Geneva Health Forum Archive

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Financial Accessibility of Health Services for the Population of Dodoma Region: Tanzania

Author(s): Manfred Stoermer1, Manoris Meshack2, Karin Wiedenmayer1
Affiliation(s): 1Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Health Promotion and System Strengthening Project, Dodoma, Tanzania
1st country of focus: Switzerland
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): A household survey is presently being carried out in the framework of the "Health Promotion and System Strengthening" (HPSS) project funded by the Swiss Agency for Development and Cooperation, and implemented by the Swiss Tropical and Public Health Institute. The results will inform the project on health seeking behaviour of the population of Dodoma Region, Tanzania, and the associated costs. This important baseline information on financial accessibility will help the project to transform the existing provider-based prepayment schemes of "Community Health Funds" into a professionalized social health insurance approach. The results of the household survey will be available by March 2012.
Background (max 200 words): Financial accessibility of health services is one of the strongest determinants for improving the health status of populations, especially for the poorer segments of the population. Improving financial accessibility to health services is one of the objectives pursued by the “Health Promotion and System Strengthening” (HPSS) project in Dodoma Region in Tanzania. The HPSS project is being funded by the Swiss Agency for Development and Cooperation (SDC) and was launched in June 2012, after a one-year preparatory phase. The Swiss Centre for International Health (SCIH) of the Swiss Tropical and Public Health Institute (Swiss TPH) is mandated with the implementation of the project. The HPSS project aims at improving access to, quality and utilization of health resources and services in Dodoma Region and at contributing to an effective and well governed health system. Following the philosophy of an integrated “health systems strengthening” approach, the project aims at achieving improvements in a number of working areas: community based health promotion activities, health financing, medicine supply management support, and physical resource management support. The project will determine the effectiveness of its approaches in Dodoma with an operational research component. In order to improve financial access to health services, the HPSS project works on transforming the existing Community Health Funds into a professionalized health insurance structure, especially for the rural population.
Objectives (max 100 words): The household study will provide information on health seeking behaviour and financial costs involved, along a social stratification. The analysis will highlight the financial accessibility of health services for the population of Dodoma Region in Tanzania.
Methodology (max 400 words): Between September and December 2011 a baseline study is being carried out by the HPSS project, with the objectives of firstly informing the design of activities appropriate to the local situation, and secondly of providing a baseline for monitoring change and project progress. The baseline study includes a household survey with a sample size of 3500 households, covering the households of five rural districts and one urban district of Dodoma Region. The household study will provide information on health seeking behaviour and financial costs involved, this being crucial information for a future professionalized health insurance structure for the informal sector. The field phase of the baseline study is expected to be completed by end of 2011. The results are expected to be available by March 2012.
Results (max 400 words): The household survey is expected to highlight the health care seeking behaviour of the population of Dodoma Region, both in a rural and an urban context. This presentation will especially explore the question of financial accessibility of health services for the population, along a socio-economic stratification. The households will report on the kind of health services utilized during a recall period of 12 months for outpatient services, respectively 3 months for inpatient services. Costs incurred and sources of funding will be assessed especially for outpatient services and maternity care at all levels of the health system, and inpatient care at hospitals. Further, the perception of the role of user fees presently being charged in the health system will be explored. Finally, the satisfaction of the households with the “Community Health Funds” (CHFs), a government scheme for providing a basic health insurance mechanism, will be highlighted.
Conclusion (max 400 words): The conclusions will be based on the analysis of the household survey results available in March 2012.

Impoverishment Impact of Out-of-Pocket Payments for Chronic Illnesses: Rural Bangladesh

Author(s): Syed Abdul Hamid1,3, Syed M. Ahsan2,3
Affiliation(s): Institute of Health Economics, University of Dhaka, Dhaka, Bangladesh, Department of Economics, Concordia University, Montreal, Canada, Canada, 3Institute of Microfinance (InM), Dhaka, Bangladesh
1st country of focus: Bangladesh
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This study measures the impact of out-of-pocket-payments for chronic illnesses in rural Bangladesh on impoverishment. We used the data from the baseline survey on about 4,000 households in the Microinsurance and Vulnerability project of the Institute of Microfinance. We estimated the impoverishment impact of OPP by comparing the difference between the average level of head count poverty or poverty gap before health care payments and after payments. The study finds that about 7.72 percent of those who had chronic illnesses fall into poverty after accounting for OPP payments. The study suggests that when introducing health insurance, adopting proper measures for effective rationing of the prices of essential drugs and imposing restrictions on selling over the counter drugs also needs to occur.
Background (max 200 words): Over the last few decades the prevalence of chronic illnesses (e.g., diabetes, cancer, heart and kidney diseases) has increased both in the developed and developing countries. Enormous expenses are incurred for managing these diseases.  In developing countries the major source of financing these expenses comes from out-of-pocket payments (OPP). OPP, the most inequitable and least efficient approach to health care financing, severely affects consumption of poor households during periods of major chronic illness and/or forces the poor to forego treatment, which raises the chance of long-term deterioration in health and earning capacity. OPP is therefore claimed to be a major cause of poverty in low-income countries. OPP is the single largest component of total health expenditure in Bangladesh.  A significant part of this expenditure is incurred for chronic illnesses. This may play an important role in exacerbating poverty in rural Bangladesh. Reducing OPP, especially for chronic illnesses, is crucial for achieving universal health coverage as well as maintaing the success in poverty reduction measures adopted by Bangladesh. Thus, for policy discussion, it is crucial to expose the extent to which OPP affects poverty levels. Although one study measured overall impoverishment impact of OPP in Bangladesh, there is no evidence on impoverishment impact of OPP incurred for chronic illness.
Objectives (max 100 words): The primary purpose of the research is to expose the extent to which OPP incurred for chronic illnesses contributes to poverty. The specific objectives are:  (i) to explore the overall impact of OPP on the incidence and depth of poverty;  (ii) to examine the impoverishment impact of OPP incurred for chronic illnesses; and (iii) to examine the impoverishment impact of OPP incurred for acute illnesses.
Methodology (max 400 words): This paper uses data from the baseline survey of a longitudinal study project entitled ‘Microinsurance and Vulnerability’ undertaken by Microinsurance Research Unit (MRU) of the Institute of Microfinance (InM).  The survey subjects were 4,010 stratified randomly selected households from 120 villages of 7 districts in Bangladesh, which incorporated about 20,000 individuals.  We asked about any acute or chronic condition suffered by any individual in the household during the 12 months preceding the interview. We used both WHO fact sheets and CMS guidelines to define chronic diseases. The information about OPP for consultations, drugs, diagnostic tests, surgical operations, bed charge, transports and others (food, lodging, unofficial fees, etc) for each episode of illness were asked. In addition to questions regarding illness and out-of-pocket payments, the questionnaire for the household survey included a detailed set of questions on household demographic conditions, occupations, education, income, expenditure and assets.  We constructed the overall OPP of a household by adding the expenses incurred for consultations, drugs, diagnostic tests, surgical operations, bed charge, transports and food, lodging, unofficial fees, etc. for each episode of illness for the 12 months preceding the survey. OPP for chronic and acute illnesses was constructed by adding the expenses of the same categories incurred for each episode of illness of the respective condition for the 12 months preceding the survey. We have estimated head count poverty and depth of poverty using Cost of Basic Needs approach (CBN). Like earlier studies, we have estimated the poverty impact of OPP by comparing the difference between the average level of head count poverty or poverty gap before health care payments and after payments.  We used both food and non-food consumption as a proxy for household income. For measuring food consumption we considered the expenditure on all the food bundles consumed by the households for the week preceding the survey. For non-food consumption we considered expenditure against the following items: clothing, toiletries, cookware, blankets, furniture, lamp, torch light, candle, match, kerosene, electricity bill, transportation, recreation, tuition fees, stationeries, mobile and land telephone bills, festivals and traditional ceremonies and electronic equipment. To obtain per capita consumption the sum of food and non-food expenditure was divided by age and sex adjusted to household size.
Results (max 400 words): About 88 percent households reported at least one episode of illness; and about 55 percent of them (or 48% of the sampled households) had more than one (about 35% had 2 episodes and about 20% had 3 or more) in one year. The survey covered 19,424 individuals of which about 33 percent had some sort of self-reported morbidity over the 12 months. About one-third of the ill persons suffered from general cough and fever. The other major symptoms were gastrointestinal disorder, pain, diarrhea, typhoid, headache, blood pressure, skin diseases and dysentery. About 20 percent of the cases were chronic and the remainder were acute.  OPP per affected and sampled household from all episodes of illnesses during the 12 months preceding the survey stood at USD 68 and USD 59 respectively. Drug expenses are the major component accounting for about 53 percent of OPP.  OPP is about 6 percent of the total consumption and about 9 percent of the food consumption. Although absolute OPP had a definite positive trend across the quintiles, there was no significant variation across the quintiles in its share against both total consumption and food consumption. OPP per episode of chronic condition (USD 86) is significantly (p-value < .01) higher than acute condition (USD 24). We find overall 4.14 percent individuals fall into poverty after accounting for OPP payments. The pre-payment head count is 38.81 percent and post-payment head count after deducting OPP payments from total consumption expenditure is 42.95 percent. The intensity of the poverty gap is 0.68. About 7.72 percent of those who had chronic illnesses fell into poverty after accounting for OPP payments (the pre-payment head count is 39.12 percent and post-payment head count after deducting OPP payments from total consumption expenditure is 46.84 percent) while the corresponding figure for acute illnesses is 3.44 percent (the pre-payment head count is 38.54 percent and post-payment head count after deducting OPP payments from total consumption expenditure is 41.98 percent). The intensity of the poverty gap for chronic illnesses is more than double (1.13) compared to acute illnesses (0.55).
Conclusion (max 400 words): The study finds OPP for chronic illnesses accounts for a significant percentage of individuals falling into poverty. This also has a large impact on deepening poverty. Thus, Bangladesh needs to introduce alternative ways to raise funds for the provision of health care in the rural areas. As health insurance is an innovative way to raise funds for provision of health care and there is evidence that health insurance reduces the catastrophic payments, we suggest designing appropriate health insurance (e.g., micro health insurance) products for the rural population with the provision of a safety net for the poor.  The high proportion of drug expenses in OPP also requires some policy measures concerned with drug price control. Compared to the neighbouring countries drug prices are quite high in Bangladesh.  Although Bangladesh National Drug Policy aimed to ensure the rational pricing of essential drugs, it is evident that the regulatory authorities have little control over drug prices. There is also over use of drugs in Bangladesh. Evidence shows that at least half of the drugs are not prescribed, dispensed or sold appropriately. Self-medications and purchasing of all type of drugs without any prescription, and thousands of illegal and unlicensed drug stores, are the major reasons for over use of drugs. Thus, we also suggest the adoption of proper measures for effective rationing of the prices of essential drugs and imposing restrictions on selling over the counter drugs.

