Care In Low-income Countries Research Articles

Primary Health Care in Low-Income Countries

Primary Health Care in Low-Income Countries

Community participation and voice mechanisms under performance‐based financing schemes in Burundi

Community participation is often described as a key for primary health care in low-income countries. Recent performance-based financing (PBF) initiatives have renewed the interest in this strategy by questioning the accountability of those in charge at the health centre (HC) level. We analyse the place of two downward accountability mechanisms in a PBF scheme: health committees elected among the communities and community-based organizations (CBOs) contracted as verifiers of health facilities' performance. We evaluated 100 health committees and 79 CBOs using original data collected in six Burundi provinces (2009-2010) and a framework based on the literature on community participation in health and New Institutional Economics. Health committees appear to be rather ineffective, focusing on supporting the medical staff and not on representing the population. CBOs do convey information about the concerns of the population to the health authorities; yet, they represent only a few users and lack the ability to force changes. PBF does not automatically imply more 'voice' from the population, but introduces an interesting complement to health committees with CBOs. However, important efforts remain necessary to make both mechanisms work. More experiments and analysis are needed to develop truly efficient 'downward' mechanisms of accountability at the HC level.

Prehospital Trauma System Reduces Mortality in Severe Trauma: A Controlled Study of Road Traffic Casualties in Iraq

In low-resource communities with long prehospital transport times, most trauma deaths occur outside the hospital. Previous studies from Iraq demonstrate that a two-tier network of rural paramedics with village-based first helpers reduces mortality in land mine and war-injured from 40% to 10%. However, these studies of prehospital trauma care in low-income countries have been conducted with historical controls, thus the results may be unreliable due to differences in study contexts. The aim of this study was to use a controlled study design to examine the effect of a two-tier prehospital rural trauma system on road traffic accident trauma mortality. A single referral surgical hospital was the endpoint in a single-blinded, non-randomized cohort study. The catchment areas consisted of some districts with no formal Emergency Medical Services (EMS) system, and other districts where 95 health center paramedics had been trained and equipped to provide advanced life support, and 5,000 laypersons had been trained to give on-site first aid. The hospital staff registered trauma mortality and on-admission physiological severity blindly. Assuming that prehospital care would have no significant impact on mortality in moderate injuries, only road traffic accident (RTA) casualties with an Injury Severity Score (ISS)≥9 were selected for study. During a three-month study period, 205 patients were selected for study (128 in the treatment group and 77 in the control group). The mean prehospital transit time was approximately two hours. The two groups were comparable with regards to demographic characteristics, distribution of wounds and injuries, and mean anatomical severity. The mortality rate was eight percent in the treatment group, compared to 44% in the control group (95% CI, 25%-48%). Adjusted for severity differences between the treatment and control groups, prehospital care was a significant contributor to survival. Where prehospital transport time is long, a two-tier prehospital system of trained paramedics and layperson first responders reduces trauma mortality in severe RTA injuries. The findings may be valid for civilian Emergency Medical Services interventions in other low-resource countries.

Effect of corruption on medical care in low‐income countries

Effect of corruption on medical care in low‐income countries

Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda

BackgroundImproving knowledge of obstetric danger signs and promoting birth preparedness practices are strategies aimed at enhancing utilization of skilled care in low-income countries. The aim of the study was to explore the association between knowledge of obstetric danger signs and birth preparedness among recently delivered women in south-western Uganda.MethodsThe study included 764 recently delivered women from 112 villages in Mbarara district. Community survey methods were used and 764 recently delivered women from 112 villages in Mbarara district were included in study. Interviewer administered questionnaire were used to collect data. Logistic regression analyses were conducted to explore the relationship between knowledge of key danger signs and birth preparedness.ResultsFifty two percent of women knew at least one key danger sign during pregnancy, 72% during delivery and 72% during postpartum. Only 19% had knowledge of 3 or more key danger signs during the three periods. Of the four birth preparedness practices; 91% had saved money, 71% had bought birth materials, 61% identified a health professional and 61% identified means of transport. Overall 35% of the respondents were birth prepared. The relationship between knowledge of at least one key danger sign during pregnancy or during postpartum and birth preparedness showed statistical significance which persisted after adjusting for probable confounders (OR 1.8, 95% CI: 1.2-2.6) and (OR 1.9, 95% CI: 1.2-3.0) respectively. Young age and high levels of education had synergistic effect on the relationship between knowledge and birth preparedness. The associations between knowledge of at least one key danger sign during childbirth or knowledge that prolonged labour was a key danger sign and birth preparedness were not statistically significant.ConclusionsThe prevalence of recently delivered women who had knowledge of key danger signs or those who were birth prepared was very low. Since the majority of women attend antenatal care sessions, the quality and methods of delivery of antenatal care education require review so as to improve its effectiveness. Universal primary and secondary education programmes ought to be promoted so as to enhance the impact of knowledge of key danger signs on birth preparedness practices.

