Specialists and health care for the poor

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.

Do NGOs corrupt health institutions?

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

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

Corruption at health institution

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

Malaria mortality declines in Ethiopia

ResearchBlogging.org BBC World Service citing the Global Fund (Early Evidence of Sustainable Impact on Malaria) reported yesterday that malaria mortality declined by almost 50% in Ethiopia. The Global fund report states a 54% decline in malaria cases and 48% decline in malaria deaths.

Are such figures true? Working on malaria research projects in south Ethiopia I can confirm that fewer malaria patients are admitted to health centres and hospitals. Our preliminary data show that people use bed nets, community health workers diagnose and treat malaria cases, and malaria deaths do not occur as often as previously.

But, we have learned that malaria is a focal disease. In our research on malaria and climate we observe the last years have been dry in large parts of south Ethiopia. After the rains we first see increases in the mosquito densities followed by increases in malaria cases. There are more mosquitoes and cases after the heavy rains in early 2010, compared with 2009. Although we believe that malaria control efforts are effective, we need more time to get a full picture on the links between interventions, malaria sickness and death and naturally occurring variations.

Recent demographic data show decline in under-five mortality rates in Ethiopia from 204 to 123 per 1000 live births between 1990 and 2005. Ethiopia shows good progress was observed in controlling HIV/AIDS and malaria, but not for tuberculosis (Otten M et al, 2009; Accorsi S et al, 2009). Although a downward trend was observed in the maternal mortality ratio, it is too early to reach any firm conclusion about the possibility of achieving MDG5 because of sampling variability (Hogan M et al, 2010).

The good achievements in controlling malaria and increasing immunisation coverage show that scheduled routine interventions is well handled by the current health care system. However, interventions that rely on clinical services near to households with 24h availability, such as skilled care at birth, are weak. With the good achievements on malaria and immunization coverage, Ethiopia now needs to strengthen health institutions such as hospitals and health centres.

Otten, M., Aregawi, M., Were, W., Karema, C., Medin, A., Jima, D., Kebede, W., Gausi, K., Komatsu, R., Korenromp, E., Low-Beer, D., & Grabowsky, M. (2009). Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment Malaria Journal, 8 (1) DOI: 10.1186/1475-2875-8-14

Accorsi, S., Bilal, N., Farese, P., & Racalbuto, V. (2010). Countdown to 2015: comparing progress towards the achievement of the health Millennium Development Goals in Ethiopia and other sub-Saharan African countries Transactions of the Royal Society of Tropical Medicine and Hygiene, 104 (5), 336-342 DOI: 10.1016/j.trstmh.2009.12.009

Hogan, M., Foreman, K., Naghavi, M., Ahn, S., Wang, M., Makela, S., Lopez, A., Lozano, R., & Murray, C. (2010). Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5 The Lancet DOI: 10.1016/S0140-6736(10)60518-1

Active case-finding to improve tuberculosis control.

Is active case finding necessary to control tuberculosis in developing countries?

Tuberculosis is one of the world’s leading causes of death and disease. Despite effective treatment, tuberculosis still results in several million deaths each year. Reducing the burden of global TB disease is a part the Millennium Development Goals. Earlier, health authorities thought that DOTS (Direct Observed Treatment, Short course) would control tuberculosis. However, we now recognize that DOTS alone is unable of reducing TB incidence in high endemic countries.

Active case finding is to find, diagnose, and treat and follow up tuberculosis patients in the local communities.

To find out the efficacy of community-based case finding, we did a community randomized trial and cost-effectiveness analysis in south Ethiopia. The trial Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009 and Datiko and Lindtjørn, 2010).

The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.

Recently, National TB Control Programme in Ethiopia started to decentralize case finding and treatment to local communities (in Ethiopia called kebeles) using community based-treatment by health extension workers.

We plan to follow up our earlier studies and develop a model for community DOTS in rural Ethiopia. We aim to improve the community-based implementation of case finding and treatment of TB in rural settings of southern Ethiopia. This will try to develop community-based tuberculosis registries, and registries of patients with symptoms suggestive of tuberculosis.  Through this work we aim to see if case finding and treatment outcomes can be improved on a larger scale and involving larger populations

Datiko, D., & Lindtjørn, B. (2009). Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial PLoS ONE, 4 (5) DOI: 10.1371/journal.pone.0005443

Datiko, D., & Lindtjørn, B. (2010). Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009158

Operational research

ResearchBlogging.orgIn global health, operational research is an idea increasingly used by donors and policy makers. It involves analytical methods to help improve public health interventions and treatment of diseases in real-life situations. It is thus different from randomized clinical trials that determines efficacy of an intervention in a strictly controlled environment with inclusion and exclusion criteria, whereas operational research assess effectiveness within routine, and real-life settings.

Recently Zachariah and colleagues (2009) defined operational research as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done”.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials refer to whether an intervention works in people to whom it has been offered, and should in my view form an integral part of operational research. Results from such randomized trials can be are translated to benefit in the diverse setting of routine care.

For a health programme, the relevance of such research is whether it contributes to an improved performance or influences policy change at district, national, or even international levels.

Some examples of operational research from south Ethiopia include:

  • Antiretroviral treatment in resource limited settings (Jerene et al 2006): This cohort study assessed feasibility and effectiveness of antiretroviral therapy by use of historical controls.
  • An effectiveness trial in south Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009). The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.

