Category Archives: Global health

Active case finding in tuberculosis

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ResearchBlogging.orgEven if 36 million patients with tuberculosis were successfully treated, and up to 6 million lives were saved during the past 15 years, tuberculosis remains a major public health problem. More than 9 million cases occur every year.

Unfortunately, only a little more that half of the expected cases are identified yearly and receive proper care. We therefore need novel measures to diagnose, treat, and thus stop transmission of tuberculosis.

Many have previously questioned the role of active case finding in reducing tuberculosis prevalence. Recently, several active case-finding strategies for tuberculosis were tested and proved to be effective, both in urban (Corbett, Bandason et al. 2010) and rural settings (Datiko and Lindtjørn 2009). The Lancet study (Corbett, Bandason et al. 2010) also documented the effect on the prevalence of culture-positive tuberculosis. The study from Ethiopia also showed that active case finding is a cost-effective strategy (Datiko and Lindtjørn 2010).

These studies highlight active case-finding in tuberculosis control efforts, especially in settings where HIV is prevalent and in weak health systems.

Some of the research priorities for countries with weak health systems should include:

  • Evaluate tools for effective active case-finding so it reduces tuberculosis prevalence. To do this we should also set up good records on tuberculosis prevalence, and thus be able to document a future decline in tuberculosis prevalence.
  • We need to develop different models for active case finding in communities. By this, I mean practical tools on how to do this in a local community. We are starting a new research in Ethiopia to develop “tuberculosis suspect registries” in the communities as a tool to identify patients with tuberculosis.
  • In addition, we urgently need fast, accurate, and simple diagnostic test.

And, scaling up active case-finding outside health institutions needs to be paired with increased scientific interest, research investment, and political commitment for high-quality basic and operational research.

Corbett, E., Bandason, T., Duong, T., Dauya, E., Makamure, B., Churchyard, G., Williams, B., Munyati, S., Butterworth, A., & Mason, P. (2010). Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial The Lancet, 376 (9748), 1244-1253 DOI: 10.1016/S0140-6736(10)61425-0

Datiko DG, Lindtjorn B (2009) Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.

Datiko DG, Lindtjorn B (2010) Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 5: e9158.

Achieving MDGs?

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The United Nations recently discussed the achievements so far in achieving the Millennium Development Goals. The goals aim to:

  • Eradicate extreme poverty and hunger
  • Achieve universal primary education
  • Promote gender equality and empower women
  • Reduce child mortality
  • Improve maternal health
  • Combat HIV/Aids, malaria and other diseases
  • Ensure environmental sustainability
  • Develop a Global Partnership for Development

The Prime Minister of Norway, Jens Stoltenberg and the Gordon Brown, former PM of Great Britain, underline that governments of poorer nations have to put resources into education and health, and not into corruption.

As I have outlined previously, corruption is widespread at health institutions. Fighting corruption is necessary because corruption reduces the resources available for health. Corruption also lowers the quality, equity and effectiveness of health care services, and it decreases the volume and increases the cost of provided services. Corruption also discourages people to use and pay for health services.

It is encouraging that world leaders talk about broadening the tax base, and identify fighting corruption as a means of achieving the MDGs. The leading donors should encourage governments to put in place mechanisms at each institution to reduce corruption. This should include such basic functions and proper accounting systems and mechanisms for independent financial audits.

Maternal Mortality in Ethiopia

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In a special issue of the Ethiopian Journal of Health Development, eight papers discuss important topics such as maternal mortality trends, infrastructure and resources available for maternal health, and maternal health care use.

The articles show there have been improvements in antenatal care coverage and Tetanus Toxoid immunization. Unfortunately, delivery by skilled attendants and post-natal care coverage remain low. Ethiopia is making little progress in the indicator (skilled attendance at birth) that is considered to be the most important predictor of maternal mortality.

One of the papers discusses how to interpret trend data on maternal mortality ratio. Comparing the results of 2000 and 2005 Ethiopian Demographic Health Survey show there appears to be a decline in maternal mortality. However, as the overlaps in the 95% confidence intervals overlap, we cannot be certain about the decline.

Specialists and health care for the poor

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I recently had a long chat with young general practitioners in south Ethiopia. «Our aim is to become specialist doctors», they said. I replied that most specialists do not return to the rural areas they come from and where they first intended to work in. Their answer was there was a need for specialist in the large city hospitals, and after having endured hardship as General Practitioners and with established families, they found it natural not to return to the rural and poor South Ethiopia.

And the tendency is that general specialists in fields as internal medicine and surgery want to continue training and become subspecialists.

A recent Naturejobs paper discusses the career of PhD graduates. Some PhD graduates end up doing very specific tasks, often in academic institutions. However, through their PhD training they gain valuable general skills that qualify them for more general careers. Industry usually wants highly skilled and trained people with a flexible attitude. The PhD researcher who insists on limiting their work to a narrow area of research specialisation sometimes end as «Research Geek».