A conference report on prenatal corticosteroid use in low- and middle-income countries

Objective To evaluate the evidence for prenatal corticosteroid use in low- and middle-income countries and to make recommendations regarding implementation and further research. Methods Studies and meta-analyses on prenatal corticosteroids relevant to low- and middle-income countries were identified and reviewed at the Maternal and Child Health Integrated Project (MCHIP) Antenatal Corticosteroid Conference held in Washington on October 19, 2010. Results There is strong evidence regarding the effectiveness of prenatal corticosteroid use in hospitals in high- and middle-income countries, usually in settings with high-level newborn care. For births occurring in hospitals in low-income countries without high-level neonatal care or for births outside hospitals, no studies have been conducted to evaluate prenatal corticosteroid use. The efficacy and safety of prenatal corticosteroid use in these settings must be evaluated. Conclusions The conference working group recommended expanding the use of prenatal corticosteroids in hospitals with high-level newborn care in low-income countries. For other low-income country settings, further research regarding efficacy and safety should precede the widespread introduction of prenatal corticosteroids.

Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries

While World Health Organization member countries embraced the concept of universal coverage as early as 2005, few low-income countries have yet achieved the objective. This is mainly due to numerous barriers that hamper access to needed health services. In this paper we provide an overview of the various dimensions of barriers to access to health care in low-income countries (geographical access, availability, affordability and acceptability) and outline existing interventions designed to overcome these barriers. These barriers and consequent interventions are arranged in an analytical framework, which is then applied to two case studies from Cambodia. The aim is to illustrate the use of the framework in identifying the dimensions of access barriers that have been tackled by the interventions. The findings suggest that a combination of interventions is required to tackle specific access barriers but that their effectiveness can be influenced by contextual factors. It is also necessary to address demand-side and supply-side barriers concurrently. The framework can be used both to identify interventions that effectively address particular access barriers and to analyse why certain interventions fail to tackle specific barriers.

Rwandan Surgical and Anesthesia Infrastructure: A Survey of District Hospitals

In low-income countries, unmet surgical needs lead to a high incidence of death. Information on the incidence and safety of current surgical care in low-income countries is limited by the paucity of data in the literature. The aim of this survey was to assess the surgical and anesthesia infrastructure in Rwanda as part of a larger study examining surgical and anesthesia capacity in low-income African countries. A comprehensive survey tool was developed to assess the physical infrastructure of operative facilities, education and training for surgical and anesthesia providers, and equipment and medications at district-level hospitals in sub-Saharan Africa. The survey was administered at 21 district hospitals in Rwanda using convenience sampling. There are only nine Rwandan anesthesiologists and 17 Rwandan surgeons providing surgical care for a population of more than 10 million. The specialty-trained Rwandan surgeons and anesthesiologists are practicing almost exclusively at referral hospitals, leaving surgical care at district hospitals to the general practice physicians and nurses. All of the district hospitals reported some lack of surgical infrastructure including limited access to oxygen, anesthesia equipment and medications, monitoring equipment, and trained personnel. This survey provides strong evidence of the need for continued development of emergency and essential surgical services at district hospitals in Rwanda to improve health care and to comply with World Health Organization recommendations. It has identified serious deficiencies in both financial and human resources-areas where the international community can play a role.

The Quality of Medical Care in Low-Income Countries: From Providers to Markets

Jishnu Das provides a perspective on a research article by Paul Garner and colleagues that reports a systematic review of 80 studies comparing the quality of private versus public ambulatory health care in low and middle income countries.

