Geneva Health Forum Archive

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

Parents and Teachers Battling Trachoma: A School Based Initiative in Uganda

Author(s): Kimbugwe Yusuf1
Affiliation(s): 1Youth Revival Association, Kabala, Uganda
1st country of focus: Uganda
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): The project was initiated with the aim of community and students participation in health issues.
Background (max 200 words): The poor state of children's health was identified as a major cause of the poor education achieve-Lents by the Ministry of Education in Uganda. In 1999, a baseline survey in the schools in Kinkizi district identified several health problems, including vision problems: 27 percent of the students had conjunctivitis; 23 percent ad trachoma; and 12.31 percent had a vision of less than 7/10 (English system). After the survey, Save the Children USA (SC/US) began implementing School Health and Nutrition {SHN) activities in Kinkizi  district in Western region.
Objectives (max 100 words): Design an innovative low-cost health intervention; include immunities in planning of health interventions; and make health interventions simpler and user-friendly for parents and students.
Methodology (max 400 words): Working with parents and teachers, decisions were made about which SHN interventions to include and innovative solutions were created on how to reduce costs. To address the vision-related problems, SC/US and the communities adopted two activities.  1) Teachers and parents were trained in identifying and treating trachoma. To ensure sustainability, the schools were also provided with wash basins, and students were taught by teachers and parents to wash their faces once a day instead of relying solely on a cure by using antibiotics.  2) All teachers were trained to use eye charts to identify children whose vision required them to be moved to the front of the classroom or be referred to health centers. When funds for eye charts were not available, the teachers and community members developed a strategy in which the teachers wrote words of different sizes on the blackboard to determine the seat  location of students in the classes. This is done during the first week of school with assistance of the parents.
Results (max 400 words): The level of trachoma infection among the children dropped from 25 percent in 2000 to 0.2 percent in 2004. During 2004, 1,040 out of 8,388 children were placed closer to the blackboard based on the blackboard eye test. In 2004, SC/US again invited teachers, parents and other community members to participate in the strategy and planning of the SHN program for the next three years. To ensure full participation of those who could not attend the meetings, local radios were used to broadcast the discussions. The members of the management committees of the communities appreciate that the SC/US SHN program respects and values their input in the planning and implementation of the SUN program.
Conclusion (max 400 words): There are many health activities that are not implemented due to lack of funds. With the involvement of community members, innovative solutions can be created that not only allow implementation with limited funding but also provides sustainability.

An Assessment of Rational Drug Use in Public Tertiary Hospitals in Edo State, Nigeria

