Jennifer Palmer

Mapping human resources for eye health in 21 countries of sub-Saharan Africa: current progress towards VISION 2020

BackgroundDevelopment of human resources for eye health (HReH) is a major focus of the Global Action Plan 2014 to 2019 to reduce the prevalence of avoidable visual impairment by 25% by the year 2019. The eye health workforce is thought to be much smaller in sub-Saharan Africa than in other regions of the world but data to support this for policy-making is scarce. We collected HReH and cataract surgeries data from 21 countries in sub-Sahara to estimate progress towards key suggested population-based VISION 2020 HReH indicators and cataract surgery rates (CSR) in 2011.MethodsRoutinely collected data on practitioner and surgery numbers in 2011 was requested from national eye care coordinators via electronic questionnaires. Telephone and e-mail discussions were used to determine data collection strategies that fit the national context and to verify reported data quality. Information was collected on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined with publicly available population data to calculate practitioner to population ratios and CSRs. Associations with development characteristics were conducted using Wilcoxon rank sum tests and Spearman rank correlations.ResultsHReH data was not easily available. A minority of countries had achieved the suggested VISION 2020 targets in 2011; five countries for ophthalmologists/cataract surgeons, four for ophthalmic nurses/clinical officers and two for CSR. All countries were below target for optometrists, even when other cadres who perform refractions as a primary duty were considered. The regional (sample) ratio for surgeons (ophthalmologists and cataract surgeons) was 2.9 per million population, 5.5 for ophthalmic clinical officers and nurses, 3.7 for optometrists and other refractionists, and 515 for CSR. A positive correlation between GDP and CSR as well as many practitioner ratios was observed (CSR P = 0.0042, ophthalmologists P = 0.0034, cataract surgeons, ophthalmic nurses and optometrists 0.1 > P > 0.05).ConclusionsWith only a minority of countries in our sample having reached suggested ophthalmic cadre targets and none having reached targets for refractionists in 2011, substantially more targeted investment in HReH may be needed for VISION 2020 aims to be achieved in sub-Saharan Africa.RésuméContexteLes ressources humaines en santé oculaire semblent être moindres en Afrique subsaharienne que dans les autres régions du monde, mais peu de données sont disponibles. Nous avons collecté des données sur les ressources humaines et le taux de chirurgie de la cataracte dans 21 pays de l’Afrique subsaharienne afin d’estimer pour 2011 les progrès réalisés concernant les indicateurs suggérés de ressources humaines et de chirurgie de la cataracte de VISION 2020.MéthodesLes données sur les six catégories de cadre de santé et les opérations de chirurgie régulièrement collectées en 2011 ont été demandées aux coordinateurs des programmes nationaux par questionnaire envoyé électroniquement. Des discussions par courrier électronique et téléphone ont permis de vérifier la qualité des données. Les associations avec les caractéristiques de développement ont été menées en utilisant le test de la somme des rangs de Wilcoxon et les coefficients de corrélation de Spearman.RésultatsUne minorité de pays ont atteint les cibles suggérées de VISION 2020: cinq pays pour les ophtalmologistes et les opérateurs de cataracte, quatre pays pour les infirmiers en ophtalmologie et les techniciens supérieurs en ophtalmologie et deux pays pour les opérations de cataracte. Tous les pays n’ont pas assez d’optométristes. Le ratio régional (échantillon) pour les chirurgiens (ophtalmologistes et operateurs de cataracte) était de 2,9 par million de population, 5,5 pour les infirmiers en ophtalmologie et les techniciens supérieurs en ophtalmologie, 3,7 pour les optométristes et autres réfractionnistes, et 515 pour le taux de chirurgie de cataracte. Il existe une corrélation positive entre PNB et le taux de chirurgie de cataracte et le PNB et le nombre de la plupart des professionnels (opération de cataracte P = 0.0042, ophtalmologistes P = 0.0034, opérateurs de cataracte, infirmiers en ophtalmologie et optométristes 0.1 > P > 0.05).ConclusionEtant donné que seulement une minorité de pays d’Afrique subsaharienne dans notre échantillon ont atteint en 2011 les cibles suggérées VISION 2020 en termes de nombre de professionnels de la santé oculaire et qu’aucun pays n’a un nombre suffisant de réfractionnistes, il est nécessaire et urgent d’investir dans les ressources humaines de la santé afin de pouvoir atteindre les objectifs VISION 2020.