Access to emergency and surgical care in sub-Saharan Africa: the infrastructure gap

The effort to increase access to emergency and surgical care in low-income countries has received global attention. While most of the literature on this issue focuses on workforce challenges, it is critical to recognize infrastructure gaps that hinder the ability of health systems to make emergency and surgical care a reality. This study reviews key barriers to the provision of emergency and surgical care in sub-Saharan Africa using aggregate data from the Service Provision Assessments and Demographic and Health Surveys of five countries: Ghana, Kenya, Rwanda, Tanzania and Uganda. For hospitals and health centres, competency was assessed in six areas: basic infrastructure, equipment, medicine storage, infection control, education and quality control. Percentage of compliant facilities in each country was calculated for each of the six areas to facilitate comparison of hospitals and health centres across the five countries. The percentage of hospitals with dependable running water and electricity ranged from 22% to 46%. In countries analysed, only 19-50% of hospitals had the ability to provide 24-hour emergency care. For storage of medication, only 18% to 41% of facilities had unexpired drugs and current inventories. Availability of supplies to control infection and safely dispose of hazardous waste was generally poor (less than 50%) across all facilities. As few as 14% of hospitals (and as high as 76%) among those surveyed had training and supervision in place. No surveyed hospital had enough infrastructure to follow minimum standards and practices that the World Health Organization has deemed essential for the provision of emergency and surgical care. The countries where these hospitals are located may be representative of other low-income countries in sub-Saharan Africa. Thus, the results suggest that increased attention to building up the infrastructure within struggling health systems is necessary for improvements in global access to medical care.

A mental health training program for community health workers in India: impact on knowledge and attitudes

BackgroundUnmet needs for mental health treatment in low income countries are pervasive. If mental health is to be effectively integrated into primary health care in low income countries like India then grass-roots workers need to acquire relevant knowledge and skills to be able to recognise, refer and support people experiencing mental disorders in their own communities. This study aims to provide a mental health training intervention to community health workers in Bangalore Rural District, Karnataka, India, and to evaluate the impact of this training on mental health literacy.MethodsA pre-test post-test study design was undertaken with assessment of mental health literacy at three time points; baseline, completion of the training, and three month follow-up. Mental health literacy was assessed using the interviewer-administered Mental Health Literacy Survey. The training intervention was a four day course based on a facilitator's manual developed specifically for community health workers in India.Results70 community health workers from Doddaballapur, Bangalore Rural District were recuited for the study. The training course improved participants' ability to recognize a mental disorder in a vignette, and reduced participants' faith in unhelpful and potentially harmful pharmacological interventions. There was evidence of a minor reduction in stigmatizing attitudes, and it was unclear if the training resulted in a change in participants' faith in recovery following treatment.ConclusionThe findings from this study indicate that the training course demonstrated potential to be an effective way to improve some aspects of mental health literacy, and highlights strategies for strengthening the training course.

Innovative approaches to reducing financial barriers to obstetric care in low-income countries.

Lack of access to quality care is the main obstacle to reducing maternal mortality in low-income countries. In many settings, women must pay out-of-pocket fees, resulting in delays, some of them fatal, and catastrophic expenditure that push households into poverty. Various innovative approaches have targeted the poor or exempted specific services, such as cesarean deliveries. We analyzed 8 case studies to better understand current experiments in reducing financial barriers to maternal care. Although service utilization increased in most of the settings, concerns remain about quality of care, equity between rich and poor patients and between urban and rural residents, and financial sustainability to support these new strategies.

Using the three delays model to understand why newborn babies die in eastern Uganda

To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach. Methods Data collected on 64 neonatal deaths from a demographic surveillance site were coded for causes of deaths using a hierarchical model and analysed using a modified three delays model to determine contributing delays. A survey was conducted in 16 health facilities to determine capacity for newborn care. Of the newborn babies, 33% died in a hospital/health centre, 13% in a private clinic and 54% died away from a health facility. 47% of the deaths occurred on the day of birth and 78% in the first week. Major contributing delays to newborn death were caretaker delay in problem recognition or in deciding to seek care (50%, 32/64); delay to receive quality care at a health facility (30%; 19/64); and transport delay (20%; 13/64). The median time to seeking care outside the home was 3 days from onset of illness (IQR 1-6). The leading causes of death were sepsis or pneumonia (31%), birth asphyxia (30%) and preterm birth (25%). Health facilities did not have capacity for newborn care, and health workers had correct knowledge on only 31% of the survey questions related to newborn care. Household and health facility-related delays were the major contributors to newborn deaths, and efforts to improve newborn survival need to address both concurrently. Understanding why newborn babies die can be improved by using the three delays model, originally developed for understanding maternal death.

Percentage of Cesarean Sections Among Total Surgical Procedures in Sub‐Saharan Africa: Possible Indicator of the Overall Adequacy of Surgical Care

The aim of this study was to assess emergency and essential surgical care in low-income countries, review of the literature to obtain data on the number of cesarean sections, and compare the results with the total number of all operations. This cesarean section/total operations ratio was much higher for low-income countries than for high-income countries. We recommend more research into the validity of this tool for use as a possible proxy indicator for overall adequacy of emergency and essential surgical care.