First: Alex
Last: Okoh
1st country of focus: Nigeria
Relevant to the conference theme: Medicines and diagnostics
Summary (max 100 words): Rational use of medicine requires that patients receive quality efficacious medicines appropriate to their needs, in doses that meet their individual requirements, for the adequate period of time and at the lowest cost to them and to the community. Only 12% value of budgetary allocation for drugs in developing countries are received by consumers. Irrational use of medicines and its detrimental effects are likely to increase, unless action is taken. Findings from studies like this will provide the basis of such actions. Irrational drug use may cause considerable waste and poor quality of care. In Nigeria’s reality, waste is unacceptable.
Background (max 200 words): The appropriate, effective and fiscally responsible use of pharmaceutical products is often a neglected issue in international health programmes in developing countries. They have focused on low-technology, low-cost interventions for family planning, maternal health, child survival, malnutrition, prevention of sexually transmitted infections and environmental health problems. However, regular availability and proper use of pharmaceuticals is key to the success of many of these interventions, e.g., malaria prophylaxis and treatment, directly observed treatment shortcourse (DOTS)  strategy for tuberculosis, supplementation and management of complications of pregnancy and delivery, among a host of other chronic communicable and non- communicable conditions. Medical consequences of irrational use of drugs include: Adverse, possible lethal effects; Limited efficacy; Antibiotics resistance; Drug dependence; Risk of infection due to improper use of injections. This study considerably highlighted the principles of rational drug use and the extent to which it is being put into practice in public tertiary hospitals in Edo State, Nigeria.
Objectives (max 100 words): This study focused on drug prescribing and dispensing practices in public tertiary health facilities in Edo State, Nigeria. It also looked at consumers’ attitude towards drug use. Strengthening rational drug use is not merely desirable in reducing the high morbidity and mortality rates, especially in chronic diseases; it is a requirement in current time of economic hardship. This study will help to show where we truly are as at date with respect to drug use practices in public tertiary hospitals in Edo State, Nigeria, and reveal grey areas for future drug use intervention programmes.
Methodology (max 400 words): All three public tertiary health facilities in the state were used for the study: University of Benin Teaching Hospital (UBTH), Benin City, Psychiatric Hospital, Uselu (PHU), Benin City and Irrua Specialist Teaching Hospital (ISTH), Irrua. The general out-patient departments (GOPDs) of these tertiary hospitals were used for this study. A descriptive cross sectional study design was carried out. Selection of outpatients: From records available, it was found that in the GOPDs, the average number of patients seen per day was 220, 120, and 100 for UBTH, ISTH and PHU respectively, giving an average daily total of 440 patients, i.e. 2200 patients weekly, across the three health facilities. Six hundred and sixty patients were selected across all three health facilities over a 3-week period i.e. 220 patients per week and 44 per day. The subsample from each facility was proportional to the number of out-patients estimated for that facility, 22, 12, 10 patients per day for the health facilities respectively i.e. sampling proportional to size (SPS).  At each health facility the individual patient was selected by systematic sampling method at an interval of 1to 10. The first patient was selected by simple random sampling and subsequently every 10th patient was selected for the study until the daily required number for the facility was reached. This continued throughout the data collection period until the required sample size was attained. Selection of prescribers and dispensers: A total population study of all the prescribers and dispensers in the GOPD of these health facilities (146 prescribers and 36 dispensers) was done. Quantitative data collection methods: Questionnaires: A structured, researcher administered questionnaire was administered to out-patients (drug consumers). Also interviewed were prescribers and dispensers on their knowledge of rational drug use, their drug use practices, and their perceived reasons for their drug use practices as well as suggestion on ways of improvement. Nine hundred and sixty prescription sheets for the past one year were retrieved by systematic sampling method and reviewed using the WHO drug use indicators as a guide.  Qualitative data collection methods:  An interview with heads of clinical services of the health facilities studied was carried out using an interview guide.  SPSS version 16.0 and Pepi software programmes were used for the statistical analysis of data. The level of significance was set at p < 0.05.
Results (max 400 words): Mean ages of the respondents studied were 34.9 ± 6.2, 36.7 ± 8.1 and 29.2 ± 8.8 years for prescribers, dispensers and patients respectively. Few prescribers (23.5%) and some dispensers (41.7%) could tell correctly what rational drug use is all about. Fewer prescribers (13.7%) and dispensers (13.9%) had received training in rational drug use. Average number of drugs prescribed per encounter was 3.77. It was found that (54.2%) drugs were prescribed by generic names, encounters with an antibiotic prescribed was 15.5%, while 7.3% were with an injection prescribed. Though, essential drug list was not available in one of the three institutions studied, 62.6% of drugs were prescribed from essential drug list. Most prescribers (75.3%) were usually influenced in their prescription pattern by the nature of ailment being treated. The problem of lack of dispensing materials was most frequently recounted by dispensers (52.8%) as the commonest dispensing problem in the health facilities; most of them (86.1%) also felt that their dispensing environment was not conducive enough for patient counseling. Adequate labeling of drugs was found in 80.3% of encounters and availability of drugs in stock was 86.6%. Patients' knowledge of correct dosage was high, 84.2%, but 77.4% of them were reported to have self medicated wrongly. Average drug cost per encounter was found to be N 1224.38 (US$ 7.91) and 84.5% of patients said they felt satisfied with the treatment and general services they received in the health facility.  The findings of this survey therefore suggests that drug prices in Nigeria was quite high compared to the international reference prices for medicines and that these prices could be reduced, to some extent, if generic equivalents are adhered to in prescribing and dispensing. Since the hallmark of hospital services is to achieve patient’s satisfaction, it is therefore imperative that hospital services should be geared towards providing optimal, low cost, and effective medicines to the patients.
Conclusion (max 400 words): Appreciable gaps in knowledge with respect to rational drug use, still exists among the cadre of healthcare professionals studied. This has influenced the drug use pattern in the hospitals studied. The gap has been occasioned by inappropriate source of drug information as well as lack of training. Though generic prescribing was relatively poor and the tendency to prescribe too many drugs than are clinically required was also observed, the overall prescription pattern was encouraging with respect to the use of antibiotics, injections and essential drug list. There is still a lot of room for improvement, especially in the use of standard treatment guidelines. Drug supply and labeling was adequate, even with poor drug dispensing environment and lack of some dispensing materials. Patient’s counseling by pharmacists still leaves a lot to be desired. Hence the general attitude of patients towards drug use can best be described as poor. This poor compliance to drugs by patients was influenced mainly by the educational status of the patient (being poorest in those with non-formal education), the accessibility of the health facility personnel/ their attitude to the patient on drug issues, as well as the cost of purchasing the prescribed drugs. Despite relatively high drug cost which can be made cheaper and yet effective, patient satisfaction rate was still very encouraging.  Prescribers should be encouraged to comply with the standard therapeutic guidelines in their day-to-day practice. Educational and behavioral intervention and use of pre-packaged drugs would probably improve the dispensing practice. The use of pictograms for packaging drugs is useful for all but especially for illiterate patients.  A review of the present drug procurement and selection policy in the public tertiary health facilities may be necessary to reduce medicine cost. Since most Nigerians purchase their medicines out of pocket, high medicine prices would constitute a major barrier to access of healthcare. There should be an intervention programme involving concerted continuing education to influence the knowledge, attitude and practice of prescribers and dispensers. This would help sustain the right practices and correct the wrong ones.

Implementing Point-Of-Care Testing for HIV in Pharmacies: A Pilot Evaluation in the United Kingdom

