Anna-Karin Hurtig

The implications of policy changes on the uptake of a PMTCT programme in rural Malawi: first three years of experience

Objective: To study how the demand for antenatal care (ANC), HIV testing and hospital delivery was influenced by policy changes among pregnant women in rural Malawi. Design: Retrospective analysis of monthly reports. Setting: Malamulo SDA hospital in Thyolo district, Makwasa, Malawi. Methods: Three hospital-based registers were analysed from 2005 to 2007. These were general ANC, delivery and Prevention of Mother to Child Transmission (PMTCT) registers. Observations were documented regarding the introduction of specific policies and when changes were effected. Descriptive analytical methods were used. Results: The ANC programme reached 4,528 pregnant mothers during the study period. HIV testing among the ANC attendees increased from 52.6 to 98.8% after the introduction of routine (opt-out) HIV testing and 15.6% of them tested positive. After the introduction of free maternity services, ANC attendance increased by 42% and the ratio of hospital deliveries to ANC attendees increased from 0.50:1 to 0.66:1. Of the HIV-tested ANC attendees, 52.6% who tested positive delivered in the hospital and got nevirapine at the time of delivery. Conclusions: Increasing maternity service availability and uptake can increase the coverage of PMTCT programmes. Barriers such as economic constraints that prevent women in poor communities from accessing services can be removed by making maternity services free. However, it is likely, particularly in resource-poor settings, that significant increases in PMTCT coverage among those at risk can only be achieved by substantially increasing uptake of general ANC and delivery services.

Pesticide use among farmers in the Amazon basin of Ecuador.

Pesticide use is one of the most significant occupational exposures for agricultural workers in the Amazon basin of Ecuador. A structured questionnaire was developed focusing on sociodemographic characteristics, knowledge and experience of adverse health effects related to pesticide use, details of work practices, and an inventory of pesticides used on the farm. Of the 112 farmers interviewed, 111 (99.1%) used pesticides. Paraquat was most commonly used (77.4%), followed by glyphosate (65.7%). Respondents had good knowledge about the acute health effects of pesticides and their exposure routes. Risk behaviors were identified as frequent pesticide use, washing pesticide equipment in water sources used by humans, inadequate disposal of empty pesticide containers, eating and drinking during pesticide application, and using inadequate protective clothing. Training and educational campaigns on pesticide use should be encouraged for this cohort, along with suggestions for alternative methods of pest control.

Incidence of childhood leukemia and oil exploitation in the Amazon basin of Ecuador.

Abstract To determine whether there was any difference in childhood leukemia incidence rates between populations living in the proximity to oil fields and those living in areas free from oil exploitation in the Amazon basin of Ecuador, 91 cancer cases among children (0–14 years) from the provinces of Sucumbios, Orellana, Napo, and Pastaza during the period 1985–2000 were studied. The relative risks for all leukemias indicated significantly elevated levels in the youngest age group (0–4 years), both genders combined (RR 3.48, 95% CI 1.25–9.67), and in all age groups (0–14 years) combined for females (RR 2.60, 95% CI 1.11–6.08) and both genders combined (RR 2.56,95% CI 1.35–4.86). There was no significant difference between the two groups in all other cancer sites combined. Study results are compatible with a relationship between childhood leukemia incidence and living in the proximity of oil fields in the Ecuadorian Amazon.

Decentralization and health care prioritization process in Tanzania: from national rhetoric to local reality.

During the 1990s, Tanzania like many other developing countries adopted health sector reforms. The most common policy change under the health sector reforms has been decentralization, which involves the transfer of power and authority from the central level to local authorities. Based on the case study of Mbarali district in Tanzania, this paper uses a policy analysis approach to analyse the implementation of decentralized health care priority setting. Specifically, the paper examines the process, actors and contextual factors shaping decentralized health care priority setting processes. The analysis and conclusion are based on a review of documents, key informant interviews, focus group discussion, and notes from non-participant observation. The findings of the study indicate that local institutional contexts and power asymmetries among actors have a greater influence on the prioritization process at the local level than expected and intended. The paper underlines the essentially political character of the decentralization process and reiterates the need for policy analysts to pay attention to processes, institutional contexts, and the role of policy actors in shaping the implementation of the decentralization process at the district level.