Health Insurance and Depression: A Longitudinal Study by Beijing Normal University: China

Author(s): Zhiyong QU1, Wenkang Zhang1, Donghua Tian1, Xiulan Zhang1
Affiliation(s): 1Beijing Normal University, Beijing, China
1st country of focus: China
Relevant to the conference theme: Equity and empowerment
Summary (max 100 words): The objective of this study is to determine how the basic health insurance scheme influences depression in Northwest China. Participants were selected from 32 communities in two northwestern Chinese cities through a three-stage random sampling. Three waves of interviews were completed in April 2006, December 2006, and January 2008.  Depression symptoms were measured by the CES-D. The percentages of participants with severe depressive symptoms in the three waves were 21.7%, 22.0%, and 17.6%. Depressive symptoms were found to be more severe among participants without health insurance in the follow-up surveys.
Background (max 200 words): China is in the period of "type-transforming", and people are facing all kinds of perplexities and problems. A large-scale mental health survey in 2009 revealed that the prevalence of mental disorders among the population aged 15 and older reached 17.5%, of which 6.7% had mood disorders, including depression. In addition, Chinese people tend to deny depression or express it somatically. They are inclined to express their emotional feelings using body-part terms. As a result, the somatic expression of depression encourages patients with mood disorders to seek support from primary healthcare professionals, such as physicians, rather than mental health professionals, as the service provided by the former is covered by the Basic Health Insurance of China.  The Basic Health Insurance system (including the Urban Employee Basic Health Insurance Scheme (BHIS) and Urban Resident Basic Medical Insurance (URBMI)) is the universal and affordable health care system in urban cities of China. This system offers low-cost health insurance for urban residents. Few studies have explored the correlation between health insurance and mental health and little is known about the influence of health insurance on mental disorders, such as depression.
Objectives (max 100 words): The objective of this study is to determine how the basic health insurance scheme influences depression in Northwest China.
Methodology (max 400 words): A three-stage cluster sampling process was used to select households for the survey. In the first two stages, “probability proportional to size” sampling was used to select districts and communities according to their population size. A total of 5,537 households from 32 communities were eventually selected from the two cities.  One person aged greater than 16 per household was asked to answer questions related to depression and physical health. The baseline depression assessment was completed by April 2006. A total of 4,079 people completed the depression assessment. The mean age of participants was 47.5 (min=16.0, max=90.4; SD=13.1). 2,160 participants were female, and 231 were ethnic minorities. As for educational status, 54.9% were junior high school graduates or lower, 33.9% were senior high school graduates, and 11.1% were college graduates or above.  The first follow-up survey was completed in December 2006, when 2,220 participants completed the depressive symptom assessment. The second Follow-up was completed in January 2008, and 1,888 participants completed the depressive symptom assessment.  The Center for Epidemiologic Studies Depression Scale (CES-D) Chinese edition was used to assess depressive symptoms. The Cronbach's Alpha reliability is 0.88 in baseline, 0.89 in the first follow-up, and 0.88 in the second follow-up. This study defined four groups of depressive symptoms: (1) little or no symptoms of depression (CES-D Scale score <16), (2) mild depressive symptoms (16–20), (3) moderate depressive symptoms (21–25), and (4) severe depression (≥26). The study asked for information about the types of health insurance that participants were enrolled in. The available choices included all types of Chinese health insurance.  Results were recorded using a two-category variable: having no insurance at all and having at least one type of health insurance. In addition, the variable was further recorded into four categories: (1) having no health insurance in both baseline and follow-up survey, (2) having insurance in baseline but no insurance in follow-up, (3) having no insurance in baseline but having insurance in follow-up, (4) having insurance in both baseline and follow-up surveys. A number variables were included as potential confounders, including city, gender, age category, nationality, educational status, employment, and poverty which is defined by Dibao (whether family was receiving the minimum living standard subsidy or not), major Family events, smoking, drinking, and physical activities, Body mass index (BMI) , and any occurrence of disease in the previous four weeks.
Results (max 400 words): In the baseline survey, 1,630 participants (40.0%) were enrolled in at least one health insurance or medical subsidy scheme. In addition, among these participants who had at least one type of health insurance, 1,547 (94.9%) were enrolled in the BHIS. In the first follow-up interview, 1,894 (85.3%) had no change in their insurance enrollment status; 164 (7.4%) participants were newly enrolled in insurance; and 162 (7.3%) lost their insurance. In the second follow-up, 1,097 participants (58.1%) had no change in their health insurance status; 636 participants (33.7%) were newly enrolled in insurance; and 135 (8.2%) had lost their insurance.  Previous studies indicate that the cutoff point of 21 has better positive predictive value for depression among Chinese. According to this standard, 33.1% (95%CI, 32.0-34.3) of the sample had clinically significant depressive symptoms in baseline. Further, if adopting 26 as the cutoff point for severe depression, as is used in previous studies, 21.7% (95%CI, 20.5-23.0) of the sample had severe depressive symptoms in the baseline survey.  In the first follow-up survey, the percentage of participants with depressive symptoms significantly increased in the group without health insurance. In contrast, among those who had severe depressive symptoms in the baseline survey (CES-D scale scores ≥26), 39.7% of those who had no health insurance still had severe depressive symptoms in the first follow-up, while the rate was much lower (19.9%) for those who had health insurance. Similar trends appeared in the follow-up interview 20 months after the baseline survey.  In the analyses adjusted for baseline depressive level, compared to participants who had health insurance in the baseline and the first follow-up surveys, participants without health insurance were more likely to have severe depressive symptoms (OR, 1.61; 95%CI, 1.31-1.98).  Similarly, after adjusting for baseline depressive symptoms, city, sex, age, education, marital status, employment, economic status (Dibao), major family events, physical exercise, drinking behavior, BMI, and chronic disease in the previous four weeks, participants without health insurance were more likely to have severe depressive symptoms both in the baseline and first follow-up surveys , compared with their counterparts (OR, 1.40; 95% CI, 1.08-1.80).  This relationship was also found when comparing the baseline and second follow-up surveys.
Conclusion (max 400 words): In communities of the northwestern Chinese cities, people without basic health insurance have a higher risk of having depression than those with health insurance.