Author(s) 1Sheere Brooks, 2Wendy Hachmoller, 2Janet Tucker
Affiliation(s) 1College of Agricultural Science, Engineering and Education, Portland, Jamaica, 2NHS Newham, London, United Kingdom
1st country of focus: United Kingdom
Relevant to the conference theme: New roles and responsibilities of health personnel
Summary (max 100 words): In 2010, NHS Newham in the United Kingdom, implemented a pilot for Point-of-care (PoCT) testing for HIV pharmacies situated in the East London borough of Newham. The aim has been to increase the availability of services for HIV testing beyond traditional clinical care settings. This paper outlines the practical experience of implementing Point-of-Care testing for HIV in pharmacies.
Background (max 200 words): In order to address the problem of late diagnosis and undiagnosed HIV infection in the UK, in 2009 the British HIV Association (BHIVA), the British Association for Sexual Health and HIV (BASHH) and the British Infection Society (BIS) issued national guidelines recommending the expansion of HIV testing beyond antenatal and STI clinic settings. The guidelines also recommend the routine offer of an HIV test to all adults registering in general practice and all general medical admissions where the local diagnosed HIV prevalence of HIV infections is greater than two in 1,000.  A major challenge faced by HIV testing and delivery services is the large number of people who test for HIV, but who never return for test results. Late diagnosis of HIV is associated with increased morbidity and mortality. UK statistics show that in 2009, an estimated 52% of newly diagnosed patients were considered to have been diagnosed late (after a point at which treatment should have commenced).
Objectives (max 100 words): NHS Newham implemented a pilot for Point-of-care testing of HIV in 3 Pharmacies in Newham. Pharmacists opportunistically offered rapid HIV testing to clients during their visits. Accepting clients are tested following a pre test discussion. All reactive antibody tests are linked to HIV clinical services. The Rapid HIV test was performed using the INSTI HIV-1/HIV-2 testing kit. The pilot lasted from September 2010 to June 2011.  The evaluation of this pilot sought to assess the practicalities of implementing Point-of-care (PoCT) testing of HIV in pharmacies in Newham. The evaluation also assessed the experience of integrating Point-of-care testing of HIV with other service provision from the point of view of staff engaged in administering HIV testing. The evaluation had the following objectives: 1. Capacity of staff to do all aspects of rapid HIV testing (blood test and conduct of pre and post test discussion)  2. Compatibility of rapid HIV testing in a pharmacy setting 3. Convenience and availability of HIV testing  4. Issues surrounding confidentiality 5. Referrals process to clinical services 6. Sustainability and extension of Point-of-care testing of HIV in all pharmacies in East London.
Methodology (max 400 words): Evaluation of the pilot for Point-of-care testing of HIV took place from March 2011 to May 2011.  This was a qualitative research study. In-depth interviews were carried out to gain insights into the experience of pharmacies in implementing rapid HIV testing in pharmacies settings.  Pharmacists drawn from three (3) participating pharmacies in the pilot study were interviewed.  Analysis of data involved transcribing interviews and entering findings under thematic headings based on the evaluation objectives, and using the qualitative software programme, Nvivo. This process of data analysis enabled there to be a comparison of findings between pharmacies, in understanding the differential experience of implementing and integrating Point-of-care testing of HIV in pharmacies.
Results (max 400 words): It was found that a more structured approach to administering HIV testing existed in pharmacies and this was attributed to a ‘newness’ of the service; an awareness of risk factors surrounding HIV testing and a wish to ensure the service is a success.  The convenience of using a simple HIV test kit was considered suited to a pharmacy setting and provides an opportunity for reaching clients who might not be accessing clinical services. However, some clients had concerns about confidentiality and accepting an HIV test in a pharmacy.  It was felt there is scope to increase the promotion of Point-of-care testing of HIV in the community and particularly in relation to forging stronger partnership links between pharmacies and other HIV services.
Conclusion (max 400 words): The findings of this evaluation revealed that HIV testing in a pharmacy is feasible and offers an opportunity to reach segments of the population who may not have access to HIV testing in primary care settings.  This indicates the need for NHS Newham to expand HIV testing in Pharmacies.  NHS Newham will need to develop a protocol for implementing Point-of-care testing for HIV.  This should provide guidelines on integrating and administering PoCT in a pharmacy. This should in turn act as a tool for guiding other pharmacies in Newham, intending to offer PoCT as the service expands.  In addition, there is scope to develop a forum for pharmacies to exchange ideas and practice experience in implementing and integrating Point-of-care testing of HIV as part of their service provision.  This will provide an opportunity for learning about best practices that could assist in the streamlining of Point-of-care testing (PoCT) for HIV in pharmacies as the testing service expands across East London.

Tuberculosis Services in Pakistan – Getting the Community Moving


Author(s): 1Sadiq Bhanbhro, 2Rafiq Wassan
Affiliation(s): 1Aga Khan University, Karachi, Pakistan, 2University of Sindh, Jamshoro, Pakistan
1st country of focus: Pakistan
Relevant to the conference theme: Equity and empowerment
Summary (max 100 words): Rural health centers are primary care facilities and in addition to providing routine services some of them are designated as TB control centers which provide preventive and curative TB services to the community. These TB control centres are equipped with adequate human and matieral resources, but are grossly underutilized due to several factors which may be lack of community awareness about the services availability but also the influence of social, cultural and economical forces. The TB center patient attendance register 2009 was compared with that of 2010 after a mobilization program in that community. Semi-structured interviews with members of the community were also conducted. The results showed that the total number of patient attendance and treatments received in 2010 increased by 106% when compared to that of 2009. Community awareness of TB services also increased.
Background (max 200 words): According to the WHO Global Tuberculosis Control 2009 Pakistan ranks eighth on the list of 22 high-burden TB countries in the world. In 2007 an estimated 297,108 people in Pakistan (primarily adults in their productive years) developed TB. The emergence of multi drug-resistant (MDR) TB and TB-HIV co-infection is a growing concern in the country. TB carries a social stigma because of its link with poverty and overcrowded living conditions. Government designated health centers are equipped with TB services but the majority of people are not aware of these services, therefore TB services remained underutilized. A group of local Community Based Organizations (CBOs) initiated a project to mobilize the community through community outreach health workers and social mobilizers. The aim of the project was to mobilize the community through community outreach health workers and social mobilizers to provide awareness about availability of services, opening times, location, the importance of seeking treatment, the identification of TB symptoms during regular house visits and motivating suspected patients to attend nearby health centers for diagnosis.
Objectives (max 100 words): The main objective of the study was to assess the impact of community mobilization program on the utilization of TB prevention and control services at the Rural Health Center, Khuhra.
Methodology (max 400 words): A mixed method study design was employed. The daily TB center patient attendance register at the Rural Health Center Khuhra which recorded patient attendance by adult males, females and children in 2010 was compiled and summarized and compared with those obtained in 2009 after the community mobilization project. In addition, a twenty minute short semi-structured interview with 170 community members (male = 95 and female = 75) was conducted using an interview guide.
Results (max 400 words): The results illustrate that there were a total of 324 patients in 2009 and this increased to 667 (106%) in 2010. A total of 156 male patients in 2009 increased to 275 (76%) in 2010. A total of 128 female patients were seen in 2009 and increased by 316 (147%) in 2010. With regards to children patients, 40 patients were seen in 2009 and this had increased by 76 (90%) in 2010. There was increased community awareness about the TB diagnostic center (location and timings), the process required to seek treatment (and any misconception about cost for example), after the mobilization campaign. A random sample of 170 male and female community members across the villages of targeted Union Council correctly identified treatment duration, location of diagnostic laboratory and treatment center, and the significance of adherence to treatment. The interview findings revealed that most of community members were satisfied with the TB services and found the community mobilization initiative useful. These improvements in the utilization of TB services at the Rural Health Center, Khuhra followed the intensive and organized continuous community mobilization campaign.
Conclusion (max 400 words): This study shows that community mobilization in conjunction with properly equipped facilities could be important factors in the utilization of health services, especially TB prevention and control services. We strongly recommend that government health facilities engage in active, purposeful and continuous mobilization of the community to promote ownership and sustainable improvements in the utilization of health services.