Home deliveries: implications for adherence to nevirapine in a PMTCT programme in rural Malawi.

Abstract Although nevirapine (NVP) is provided by prevention of mother-to-child-transmission (PMTCT) of HIV programmes to be taken at onset of labor independent of place of delivery, few studies have assessed adherence to NVP outside the hospital setting. This study aimed to follow women in a PMTCT programme up to delivery and to assess the adherence to the prophylaxis in rural Malawi. A total of 75 HIV-positive women were registered in the PMTCT at Malamulo SDA hospital between January and June 2005. Forty women (53%) delivered in the hospital and 35 (47%) did not. Of the 35 women who delivered at home, it was possible to trace 27 (77.2%). All women who delivered in the hospital took their NVP tablets and all their babies had NVP syrup except one baby who died soon after delivery. Of the 27 traced women who had not delivered in the hospital, 16 (59.3%) had access to NVP and had taken their tablets during labor. However, none of their babies was taken back to the health facility for NVP syrup. Traditional birth attendants might be crucial in efforts aiming to increase adherence to NVP among women and their babies.

“It is a challenge to do it the right way”: an interpretive description of caregivers’ experiences in caring for migrant patients in Northern Sweden

BackgroundExperiences from nations with population diversity show extensive evidence on the need for cultural and linguistic competence in health care. In Sweden, despite the increasing diversity, only few studies have focused on challenges in cross-cultural care. The aim of this study was to explore the perspectives and experiences of caregivers in caring for migrant patients in Northern Sweden in order to understand the challenges they face and generate knowledge that could inform clinical practice.MethodsWe used an interpretive description approach, combining semi-structured interviews with 10 caregivers purposively selected and participant observation of patient-provider interactions in caring encounters. The interviews were transcribed and analyzed using thematic analysis approach. Field notes were also used to orient data collection and confirm or challenge the analysis.ResultsWe found complex and intertwined challenges as indicated in the three themes we present including: the sociocultural diversity, the language barrier and the challenges migrants face in navigating through the Swedish health care system. The caregivers described migrants as a heterogeneous group coming from different geographical areas with varied social, cultural and religious affiliations, migration histories and statuses, all of which influenced the health care encounter, whether providing or receiving. Participants also described language as a major barrier to effective provision and use of health services. Meanwhile, they expressed concern over the use of interpreters in the triad communication and over the difficulties encountered by migrants in navigating through the Swedish health care system.ConclusionsThe study illuminates complex challenges facing health care providers caring for migrant populations and highlights the need for multifaceted approaches to improve the delivery and receipt of care. The policy implications of these challenges are discussed in relation to the need to (a) adapt care to the individual needs, (b) translate key documents and messages in formats and languages accessible and acceptable to migrants, (c) train interpreters and enhance caregivers’ contextual understanding of migrant groups and their needs, (d) and improve migrants’ health literacy through strategies such as community based educational outreach.

Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries.

BackgroundDespite the development of national community-based health worker (CBHW) programmes in several low- and middle-income countries, their integration into health systems has not been optimal. Studies have been conducted to investigate the factors influencing the integration processes, but systematic reviews to provide a more comprehensive understanding are lacking.MethodsWe conducted a systematic review of published research to understand factors that may influence the integration of national CBHW programmes into health systems in low- and middle-income countries. To be included in the study, CBHW programmes should have been developed by the government and have standardised training, supervision and incentive structures. A conceptual framework on the integration of health innovations into health systems guided the review. We identified 3410 records, of which 36 were finally selected, and on which an analysis was conducted concerning the themes and pathways associated with different factors that may influence the integration process.ResultsFour programmes from Brazil, Ethiopia, India and Pakistan met the inclusion criteria. Different aspects of each of these programmes were integrated in different ways into their respective health systems. Factors that facilitated the integration process included the magnitude of countries’ human resources for health problems and the associated discourses about how to address these problems; the perceived relative advantage of national CBHWs with regard to delivering health services over training and retaining highly skilled health workers; and the participation of some politicians and community members in programme processes, with the result that they viewed the programmes as legitimate, credible and relevant. Finally, integration of programmes within the existing health systems enhanced programme compatibility with the health systems’ governance, financing and training functions. Factors that inhibited the integration process included a rapid scale-up process; resistance from other health workers; discrimination of CBHWs based on social, gender and economic status; ineffective incentive structures; inadequate infrastructure and supplies; and hierarchical and parallel communication structures.ConclusionsCBHW programmes should design their scale-up strategy differently based on current contextual factors. Further, adoption of a stepwise approach to the scale-up and integration process may positively shape the integration process of CBHW programmes into health systems.