Use of Multi-Method Rapid Evaluation to Assess Complex Non-Communicable Condition (Diabetes) in Low Income Countries

Author(s): Dina Balabanova1, Ivdity Chikovani2, Oksana Ivanuto3, Martin McKee1
Affiliation(s): 1London School of Hygiene and Tropical Medicine, London, United Kingdom. 2Curatio International Foundation, Tbilisi, Georgia, 3Center for Social and Political Research, Belarusian State University, Minks, Belarus
1st country of focus: Georgia
Additional countries of focus: Belarus, Ukraine, Moldova, Russia, Armenia
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): In five post soviet countries a rapid appraisal of health systems is underway to evaluate diabetes care. A relatively quick and effective methodology enables the identification of core problems in chronic disease management and defines policy options to address them.
Background (max 200 words): The growing burden of non-communicable disease in low income settings poses new challenges to already overburdened health systems. Diabetes contributes significantly to disability and premature death in the population, although the disease is manageable when treated properly.  Successful chronic disease management has been a challenge to many health systems, especially in settings where systems broke down after political transformations.  The principles of effective delivery of diabetes care are widely agreed. It requires evidence-based care, integration across specialist teams delivering recognized interventions, a reliable pharmaceutical supply, and promoting self-management and empowerment of patients.  Effective diabetes care can be seen as a tracer for evaluating health system performance in terms of outcomes, level of integration and responsiveness.
Objectives (max 100 words): To evaluate performance of health systems in low-resource settings with regard to diabetes management. This will demonstrate the ability of health systems to function adequately to meet chronic disease care requirements beyond diabetes. The study seeks to identify core problems and pragmatic policy options will be developed to address these gaps.
Methodology (max 400 words): The study applies rapid appraisal methodology already used in earlier studies in two former Soviet Union countries Georgia and Kyrgyzstan in 2005-06. It is based on a conceptual model that seeks to identify the inputs (physical, human, intellectual, and social resources) required to delivery effective care, the outputs such as diabetes-related mortality and severe complications indicating system failure, and the mechanisms by which outputs were converted into outcomes (e.g. implementation processes and patient pathways).  Current work is underway in five countries in the former Soviet Union: Belarus, Russia, Ukraine, Moldova and Armenia (Autumn-Winter, 2011).  The research is done in the frame of
the HITT-CIS project supported by EU Seventh Framework Program. Data will be triangulated from different sources such as: interviews with patients, providers and key informants, policy documents, data on clinical and social outcomes from diabetes. Patients and health care providers are interviewed at all levels of care.  An analytic report will be done on each country and a comparative analysis between country systems performance will be completed.
Results (max 400 words): The studies will be finalised in spring 2012.  Results of the Georgia study and preliminary results from Belarus show some similarities and differences in the way health systems respond to the growing burden of diabetes. Both health systems emerge from a “Semashko” model, universal to all former Soviet countries; a model that was hierarchal, centrally planned, financed from the central budget and provided formally free care.  The system was resource intensive, oriented on curative services, facilities were poorly equipped and care was based on Soviet medical science isolated from international developments.  Following independence from the Soviet Union Georgia embarked into radical reforms embracing democracy and economic liberalisation. Major reform directions implied privatization of health care facilities, introduction of health insurance, formalization of out-of-pocket payment, and introduction of family practice. In contrast, Belarus health care systems only underwent incremental changes, retiming the main principles of the Semashko models. The system aims at providing the entire population with universal access to care, free at the point of use. The system is managed by the central government with some decentralisation of funding and delivery of primary and secondary care to sub-national level. Essential inputs for diabetes care are in place in both countries (free insulin, training for primary care physicians, financed package of care). However constraints within the system in Georgia hamper the delivery of accessible and affordable care. Obtaining hypoglycaemic drugs, syringes and self-monitoring equipment remains difficult. Diagnosis and treatment of diabetes complications involve hospital admissions and unaffordable out-of-pocket payments. In Belarus hypoglycaemic drugs are provided free of charge to the patients, self-monitoring equipment and injection supplies are provided to certain groups of patients and are affordable to almost everyone due to it’s relatively low cost; however, there are major concerns about the sustainability.  Despite the increasing emphasis of the role of primary health care practitioners, in both countries the scope of work of primary care practitioners is limited as they rarely diagnose and manage diabetes, which instead is done by specialists. In Belarus hospital care is provided free of charge to the patients requiring treatment regimens changes or experiencing complications. This frequently results in overburdening of hospital services and unnecessarily expenditures.   In Georgia as well as in Belarus the continuity of care is often disrupted. There are poor linkages between primary and secondary care and ineffective patient follow-up. There is little effort to promote self-care, adherence to drug regimens and appropriate lifestyle, or to empower patients.
Conclusion (max 400 words): The study offers a major opportunity to conduct comparative health systems analysis and elicit how particular health system characteristics obstruct or enable care of patients with diabetes. Initial results from two countries so far have shown that a move towards liberalisation and reformed health systems has created new problems of access to adequate care. However, in both countries there are underlying problems with system design and clinical culture – for example, insufficient role of primary care in managing diabetes -  despite the efforts to retain an effective primary care in Belarus or radically reform it in Georgia.