Validity and feasibility of a satellite imagery-based method for rapid estimation of displaced populations

BackgroundEstimating the size of forcibly displaced populations is key to documenting their plight and allocating sufficient resources to their assistance, but is often not done, particularly during the acute phase of displacement, due to methodological challenges and inaccessibility. In this study, we explored the potential use of very high resolution satellite imagery to remotely estimate forcibly displaced populations.MethodsOur method consisted of multiplying (i) manual counts of assumed residential structures on a satellite image and (ii) estimates of the mean number of people per structure (structure occupancy) obtained from publicly available reports. We computed population estimates for 11 sites in Bangladesh, Chad, Democratic Republic of Congo, Ethiopia, Haiti, Kenya and Mozambique (six refugee camps, three internally displaced persons’ camps and two urban neighbourhoods with a mixture of residents and displaced) ranging in population from 1,969 to 90,547, and compared these to “gold standard” reference population figures from census or other robust methods.ResultsStructure counts by independent analysts were reasonably consistent. Between one and 11 occupancy reports were available per site and most of these reported people per household rather than per structure. The imagery-based method had a precision relative to reference population figures of <10% in four sites and 10–30% in three sites, but severely over-estimated the population in an Ethiopian camp with implausible occupancy data and two post-earthquake Haiti sites featuring dense and complex residential layout. For each site, estimates were produced in 2–5 working person-days.ConclusionsIn settings with clearly distinguishable individual structures, the remote, imagery-based method had reasonable accuracy for the purposes of rapid estimation, was simple and quick to implement, and would likely perform better in more current application. However, it may have insurmountable limitations in settings featuring connected buildings or shelters, a complex pattern of roofs and multi-level buildings. Based on these results, we discuss possible ways forward for the method’s development.

Trends and implications for achieving VISION 2020 human resources for eye health targets in 16 countries of sub-Saharan Africa by the year 2020

BackgroundDevelopment of human resources for eye health (HReH) is a major global eye health strategy to reduce the prevalence of avoidable visual impairment by the year 2020. Building on our previous analysis of current progress towards key HReH indicators and cataract surgery rates (CSRs), we predicted future indicator achievement among 16 countries of sub-Saharan Africa by 2020.MethodsSurgical and HReH data were collected from national eye care programme coordinators on six practitioner cadres: ophthalmologists, cataract surgeons, ophthalmic clinical officers, ophthalmic nurses, optometrists and ‘mid-level refractionists’ and combined them with publicly available population data to calculate practitioner-to-population ratios and CSRs. Data on workforce entry and exit (2008 to 2010) was used to project practitioner population and CSR growth between 2011 and 2020 in relation to projected growth in the general population. Associations between indicator progress and the presence of a non-physician cataract surgeon cadre were also explored using Wilcoxon rank sum tests and Spearman rank correlations.ResultsIn our 16-country sample, practitioner per million population ratios are predicted to increase slightly for surgeons (ophthalmologists/cataract surgeons, from 3.1 in 2011 to 3.4 in 2020) and ophthalmic nurses/clinical officers (5.8 to 6.8) but remain low for refractionists (including optometrists, at 3.6 in 2011 and 2020). Among countries that have not already achieved target indicators, however, practitioner growth will be insufficient for any additional countries to reach the surgeon and refractionist targets by year 2020. Without further strategy change and investment, even after 2020, surgeon growth is only expected to sufficiently outpace general population growth to reach the target in one country. For nurses, two additional countries will achieve the target while one will fall below it. In 2011, high surgeon practitioner ratios were associated with high CSR, regardless of the type of surgeon employed. The cataract surgeon workforce is growing proportionately faster than the ophthalmologist.ConclusionsThe HReH workforce is not growing fast enough to achieve global eye health targets in most of the sub-Saharan countries we surveyed by 2020. Countries seeking to make rapid progress to improve CSR could prioritise investment in training new cataract surgeons over ophthalmologists and improving surgical output efficiency.Additional non-English language abstract (French)ContexteLe développement des ressources humaines pour la santé oculaire est une priorité majeure des initiatives globales pour la réduction de la cécité d’ici à 2020. Sur la base de notre analyse précédente sur la situation en 2011, nous avons calculé les indicateurs de performance pour 2020 pour 16 pays de l’Afrique sub-saharienne.MéthodesLes données chirurgicales et en ressources humaines ont été collectées auprès des coordinateurs de programmes nationaux pour 6 cadres de santé (ophtalmologistes, opérateurs de la cataracte, techniciens supérieurs en ophtalmologie (TSO), infirmiers en ophtalmologie, optométristes et réfractionnistes) combinées avec les données démographiques. Les données sur entrée et sortie (2008–2011) de la force de travail ont été utilisées pour projeter le taux professionnel-population et le taux d’opérations chirurgicales entre 2011 et 2020. Les associations entre indicateur de performance et présence d’opérateurs de la cataracte ont été analysées en utilisant les tests de rang de somme Wilcoxon et les corrélations Spearman.RésultatsLes taux professionnel-population vont augmenter légèrement pour les chirurgiens (ophtalmologistes/opérateurs de la cataracte, de 3,1 en 2011 à 3,4 en 2020) et les TSO/infirmier en ophtalmologie (5,8 à 6,8) mais restent bas pour les réfractionnistes (optométristes inclus, à 3,6). Parmi les pays qui ont déjà atteint les indicateurs cibles en 2011, la croissance actuelle sera insuffisante pour atteindre les cibles en termes de chirurgiens et réfractionnistes d’ici à 2020. Seul un pays peut atteindre la cible chirurgien après 2020. Pour les infirmiers, deux pays vont atteindre la cible en 2020 tandis qu’un troisième sera juste en dessous. En 2011, les taux importants en chirurgiens étaient associés avec de hauts taux d’opérations de chirurgie quel que soit le type de chirurgien employé. La population en opérateur de chirurgie augmente proportionnellement plus rapidement que celle d’ophtalmologistes.ConclusionLa force de travail en santé oculaire n’augmente pas assez vite pour atteindre les cibles de performance d’ici à 2020 dans la plupart des pays d’Afrique sub-saharienne. Les pays qui veulent augmenter rapidement leur taux de chirurgie devraient investir sur les opérateurs de la cataracte plutôt que sur les ophtalmologistes, puisque cette population de professionnels peut s’accroitre plus rapidement.