Availability of drugs and medical supplies for emergency obstetric care: experience of health facility managers in a rural District of Tanzania

BackgroundProvision of quality emergency obstetric care relies upon the presence of skilled health attendants working in an environment where drugs and medical supplies are available when needed and in adequate quantity and of assured quality. This study aimed to describe the experience of rural health facility managers in ensuring the timely availability of drugs and medical supplies for emergency obstetric care (EmOC).MethodsIn-depth interviews were conducted with a total of 17 health facility managers: 14 from dispensaries and three from health centers. Two members of the Council Health Management Team and one member of the Council Health Service Board were also interviewed. A survey of health facilities was conducted to supplement the data. All the materials were analysed using a qualitative thematic analysis approach.ResultsParticipants reported on the unreliability of obtaining drugs and medical supplies for EmOC; this was supported by the absence of essential items observed during the facility survey. The unreliability of obtaining drugs and medical supplies was reported to result in the provision of untimely and suboptimal EmOC services. An insufficient budget for drugs from central government, lack of accountability within the supply system and a bureaucratic process of accessing the locally mobilized drug fund were reported to contribute to the current situation.ConclusionThe unreliability of obtaining drugs and medical supplies compromises the timely provision of quality EmOC. Multiple approaches should be used to address challenges within the health system that prevent access to essential drugs and supplies for maternal health. There should be a special focus on improving the governance of the drug delivery system so that it promotes the accountability of key players, transparency in the handling of information and drug funds, and the participation of key stakeholders in decision making over the allocation of locally collected drug funds.

Challenges to the implementation of health sector decentralization in Tanzania: experiences from Kongwa district council

Background During the 1990s, the government of Tanzania introduced the decentralization by devolution (D by D) approach involving the transfer of functions, power and authority from the centre to the local government authorities (LGAs) to improve the delivery of public goods and services, including health services. Objective This article examines and documents the experiences facing the implementation of decentralization of health services from the perspective of national and district officials. Design The study adopted a qualitative approach, and data were collected using semi-structured interviews and were analysed for themes and patterns. Results The results showed several benefits of decentralization, including increased autonomy in local resource mobilization and utilization, an enhanced bottom-up planning approach, increased health workers’ accountability and reduction of bureaucratic procedures in decision making. The findings also revealed several challenges which hinder the effective functioning of decentralization. These include inadequate funding, untimely disbursement of funds from the central government, insufficient and unqualified personnel, lack of community participation in planning and political interference. Conclusion The article concludes that the central government needs to adhere to the principles that established the local authorities and grant more autonomy to them, offer special incentives to staff working in the rural areas and create the capacity for local key actors to participate effectively in the planning process.

Fear of deportation may limit legal immigrants' access to HIV/AIDS-related care: a survey of Swedish language school students in Northern Sweden.

The increasing rates of HIV infection that are currently being reported in high-income countries can be partly explained by migration from countries with generalized epidemics. Yet, early diagnosis of HIV/AIDS in immigrants remains a challenge. This study investigated factors that might be limiting immigrants’ access to HIV/AIDS care. Data from 268 legal immigrant students of two Swedish language schools in Northern Sweden were analyzed using logistic regression. Thirty-seven percent reported reluctance to seek medical attention if they had HIV/AIDS. Fear of deportation emerged as the most important determinant of reluctance to seek care after adjusting for socio-demographic factors, knowledge level, stigmatizing attitudes and fear of disclosure. Targeted interventions should consider the heterogeneity of migrant communities and the complex interplay of various factors which may impede access to HIV-related services. The myth about deportation because of HIV/AIDS should be countered.