Sheba Gitta

Private and public health care in rural areas of Uganda

BackgroundIn many low and middle income countries, the private sector is increasingly becoming an important source of health care, filling gaps where no or little public health care is available. However, knowledge on the private sector providers is limited The objective of this study was to determine the type and number of different types of health care providers, and the quality, cost and utilization of care delivered by those providers in rural Uganda.MethodsThe study was carried out in three rural districts. Methods included (1) mapping of health care providers; (2) a household survey to determine morbidity and health care utilization; (3) a health facility survey to assess quality of care; (4) focus group discussions to get qualitative information on providers and provider choice; and (5) key informant interviews to further explore service characteristics.Results95.7% of all 445 facilities surveyed were private while 4.3% were public. Traditional practitioners and general merchandise shops that sold medicines comprised 77.1% of all providers. They had limited infrastructure and skills but were often located in the villages and therefore easily accessible. Among the formal providers there were 4 times as many private for profit providers than public, 76 versus 18. However, most of the private units were one-person drug shops.In the household survey, 2580 persons were interviewed. 1097 (42%) had experienced illness during the preceding month. Care was sought in 54.1% of the cases. 35.6% were given self-treatment and in 10.3% no action was taken. Of the episodes for which people sought care at a health care facility, 37.0% visited a public health care provider, 39.7% a for profit provider, 11.8% a private not for profit provider, and 10.6% a traditional practitioner. Private for profit facilities were the most popular for ambulatory health care, while public facilities were preferred for more serious conditions and for hospitalization. Traditional practitioners were many but saw relatively few patients. They were mostly used for social problems and limited medical specific conditions.ConclusionsPrivate providers play a major role in health care delivery in rural Uganda; reaching a wide client base. Traditional practitioners are many but have as much a social as a medical function in the community. The significance of the private health care sector points to the need to establish a policy that addresses quality and affordability issues and creates a strong regulatory environment for private practice in sub-Saharan Africa.

Laboratory capacity building for the International Health Regulations (IHR[2005]) in resource-poor countries: the experience of the African Field Epidemiology Network (AFENET)

Laboratory is one of the core capacities that countries must develop for the implementation of the International Health Regulations (IHR[2005]) since laboratory services play a major role in all the key processes of detection, assessment, response, notification, and monitoring of events. While developed countries easily adapt their well-organized routine laboratory services, resource-limited countries need considerable capacity building as many gaps still exist. In this paper, we discuss some of the efforts made by the African Field Epidemiology Network (AFENET) in supporting laboratory capacity development in the Africa region. The efforts range from promoting graduate level training programs to building advanced technical, managerial and leadership skills to in-service short course training for peripheral laboratory staff. A number of specific projects focus on external quality assurance, basic laboratory information systems, strengthening laboratory management towards accreditation, equipment calibration, harmonization of training materials, networking and provision of pre-packaged laboratory kits to support outbreak investigation. Available evidence indicates a positive effect of these efforts on laboratory capacity in the region. However, many opportunities exist, especially to support the roll-out of these projects as well as attending to some additional critical areas such as biosafety and biosecuity. We conclude that AFENET’s approach of strengthening national and sub-national systems provide a model that could be adopted in resource-limited settings such as sub-Saharan Africa.

Field Epidemiology Training Programmes in Africa - Where are the Graduates?

BackgroundThe current shortage of human resources for health threatens the attainment of the Millennium Development Goals. There is currently limited published evidence of health-related training programmes in Africa that have produced graduates, who remain and work in their countries after graduation. However, anecdotal evidence suggests that the majority of graduates of field epidemiology training programmes (FETPs) in Africa stay on to work in their home countries--many as valuable resources to overstretched health systems.MethodsAlumni data from African FETPs were reviewed in order to establish graduate retention. Retention was defined as a graduate staying and working in their home country for at least 3 years after graduation. African FETPs are located in Burkina Faso, Ethiopia, Ghana, Kenya, Nigeria, Rwanda, South Africa, the United Republic of Tanzania, Uganda and Zimbabwe. However, this paper only includes the Uganda and Zimbabwe FETPs, as all the others are recent programmes.ResultsThis review shows that enrolment increased over the years, and that there is high graduate retention, with 85.1% (223/261) of graduates working within country of training; most working with Ministries of Health (46.2%; 105/261) and non-governmental organizations (17.5%; 40/261). Retention of graduates with a medical undergraduate degree was higher (Zimbabwe 80% [36/83]; Uganda 90.6% [125/178]) than for those with other undergraduate qualifications (Zimbabwe 71.1% [27/83]; Uganda 87.5% [35/178]).ConclusionsAfrican FETPs have unique features which may explain their high retention of graduates. These include: programme ownership by ministries of health and local universities; well defined career paths; competence-based training coupled with a focus on field practice during training; awarding degrees upon completion; extensive training and research opportunities made available to graduates; and the social capital acquired during training.