Impact of Bao’an District Community Health Service Reform on Hypertension Management and Control: China

First: Chenggang Jin1, Chen Li1, Xia Tingsong2, Liang Xiaoyun1
Last: 1Beijing Normal University, Beijing, China, 2Health Bureau of Bao'an District, Shenzhen City
1st country of focus: China
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): This study aims at evaluating the impact of community health service reform implemented in Bao’an District, Shenzhen City for hypertension management. This study utilized electronic records and formed a retrospective controlled cohort study. The longitudinal negative binomial regression of random effect model and difference in difference (DID) strategy were employed to assess the impact of reform on hypertension management. We found that the rate of regular management of hypertension increased by 0.29 time (P<0.05), and the rate of BP control increased by 0.26 time (P<0.05). Bao'an community health service reform has improved the capability of hypertension management.
Background (max 200 words): Hypertension is one of the most significant causes of mortality and morbidity among the elderly. In the year 2004, the prevalence of hypertension among Chinese adults is 18.8%. The high prevalence, high morbidity and high mortality of hypertension have made it one of the major tasks of public health in China. Hypertension as a chronic disease needs long term, continuous health service, while Community health service center is just capable of offering such kind of services, and could play an important role in chronic disease management. But in Bao’an district of Shenzhen city, community health service centers are subordinated to hospitals, and the subordination has restricted the development and limited the functions of several aspectsog health care such as personnel management, financial compensation and performance management. To get rid of these restrictions, Bao’an district has launched a community health service reform in 2009, which empower the community health service centers some autonomy, and enables centers to carry out a performance appraisal scheme which encourages physicians to pay more attention to chronic disease management. The change of physicians’ performance to hypertension management may lead to patients’ better medication compliance, healthier life style, and eventually better blood pressure control.
Objectives (max 100 words): The aim of this study is to evaluate the impact of community health service reform on regular hypertension management and blood pressure control, and analyze the impact mechanism between reform and hypertension management.
Methodology (max 400 words): Study Design - This study employed retrospective cohort study design and difference in difference (DID) strategy. Patients monitored by physicians formed a dynamic follow-up cohort. The intervention group is the patient cohort in Guanlan street community health service center which is one of the pilot agencies of the reform. Control group is Songgang Street which hasn’t launched the reform till now.  In Guanlan Street, the reform started at June 1, 2009. We collected data for one year before the reform (June 2008 to May 2009) and one year after the reform (June 2009 to May 2010) from both the intervention group and control group. Then we divided 2 year follow-up periods into 4 equal panels, and each panel lasted half a year. An intervention cohort was constructed which has two panels before the reform and two after, and a control cohort has the same panels in the same periods. Variables’ selection and definition: 1. Dependent variables - (a) Regular hypertension management is measured by the total days that a patient is in a regular management in each panel. If the interval between a patient’s two adjacent BP monitorings is no longer than 35 days, then we assumes that it is a regular management, and this interval will be contributed to the total days of regular hypertension management.  (b) Blood pressure control is measured by the total days when a patient’s BP is lower than 140/90 mmHg in each panel. If a patient’s BP monitoring is lower than 140/90 mmHg, then we assume that the patient’s BP would stay normal until the next BP monitoring. 2. Independent variables: We used variable Group to catch the difference between intervention group and control group. We used variable Wave to catch the difference resulting from time changes. We used interaction terms of Group and Wave to catch the true effect of the reform on the dependent variables. We also included variables such as patients’ gender, local or not, age group, health insurance status, health service contract status and education to control confounding. Statistical analysis: The type of dependent variables in this study count the days, which is appropriate to analysis using Poisson regression. We employ negative binomial regression instead which is similar to Poisson regression and loosens the assumption that the mean is equal to the deviation which Poisson regression required and our data doesn’t meet.
Results (max 400 words): Study sample characteristics: This study collected 1,221 hypertension patients’ electronic medical records, including 637 records from the intervention group, and 584 records from the control group. There is no significant change on each character between before and after the reform either in intervention group or in control group.  Impact of the reform on regular hypertension management : Descriptive result shows that in control group, the number of day of regular management in each panel is decreasing from 80.09 days in panel 1 to 48.01 days in panel 4. In the intervention group, this number is also decreasing in the same way from 80.71 days in panel 1 to 61.97 days in panel 4, but with an irruption in panel 2. Days of regular management are similar between control group and intervention in baseline. But in panel 4, intervention group is much higher than control group. From fig.1, we can see the percentages of regular management don’t have a constant trend. To evaluate the impact on regular management, we have to control the confounding and rule out chances, so we carried out the negative binomial regression. The regression results show that the rate of standard management of hypertension was increased by 0.29 time (P<0.05). Impact of the reform on blood pressure control: In the control group, the percentage of days with controlled BP out of total days of management is waving slightly from 86.15% to 89.31% in the four panels. In the intervention group, this percentage increased from 76.63% in panel 1 to 84.05% in panel 4. Table 5 also contains results from negative binomial regression on days of BP under control. The regression results show that, after controlled, the confounding such as gender, age and health insurance, rate of BP control increased by 0.26 time (P<0.05).
Conclusion (max 400 words): Community health service reform enhances the capability of hypertension management of community health service centers through following mechanisms.  Firstly, the reform changed the relationship between hospitals and community health service centers. Before the reform, community health service centers were subordinated to hospitals, and restricted by the hospitals, and hinder the important function in public health services. The reform empowered the community health service centers by enabling some autonomy, which ensured the Government's compensation for public health services would directly be spent on target people instead of being diverted.  Secondly, as the reform enables centers to carry out their own performance appraisal scheme, the centers in intervention group of this study carried out a scheme which give credits, not just to clinical services which would be directly paid by patients or insurance, but also to public health services which would be compensated by government or not. Physicians could earn an extra bonus by delivering public health services to the residences including regularly BP monitoring and health education. Finally, the change of physicians’ performance on hypertension management lead to the patients’ better medication compliance, healthier life style, and eventually better blood pressure control. As the study was only based on medical records of hypertension patients, the results may be confounded by the patients’ income and occupations. The policy and economic environment changes may differ between Guanlan Street and Songgang Street. Besides, as we intended to look into the long-term impact of the reform on hypertension management, we have seen there is a positive short-term impact. To conclude, the results suggested that Bao'an community health service reform has improved the management of hypertension and BP control.