A Mixed Methods Study of a Health Worker Training Intervention to Increase Syndromic Referral for Gambiense Human African Trypanosomiasis in South Sudan

Background Active screening by mobile teams is considered the most effective method for detecting gambiense-type human African trypanosomiasis (HAT) but constrained funding in many post-conflict countries limits this approach. Non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases for testing based on symptoms. We tested a training intervention for HCWs in peripheral facilities in Nimule, South Sudan to increase knowledge of HAT symptomatology and the rate of syndromic referrals to a central screening and treatment centre. Methodology/Principal Findings We trained 108 HCWs from 61/74 of the public, private and military peripheral health facilities in the county during six one-day workshops and assessed behaviour change using quantitative and qualitative methods. In four months prior to training, only 2/562 people passively screened for HAT were referred from a peripheral HCW (0 cases detected) compared to 13/352 (2 cases detected) in the four months after, a 6.5-fold increase in the referral rate observed by the hospital. Modest increases in absolute referrals received, however, concealed higher levels of referral activity in the periphery. HCWs in 71.4% of facilities followed-up had made referrals, incorporating new and pre-existing ideas about HAT case detection into referral practice. HCW knowledge scores of HAT symptoms improved across all demographic sub-groups. Of 71 HAT referrals made, two-thirds were from new referrers. Only 11 patients completed the referral, largely because of difficulties patients in remote areas faced accessing transportation. Conclusions/Significance The training increased knowledge and this led to more widespread appropriate HAT referrals from a low base. Many referrals were not completed, however. Increasing access to screening and/or diagnostic tests in the periphery will be needed for greater impact on case-detection in this context. These data suggest it may be possible for peripheral HCWs to target the use of rapid diagnostic tests for HAT.