Cholera Surveillance in Uganda: An Analysis of Notifications for the Years 2007–2011

INTRODUCTION Cholera outbreaks have occurred periodically in Uganda since 1971. The country has experienced intervals of sporadic cases and localized outbreaks, occasionally resulting in prolonged widespread epidemics. METHODS Cholera surveillance data reported to the Uganda Ministry of Health from 2007 through 2011 were reviewed to determine trends in annual incidence and case fatality rate. Demographic characteristics of cholera cases were analyzed from the national line list for 2011. Cases were analyzed by district and month of report to understand the geographic distribution and identify any seasonal patterns of disease occurrence. RESULTS From 2007 through 2011, Uganda registered a total of 7615 cholera cases with 181 deaths (case fatality rate = 2.4%). The absolute number of cases and incidence per 100 000 varied from year to year with the highest incidence occurring in 2008 following heavy rainfall and flooding in eastern Uganda. For 2011, cholera cases occurred in 1.6 times more males than females. The geographical areas affected by the outbreaks shifted each year, with the exception of a few endemic districts. No clear seasonal trends in cholera occurrence were identified for this time period. CONCLUSIONS We observed an overall decline in cases reported during the 5 years under review. During this period, concerted efforts were made by the Ugandan government and development partners to educate communities on proper sanitation and hygiene and provide safe water and timely treatment. Mechanisms to ensure timely and complete cholera surveillance data are reported to the national level should continue to be strengthened.

The genesis and evolution of the African Field Epidemiology Network

Background ABO blood group antigens are formed by terminal glycosylation of glycoproteins and glycolipid chains present on cell surfaces. Glycosylation modulates all kinds of cell-to-cell interactions and this may be relevant in malaria pathophysiology, in which adhesion has been increasingly implicated in disease severity. This study was done to determine the association between ABO phenotypes and the severity of P. falciparum malaria in children. Methods One hundred and twenty one children were assessed at the Department of Child Health, KBTH from May to August 2008. ABO blood groups were determined by agglutination. The haemoglobin measurement was done with the haematology analyzer, Sysmex KX-21N. Malaria parasites were enumerated and the presence of malaria pigment noted. Identification of P. falciparum was done. Statistical tests used were odds ratio and chi square at a significance level of p<0.05. Results 24.3% of the 121 children had severe falciparum malaria, and their mean haemoglobin was 4.49 g/dl (SD ±1.69). No significant association was found between the ABO phenotypes and malaria infection (p>0.05). Blood group A was associated with more severe malaria as compared to the blood group O individuals (Odds ratio=0.79, p>0.05); blood group AB (Odds ratio=0.14, p>0.05) and also there was a significant difference in severity of malaria between blood group O and blood group B (Odds ratio=1.28, p>0.05). Conclusion Non-O blood group children are more prone to severe malaria caused by P. falciparum malaria than the group O, despite the lack of significant association between ABO blood groups and falciparum malaria.

Performance of an HRP-2 Rapid Diagnostic Test in Nigerian Children Less Than 5 Years of Age

The diagnostic performance of histidine-rich protein 2 (HRP-2)-based malaria rapid diagnostic test (RDT) was evaluated in a mesoendemic area for malaria, Kaduna, Nigeria. We compared RDT results with expert microscopy results of blood samples from 295 febrile children under 5 years. Overall, 11.9% (35/295) tested positive with RDT compared with 10.5% (31/295) by microscopy: sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 100%, 98.5%, 88.6%, and 100%, respectively. The RDT sensitivity was not affected by transmission season, parasite density, and age. Specificity and positive PV decreased slightly during the high-transmission season (97.5% and 83.3%). The RDT test positivity rates in the low- and high-transmission seasons were 9.4% and 13.5%, respectively. Overall, the test performance of this RDT was satisfactory. The findings of a low proportion of RDT false positives, no invalid and no false-negative results should validate the performance of RDTs in this context.

