Category Archives: Health system

About obstetric fistulas

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The vesico vaginal fistula (VVF) is as old as mankind, and has always been a source of misery of the affected women. Most communities consider these women as outcasts, because they leak urine down their legs, their clothes are wet, and the women smell.

The main case of VVF is obstructed labour which is not relieved in time by a caesarean section. The vagina and bladder walls become compressed between the foetal scull and the maternal pelvis, resulting in pressure necrosis. This results in obstetric fistula.

Obstetric fistulas have disappeared in the industrialized countries. In developing countries it is a public health problem, and 1-2 women per 1000 deliveries end in obstetric fistula.

In south-west Ethiopia we work on a programme to reduce maternal deaths and obstetric fistulas. With an estimated population of 2.6 million, and a crude birth rate of 38/1000, we have estimated that about 800 women die every year and 150 women get an obstetric fistula.

The main aim of our current work in south Ethiopia is to reduce these death and fistulas.

Obstetric fistula in Arba Minch

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In Ethiopia, obstetric fistula remains one of the most visible indicators of inadequate maternal health care. Obstetric fistula still exists because health care systems fail to provide accessible, quality maternal health care, including family planning, skilled birth attendance, and basic and emergency obstetric care, and affordable treatment of fistula.

Thankfully, prevention and treatment of obstetric fistula has during the last three years gained attention in South Ethiopia. In 2005, the Yirga Alem Fistula Hospital opened. This was build with Norwegian support, and Addis Ababa Fistula Hospital runs the unit.

This week, we opened the second Fistula Unit in Arba Minch in south Ethiopia. It is a private gift. Altogether it has a new delivery (16 beds) and gynaecological (40 beds) wards, new outpatient departments for women and children, and a 24-bed fistula unit, and two new operation theatres. Through this work we hope to reduce maternal deaths and reduce obstetric fistulas.

We have agreed with the local government and peasant associations to help us in finding women with fistulas.

During the past two years, 250 women from this area were operated in Yirga Alem. Now they do not need to travel 250 km to get treatment.

Our work shall be done in close collaboration the Addis Ababa Fistula Hospital and with the Unit in Yirga Alem.

The influenza epidemic

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The H1N1 influenza epidemic has received much media attention. Authorities fear a severe epidemic resembling the Spanish Flue, and they have taken their precautions. Norway has bought vaccines for the whole population, and has upgraded its hospitals to treat severe complications such as respiratory failure. The cost is uncertain, but is in the order of 1 billion Norwegian kroner (USD 160 million).

Some researchers question the government’s priorities in combating this epidemic:

Should Norway use such large funds on a mild influenza epidemic? Already in the early days of the epidemic, we got information that this was not an epidemic with high case fatality rates. The virus mainly infected young adults.

Has any estimate of the cost-effectiveness of this intervention been calculated? And, has this intervention been discussed in relation to other pressing health needs in the country? Would an intervention targeted at specific population groups be more cost-effective?

How sound is the government policy to buy 9 million doses (two doses per person) of a vaccine that is not thoroughly tested, and where the pharmaceutical industry would not cover the liabilities?

Other questions are:
How sound is the epidemiological modelling used by the Norwegian government? Should not their mathematical models have been adjusted as we learned how this epidemic evolved in other countries?

Does Norway need to strengthen its epidemiological research environment?

However, working is south Ethiopia; my most important question is how one of the richest countries in the world uses its huge wealth when meeting an irrational fear as a new swine-flue virus.
Could more lives have been saved if the rich countries used a smaller part of their influenza expenses to combat malnutrition, childhood diseases, maternal deaths tuberculosis, HIV, and malaria?

Antiretroviral therapy is cost-effective

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As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. We therefore assessed the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.

We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenses of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and in-patient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.

ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.

The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.

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Bikilla AD, Jerene DS, Robberstad B and Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:13doi:10.1186/1478-7547-7-13

Also see [intlink id=”146″ type=”post”]previous post on cost of HIV treatment[/intlink]:

Bikilla AD , Jerene D, Robberstad B and Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:6doi:10.1186/1478-7547-7-6

Doctors and non-physician clinicians (NPC)

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There is a severe shortage of trained health staff in rural Africa. We try to solve this issue by using doctors and non-physician clinicians (NPC). A recent problem we have seen in south Ethiopia is that these two categories of health personnel do not collaborate.

As non-physician clinicians (NPC) take over doing surgical tasks, the doctors withdraw from this important part of the work. General practitioners work on internal medicine and paediatrics, leaving surgery and obstetrics to NPC. In one hospital we have also seen the physician, who has only one year of clinical experience, leave the hospital when the non-physician clinician (NPC) started work.