In research, as in practical medicine, most of the work is routine, and deals with everyday problems. Specialist gain general skills during their training that they could and should use for the benefit of patients and health problems beyond their narrow specialisation.

A few days ago I was working at the remote Saula Hospital in South-west Ethiopia. During the rounds in the inn-patient ward I realised that many of the seriously sick patients had not been diagnosed properly. A patient with pyomyositis (multiple abscesses) had an underlying leukaemia. A patient with grossly swollen breasts did not have a breast disease, but a severe heart failure. A three-year-old child with fast breathing had been treated for pneumonia, but had severe falciparum malaria infection.

Poor diagnostic work leads to poor treatment and care, and is probably the reason only 10 patients were admitted to Saula Hospital from a population of 800.000 people in its catchment area. Hospitals as Saula needs specialists, but of a kind that is willing to go beyond their own specialisation.

Unfortunately, the international trend, now also affecting developing countries, is to increase specialisation and thus leave a large part of the work to nurses, non-physician clinicians, and to newly educated doctors doing compulsory services in remote hospitals.

New issue of Ethiopian Journal of Health Development

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The contents include:
Editorial
Original articles
Bibliography on HIV/AIDS

Reducing maternal deaths in south-west Ethiopia

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Deaths from maternal causes still represent the leading cause of deaths among women of reproductive age in Ethiopia. We work on a public programme with the Ministry of Health in South-west Ethiopia to improve maternal health and reduce maternal and neonatal deaths (population 2.8 million).

As seen from the First Half-year report 2010 for our project, the number of institutions carrying out Comprehensive Obstetric care has since 2008 increased from two hospitals to 7 institutions (five hospitals and two health centres). The number of Caesarean Sections is doubled, and many lives of mothers and children have been saved.

We hope by 2011 to enable four more health centres doing these essential functions.

Do NGOs corrupt health institutions?

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Many international organizations and Non-Governmental Organizations (NGOs) support health work in developing countries. Often, their work is to train staff to get necessary skills, and thus improve health services. Each NGO have their specific goals, and wish these tasks to be carried out at institution. Good examples that have helped many patients include HIV work, reproductive health, and support to specialists to carry out operations at rural institutions.

Although the NGOs do this with the best of intentions, their support is often misused, and unfortunately weakens institutional sustainability and equity.

Some negative examples from south Ethiopia include:

  1. A NGO supports that patients with diseases such cleft lips are operated at district hospitals. The organizations provide the local staff with good training to carry out such treatment. Many patients receive good treatment. Unfortunately, we often note after the early campaigns, operations are not done between campaigns as planned. The NGO pays extra for each operation to the staff during campaigns, but not for operations done between campaigns. This often leads to staff only operating when they receive extra payment. This is an example of “misuse of entrusted power for private gain” (Transparency international definition of corruption).
  2. UN organizations and NGOs often organize training seminars and workshops. The participants might receive daily allowances up to half of their monthly salaries. Unfortunately, some participants are not even qualified to carry out the intended work. We know of examples when managers, without medical training, took part in course on how to treat drug resistant tuberculosis. And some staff take part in courses to resuscitate neonates, but never work in a delivery ward. Again, examples of “misuse of entrusted power for private gain”.

I believe it is time for NGOs and International organizations to look into the side effects of their massive support to health institutions. A proper question is: Are there alternative ways to support institutions with much needed training, and at the same time not tempting the institutions and individuals to take part in corruption?

Most international organizations and NGOs have increased sustainability and equity as part of their visions. If sustainability and equity is a goal for such organization, new ways to support the institutions should be sought.

Reducing corruption at health institutions

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ResearchBlogging.orgCorruption depletes resources from the health institutions such as hospitals and health centres. For example, countries with a high corruption index have higher child mortality rates. How can health institutions reduce corruption, and increase available resources for patient treatment?

In a good review article, Taryn Vian (2007) defines what corruption at health institutions is, explains why it reduces necessary and scarce resources, and how corruption can be reduced. Vian outlines the mechanisms on how managers rationalize social norms, moral or ethical beliefs, attitudes and personalities to their own benefit. Weak accountability, lack of citizen voice and transparency turn out to be opportunities for abuse. And, poor wages and pressures from clients become pressures for misuse.

Unfortunately, many health institutions have weak management, inadequate accounting, and there are few lawyers to follow up financial misuse at health institutions. However, much can be done to reduce corruption. In our work in Ethiopia we try to focus on the following points as part of a ways to ensure sustainable health institutions.

  1. Each institution needs good and sound accounting carried out by trained staff. The institution should produce regular and acceptable financial reports
  2. Each institution must simplify the cash collection procedures, and internal auditors must daily check the cash collection.
  3. The institutional board should routinely review that purchases are done as wanted by the government
  4. Institutions should regularly be supervised and checked by public licensing authorities
  5. Each institutions should keep an absentee registry, and thus assure that workers do not collect salaries and work at other places
  6. Each institution needs yearly financial audits. As health institutions collect patient fees, institutions are accountable to the public. Therefore both public and certified auditing institutions should audit the finances of health institutions.