High concentration of blood lead levels among young children in Bagega community, Zamfara - Nigeria and the potential risk factor.

Introduction In May 2010, lead poisoning (LP) was confirmed among children <5years (U5) in two communities in Zamfara state, northwest Nigeria. Following reports of increased childhood deaths in Bagega, another community in Zamfara, we conducted a survey to investigate the outbreak and recommend appropriate control measures. Methods We conducted a cross-sectional survey in Bagega community from 23rd August to 6th September, 2010. We administered structured questionnaires to parents of U5 to collect information on household participation in ore processing activities. We collected and analysed venous blood samples from 185 U5 with LeadCare II machine. Soil samples were analysed with X-ray fluorescence spectrometer for lead contamination. We defined blood lead levels (BLL) of >10ug/dL as elevated BLL, and BLL ≥45ug/dL as the criterion for chelation therapy. We defined soil lead levels (SLL) of ≥400 parts per million (ppm) as elevated SLL. Results The median age of U5 was 36 months (Inter-quartile range: 17-48 months). The median BLL was 71µg/dL (range: 8-332µg/dL). Of the 185 U5, 184 (99.5%) had elevated BLL, 169 (91.4%) met criterion for CT. The median SLL in tested households (n = 37) of U5 was 1,237ppm (range: 53-45,270ppm). Households breaking ore rocks within the compound were associated with convulsion related-childrens death (OR: 5.80, 95% CI: 1.08 - 27.85). Conclusion There was an LP outbreak in U5 in Bagega community possibly due to heavy contamination of the environment as a result of increased ore processing activities. Community-driven remediation activities are ongoing. We recommended support for sustained environmental remediation, health education, intensified surveillance, and case management.

Morbidity and mortality due to malaria in Est Mono district, Togo, from 2005 to 2010: a times series analysis

BackgroundIn 2004, Togo adopted a regional strategy for malaria control that made use of insecticide-treated nets (ITNs), followed by the use of rapid diagnostic tests (RDTs), artemisinin-based combination therapy (ACT). Community health workers (CHWs) became involved in 2007. In 2010, the impact of the implementation of these new malaria control strategies had not yet been evaluated. This study sought to assess the trends of malaria incidence and mortality due to malaria in Est Mono district from 2005 to 2010.MethodsSecondary data on confirmed and suspected malaria cases reported by health facilities from 2005 to 2010 were obtained from the district health information system. Rainfall and temperature data were provided by the national Department of Meteorology. Chi square test or independent student’s t-test were used to compare trends of variables at a 95% confidence interval. An interrupted time series analysis was performed to assess the effect of meteorological factors and the use of ACT and CHWs on morbidity and mortality due to malaria.ResultsFrom January 2005 to December 2010, 114,654 malaria cases (annual mean 19,109 ± 6,622) were reported with an increase of all malaria cases from 10,299 in 2005 to 26,678 cases in 2010 (p<0.001). Of the 114,654 malaria cases 52,539 (45.8%) were confirmed cases. The prevalence of confirmed malaria cases increased from 23.1 per 1,000 in 2005 to 257.5 per 1,000 population in 2010 (p <0.001). The mortality rate decreased from 7.2 per 10,000 in 2005 to 3.6 per 10,000 in 2010 (p <0.001), with a significant reduction of 43.9% of annual number of death due to malaria. Rainfall (β-coefficient = 1.6; p = 0.05) and number of CHWs trained (β-coefficient = 6.8; p = 0.002) were found to be positively correlated with malaria prevalence.ConclusionThis study showed an increase of malaria prevalence despite the implementation of the use of ACT and CHW strategies. Multicentre data analysis over longer periods should be carried out in similar settings to assess the impact of malaria control strategies on the burden of the disease. Integrated malaria vector control management should be implemented in Togo to reduce malaria transmission.