Affordable Health for all: An Experience of Social Health Insurance in Nepal

First: P. Karki1, N. Jha2
Last: 1Department of Internal Medicine, B.P.Koirala Institute of Health Sciences, Dharan, Nepal, 2Department of Community Medicine, B.P.Koirala Institute of Health Sciences, Dharan, Nepal
1st country of focus: Nepal
Additional countries of focus: Least - developed & low -middle -income countries
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): Social Health Insurance (SHI) is a form of financing & managing health care based on risk pooling. Social Health Insurance (SHI) is seen as a health financing approache with strong potential to share risks across population groups and time. As membership is mandatory, it avoids many of the problems of adverse selection which smaller, voluntary health insurance schemes face. One important measure to increase affordability is to reduce the out – of- pocket payments which users make for health care. These are widely recognized as creating a barrier to access, especially in poorer countries, and as pushing households further into poverty.  There is considerable interest at present in exploring the potential of Social Health Insurance (SHI) to increase access to and affordability of health care in South Asia. Desirable though it is, not many least –developed and low- middle –income countries have succeeded in adequately expanding coverage of SHI.A numbers of countries are currently experimenting with different approaches. The study aims to provide a preliminary assessment of the Social Health Insurance (SHI) programme of B.P.Koirala Institute of Health Sciences (BPKIHS) in Nepal.
Background (max 200 words): In the light of the Millennium Development Goal (MDG) targets for health gains & poverty reductions, there is a growing impetus towards providing universal coverage of health services , meaning that all of the population has access to appropriate health care when needed, and at an affordable cost. Health care costs, particularly for inpatient care, poses a barrier to seeking health care & cost is a major cause of indebtedness and impoverishment, particularly among the poor in Nepal. An individual with a low income may be unable to afford preventive or curative care in the event of illness, which may result in worsening of his or her state of health. The Ministry of Health & Population in Nepal intends to initiate alternative financing schemes such as Community and Social Health Insurance schemes as a means to supplement the government health sector financing source.  Social Health Insurance (SHI) pools both the health risks of the people on one hand & the contributions of individuals, households, enterprises, & the government on the other. Thus, it protects people against financial & health burden and is a relatively fair method of financing health care. Until recently, there were very few large-scale SHI schemes operating in South Asia. Over past decade experiments in Social Health Insurance have been springing up in number of countries.  As these schemes are still young & evolving, few have yet been systematically evaluated.  Considering all these facts B.P.Koirala Institute of Health Sciences (BPKIHS) has introduced SHI scheme in 2000 as an alternative health care financing mechanism to the community people of Sunsari and Morang districts. In the beginning a small area was elected as a pilot project to launch the scheme. BPKIHS SHI scheme is the outcome of the visionary thinking on social solidarity and as an alternative health care financing mechanism to the community.
Objectives (max 100 words): Objectives:  1.To provide quality care treatment by the provision of net contribution from better off participants for the net benefits of the poor and rich people.  2. To reduce poverty caused by paying for health care and to prevent already vulnerable families from falling into deeper poverty when facing health problems.
Methodology (max 400 words): A total of 26 organizations with 19,799 populations were in SHI scheme. Sixteen rural based organizations with 14,047 populations and 10 urban based organizations with 5,752 people are the beneficiaries in the scheme.  BPKIHS is mobilizing people’s organizations and offering health services through its health insurance scheme at subsidized expenses.  This has helped people to avail themselves of health facilities who otherwise would have been left vulnerable because of their penetrating health needs.
Results (max 400 words): There was a huge gap between premium collection and expenditures. The expenditures were more and this may be due to  a knowledge gap in the program. If conditions are unsuitable, SHI can lead to higher costs of care, inefficient allocation of health care resources, inequitable provision and dissatisfied patients. It can also be more difficult to realize the potential advantages of SHI in future. Experience of the people about the scheme is very positive and encouraging because of the health care services that BPKIHS provides through its scheme. But some dissatisfactions are; the attitude of health care providers at the hospital, administrative barriers, transport facilities, referral services and extension of the scheme to the other teaching hospitals.
Conclusion (max 400 words): The future challenges confronting the scheme are in providing the continuity and sustainability of the program to its catchments areas. This might entail a shift in its program operation mechanism. People’s active involvement is required, which will further provide a sense of ownership in the scheme amongst the people. In the longer term, the investment costs in BPKIHS SHI will only be justified if it is able to increase the cost-effectiveness of purchasing & the responsiveness of the system as a whole. It is important that it is carefully monitored and challenges facing it openly debated.

The Impact of an Invasive and Interventional Cardiology Program in Eastern Nepal: A Preliminary Evaluation