Repositioning Primary Healthcare for Better Service Delivery in Rural Communities in Nigeria

Author(s): Femi Tinuola1, Mariyetu Tenuche2
Affiliation(s): 1Population Health, Faculty of Social Sciences, Kogi State University, Anyigba, Nigeria, 2Department of Political Science, Kogi State University, Anyigba, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Redesigning health services
Summary (max 100 words): The increasing epidemiological challenge in rural communities in Nigeria is a threat to public health. Poor environmental management and the inability of government to improve on the socio-economic conditions of citizens has worsened the health conditions of rural dwellers. Government responses to the increasing morbidity and mortality resulted in the establishment of Primary Health Care (PHC) facilities in order to bring health closer to the grassroots. Since its inception, how far has PHC been able to respond to the increasing morbidity? This study is an assessment of the efficacy of PHC towards its repositioning in meeting the challenges of rural health.
Background (max 200 words): About 55% of Nigerians live in houses without indoor plumbing and electricity in rural communities. With increasing prevalence of diseases resulting from lack of basic facilities and the inability of rural dwellers to effectively manage the socio-physical environment, available Healthcare infrastructures have been overstressed by the increasing demand for healthcare. Primary Health Care (PHC) was launched in 1987 to accelerate healthcare, improve health data management and implement the Expanded Program on Immunization in rural communities. PHC began operation with full funding from the Federal Government under the military administration. Several health facilities were established in rural areas to bring healthcare closer to the grassroots. Funded by tax payers’ money, have the PHC infrastructures responded effectively to emerging challenges of infectious diseases that claim significant lives among rural dwellers? Several epidemiological reports have consistently shown that malaria, dysentery, diarrhea and cholera are killer diseases affecting mostly women and children. Preventive measures by government and public health practitioners have not yielded desired results due to poor housing structures, poor environmental sanitation and the ineffective control of water infrastructures. The need arises to assess the efficacy of PHC and make recommendations towards repositioning it to meet the challenges of rural health in Nigeria
Objectives (max 100 words): This study is an assessment of the Primary Health facilities in two North/central States and one State in Southwest Nigeria. The objectives are to examine: 1. socio/political considerations in the location and management of PHC infrastructures 2. Document available PHC facilities in selected rural communities  3. qualification and distribution of health personnel across various departments of PHC 4. morbidity challenges prevalent in the selected rural communities through available medical statistics. 5. Factors influencing patronage of PHC facilities 6. Users’ assessment of (non)efficacy of PHC facilities 7. Make proposals towards repositioning PHC for better service delivery.
Methodology (max 400 words): Data were obtained from primary and secondary sources. Five rural communities were selected in each of the Ekiti, Kogi and Benue States, making a total of 15 rural communities for the entire study. The communities were selected using purposive random sampling technique, on the criterion of epidemiological data in the Nigerian Demographic & Health Survey Report, 2010. In each of the rural communities, 50 respondents aged 18years & above were randomly selected to respond to a structured questionnaire which contains 95% closed ended questions on issues bordering on patronage and efficacy of Primary Health facilities. A total of 750 questionnaires were administered, from where volumes of quantitative data were explored. The instrument was validated by a group of experts in Medicine, Nursing, Community Health, sociology and a reliability coefficient of 0.95 was achieved with the use of chi-Square technique. The questionnaire was administered by three trained field workers in each States. The questions were translated into local dialects to facilitate better understanding with illiterate respondents. Secondary data drew from the medical statistics records of fifteen selected PH infrastructures in all the communities. Data were obtained from:  The law establishing PHC facilities Staff qualifications, strength, distribution across Departments  Availability and supply of drugs and other medical kits the role of PHC in immunization against the  child killer diseases programs Patients records of health seeking  Process and cases of referral options for the patients A model instrument was designed to obtain the secondary data to ensure uniformity and ease data analysis, interpretations and discussions. A staff in each of the PHC facilities assisted the field workers to facilitate the release of the required information after necessary permission had been obtained from the management of the health institutions. A letter of request to obtain data from PH facilities earlier approved by Health Management Board was given to the field workers for presentation at the various PHC facilities. Data were analyzed with Predictive Analytical Software in descriptive statistics and presented in percentages. Relevant hypotheses were tested with the use of Chi-Square technique at 0.05 level of significance. Secondary data were analyzed in content and forms a separate heading. A synopsis of the primary and secondary data was discussed under a separate subheading to provide a qualitative assessment of the PHC.
Results (max 400 words): The data confirms the dominant role of malaria, dysentery & cholera in the epidemiological scenario of the rural communities. Over 60% of cases reported by in-and-out patients resulted from contact with anopheles mosquito, causing malaria infection and contaminated water resulting in various cases of water borne diseases. Other reported cases of illnesses were related to maternal health conditions of pregnant women, including VVF, bleeding in pregnancy and spontaneous abortion. The maternal health problems were mostly reported in Kogi and Benue states due to primary factors such as early age pregnancy, early marriage and early child birth and secondary factors such as lack of interest in antenatal clinics and lack of adequate medical attention in PHC facilities, for those who visited them. About 25% patronized PHC facilities only 58% patronized PHC and traditional cures, 17% visited traditional & spiritual healers. Those who patronized PHC facilities only indicated problems such lack of drugs, lack of qualified personnel, and slow process of referral. Secondary problems such as poor funding, resistance from health personnel, restricted primary health interventions reinforced a culture of survival in the rural communities where many people believe that public health is an emergency response embodying vaccines, drug, ephemeral training of lay personnel. A review of laws establishing PHC show that it was patterned and packaged by the then military administration and some of these laws are no longer relevant in the present democratic dispensation.
Conclusion (max 400 words): Since PHC has become an integral part of the Nigeria Health system, with its major focus on improving the health status of rural populace, involving the beneficiary communities in the process of location of the facilities to ensure a feeling of ownership status, PHC will enhance the protection of available infrastructures, effective patronage and utilization and enhance meaningful contributions by the last communities. The unitary structure of the military administration that established PHC and its operations through military decrees led to the centralization of its activities. At the inception of the democratic experience in Nigeri, the ownership of PHC rests with the federal government in collaboration with the States. The local council where these PHC facilities are located do not really have direct ownership. This has affected community patronage protection of PHC facilities.  The laws establishing PHC facilities should be reviewed to reflect the present democratic realities. The Federal and States governments should allow the local government that is the closest to the people to manage PHC. Budgetary allocation should be increased, local people should be trained in middle level health training, health facilities should be adequate and the present PHC facilities should be completely overhauled for effective performance. Health issues such as potable water and environmental sanitation should be improved upon. Improvement of the socio-economic conditions of the people through empowerment and poverty alleviation programmes will enhance the health of local people. Health education for the locals will improve their lifestyles and better health

