Hawassa University

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Hawassa University is the oldest and largest university in the Southern Nations Nationalities and People’s Regional State (SNNPRS) in south Ethiopia. The University offers courses such as Medicine and Health Sciences, Natural and Physical Sciences, Agriculture, Forestry and Natural Resources Management, Law, Business, Humanities and Arts.

A few days ago I had a meeting with about 20 staff from the University. We discussed the current status of collaboration and how to strengthen the collaboration between the Hawassa University and Centre for International Health at the University of Bergen.

I was encouraged to learn the university now is about to launch a Masters programme and a Phd programme in public health. This will be done in collaboration with the Addis Ababa Institute of Public Health.

My presentation at the meeting can be downloaded here.

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

Malaria mortality declines in Ethiopia

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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.

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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

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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

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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

Smear negative pulmonary tuberculosis in HIV infected patient

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Clinicians working with HIV patients know how difficult it is to make a certain tuberculosis diagnosis in the smear negative pulmonary tuberculosis. Often the diagnosis is made on clinical and radiological criteria, and is based on national guidelines and international recommendations.

In a recent paper in PLoSONE, Davies and colleagues show that Clinical and radiographic criteria did not help diagnose smear-negative pulmonary tuberculosis among HIV-infected patients with unexplained cough in a low-income setting.

In their paper they evaluated if commonly used clinical and radiological signs could predict if the patient had tuberculosis, and they used culture as their god standard for diagnosing a definite tuberculosis diagnosis. However, their paper does not discuss the limits in doing cultures, and their samples might not have been representative.

In a recently research from south Ethiopia we found that patients receiving antituberculosis drugs had better survival than patients without tuberculosis. This unexpected finding may be because many patients remain undiagnosed with tuberculosis. In the Arba Minch Hospital Cohort Study we evaluated the survival of 1428 patients receiving antiretroviral treatment over a six-year period.

It further underlines Davis’s  recommendation that we need improved tools to diagnose smear-negative tuberculosis in developing countries.

Davis, J., Worodria, W., Kisembo, H., Metcalfe, J., Cattamanchi, A., Kawooya, M., Kyeyune, R., den Boon, S., Powell, K., Okello, R., Yoo, S., & Huang, L. (2010). Clinical and Radiographic Factors Do Not Accurately Diagnose Smear-Negative Tuberculosis in HIV-infected Inpatients in Uganda: A Cross-Sectional Study PLoS ONE, 5 (3) DOI: 10.1371/journal.pone.0009859

Important health research from Ethiopia

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Although the disease burden among people in the developing world is much larger than that of the rich countries, most of health research is on health problems for the rich.

Peer-reviewed journal from countries such as Ethiopia are not widely read. However, journals such as Ethiopian Journal of Health Development contains many important studies for improving health care in the country, as shown in some examples of references below.

Tadele G. ‘Unrecognized victims’: Sexual abuse against male street children in Merkato area, Addis Ababa. Ethiop J Hlth Dev. 2009;23(3):174-82.

Ayalew Astatkie and Amsalu Feleke (2009). Utilization of insecticide treated nets in Arba Minch Town and the malarious villages of Arba Minch Zuria District, Southern Ethiopia. Ethiopian Journal of Health Development, 23 (3), 206-215

The Templeton Prize

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This year’s Templeton Prize was last week awarded Francisco J. Ayala. Professor Ayala, a geneticist and biologist and a former Dominican priest, has opposed entangling science and religion while calling for mutual respect between the two. He denies that science contradicts religion, and says “they cannot be in contradiction because science and religion concern different matters, and each is essential to human understanding.”

Ayala’s research is also on parasitic diseases such as trypanosomiasis and malaria. He developed accurate ways to read genetic clocks to find out the timing of steps in the evolution of a species. Recently, he and colleagues determined that malaria was likely first transmitted from chimpanzees to humans a few thousand years ago, and that gorillas and chimps may serve as reservoirs for the parasites that cause human malaria.

Earlier prize winners vary in their views on thought, science and religion, and include people such as Billy Graham, Aleksandr Solzhenitsyn John C. Polkinghorne, and Bernard d’Espagnat. These represent persons with different views on science and religion than what Ayala advocates, and Science recently wrote the John Templeton Foundation, which awards the Templeton Prize, in recent years has become more mainstream..

You can read more about Ayalas works on science and religion at http://www.templetonprize.org/currentwinner.html

New articles from EJHD

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The latest issue of the Ethiopian Journal of Health Development contains many interesting articles.

Among these important public health articles, I would like to highlight one paper: Getnet Tadele from the Department of Sociology at Addis Ababa University writes about sexual abuse against male street children in Addis Ababa (1). He worked in the Merkato (main market) area in Addis Ababa, and found that sexual abuse against male children around Merkato area is widespread.

Male homosexuality makes up a major HIV transmission route in the Americas, Eastern Europe and parts of Asia but is rare in Africa. Although anthropologists have reported homosexual behaviour in Africa since the 17th century, it remains as a taboo subject. Recent information suggests that homosexuality is common in Ethiopia. This adds to increasing evidence that the HIV epidemic in Ethiopian towns is more complex that previously anticipated (2 – 4) .

References

1.         Tadele G. ‘Unrecognized victims’: Sexual abuse against male street children in Merkato area, Addis Ababa. Ethiop J Hlth Dev. 2009;23(3):174-82.

2.         Kloos H, Mariam D, Lindtjørn B. The AIDS Epidemic in a Low-Income Country: Ethiopia. Human Ecology Review. 2007 Jan 1;14(1):39-55.

3.         Tadele G. Bleak prospects: young men, sexuality and HIV/AIDS in an Ethiopian town. PhD Thesis. Amsterdam: University of Amsterdam; 2005.

4.         Gebreyesus SH, Mariam DH. Assessment of HIV/AIDS related risks among men having sex with men (MSM) in Addis Ababa, Ethiopia. J Public Health Policy. 2009 Sep;30(3):269-79.