Author(s): N. R. Shrestha1, P. Karki1, A. Basnet1, P. Shah1, K. Sherpa1, T. Pilgrim2, S. Cook3, P. Urban4
Affiliation(s): 1B.P. Koirala Institute of Health Sciences, 2Swiss Cardiovascular Centre, Bern, Switzerland, 3University and Hospital. Fribourg, Switzerland, 4Hopital de la Tour, Geneva, Switzerland
1st country of focus: Nepal
Relevant to the conference theme: Emergencies
Summary (max 100 words): We compared the in-hospital outcome of patients admitted for acute coronary syndrome (ACS) to a tertiary referral hospital in Eastern Nepal, before (2008) and after (2011) the availability of an invasive cardiology program. In 2008 153 patients were admitted with ACS. The in-hospital mortality was 14%.  From January 2011 until October 2011 177 patients were admitted with ACS. 78 patients (45%) underwent coronary angiography and 24 (36%) underwent angioplasty. The in-hospital mortality was 7%. These preliminary results are encouraging and indicate that the availability of invasive techniques is associated with an increasing number of admissions for ACS plus improved in-hospital outcomes.
Background (max 200 words): Ischemic heart disease (IHD) and acute coronary syndrome (ACS) continues to be the major cause of morbidity and mortality globally. While there has been a decline in the age-adjusted death rates in developed countries, the burden of ischemic heart disease (IHD) in developing countries is increasing and this trend is attributable primarily due to the social and economic changes that have occurred with urbanization and industrialization, leading to a higher prevalence of the main cardiovascular risk factors. The problem is compounded by low availability of evidence-based therapies and interventions for the great majority of patients, and their outcome, both in terms of morbidity and mortality, is thus often poor. Furthermore, patients in South Asia are often afflicted with IHD at a relatively young age, thus impacting more severely upon the working-age population with major consequences for  families who lose wage earners and national development due to the adverse effects of lost productivity.
Objectives (max 100 words): The objective of the present study was to assess the outcome of patients presenting with ACS to B.P. Koirala Institute of Health Sciences (BPKIHS) a tertiary referral hospital in eastern Nepal  after the cardiac catheterization laboratory services commenced from January 2011 till present (October 2011) and to compare their in-hospital outcomes with those patients who presented with ACS in 2008 when interventional procedures were not available at our centre.
Methodology (max 400 words): B.P. Koirala Institute of Health Sciences (BPKIHS) is a university hospital in Dharan, eastern Nepal, established in 1993 with undergraduate and postgraduate medical and paramedical programs, The hospital has 750 beds and hosts over 30,000 patients per year. About 180,000 patients consult the out patients department yearly. The town of Dharan has a population of 1.2 million, and the hospital is the only referral center outside Kathmandu for the inhabitants of eastern Nepal, and also serves parts of neighboring states of West Bengal and Bihar in India. The coronary angiography laboratory at BPKIHS became functional in January 2011.  The main operator had been fully trained in invasive techniques in a high volume centre in Switzerland, and continued on-site training was given by experienced visiting physicians from Geneva and Berne, Switzerland. Since then routine coronary angiography, angioplasty and primary percutaneous coronary interventions for ACS have been performed and are available to patients presenting to our centre. Prior to this there were only two such cardiac catheterization laboratories in Nepal which were both located in Kathmandu, more than 500 kilometers away. A cross sectional descriptive study was conducted on consecutive patients presenting to BPKIHS with acute coronary syndrome from January 2011 to October 2011 and compared to similar data collected from January to December 2008. All patients admitted to the 6-bed Coronary Care Unit (CCU) and the medicine ward of the hospital with a clinical diagnosis of ACS were included, and assigned to one of 3 groups: ST Segment Elevation Myocardial Infarction (STEMI), Non ST Segment Elevation Myocardial Infarction (NSTEMI) and Unstable Angina (UA). During the first period, all patients were treated medically and/or transferred to Kathmandu. During the second period, patients were either managed by an invasive procedure (coronary angiography with or without angioplasty) or were treated conservatively depending on delays, clinical presentation and the patient’s financial resources. We collected data regarding the modes of presentation of ACS, age, gender, treatment during hospital stay, need for invasive evaluation and intervention and in-hospital outcome.
Results (max 400 words): In 2008, 153 patients were admitted with ACS and a diagnosis of STEMI was made in 58 patients (38%), NSTEMI in 28 patients (18%) and UA in 67 patients (44%). 20 (34%) patients with STEMI were treated with streptokinase. The mean hospital stay at BPKIHS was 5 days, and 6 patients were transferred to Kathmandu emergently. There were 22 (14%) deaths in hospital and the mortality was highest for STEMI patients (17%) but was also high for NSTEMI (14%) and UA (12%). From January 2011 till October 2011, 177 patients were admitted with ACS. A (34%) diagnosis of STEMI was made in 69 patients (40%), NSTEMI in 46 patients (26%) and UA in 62 patients (34%). These 177 patients admitted to the medical ward of cardiovascular disease represented 18% of all hospital admissions at BPKIHS during the same period. There is no national health insurance system in Nepal so therefore the vast majority of people must pay for medical services and treatment themselves. Thus among these 177 patients who presented with ACS, 78 (45%) of them underwent invasive evaluation with a coronary angiography with or without angioplasty.  It was noted that among 69 patients who presented with STEMI, 48 (70%) underwent coronary angiography, 24 (36%) underwent percutaneous coronary intervention (PCI) with one or more stents and 3 (4%) patients were referred for surgical revascularization.  Of the 46 patients who were diagnosed to have NSTEMI, 6 (13%) underwent coronary angiography and only one underwent angioplasty. Coronary angiography was performed in 23 (37%) patients who presented with UA, and none of them underwent PCI. The remaining 99 patients (55%) who were diagnosed to have ACS did not undergo invasive evaluation. This cohort had STEMI as a diagnosis in 21 (30%) patients, NSTEMI in 40 (87%) patients and UA in 38 (63%) patients. 166 (93%) patients were discharged after a mean stay of 4 days in the hospital, and there were 11 (7%) deaths. Three deaths (3.8%) occurred in the group that underwent invasive evaluation and 8 deaths (8%) occurred among patients treated conservatively. In the invasive group, all three patients who died had a diagnosis of STEMI and had been admitted in cardiogenic shock. Among those treated conservatively five deaths occurred in STEMI patients and there was one death in the NSTEMI and two deaths in the UA group respectively.
Conclusion (max 400 words): This preliminary analysis highlights two main findings: 1) There is an encouraging trend toward a lower overall crude hospital mortality with the introduction of invasive and interventional techniques (14% in 2008 vs. 7% in 2011).  2) The absolute number of patients admitted with ACS appear to be increasing (+ 39% for 2008 vs. 2011), possibly because the availability of interventional treatment has encouraged people with chest pain to reach the ER earlier.  During the first 10 months of 2011, however, only 177 patients were admitted with a diagnosis of ACS to the single coronary angiography laboratory available in eastern Nepal. It is thus fair to assume that this patient group only represents the tip of the iceberg, and that the overall incidence of ACS must be larger. As Nepal is a resource-poor country with no or little health insurance, the costs of treatment are borne by the patients themselves. This largely explains why only 45% of all patients presenting with ACS underwent coronary angiography with or without angioplasty. However, it is noteworthy that 70% of patients who presented with STEMI, the subset most likely to benefit from timely revascularization, did actually undergo invasive evaluation of their coronary anatomy and 36% of them were treated with PCI.

Implications of the High-Level Meeting for Scaling Up NCD Prevention at the Country Level

Author(s): Frank Nyonator1, Mabel Segbafah1
Affiliation(s): 1Ghana Health Service, Ministry of Health, Accra, ,Ghana
1st country of focus: Ghana
Relevant to the conference theme: Non-communicable chronic diseases
Summary: Non-communicable diseases (NCDs) are getting increased attention and interest around the world. This is because of the global appreciation of the grave and unparalleled socio-economic impact of morbidity, disability and premature deaths that result from NCDs.  The good news however is that there is also the potential availability of proven cost-effective interventions and “best buys” including lessons from HIV programme approaches, tools and systems, and if implemented they could rapidly reduce the incidence, morbidity and mortality from NCDs.
What challenges does your project address and why is it of importance?: Ghana, realizes the need to translate and go beyond political rhetoric towards palpable political commitment.  The challenges are to implement strategies that will provide legislative and policy environments that reduce population exposures and individual risk factors for NCDs.  It requires not only the promotion of healthy lifestyles, but also putting in place systems to control and prevent substance misuse and abuse, encourage immunizations, provide early detection and screening of NCDs as well as dietary regulations and food labelling. Although the actual burden of NCDs is not yet quantified, there is full support for developing strategies and a working model that will cost-effectively and efficiently integrate its management into the existing health platforms being run by various national programmes and routine services in the country.
How have you addressed these challenges? Do you see a solution?: Ghana recognises an opportunity to integrate NCD care into its existing platforms for health care management with much evidence being drawn from the success in HIV&AIDS management nationwide. There is also enough of a body of evidenceto illustrate that risk factors for NCDs are closely linked to many health programmes currently targeting HIV, malaria, tuberculosis, maternal and child health and nutrition interventions. What remains is to pull together adequate funding and human resources to manage the copious burden of disease and a pragmatic model to integrate NCD management.  Expanding the NHIS net to cover the integrated management of NCD within the existing health programmes – child health, maternal health, HIV -will be an opportunity to make use of existing laboratory and technology as well as Behaviour change communication models to provide adherence counselling, nutrition and lifestyle changes as well as provide community support groups for patients living with NCDs.  Another challenge is ensuring “Whole –of Government” and “Whole –of –Society” are involved in joint planning  and coordination to combat NCDs. The country proposes to use the PHC approach, which will be revitalised to expand the care and support for people with NCDs with access to accessible, affordable and essential technologies, medicines and supplies that are available.  Finally, the country will work to strengthen national capacity to manage NCDS, institutionalize a Surveillance Framework that monitors key risk factors, morbidity and mortality and health systems capacity for NCDs, develop and strengthen the implementation national research and development agenda for NCDs and essentially, strengthen international cooperation to support the development of national legislations, policies and plans and health systems capacity to provide quality NCDs services.
How do you know whether you have made a difference?: For instance, the success rate in increasing post natal care coverages nationwide is a typical example which includes integrating screening for breast and cervical cancers in women. The post natal period is covered by registration with the NHIS. In addition, certain screening and laboratory tests which are routine for PLHIV and linked to risk factors for NCDs form part of subsidies under the NHIS.
Have you or the project mobilized others and if so, who, why and how?: As part of ongoing integration and strategy direction, Ghana has since developed a Cancer policy and a Cancer registry to collect information on cancer cases in the country and to help define the cancer burden.
When your donor funding runs out how will your idea continue to live?: As part of the model of integration, re-strategising the National Health Insurance Scheme will be a decisive move to contain risk-pooling and also cover the costs of managing NCDs