Availability and Affordability of Essential Medicines: Exploring the Health Seeking Behaviours and Health Services Utilization for Children Under-5 Years, Living in Squatter Settlements of Karachi, Pakistan.

First: Yasir
Last: Shafiq
1st country of focus: Pakistan
Relevant to the conference theme: Medicines and diagnostics
Summary (max 100 words): Child health outcomes in the poor communities are largely affected by the non-availability and non-affordability of essential medicines. We examined the shelf-availability of medicines for children under-5 years of age at a rural health center, conducted focus group discussions with the mothers and interviewed health care providers of the area to study the phenomenon. We found an erratic and insufficient supply of essential medicines at the facility and a limited purchasing power to buy medicines from a retail pharmacy, led to considerable ‘financial burden’ on the poor people, non-compliance with the treatment, health care seeking from informal health providers and healer shopping.
Background (max 200 words): People living in the squatter settlements or urban slums are exposed to various health related threats: poverty, dilapidated living conditions, lack of civic amenities and limited availability and access to health services. Consequently, the health outcomes in such settlements remain jeopardized. For instance, under-5 mortality was found to be 2.5 times higher in the squatter settlements as compared to urban areas in the developing countries, where the health indicators are already poor. In Pakistan, the under-5 mortality is found to be 90/1000 live births, with greater proportion in poor settlements because of preventable causes. Health seeking behavior and health service utilization can be defined on the basis of perceived anticipation and perceived effectiveness of the health services which includes availability of essential medicines and affordability of prescribed medicines as major determinant. Under the philosophy of ‘Primary Health Care’, the concept of ‘Essential Medicines’ was given, available at all the times in adequate quantity, appropriate dosage and affordable prices. Yet, one third of the world population does not have access to essential medicines; more than half of which is living in Africa and Asia, leading to poor health outcomes. Many people are still facing catastrophic health expenditure. As a result, people turn to seek care from unskilled and non-formal healers. This inappropriate HSB and HSU multiply the chances of poor health outcomes.
Objectives (max 100 words): Study questions: 1. What is the state of availability of essential medicines for children under 5 years at a government health facility in the study area?    2. How does the non-availability and non-affordability of essential medicines affect parents’ health seeking patterns? The study had two main objectives: (i) to authenticate the shelf-availability of essential medicines at primary health care facility for children under-5 year of age in the month of July 2010; and (ii) to explore the effects of non-availability and non-affordability of medicines on health seeking behavior and health service utilization for children under-5 year of age.
Methodology (max 400 words): a) Study setting and Population under study: The study was conducted in a squatter settlement near coastal areas of Karachi, Pakistan. This study aimed to investigate the health seeking behaviors and patterns for children under-5 years in the squatter settlement; therefore, all the mothers were included who had at least one sick child suffering from acute neonatal tetanus, diarrhea, dysentery, acute respiratory tract infection, pneumonia; typhoid, malaria, and meningitis during the month of June 2010. Health care providers included general practitioners, government doctors, nurses, LHW, LHV, CHW, dispensers and retail chemists in the squatter settlement, practicing full time and willing to participate in the study. b) Study design A 'qualitative descriptive component' comprised ‘focus group discussions’ (FGD) with mothers of children under-5 because of homogeneity in the group; whereas ‘in-depth interviews’ with health care providers were conducted because these represented quite heterogeneous cadres. The literature review was used for developing the focus group and the in-depth interview guide.  The second study component comprised of the ‘observational visits’ of government health facility to collect data on shelf-availability of essential medicines for selected childhood illnesses. This approach helped us validating the information and for data triangulation. The study duration was July- September, 2010. d) Sampling and data collection: We selected eight geographic sectors randomly in the study area and with the help of LHW in each selected sector, study participants (mothers) were invited for discussion. The eight FGDs were conducted, each with group around 7-9 mothers to discuss the issues around availability and accessibility of the essential medicines for children. Similarly, in-depth interviews were conducted to capture the perceptions and experiences of the health care providers on similar arguments. In-depth interviews with one government physicians, two local drug dispensers, one LHV, four LHWs, two CHWs and a local private general practitioner were carried out. The FGD guide and the in-depth interview questionnaire were translated in Urdu for the execution purpose and then transcribed in Urdu as well. Later, all the transcripts were translated back in English and checked for reliability by another person, not working with the research team. For one calendar month .i.e. July 2010, data was collected on the shelf-availability of selected essential medicines for treating childhood illnesses in the government health facility. The shelf stock was monitored on assigned days every week on different timings i.e. 1st, 7th, 14th and 21st day.
