisation, continuous quality improvement, and controlled expenditure on health. As with any such novel advance, case-mix has undergone multiple developments and ‘rebirths’, but these reincarnations have not always factored in prior experiences and evaluations. The processes involved in its development reflect the necessity to understand and research its innovations in distinctive ways, particularly when the site for such innovations is a developing country such as India. This study develops an original approach towards research regarding potential case-mix innovations for public hospital management in India.


Several problems such as prolonged waiting lists, inefficient health service delivery, poor quality of services, and lack of transparency in management have contributed to the growing criticisms of public hospitals in Jaipur (capital district in the State of Rajasthan). Drawing encouragement from the recent policies of the Union government, a case-mix ‘action research’ was developed. The study employed constructivist logic, whereby a quasi-experimental research design was constructed with the utilisation of soft systems concepts. The process began by developing an orchestrated ‘human activity system’ amongst the major players of public hospitals in Jaipur. The stage for this orchestration integrated the objectives of the study into three analysis modes: exploratory, diagnostic and design. Roles were designated for the 28 ‘actors’ involved in the study and 19 inquiry questions were developed to concentrate their focus. The actors were classified as ‘problem owners’, ‘decision takers’ and a ‘problem solver’, and their involvement was expected to provide meaningful solutions to the process of introducing case-mix in Jaipur.


The exploratory inquiries led to an appreciation of the underlying problem situation and resulted in the problem-solving system, which took into account the ‘worldviews’ of the problem owners as well as constructing explanations for purposeful case-mix innovations. 34 worldviews were identified, which were grouped into 12 change elements. The diagnostic inquiries developed specific ‘lines of thought’ leading to the identification of 24 barriers, and 26 advantages and disadvantages of case-mix innovation. During the design mode, a conceptual model was developed as a pathway for case-mix innovations in India.

Lessons learned:

The designers of the study consider that the strength of this conceptual model will be limited to the lines of thought that were used in the process of developing the model. The study encourages future case-mix research in India to gain from the model. A failure to view the entirety and interactions of other elements involved in case-mix innovations could lead to redundant case-mix developments. Therefore, it is considered essential that a systems approach to case-mix innovations is adopted to develop changes that are commensurate with the needs of Jaipur or even India as a whole. The study develops the idea of patient empowered case-mix systems. In this regard, the study first, proposes the concept of ‘twin pilot projects’: one that develops ‘patient-centric’ product line management methods and the other that sets up a platform for the construction of native case-mix classification systems (Indian Diagnosis Related Groups).

The Impact of the Global Economic Crisis on Maternal Health Conditions of Teenage Mothers in Rural Nigeria

Author(s): F. R. Tinuola1
Affiliation(s): 1Population Health, Kogi State University, Anyigba, Nigeria
Keywords: Teenage, Maternal, Economic Crisis, Health, Services

World Development Index, 2009, ranks Nigeria among the 5 worst countries with highest maternal death in the world Real life experiences indicate that most teenage pregnant women in rural areas suffer malaria, diarrhoea, miscarriage, edema, hemorrhoids, varicose veins, bleeding gums, and UVF&VVF. The problem is compounded by poor environmental, corruption, decreased revenue occasioned by the current Global Economic Crisis (GEC) and poor socio-economic conditions of teen mothers. The state of maternal health have worsened by the drop in budgetary allocation to health sector occasioned by the fluctuation in crude oil prices, the major export earning. Some States could not pay salaries of health workers resulting in strike action that nearly paralysed the health sector. This study examines the impact of the GEC on maternal health conditions of teenage mothers in selected rural communities in Nigeria.


This social survey draws data from primary and secondary sources. To obtain primary data, 15 rural communities, with <20,000 population each, were selected using stratified random sampling in selected three States in Nigeria. The States selection was based on maternal health reports of previous Demographic and Health Surveys of the Federal Ministry of Health. In each State, 5 rural communities were selected in all the Senatorial Districts.Respondents were selected among married teenage women (13 – 19 years) who had previously experienced a minimum of 2 pregnancies with at least one child delivery. Using purposive random sampling technique, 25 teenage mothers were selected in each of the rural communities making a total of 375 for the study. The instrument is a structured questionnaire containing both closed and open-ended questions. This study adopts the national maternal health indicators of the instrument used by the Federal government to conduct the National Population & Housing Census and National AIDS and Reproductive Health Survey, 2005 with few moderations. This was done to monitor and assess the various maternal health indicators to ascertaining the progress or otherwise made in the pursuance of MDGs on maternal health. The instrument was placed on 2 period scale in order to assess the specific impact of the GEC on maternal health conditions. The instrument contains questions on socio-economic conditions, incidences of diseases, factors in accessing reproductive health services and availability & efficacy of primary health infrastructures. Secondary data were obtained from results of maternal health indicators in the reports of various Demographic and Health Surveys, National AIDS & Reproductive Health Surveys and National Population and Housing Census data. Budgetary allocations to health were obtained from the Federal and States governments for 5 years. Five-year records of antenatal and post natal care of primary health, records of the quality of staff & strengths were analysed. Content Analytical Method was used to analyse qualitative data while Bi-variate statistical tools analysed quantitative data. Hypotheses were tested using Chi-square and Pearson Product Moment Correlation Co-efficient.


Generally, health indices worst off as the number of death among would-be mothers continues to soar. Findings show that the state of maternal health among teenage women has been worsened by the current World GEC in respect of poor environmental conditions, unbalanced nutrients in foods, opportunity cost of accessing maternal health services, incidences of maternal diseases and availability of drugs & qualified personnel in the primary health facilities. The need to increase revenue profile through economic diversification from crude oil, increased government commitment to implementing various health policies, aggressive health education drive and economic empowerment of rural citizens will assist in addressing   the current worst state of maternal health towards achieving the MDG on health in Nigeria.

Chagas Disease in Latin American Migrants in Europe: Overcoming the Barriers to Access to Care

Author(s): Y. Jackson*1, J. Gaspoz1, F. Chappuis2
Affiliation(s): 1Community Medicine and Primary Care, 2Division of International and humanitarian medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
Keywords: Chagas disease, migrants, access, care, information

Chagas disease, a protozoan infection due to Trypanosoma cruzi, affects around 10 millions persons mainly in Mexico, Central and South America. Most frequently an asymptomatic infection, serious cardiac and digestive complications affect thirty percent of infected persons on the long term with substantial morbidity, mortality and economic costs. Recently, millions of persons at risk have migrated to Europe. In the last few years, an increasing number of imported cases and transmission have been reported in western European countries and Chagas disease is now considered as an emerging health problem possibly affecting more than fifty thousand persons. A substantial proportion of migrants have poor or no access to medical care due to administrative reasons, engendering risks both for themselves and for local communities.


This presentation will review the situation encountered by migrants at risk of Chagas disease in different European countries regarding access to appropriate medical care. Poor acknowledgement of the disease, lack of appropriate programmes and insufficient knowledge among the European medical community will be exposed. Different scenarios will be presented and case studies will be reported.


Chagas disease is a serious emerging health problem in Europe affecting very vulnerable population of mainly undocumented migrants with consecutive serious health risks on local populations. Countries and regions widely differ on the accessibility of appropriate medical care. Lack of acknowledgement of this health issue by authorities and poor knowledge within the medical community reinforce the barriers towards effective actions. More globally, this neglected disease suffers from the lack of research and developpment, political agenda and effective funding. Access to appropriate and holistic care, in addition to empowerment of affected communities and better information dissemination within the medical community represent necessary steps to prevent both serious human and economic consequences in Europe.