Syndromic Algorithms for Detection of Gambiense Human African Trypanosomiasis in South Sudan

Background Active screening by mobile teams is considered the best method for detecting human African trypanosomiasis (HAT) caused by Trypanosoma brucei gambiense but the current funding context in many post-conflict countries limits this approach. As an alternative, non-specialist health care workers (HCWs) in peripheral health facilities could be trained to identify potential cases who need testing based on their symptoms. We explored the predictive value of syndromic referral algorithms to identify symptomatic cases of HAT among a treatment-seeking population in Nimule, South Sudan. Methodology/Principal Findings Symptom data from 462 patients (27 cases) presenting for a HAT test via passive screening over a 7 month period were collected to construct and evaluate over 14,000 four item syndromic algorithms considered simple enough to be used by peripheral HCWs. For comparison, algorithms developed in other settings were also tested on our data, and a panel of expert HAT clinicians were asked to make referral decisions based on the symptom dataset. The best performing algorithms consisted of three core symptoms (sleep problems, neurological problems and weight loss), with or without a history of oedema, cervical adenopathy or proximity to livestock. They had a sensitivity of 88.9–92.6%, a negative predictive value of up to 98.8% and a positive predictive value in this context of 8.4–8.7%. In terms of sensitivity, these out-performed more complex algorithms identified in other studies, as well as the expert panel. The best-performing algorithm is predicted to identify about 9/10 treatment-seeking HAT cases, though only 1/10 patients referred would test positive. Conclusions/Significance In the absence of regular active screening, improving referrals of HAT patients through other means is essential. Systematic use of syndromic algorithms by peripheral HCWs has the potential to increase case detection and would increase their participation in HAT programmes. The algorithms proposed here, though promising, should be validated elsewhere.

Behind the scenes: International NGOs’ influence on reproductive health policy in Malawi and South Sudan

ABSTRACT Global health donors increasingly embrace international non-governmental organisations (INGOs) as partners, often relying on them to conduct political advocacy in recipient countries, especially in controversial policy domains like reproductive health. Although INGOs are the primary recipients of donor funding, they are expected to work through national affiliates or counterparts to enable ‘locally-led’ change. Using prospective policy analysis and ethnographic evidence, this paper examines how donor-funded INGOs have influenced the restrictive policy environments for safe abortion and family planning in South Sudan and Malawi. While external actors themselves emphasise the technical nature of their involvement, the paper analyses them as instrumental political actors who strategically broker alliances and resources to shape policy, often working ‘behind the scenes’ to manage the challenging circumstances they operate under. Consequently, their agency and power are hidden through various practices of effacement or concealment. These practices may be necessary to rationalise the tensions inherent in delivering a global programme with the goal of inducing locally-led change in a highly controversial policy domain, but they also risk inciting suspicion and foreign-national tensions.

Setting the research agenda for induced abortion in Africa and Asia

Provision of safe abortion is widely recognized as vital to addressing the health and wellbeing of populations. Research on abortion is essential to meet the UN Sustainable Development Goals. Researchers in population health from university, policy, and practitioner contexts working on two multidisciplinary projects on family planning and safe abortion in Africa and Asia were brought together for a workshop to discuss the future research agenda on induced abortion. Research on care‐seeking behavior, supply of abortion care services, and the global and national policy context will help improve access to and experiences of safe abortion services. A number of areas have potential in designing intervention strategies, including clinical innovations, quality improvement mechanisms, community involvement, and task sharing. Research on specific groups, including adolescents and young people, men, populations affected by conflict, marginalized groups, and providers could increase understanding of provision, access to and experiences of induced abortion. Methodological and conceptual advances, for example in the measurement of induced abortion incidence, complications, and client satisfaction, conceptualizations of induced abortion access and care, and methods for follow‐up of patients who have induced abortions, will improve the accuracy of measurements of induced abortion, and add to understanding of womens experiences of induced abortions and abortion care.

Understanding how carers cope in a complex childhood disability in Turkana, Kenya :humanitarian setting : original research

Background Although the consequences of disability are magnified in humanitarian contexts, research into the difficulties of caring for children with a disability in such settings has received limited attention. Methods Based on in-depth interviews with 31 families, key informants and focus group discussions in Turkana, Kenya, this article explores the lives of families caring for children with a range of impairments (hearing, vision, physical and intellectual) in a complex humanitarian context characterised by drought, flooding, armed conflict, poverty and historical marginalisation. Results The challenging environmental and social conditions of Turkana magnified not only the impact of impairment on children, but also the burden of caregiving. The remoteness of Turkana, along with the paucity and fragmentation of health, rehabilitation and social services, posed major challenges and created opportunity costs for families. Disability-related stigma isolated mothers of children with disabilities, especially, increasing their burden of care and further limiting their access to services and humanitarian programmes. In a context where social systems are already stressed, the combination of these factors compounded the vulnerabilities faced by children with disabilities and their families. Conclusion The needs of children with disabilities and their carers in Turkana are not being met by either community social support systems or humanitarian aid programmes. There is an urgent need to mainstream disability into Turkana services and programmes.