Cancer Prevention and Control Training Program: China

Author(s): Hao Liang1, CI Puwa1, Qiao Youlin2
Affiliation(s): 1Peking Union Medical College, Beijing, China, 2Cancer Institute/Hospital Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
1st country of focus: China
Relevant to the conference theme: Non-communicable chronic diseases
Summary: As the world’s largest and most rapidly developing country, China is suffering the burden of cancer. Recently the Chinese government has initiated large numbers of national programs on cancer prevention and control. With the help of the training courses program, the cancer registry system in China has been perfected so that the number of cancer registry sites have increased to 193 and the early cancer screening sites have increased to 97. This program provides knowledge and capability to cancer professionals on cancer prevention and control as well as conducting cancer research.
What challenges does your project address and why is it of importance?: Cancer constitutes a serious burden of disease worldwide and has become the second leading cause of death in China. Recently,the  government has realized the serious problem of the cancer burden and initiated a top-down program to provide free breast and cervical cancer screening for 10 million rural women in China as well as a national program for early detection and treatment for the 7 major cancers in China. Two challenges need to be addressed: 1) local health professionals are scarce due to limited academic training and continuing education. 2) the three-level cancer prevention networks which were built in the 1970’s collapsed in the 1990’s due to declining government subsidies for health care and workers’ health insurance, as well as budget deficiency. The statistics at the end of year 2002 showed that only 1/3 of the cancer networks remained and they performed cancer registry and limited work related to cancer prevention and control funded by research projects. Based on the reasons above, capacity building and cancer prevention and control network rebuilding in rural area of China are  a priority.
How have you addressed these challenges? Do you see a solution?: 1) Local health professionals are scarce due to limited academic training and continuing education. Solution: We develop a core training curriculum through a 1 week intensive and didactic training entitled “Cancer Prevention and Control Course”. 40-50 health professionals from cancer hospitals, universities, centers for disease control in 32 provinces are selected each year, and training and logistic are covered by grant. Also, “hands-on” training programs in national demonstration centers of early detection and early treatment for cancers of esophagus, cervix, stomach, colon, lung, liver, nasopharynx respectively are conducted. Hands-on trainings for cancer registry, pathology, cytology, operation approach of endoscope are also available. Specialists in China approved by Technical Expert Committee from MOH train the trainees.  2) Lack of a network for knowledge transform and information collection on cancer prevention. Solution: Trainees are assisted and required to spread what they have learnt to other local health professionals and the community, collect and communicate information of basic local information about cancer prevention.  The “Train the trainer” model has been established. 40-50 health professionals from in 32 provinces in China have been trained each year, and apply for grants to train 500-800 trainees from local cancer prevention systems in China.
How do you know whether you have made a difference?: 1) A network on cancer screening and the collaboration on cancer research has been established and improved. With train the trainer model, 625 health professionals in China have been trained in 2010, and 720 in 2011. They share experiences and learn from each other. More cooperation has been initiated. 2) The program spurred the cancer registry system to be improved in the past few years. In 2002, there were only 30 cancer registry sites. The number of cancer registry sites increased impressively from 2002 (30 sites) to 2010 (193 sites). With the help of the training courses, cancer registry system is equipped and the capability of basic cancer registry sites is improved. 3) Since “Cancer Prevention and Control Training Program in China” was developed in China, general professional ability and technique ability were improved dramatically. Thus the number of early detection and treatment sites in China has impressively increased from 13 to 97 since 2006. NPEDC (National Program for Early Detection of Cancers) started in 2006,and subsidized by the central government in screening, diagnosis and training for clinicians of local hospitals. Before the program developed, in 2006, there were only 5 NPEDC sites for cervical cancer and 13 NPEDC site for all of the cancers. That was because the abilities of medical professionals at basic-level hospitals were too poor to implement National Program for Early Detection of Cancers. Accompanied with the development of “Cancer Prevention and Control Training Program in China”, the number of NPEDC sites increased every year. By the end of 2011, there have been 97 NPEDC sites. In 2012, 107 sites will have the ability to implement NPEDC. Besides, early treatment rate of esophageal cancer increased from 70.7% to 73.3% from 2010 to 2011.
Have you or the project mobilized others and if so, who, why and how?: 1) Government: With the training programexpanding large numbers of health professions have been trained. Not only has it promoted government allocation of funds to establish more cancer registry sites and NPEDC sites, it also helps the government make policy on cancer prevention and control. 2) NGO: Leverage Cancer Foundation of China helps raise funds, motivate social power, and expand the influence of the training program.  3) Within the Health industry generally the following has occured: The capacity of health professionals (epidemiologist, doctors, pathologists, cytologists) on cancer prevention and control has been strengthened. Thanks to the training program, the early detection for cervical cancer has been changed from 93.9% to 95.3%, the early diagnosis rate for esophageal cancer increased from 70.7% to 73.3%, the capacity of health professionals and hospitals on cancer control have been impressively changed. The sites for early cancer detection have increased. The number of NPEDC sites increased impressively from 2006 (13 sites) to 2011 (107 sites)  The sites for cancer registry have increased. The number of cancer registry sites increased impressively from 2002 (30 sites) to 2010 (193 sites). An extensive network of domestic and international partners to support the training course has been leveraged, including: Specialists support: officials from the Ministry of Health in China, International specialists from WHO, IARC, UICC, NCI, AXIOS in France, and Italia are invited to give lectures and offered a forum for communication during the training course.  Resources support: Some medical companies (for example, BD/ Shenzhen Gold Way) support the equipment for local health providers. Local cancer hospitals or universities provided academic, equipment and administrative support when developing the training program. The Journal of China Cancer offered a column to report the training program and expand the impact of the training program.
When your donor funding runs out how will your idea continue to live?: We have obtained the National Key Technology Research and Development Program of China during the “12th Five-Year Plan” in 2010 with the topic of cancer prevention and control in rural areas of China. Skill and capacity building in rural area in China is one aspect. The program will continue under a new national fund. We hope the training program will be the model for the whole country and be transferred into policy, which will enhance the capacity building of cancer prevention and control in rural areas in China. Currently, the grant has been posted publicly, but the funding has not been confirmed. The progress and the result of this training program will influence the policy makers (MOH) to persuade the government to include this project into its public health agenda.