This is a trend that worries us, and we need to find mechanisms to promote the collaboration between the two professions.

Any suggestions to solve this unhealthy competition?

Sustainability and task shifting in Africa

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Recently Kathryn Chu and colleagues  wrote  a very good discussion on the topic of using non-physician clinician in emergency surgery (see Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078)

In a response to their paper, I wrote a comment on PLoSMedicine:

Kathryn Chu and colleagues are to be commended for their paper on “Surgical Task Shifting in Sub-Saharan Africa”.

I work on a project to train non-physician clinicians (NPC) in Emergency Obstetrics and surgery in south Ethiopia. The Ministry of Health collaborates and recognizes the training. It is a programme for public institutions, and it consists of four months basic training, followed by two months of supervisory visits to their home institutions. An important part of the project is also to support the peripheral institutions with essential equipment.

Our experience is similar to those from Mozambique and shows that using NPC for essential surgery and obstetrics is workable. Complication rates are low. As expected, we see that staff with some years of clinical experience perform better that those coming directly from school.

As many institutions have only one trained NPC, their sustainability is often threatened, and work might be discontinued during week-ends, vacations and needed travels. Each institution needs more than one team to become sustainable.

Too often, staff receive training and acquire basic skills to return to their home institution where it is not possible to do the tasks they trained for because of lack of follow up, surgical equipment or materials. For programmes to succeed, we think it is important to continue supporting the peripheral institutions.

As most peripheral hospitals and health centres are public, and to ensure sustainable performance, we believe the national or regional health authorities should own or be a part of the programme. This would allow for needed professional and political recognition, provision of necessary incentives and continued recruitment of essential staff.

Non-physician clinicians

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We have good experience from sub-Saharan Africa, that task shifting from doctors to non-physician clinicians can address the HIV/AIDS treatment, improve tuberculosis control and manage health problems in children (IMC). Similarly, some operations usually done by surgeons and anaesthesiologists can be safely done non- specialists.

Surgical care is the safe provision of preoperative, operative, and post-operative surgical and anaesthesia services. Unfortunately, there are too few surgeons in Africa, and it is unlikely that a modest increase in the number of surgeons and anaesthesiologists will occur.

In HIV care, we recognized the Western model of care with medical specialists in secondary and tertiary hospitals, could not be copied in Africa. By adapting and selecting treatment protocols and task shifting, it was possible to treat millions of patients received antiretroviral drugs. Similarly, it is important in the surgical fields to avoid creating “islands of excellence in a sea of under provision”.

By enabling non-physician clinicians to do some essential operations, we may increase benefits while lessening harm among populations where the unmet need of surgical care is great.

Please also see a very good discussion on this topic written by Chu K, Rosseel P, Gielis P, Ford N (2009) Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

For more information about our training programme in Ethiopia click here.

Climate change and health

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Climate change will have more far-reaching effects on health than predicted. The greatest effect will be on the world’spoorest people. This is the main conclusion of a comprehensive report in The Lancet (Lancet 2009; 373: 1693–1733). The indirect effects of climate change on water, food, security,population, migration, and extreme climatic events are likely to have the biggest effect on global health, greater than the increase in vector borne diseases.

Recently, Lafferty (Ecology, 2009, 90: 888–900) wrote that although the globe is warmer than it was a century ago, there is little evidence that climate change has already favoured infectious diseases. Recent models predict range shifts in disease distributions, with some increase of vector borne diseases.

The Lancet report identified some challenges that scientists, doctors, and policy makers need to address:

There is a large information gap, particularly in low and middle-income countries.

The effects of climate change would hit the poor the hardest.

Rich countries should massively reduce their emissions.

There is a  lack of technologies to help people adapt to changes in climate such as measures to boost food production and for storing and treating water

Economic growth is needed in the poor countries to help people to adapt to global warming.

Improving tuberculosis control in Ethiopia

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By using community health workers in stead of health professionals such as nurses and doctors at institutions, Daniel Datiko at Centre for International Health has shown:

The community based approach (Community DOTS) identifies about 70% of expected tuberculosis cases, compared with only 30 % when patients have to travel to health centres and hospitals

About 90% of the tuberculosis patients were cured when they received treatment in their local communities, compared with 80% at institutions

The community based approach reduced the costs of treatment by 60%.

Most of patients treated by Community DOTS are women. This is a significant improvement from the institutional based tuberculosis control.

The community based DOTS is an approach that improves access to treatment.

These ideas are now being implemented in Ethiopia. As a start it will be carried out in the Southern Nations, Nationalities and Peoples’ Regional State in Ethiopia.