References:

Zachariah R, Harries AD, Ishikawa N, Rieder HL, Bissell K, Laserson K, Massaquoi M, Van Herp M, & Reid T (2009). Operational research in low-income countries: what, why, and how? The Lancet infectious diseases, 9 (11), 711-7 PMID: 19850229

Jerene D, Naess A, & Lindtjørn B (2006). Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients. AIDS research and therapy, 3 PMID: 16600050

Datiko, D., & Lindtjørn, B. (2010). Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial PLoS ONE, 5 (2) DOI: 10.1371/journal.pone.0009158

Integrating education, research and health care in developing countries

Models on how to integrate health service and research varies from country to country. Recently Dzau and colleagues from Duke University wrote about the experiences of using academic health science to transform medicine. They write that 5 billion people living in developing countries have inadequacies in hygiene and economic development, and health-care access are the main causes of shortened life expectancies.

They write that academic health science centres (previous medical schools) should play an important role promoting health and economic development. New organizational forms might improve health service delivery. By integrating health services, education and research and making this a collective responsibility it is possible to transform medicine, improve health, and reduce health-care disparities.

In most developing countries there is a strict division between universities and public health service providers such as hospitals and community health programmes. Often the Ministries of Education own the universities and Ministries of Health own the health institutions. Thus, universities become places where students get their degrees, and the quality of training often lacks the practical and real-life touch. The little research that is done is often weak and does not influence practice or policy making.

I believe we need new organisational frameworks integrating education, service and research to solve the huge challenges facing health in developing countries. Such an organization, that could include external partnerships, need to set research priorities, and develop models of education, care delivery and community health programmes, and has potential to enable health transformation.

Dzau, V., Ackerly, D., Sutton-Wallace, P., Merson, M., Williams, R., Krishnan, K., Taber, R., & Califf, R. (2010). The role of academic health science systems in the transformation of medicine The Lancet, 375 (9718), 949-953 DOI: 10.1016/S0140-6736(09)61082-5

2009 report on “Reducing Maternal Mortality Project”

Deaths from maternal causes represent the leading cause of deaths among women of reproductive age in Ethiopia. Thus, in line with the Millennium Development Goal for maternal health (MDG-5), this health project aims to reduce maternal mortality among the target population by two-thirds by 2015.

Experience from other countries show that two conditions are needed to reduce maternal deaths: Staff should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Vision and aims of project

In this public programme, we work with the Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau of Ethiopia (RHB) to improve maternal health and reduce maternal and neonatal deaths among the target population. The target population for this project are pregnant women in the following administrative areas of south-west Ethiopia:             Gamu Gofa Zone, South Omo Zone, Basketo Special Woreda, Dirashe Special Woreda and Konso Special Woreda.

The Project works with two levels of health institutions responsible for delivery services. Health extension workers are responsible for the kebele antenatal work, and hospitals and health centres are responsible for delivery services in the woredas and zones.

Our work has four components:

  1. Train non-clinician physicians (health officers) and midwives to carry out comprehensive emergency obstetric care (see
  2. Equip institutions to carry out comprehensive obstetric services
  3. Make delivery services available through health extension workers to all local communities and thus to pregnant women among a population of 2.6 million people.
  4. Using a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths. These community-based birth and death registries use health extension workers to register all births and deaths that occur in rural communities

Work in 2009

During 2009, 10 health officers, 10 anaesthetic nurses and 10 scrub nurses received training in Arba Minch Hospital. They now work at their home institutions. It is encouraging to see the these teams of health staff at Kemba and Konso Health centres, and Chencha, Saula, Gidole and Arba Minch hospitals routinely do emergency obstetrics, including caesarean sections. In November another four health officers and anaesthesia nurses started their training. In addition, we have trained about 150 HEWs and 30 midwives and clinical nurses.

Our project represents the first try In Ethiopia to train non-clinician physicians on a larger scale, and we are encouraged to see that comprehensive obstetric care is done at health centres in Konso and Kemba. In 2009, the number of caesarean sections increased by almost fifty per cent among our target populations, and the number of institutions routinely doing emergency obstetric care increased from two to seven.

Monitoring of work

As in many other African countries, Ethiopia lacks information on how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries. In 2009 we carried out pilot studies, and validated the tools to register births and deaths. In December we started birth and death registration for the population in Dirashe Special Woreda. This registration will enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two master students now study at Gondar University, and one PhD student shall soon start at the University of Bergen.

We use experienced staff to follow and support the health officers at the rural institutions. In addition we continuously review the quality of the work at all institutions. So far, the results are encouraging and are comparable similar work started in other African countries.

Priorities for 2010

In 2010 we shall continue to strengthen the institutions, and through our Quality assurance, we systematic monitor and evaluate the work to ensure that standards of quality are being met. In 2010, our main emphasis shall be to strengthen the capacity of health extension workers, health posts and smaller health centres. The goal is to improve institutional birth coverage and that pregnant women in need of institutional care are referred in time.

More information is found at:

http://www.lindtjorn.no/page1/page11/page11.html

http://bernt.w.uib.no/my-research-areas/reproductive-healthproject/reducing-maternal-and-neonatal-mortality/

http://bernt.w.uib.no/training-programme/