Training and Service in Public Health, Nigeria Field Epidemiology and Laboratory Training, 2008 – 2014

The health workforce is one of the key building blocks for strengthening health systems. There is an alarming shortage of curative and preventive health care workers in developing countries many of which are in Africa. Africa resultantly records appalling health indices as a consequence of endemic and emerging health issues that are exacerbated by a lack of a public health workforce. In low-income countries, efforts to build public health surveillance and response systems have stalled, due in part, to the lack of epidemiologists and well-trained laboratorians. To strengthen public health systems in Africa, especially for disease surveillance and response, a number of countries have adopted a competency-based approach of training - Field Epidemiology and Laboratory Training Program (FELTP). The Nigeria FELTP was established in October 2008 as an inservice training program in field epidemiology, veterinary epidemiology and public health laboratory epidemiology and management. The first cohort of NFELTP residents began their training on 20th October 2008 and completed their training in December 2010. The program was scaled up in 2011 and it admitted 39 residents in its third cohort. The program has admitted residents in six annual cohorts since its inception admitting a total of 207 residents as of 2014 covering all the States. In addition the program has trained 595 health care workers in short courses. Since its inception, the program has responded to 133 suspected outbreaks ranging from environmental related outbreaks, vaccine preventable diseases, water and food borne, zoonoses, (including suspected viral hemorrhagic fevers) as well as neglected tropical diseases. With its emphasis on one health approach of solving public health issues the program has recruited physicians, veterinarians and laboratorians to work jointly on human, animal and environmental health issues. Residents have worked to identify risk factors of disease at the human animal interface for influenza, brucellosis, tick-borne relapsing fever, rabies, leptospirosis and zoonotic helminthic infections. The program has been involved in polio eradication efforts through its National Stop Transmission of Polio (NSTOP). The commencement of NFELTP was a novel approach to building sustainable epidemiological capacity to strengthen public health systems especially surveillance and response systems in Nigeria. Training and capacity building efforts should be tied to specific system strengthening and not viewed as an end to them. The approach of linking training and service provision may be an innovative approach towards addressing the numerous health challenges.