Results (max 400 words): For presenting results merging of themes was done for both effects i.e. ‘effects of non-availability of essential medicines for children on health seeking behavior and health service utilization’ and ‘effects of non-affordability of essential medicines for children on health seeking behavior and health service utilization’; as similar themes were identified; except few which are mentioned separately.  1. Availability Of Essential Medicines At Primary Health Care Facility: The detail of shelf-availability of selected essential medicines (recommended by WHO for children under 5 years) at primary health care facility is given in table 2. Oral rehydration salt was available in first two weeks only. It was observed that Ciprofloxacin (3rd generation cephalosporin/antibiotic) was not available in pediatric form. Overall 61% of the selected essential medicines for selected childhood illnesses were not in the stock of RHC. It was found erratic supply chain of essential medicines  in government facility.   "RHC always have shortage of medicines; you are talking about children; they even do not have proper stock for adults. The do not have medicines for priority illness of this community. All they have is the stock of Paracetamol…” (Health care provider) 2. Affordability Of Medicines For Children Under-5: Majority of the people in the community have meager financial resources and because of the limited income generated from fishing, the cost of healthcare especially the medicines always poses a problem.“Just because of money, I left the clinic without treatment". (mother in FGD) 3. Effects Non-Availability And Non-Affordability On Health Seeking Behavior And Health Service Utilization For Children Under-5: Poor people often facing financial constraints, have limited purchasing power to buy medicines. They have to ask for financial assistance from their relatives or neighbors. Struggling to set their priorities.  "Meal for one time is an issue for us, how can we buy medicines? As a result, my husband has borrowed money from his brother." (Mother in a FGD) 4. Reasons For Switching Health Care Providers: Switching healthcare providers and doing health shopping in case if treatment is non-affordable was very common. People went to different providers either because of the non-availability of medicines at government sector or non-affordability of medicine at retail pharmacy.“They start searching for those, who provide free medicine, and we have some ‘doctors’here…so called ‘doctor’ which administer an injection in Rs10 only and people are very satisfied.” (Government healthcare provider).
Conclusion (max 400 words): Access to medicines is a complex construct because medicines not only have to be available government health facility free of cost; they also have to be affordable at private health facilities i.e. pharmacies. On the users’ side, there is a need to move beyond determining the effects of non-availability and non-affordability of essential medicines for children under-5, thus considering interventions addressing the adverse effects on child health in poor communities living in squatter settlements. Financial burden, noncompliance with the treatment prescribed, inappropriate actions, loss of trust on government health facility and healers shopping are the major effects of non-availability and non-affordability of medicines. Health education, health promotion and social marketing campaigns are needed to change existing health-seeking behaviors and patterns of poor decision making.  On the supply side, availability of essential medicines for the priority illnesses of children under-5 should be ensured at primary health care level, if we need to bring down under-5mortality and morbidity rates in Pakistan. Based on our study, we recommend that there should be proper auditing and monitoring of the drug distribution and supply system at the community and district level by involving the major stakeholders such as health personnel at facility, community elected leaders (local mayor) and members of community. Local authorities must improve coordination with the medicines suppliers and the distributors to minimize distribution delays and corruption within the system and erratic supply of medicines at the government facility. Local CBOs and NGOs must introduce safety nets in the form of treatment packages for those who are poor and cannot afford the cost of medicines. We need to sensitize all health personnel within the community to provide more empathetic care and to encourage, educate and inform the community at large, to encourage seeking appropriate and timely healthcare. Policy makers and health authorities must understand the importance of this issue and ensure provision of essential medicines for children and overcome the flaws in government health care system, especially focusing on the supply and distribution mechanism. Study limitations: Time and financial constraints limited the study to a very small scale. There could be some reporting bias during the interviews with healthcare providers. Moreover, data was limited to a selected set of illnesses in a typical settlement, so results cannot present a generalized picture. Since the study was pre-dominantly based on qualitative methodology, supported by an observational component, the concerns pertaining to the validity of the result still can arise.