During the past years we have seen hospitals worsen because of changes of staff and a lack of control mechanisms. External support to health institutions in many developing countries should be accompanied with a need for sound management, accounting and auditing practices.

Vian, T. (2007). Review of corruption in the health sector: theory, methods and interventions Health Policy and Planning, 23 (2), 83-94 DOI: 10.1093/heapol/czm048

Global warming and malaria

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ResearchBlogging.orgA recent article by Gething and colleagues in Nature (May 20th, 2010) shows that malaria has declined the past century. The decline has been largest in areas with less malaria transmission.

What is new in this paper is that the malaria decline takes place during global warming. The reasons for decline might be non-climatic factors such as better treatment and prevention. Their research addresses malaria on large scales, and the situation might be different in local areas.

Linking changes in temperatures to variations in malaria epidemiology is justified by known biological effects on life-cycle stages of the Anopheles vector and Plasmodium parasite. For example increasing temperature to 30o C results in shortened sporogonic period of the Plasmodium parasite, and differently for P. falciparum and P. vivax. Higher mean daily temperatures are not favourable for vector survival. Increased temperature speeds up development of the aquatic stages of the vector.

Therefore, some propose developing tools to forecast malaria epidemics. We use different terminology to describe malaria risks, and distinguish between long-term forecasts, early warning and early detection of epidemics.

Long-term epidemic forecasting is based on climate forecasting, and many use information such as the El Niño Southern Oscillation indices as added information to predict epidemic risks months in advance over large geographical areas. Such a forecast allows time for the population to prepare for a possible epidemic in the following malaria season.

Malaria epidemic early warning is based on surveying transmission risks to predict timing of an increase because of abnormal rainfall or temperature. Often, such risks are influenced by population vulnerability such as history of low malaria transmission. Such predictions can give lead times of weeks to months.

The long-term and early warning should however be distinguished from epidemic early detection. This involves noting the beginning of an unusual epidemic, and offers short lead time (days to weeks) for preparation of preventive measures.

We are studying the association between temperature, rainfall, mosquito development and malaria in both lowlands and highlands in Ethiopia. Through this research, we hope to improve our understanding of the local variations in malaria epidemiology. Our aim is to examine if the spatio-temporal distribution of surface temperature and rain can predict malaria epidemics (both long-term forecasting, and malaria epidemic early warning). We base this on an assumption the nature of the link between climate and occurrence of malaria is constant and similar for different settings.

Gething, P., Smith, D., Patil, A., Tatem, A., Snow, R., & Hay, S. (2010). Climate change and the global malaria recession Nature, 465 (7296), 342-345 DOI: 10.1038/nature09098

Corruption at health institution

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ResearchBlogging.orgCorruption at health institution is a concern in all countries, but it is especially in developing countries where public resources are already scarce.

Countries with high indices of corruption have for example higher rates of infant mortality.

A recent World Bank report from Ethiopia (Lindelow and Serneels 2006) report on “pilfering drugs and materials, informal health care provision and illicit charging, and corruption” at health institutions in Ethiopia. The authors focus on “weak accountability mechanisms and the erosion of professional norms in the health sector” as a main causes of corruption.

Fighting corruption is important because corruption reduces the resources available for health. Corruption also lowers the quality, equity and effectiveness of health care services, and it decreases the volume and increases the cost of provided services. Corruption also discourages people to use and pay for health services.

Some examples of corruption in health care (from Vian 2002):

  • During construction and rehabilitation of health institutions: bribes, kickbacks and political considerations influence the contracting work, and contractors fail to perform and are not held accountable
  • Buying equipment, supplies, and drugs: bribes, kickbacks, and political considerations influence specifications and winners of bids, bid rigging during procurement, lack of incentives to choose low cost and high-quality suppliers. Suppliers might fail to deliver and are not held accountable
  • Distribution and use of drugs and supplies in service delivery: Theft (for personal use) or diversion (for resale to private institutions) of drugs and supplies at storage and distribution points. It also includes sale of drugs or supplies that were supposed to be free
  • Education of health professionals: bribes to gain place in medical school or other pre-service training, bribes to obtain passing grades, and political influence, nepotism in selection of candidates for training opportunities

Preventing abuse and reducing corruption is important to increase resources available for health, and thus to improve the health status of the population.

In our health work in Ethiopia we only work with institutions that focus of transparent management procedures, and have proper accounting and perform regular external financial audit. In our experience it is also important that public auditing institutions (“Office of general audit”) regularly evaluate health institutions.

References:

Lindelow, M., & Serneels, P. (2006). The performance of health workers in Ethiopia: Results from qualitative research Social Science & Medicine, 62 (9), 2225-2235 DOI: 10.1016/j.socscimed.2005.10.015

Vian T. 2002. Corruption and the Health Sector. http://www.usaid.gov/our_work/democracy_and_governance/publications/ac/sector/health.doc