Building a public health workforce in Nigeria through experiential training

A competently trained public health workforce that can operate multidisease surveillance and response systems is required for timely detection and response to public health emergencies. The backbone of any disease control is a robust surveillance system that is interlinked with timely quality response[1, 2]. The traditional approaches of training health care workers particularly public health workers have emphasized knowledge acquisition without commensurate competency acquisition; experiential training on the other hand has been successful in creating and sustaining a skilled workforce [3, 4] Experiential training comprises acquisition of necessary knowledge, skills, competencies, attitudes and behaviors that enable a person to perform certain tasks adequately in their profession. Experiential training enables a professional to rapidly move from an awareness level in the proficiency of doing a task to being completely proficient, performing and teaching the task to others-in effect it is teaching and learning by doing. This concept of training has been adopted by a number of countries to build their public health workforces drawing experiences from the Epidemic Intelligence Service(EIS) which began training using this approach in United States of America in 1951[4–10]. This model has been adapted internationally to create the Field Epidemiology and Laboratory Training Program (FELTP) in several countries[1]. Nigeria adopted the experiential training approach to build its public health workforce in 2008 with the implementation of the multiagency Nigeria Field Epidemiology and Laboratory Training Program (NFELTP). This approach was embraced to augment other traditional training approaches by emphasizing a field based, competency-based approach to training public health workforce through a tiered approach. The training typically consists of a 2-year course leading to a masters degree in field epidemiology and public health laboratory management for midlevel public health leaders and competency-based short courses for frontline public health surveillance workers. Trainees and graduates work in multidisciplinary teams to conduct surveillance, outbreak investigations, and epidemiological studies for disease control locally and across borders. The training is multi-sectoral and multi-displinary cutting across various cadres of health care workers and animal health sector professionals in the “one health” approach[11, 12]. NFELTP is a public health service-training program in applied epidemiology aimed at preparing leaders in field epidemiology to address public health issues and strengthen public health systems throughout Nigeria. The overall goals of NFELTP are: 1) to develop a self-sustaining institutionalized capacity to train public health leaders in field epidemiology (including veterinary epidemiology) and field-oriented public health laboratory practice and 2) to provide epidemiological services to the public health system at federal, state and local government levels. It is believed that a country would have an adequate coverage of public health workers trained in the experiential approach of the FELTP if there are three to five graduates of the program per million inhabitants working in suitable public health units [2]. The NFELTP is one of the premier FELTPs on the African continent. NFELTP was started as a joint effort between the Nigeria Federal Government (GON) through the Federal Ministry of Health (FMOH), the Federal Ministry of Agriculture and Rural Development (FMARD) and U.S. government through the Centers for Disease Control and Prevention (CDC). NFELTP aims to provide the country with the public health workforce that is needed to operate public health surveillance and response systems to implement the Integrated Disease Surveillance and Response (IDSR) strategy, address the Millennium Development Goals, implement the revised International Health Regulations and operationalize closer collaborations between the animal and human health (i.e., the “one world one health concept”). The experience of the avian influenza outbreak in Nigeria in 2006 demonstrated the importance of one health through the collaboration of the health sectors (human and animal) in capacity development and disease prevention and control. During and upon completion of training, NFELTP residents and graduates provide skill services to national and sub-national public health surveillance and response systems, with growing responsibility as they gain experience. With a population of 170 million, residing in 36 states and a Federal Capital Territory (FCT) and separated into six geopolitical regions there is a need to provide state and federal public health offices manned by professionals that have the ability to strengthen public health capacity to investigate and respond to outbreaks in addition to working together across disciplines collaboratively. To provide these services and work towards improving public health systems within Nigeria there is a need for the training of highly qualified individuals in field epidemiology to respond to the vast amount of public health concerns and threats that arise throughout the country. The different climatic patterns found in the three main geographic regions of the country: mangrove swamps to equatorial forest in the South, tropical in the Central, and Savannah in the North have implications for development of multiple public health challenges. For example the northern region is vulnerable to drought, desertification, food insecurity, and diseases especially cerebrospinal meningitis. In the south, disasters such as erosion, flooding and landslides, and vector-borne diseases are common. With recurrent infectious disease outbreaks, persistence of wild polio transmission, poor health outcomes, there is a need for investment in development of an effective customized and locally developed skilled public health workforce to address public health needs and priorities across the nation. Weak surveillance systems coupled with untimely and uncoordinated response to disease outbreaks have continued to be a challenge in many African countries including Nigeria. Additionally, emerging pandemic threats require development of worldwide capacity for public health surveillance and response especially given the increased travel and urbanization. Good international public health surveillance and response, which is the basis of International Health Regulations (IHR) of 2005, cannot exist sustainably without good national surveillance and response operated by competent public health workforce in core public health positions at national and sub-national levels with a focus on disease detection, prevention and control. To achieve this, there is need to address several interrelated factors on human resources, disease surveillance and reporting capacity in an integrated and sustainable approach that enables the development of public health work force capacity in order to achieve public health surveillance and response systems that have a sustainable and adaptable capacity to address evolving public health needs[2]. This supplement is a demonstration of some of the results of NFELTP residents and graduates in addressing current public health challenges such as disease outbreaks and surveillance gaps for infectious and non-infectious diseases. The support to the program by the Government and its health development partners has enabled the program to upscale towards attaining its goal of building a public health workforce through experiential training and providing epidemiological services to improve public health in Nigeria and beyond. The authors describe the processes, operations and coverage of the program and provide disease specific examples on public health response. With the increasing appreciation of the need for global health security, NFELTP is laying the foundation for a new cadre of highly skilled public health workforce adaptable to numerous public health needs in a large diverse developing country beset with several health challenges. A skilled workforce is a prerequisite for strengthening national public health institutes and the program is creating the frontline health workers for this global initiative within the newly established Nigeria Centre for Disease Control. The authors in this supplement demonstrate the collaborative efforts of multiple agencies and the multi-disciplinary and multi-sectoral approach to optimal health of the population. With only six years of implementation and a newly developed 5 year strategic plan the program has shown that it can surmount its initial start-up challenges and play its rightful role in public health system strengthening[13].