Tackling Tuberculosis: Cameroon National Control Programme

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Author(s): Soumbou Ekoumou1, Jean-Louis Abena Foe1, Bekolo Mba1
Affiliation(s): 1National Programme of Tuberculosis, Yaounde, Cameroon
1st country of focus: Cameroon
Relevant to the conference theme: Communicable chronic diseases
Summary (max 100 words): In Cameroon as in other countries, tuberculosis is no longer only a public health problem  but a genuine problem of development. Poverty and the increasing prevalence of the HIV infection amongst the populations have greatly exacerbated the scourge.
Background (max 200 words): Tuberculosis is an infectious and contagious disease caused almost exclusively by Mycobacterium tuberculosis or Koch’s bacillus. Mycobacterium is a variant of M. tuberculosis and has been found in 10% of tuberculosis patients in Cameroon (Yaoundé). Tuberculosis is transmitted from a patient with pulmonary tuberculosis through the air. These tiny droplets are produced when patient coughs or sneezes. The real reservoir of the tubercle bacillus is a patient with sputum smear positive pulmonary tuberculosis. The detection and treatment of such a patient constitutes the basis of the control programme.
Objectives (max 100 words): The general objective of National tuberculosis control program is to progressively reduce the morbidity and mortality associated with the disease through the proper management of cases. The specific objectives of the programme are : to cure at least 85% of detected cases of sputum pulmonary tuberculosis through the use of a standardised treatment regimen, to detect at least 70% of existing cases of sputum smear positive pulmonary tuberculosis that constitute the source of infection, to protect populations through the BCG vaccination at least 80% of children born each year.
Methodology (max 400 words): The strategies for implementation of NTCP are :- Management of patients- Prevention of disease- Training of health personnel- Information, education and communication (IEC) for health workers- Epidemiological surveillance
Results (max 400 words): To attain its objectives the programme will carry out the following activities :- Ensure the supply of health facilities involved in the programme with the necessary materials and equipment- Ensure the rehabilitation of hospitalisation and laboratry units so that they meet the required technical standards- Ensure the supply of health facilities with anti-tuberculosis drugs, laboratory reagents and consumables through the national system for the procurement and supply of essential drugs.- Train health personnel at all levels according to needs- Supervise and monitor programme activities at all levels- Carry out operational research- Evaluate  the programme
Conclusion (max 400 words): They are many difficulties facing programme : Patients who discontinue because of the non full involvement of the community in the fight against tuberculosis. Break up of TB drugs due to financial mismanagement, as the mode of procurement of Cameroon is very long (six months). Operational research for multi- resistant TB drug is not complete in all regions of Cameroon (just 4 out to 10 regions that do count Cameroon). The objective of management is to obtain total compliance of patient treatment until he/she is cured. To achieve this it is necessary to explain the disease to the patient and family members while taking into consideration that there may exist some traditional or cultural beliefs about tuberculosis and explaining to the patient and family members the importance of following his/her treatment to its completion. Tuberculosis control will save millions of lives.

Reducing HIV-related stigma in health care settings: a rights-based approach focussing on infection prevention practices