Integrating innovations: a qualitative analysis of referral non-completion among rapid diagnostic test-positive patients in Uganda’s human African trypanosomiasis elimination programme

BackgroundThe recent development of rapid diagnostic tests (RDTs) for human African trypanosomiasis (HAT) enables elimination programmes to decentralise serological screening services to frontline health facilities. However, patients must still undertake multiple onwards referral steps to either be confirmed or discounted as cases. Accurate surveillance thus relies not only on the performance of diagnostic technologies but also on referral support structures and patient decisions. This study explored why some RDT-positive suspects failed to complete the diagnostic referral process in West Nile, Uganda.MethodsBetween August 2013 and June 2015, 85% (295/346) people who screened RDT-positive were examined by microscopy at least once; 10 cases were detected. We interviewed 20 RDT-positive suspects who had not completed referral (16 who had not presented for their first microscopy examination, and 4 who had not returned for a second to dismiss them as cases after receiving discordant [RDT-positive, but microscopy-negative results]). Interviews were analysed thematically to examine experiences of each step of the referral process.ResultsPoor provider communication about HAT RDT results helped explain non-completion of referrals in our sample. Most patients were unaware they were tested for HAT until receiving results, and some did not know they had screened positive. While HAT testing and treatment is free, anticipated costs for transportation and ancillary health services fees deterred many. Most expected a positive RDT result would lead to HAT treatment. RDT results that failed to provide a definitive diagnosis without further testing led some to question the expertise of health workers. For the four individuals who missed their second examination, complying with repeat referral requests was less attractive when no alternative diagnostic advice or treatment was given.ConclusionsAn RDT-based surveillance strategy that relies on referral through all levels of the health system is inevitably subject to its limitations. In Uganda, a key structural weakness was poor provider communication about the possibility of discordant HAT test results, which is the most common outcome for serological RDT suspects in a HAT elimination programme. Patient misunderstanding of referral rationale risks harming trust in the whole system and should be addressed in elimination programmes.

Including refugees in disease elimination: challenges observed from a sleeping sickness programme in Uganda

BackgroundEnsuring equity between forcibly-displaced and host area populations is a key challenge for global elimination programmes. We studied Uganda’s response to the recent refugee influx from South Sudan to identify key governance and operational lessons for national sleeping sickness programmes working with displaced populations today. A refugee policy which favours integration of primary healthcare services for refugee and host populations and the availability of rapid diagnostic tests (RDTs) to detect sleeping sickness at this health system level makes Uganda well-placed to include refugees in sleeping sickness surveillance.MethodsUsing ethnographic observations of coordination meetings, review of programme data, interviews with sleeping sickness and refugee authorities and group discussions with health staff and refugees (2013–2016), we nevertheless identified some key challenges to equitably integrating refugees into government sleeping sickness surveillance.ResultsDespite fears that refugees were at risk of disease and posed a threat to elimination, six months into the response, programme coordinators progressed to a sentinel surveillance strategy in districts hosting the highest concentrations of refugees. This meant that RDTs, the programme’s primary surveillance tool, were removed from most refugee-serving facilities, exacerbating existing inequitable access to surveillance and leading refugees to claim that their access to sleeping sickness tests had been better in South Sudan. This was not intentionally done to exclude refugees from care, rather, four key governance challenges made it difficult for the programme to recognise and correct inequities affecting refugees: (a) perceived donor pressure to reduce the sleeping sickness programme’s scope without clear international elimination guidance on surveillance quality; (b) a problematic history of programme relations with refugee-hosting districts which strained supervision of surveillance quality; (c) difficulties that government health workers faced to produce good quality surveillance in a crisis; and (d) reluctant engagement between the sleeping sickness programme and humanitarian structures.ConclusionsDespite progressive policy intentions, several entrenched governance norms and practices worked against integration of refugees into the national sleeping sickness surveillance system. Elimination programmes which marginalise forced migrants risk unwittingly contributing to disease spread and reinforce social inequities, so new norms urgently need to be established at local, national and international levels.