Anti-Retroviral Therapy and Prevention of Mother to Child Transmission: Primary Healthcare Services in Rural North Nigeria

Author(s): Sanusi Abubakar1, Matron Fatima Nuruddeen1, Jibril Jumare2, Bashir Zubayr3
Affiliation(s): 1Kumbotso Comprehensive Health Centre, Aminu Kano Teaching Hospital, Kano, Nigeria, 2Former Regional Manager, Kano Regional Office,
Institute of Human Virology Nigeria (IHVN), Nigeria, 3Regional Manager, Kano Regional Office, Institute of Human Virology Nigeria (IHVN), Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Communicable chronic diseases
Summary: The HIV prevalence for Nigeria is 3.6% in a country with an estimated population of 150 million people. Nigeria has among the worst PMTCT rates of HIV (4.1%) in the world with a high national TFR of 5.7.  Most PHC facilities that provide health services in rural areas did not previously possess the capacity to provide ART/PMTCT services. The Comprehensive Health Centre, Kumbotso and other PHC sites in the Northwestern geopolitical zone of Nigeria have been supported by the Institute of Human Virology-Nigeria (IHVN) to provide PMTCT/ART services to surrounding communities using the “hub and spoke model of care”.
What challenges does your project address and why is it of importance?: The factors that contribute to poor PMTCT rates operate differently and at different intensities in urban and rural PHC facilities providing ART/PMTCT services in Nigeria. The majority of the population resides in the rural area and by extension these areas also have a large number of HIV positive pregnant women in need of PMTCT services as well as other clients in need of ART services. The HIV prevalence among pregnant women attending ANC in the north west geopolitical zone was 2.1% which is relatively lower than that of other zones in Nigeria. However, this zone has the some of the worst social and health indices in Nigeria such as low health literacy levels, frequent lost to follow up (LFTU), poverty, stigma, discrimination, poor ANC attendance, lack of skilled attendants at births, early marriage, poor girl-child school enrolment and retention, inequitable distribution of PHC facilities and lack of access to quality health services.  The major challenges for the provision of ART/PMTCT services at rural PHC level in Nigeria are a lack of skilled health workers to provide these services, lack of ARVs, as well as stigma and discrimination towards HIV positive persons especially within the context of a closed rural populace where everyone knows everyone!
How have you addressed these challenges? Do you see a solution?: These factors present special challenges in designing health care that targets vulnerable populations in rural areas for patients with chronic diseases like HIV/AIDS.  The IHVN-ACTION project supported rural PHC facilities to conduct the following: 1. Capacity building through the training of PHC workers in the use of ARVs for PMTCT/ANC clients, ARTs for non pregnant adult and paediatric clients as well as VCT and adherence counseling services. This ensured the availability of competent health workers that can provide quality ART services. 2. Supply of adult and paediatric ARV drugs for ART and PEP services. In addition to supplying drugs for treating opportunistic infections (OIs) in PLWAs. This helped to ensure regular supplies of quality drugs and other consumables. 3. Support for HIV related laboratory services using the hub and spoke model. This ensured provision of quality diagnostic services. 4. Support for community engagement and participation through the setting up of a Community Support Services Structure, Home-based Care/Tracking Groups, Peer Support Groups and Community Advisory Groups. This ensured community participation, ownership and created demand for our services. This also greatly reduced stigma and discrimination while improving patients’ adherence to their ART medications
How do you know whether you have made a difference?: At baseline in May 2009 there was the following:  • No PHC health worker cadre with training in providing ART/PMTCT/VCT services at the Kumbotso PHC health facility• No VCT services conducted in the Kumbotso PHC health facility.• No patient enrolled for ART/PMTCT services at the Kumbotso PHC health facility.• No adherence counseling services conducted at the Kumbotso PHC facility.• No facility based peer support counseling services working at the Kumbotso PHC health facility.• No facility led integrated community support service structure that tracks patients on ART/PMTCT that are lost to follow up (LTFU) or provide home based care to PLWAs on ART or PMTCT in Kumbotso local government area.• No community based PLWA Support Group in existence at the Kumbotso PHC health facility.• No community based Mother to Mother (PMTCT) Support Group in existence at the Kumbotso PHC health facilit.The developments by the 3rd Quarter of 2011 were as follows: • Over 60% of PHC staff with training in providing ART/PMTCT/VCT services at the Kumbotso PHC health facility• Comprehensive VCT services provided in the Kumbotso PHC health facility, with over 10000 clients counseled at the facility.• Over a 100 HIV positive patients enrolled into care for ART/PMTCT services at the Kumbotso PHC health facility.• Dedicated adherence counseling services provided at the Kumbotso PHC facility.• Dedicated facility based staff (e.g. Treatment Support Specialists, Mentor Mothers) providing peer support counseling services working at the Kumbotso PHC health facility.• A fully functioning facility led integrated community support service structure (consisting of community volunteers and staff of the health facility) that tracks patients on ART that are LTFU or provide home based care to PLWAs on ART or PMTCT in Kumbotso local government area.• A community based PLWA Support Group (called Aminchi Support Group) in existence at Kumbotso LGA with links to the PHC health facility which has facilitated social support for members including encouraging marriages between members.• A community based Mother to Mother (PMTCT) Support Group in existence in Kumbotso LGA with links to the health facility.• Formation of a school health education programme targeting secondary schools in the Kumbotso for the prevention of HIV/AIDS.• Establishment of outreach PMTCT services in 3 smaller PHC facilities in adjacent communities.• Establishment of a Community Advisory consisting of respected community members from the local traditional, religious and formal government sector and staff from the health facility.
Have you or the project mobilized others and if so, who, why and how?: We are in the process of submitting this report for publication in a national journal so that the research findings will become available and accessible in the public domain so as to mobilize attention and resources for this model. In addition, we have mobilized the following stakeholders in the Kumbotso LGA, Kano, Nigeria: • Mobilization of Kumbotso local government authorities against chronic diseases such as SCD, HIV, TB etc. • Mobilization of traditional and religious leaders, notably the District and ward heads and Chief Imam of Kumbotso local government area where the rural health facility is located. By enrolling them into the Community Advisory Board.• Collaborating with a local community based organization (CBO) called Kumbotso Unity and Welfare Development Association to provide public health enlightenment activities on chronic communicable diseases such as Hepatitis B, HIV, TB.• The major development partner we had linkage with was co-funding this project i.e. the Centers for Disease Control, USA (CDC) through the Institute for Human Virology-Nigeria (ACTION Project). Significant national and local linkages have been established with other PHC facilities offering ART/PMTCT services based on the “hub and spoke model of care” within the Northwestern geopolitical zone of Nigeria. International and national linkages have also been established with partners such as the National TB/Leprosy Control Program, Society for Women and AIDS in Nigeria (SWAAN) etc.
When your donor funding runs out how will your idea continue to live?: 1. The HIV related services such as VCT, ART, PMTCT, Community Support, Adherence and Treatment Support Services that have been initiated in Kumbotso PHC health facility are embedded within the routinely provided PHC services as enshrined in the philosophy of the National Health Policy of Nigeria and can be maintained and sustained in Kumbotso PHC facility or any PHC facility once it has been set up at little or no extra cost. 2. The supply of ART/PMTCT drugs as well as drugs for the treatment of opportunistic infections can be supplied on a regular and sustainable basis by the National Health Insurance Scheme (NHIS), once the scheme is extended to rural PHC facilities. 3. The provision of laboratory support for ART/PMTCT services can also be sustained at the level of the hub sites through the NHIS once the machinery is put in place. 4. Capacity building for younger and newer staff in providing ART/PMTCT services at rural PHC level can be continued through step down trainings, on the job trainings, on site trainings by the already available critical mass of staff trained and experienced in providing ART/PMTCT services at PHC level.