First: Sumitha
Last: Chalil
1st country of focus: India
Relevant to the conference theme: Redesigning health services
Summary: HIV-related stigma is a barrier in ensuring proper care of people living with HIV in Kerala, India. Kerala State AIDS Control Society together with EngenderHealth International piloted a rights-based intervention among health care providers in select public and private institutions.  Unlike conventional models, this innovative initiative addressed and acknowledged health care providers’ risk perception in the hospital context and their right to adequately protect against contracting infections; not just HIV. The training and advocacy components of the intervention enabled them to follow non-discriminatory infection prevention practices, develop positive attitudes towards people living with HIV and providing dignified care to them.
What challenges does your project address and why is it of importance?: The south Indian state of Kerala is discussed internationally for its health indicators which are comparable to Scandinavian countries. The HIV prevalence in the state remains low despite heavy out migration and geographical proximity to high HIV prevalent states in the country. However, HIV related stigma has been an ongoing problem in various fronts of society including health care. Discriminatory practices in health care settings created hurdles for people living with HIV in accessing care and treatment and eventually affected their well-being.  Stigma in health care settings is associated with providers’ fear of HIV infection in the hospital. The pre-intervention study found poor quality of infection prevention practices partly due to lack of awareness about the basics of infection prevention among providers, health care managers and policy makers. In addition, lack of sustained measures to ensure cost effective infection prevention infrastructure compounded this fear. These concerns are genuine and require adequate attention to ensure a stigma free health care environment for people living with HIV. The project addressed the challenges of awareness about basic low cost infection prevention practices along with advocating for stigma free care for people living with HIV.
How have you addressed these challenges? Do you see a solution?: The south Indian state of Kerala is discussed internationally for its health indicators which are comparable to Scandinavian countries. The HIV prevalence in the state remains low despite heavy out migration and geographical proximity to high HIV prevalent states in the country. However, HIV related stigma has been an ongoing problem in various fronts of society including health care. Discriminatory practices in health care settings created hurdles for people living with HIV in accessing care and treatment and eventually affected their well-being.  Stigma in health care settings is associated with providers’ fear of HIV infection in the hospital. The pre-intervention study found poor quality of infection prevention practices partly due to lack of awareness about the basics of infection prevention among providers, health care managers and policy makers. In addition, lack of sustained measures to ensure cost effective infection prevention infrastructure compounded this fear. These concerns are genuine and require adequate attention to ensure a stigma free health care environment for people living with HIV. The project addressed the challenges of awareness about basic low cost infection prevention practices along with advocating for stigma free care for people living with HIV.
How do you know whether you have made a difference?: Different types of assessments were part of the intervention design. This included• baseline assessment of stigma in healthcare settings among providers• experiences and perspectives of people with HIV,• Pre-and post-assessments of trainings, and• Impact assessment of the intervention on health care providers.  The post-training assessments observed changes in the attitudes and practices of providers. Most of the providers shared that prior to the intervention, they were less or not comfortable in providing services, resulting in lower quality care and lower levels of job-satisfaction.“I have never seen a known HIV positive patient at our hospital. Once heard that there was one patient but I didn’t see him. If it happened ever, before the training, I would have avoided the chance to deal with such a patient, in any possible way. If somebody had insisted, I would have resigned from the job”.                                                                             …A Nursing Assistant All respondents in a one month post-training assessment reported favorable changes in their attitudes and practices. “He was a very rough man, with rude behaviors and I heard one saying that, it would be a wonder if he is not infected (with HIV). At that time I too felt like that, but soon I corrected my self. Why if he deserved it or not (is immaterial to me), he got it and that is all for me.”- Nurse, Calicut.        “Now I know that, (before training) I was afraid to treat them (people living with HIV), but I can very well say that (now) the fear has gone from my mind. The doubt regarding why to treat the HIV infected is also cleared now. Now I know, they (people living with HIV) need treatment and it is our responsibility to provide it. No need of giving anything extra, but as much as we give to any other patient”.                                                                                               ….. Doctor- Trivandrum“Now I am really comfortable to provide services to them (people living with HIV), because I know better the ways of transmission of HIV and also where we really need precautions. Before, we didn’t even take the temperature of the patient without using gloves. And more than that, I now feel that the distance between me and them has very much reduced.”                                                               Nurse- Calicut Facility-level changes such as introducing hand-scrub solutions at crowded OPDs, inclusion of training package in on-going training programs, modification of infection prevention infrastructure, etc. were also part of the outcomes.
Have you or the project mobilized others and if so, who, why and how?: The process and outcomes of the project were widely accepted by different stakeholders across the state. The project has developed a resource pool in the state on infection prevention practices and HIV-related stigma in health care settings. This pool includes different functionaries ranging from doctors to paramedical staff and people living with HIV. Even beyond the realm of this project, members of this pool are implementing different elements of this training program through different platforms across the state.  Apart from direct stakeholders such as people living with HIV and providers in the selected health care institutions, the project was able to mobilize the support from the Kerala State Health Department and thereby improving the infrastructural environment.  Kerala State Health Department was a buyer of the project concepts and products after the completion of the pilot phase. This has been related with the instances of nosocomial infections in the public hospitals in the state and the growing realization of poor infection practices. The buy-in was triggered by a rise in neo-natal deaths at the largest women and children hospital in the capital city where the project resource pool was utilized to intervene under the lead of Kerala State AIDS Control Society. One month long training was given to all staff members at the particular hospital using the training package and resource pool developed with required additions. This led to the adaptation of the training package on infection prevention practices to all the women and children hospitals and major hospitals in the public sector in subsequent years.  Members of the resource pool continue to express their willingness to take the lessons forward and there is a cascading effect through the trainees trained by members of the resource pool.  Key roles in advocacy and training played by the implementing partner- Kerala State AIDS Control Society, and positive networks continues as reflected in their ongoing programs and activities.
When your donor funding runs out how will your idea continue to live?: The project was funded by the United Kingdom (UK) Department for International Development (DfID) during the pilot phase. Even though scale-up plans were sought soon after the completion of project activities, no funding was allocated for the same. However, there have been efforts from the government of Kerala to disseminate the infection prevention and stigma reduction messages in health care settings. In some occasions the complete package was utilized while in some other occasions parts of the package are administered in series or by integrating other routine programs. Some of the specific measures include:• Inclusion of HIV-related stigma and discrimination component to the different capacity development programs run by Kerala State AIDS Control Society for health care providers in the state. These programs are funded through the National AIDS Control Organisation (NACO).              • The state health department has incorporated infection prevention practices as a part of its routine trainings to health care providers in larger hospitals.• Initiatives by the members of the resource pool to provide training to different health care staff at different occasions. These trainings are arranged by them or public and private hospitals, professional associations such as Indian Medical Association and service agencies such as Palliative care groups.• Incorporation of the elements of this package in the core agenda of networks of people living with HIV in the state. These networks were partnering with the project to develop advocacy tools and they have access to them. Further, facilitated dialogues between people living with HIV and health care providers during different occasions such as trainings have proved to be effective in addressing attitudinal issues and are continued to be utilized.  Apart from these, the Kerala State AIDS Control Society is planning to scale up the implementation of the pilot project across the state and funding is sought for the same. While further dissemination of the key messages on infection prevention and stigma reduction is possible through the state mechanisms and public funding, there are concerns that a core requirement for addressing stigma is yet under-focused. This is with respect to allocation of adequate resources and supply chain mechanisms for ensuring basic prevention supplies in the hospitals. This aspect needs to be further evaluated and addressed at the earliest.  Nevertheless, the project continues to live through the resource pool created and the different stakeholders involved.