Affordable primary health care in low-income countries: can it be achieved?

Affordable primary health care in low-income countries: can it be achieved?

Improving the quantitative basis of the surgical burden in low-income countries.

For decades, the primary health care paradigm with a focus on maternal and child health programs has been driving funding for health in developing countries [1]. This has led to improvements, although there are doubts that many countries will meet the ambitious Millennium Development Goals 4 and 5 of reducing maternal and childhood mortality by three-quarters and two-thirds, respectively, between 1990 and 2015 [2],[3]. Surgery has not traditionally been considered an essential component of primary health care in low-income countries. This may be changing [4]. Emergency obstetric care, including surgical interventions, is now recognized as a key health service component for reducing maternal and neonatal mortality [5]. The broader contribution of surgical services to improvements in health outcomes in developing countries is also being discussed [6]–[9].

First Things First: Effectiveness and Scalability of a Basic Prehospital Trauma Care Program for Lay First-Responders in Kampala, Uganda

BackgroundWe previously showed that in the absence of a formal emergency system, lay people face a heavy burden of injuries in Kampala, Uganda, and we demonstrated the feasibility of a basic prehospital trauma course for lay people. This study tests the effectiveness of this course and estimates the costs and cost-effectiveness of scaling up this training.Methods and FindingsFor six months, we prospectively followed 307 trainees (police, taxi drivers, and community leaders) who completed a one-day basic prehospital trauma care program in 2008. Cross-sectional surveys and fund of knowledge tests were used to measure their frequency of skill and supply use, reasons for not providing aid, perceived utility of the course and kit, confidence in using skills, and knowledge of first-aid. We then estimated the cost-effectiveness of scaling up the program.At six months, 188 (62%) of the trainees were followed up. Their knowledge retention remained high or increased. The mean correct score on a basic fund of knowledge test was 92%, up from 86% after initial training (n = 146 pairs, p = 0.0016). 97% of participants had used at least one skill from the course: most commonly haemorrhage control, recovery position and lifting/moving and 96% had used at least one first-aid item. Lack of knowledge was less of a barrier and trainees were significantly more confident in providing first-aid. Based on cost estimates from the World Health Organization, local injury data, and modelling from previous studies, the projected cost of scaling up this program was $0.12 per capita or $25–75 per life year saved. Key limitations of the study include small sample size, possible reporter bias, preliminary local validation of study instruments, and an indirect estimate of mortality reduction.ConclusionsLay first-responders effectively retained knowledge on prehospital trauma care and confidently used their first-aid skills and supplies for at least six months. The costs of scaling up this intervention to cover Kampala are very modest. This may be a cost-effective first step toward developing formal emergency services in Uganda other resource-constrained settings. Further research is needed in this critical area of trauma care in low-income countries.

Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia

BackgroundUse of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia.MethodsThematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours.ResultsThe self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system.ConclusionThe findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.

Three global health reports: towards a growing consensus?

keywords health policy, primary health care, financing, integrationIn 1978, the inspiring Alma Ata declaration on PrimaryHealth Care put the need for people-centred comprehen-sive primary care for the first time on the internationalagenda. But in the context of limited resources and highdisease burden in poor countries, these grand ideas wererapidly reduced to a few selective ‘cost-effective’ interven-tions deemed affordable (Walsh & Warren 1979). Thisapproach to health has dominated over the past 30 yearsand contributed more recently to the proliferation of globalhealth initiatives, but left the health systems partlyneglected with too little resources.Doubts about reaching the Health Millennium Devel-opment Goals (MDGs), in particular MDG5 on MaternalHealth, again fuel calls for a more comprehensiveapproach to health care in low-income countries. It isagainst this background that the 30th birthday of Alma Atain September 2008 was given attention by internationalagencies and academic institutions to discuss new strategiesto overcome the unfruitful international divide betweenhealth systems strengthening and disease-specific interven-tions. One focus of a conference in Antwerp was lookingfor synergies between disease-specific intervention andhealth systems strengthening. An example of HIV/AIDSprogrammes in Africa has been elaborated from this pointof view (ITG 2008).Overlooking the need for comprehensive people-centredprimary health care and for reduction of global healthinequities may also become increasingly politicallyincorrect, as the effects of neglecting these issues have beenwidely publicised, supported by a wealth of evidencerecently summarised in three important health reportspublished in the autumn of 2008: WHO’s World HealthReport (WHO 2008), the final report of the Commissionon Social Determinants of Health (CSDC 2008) and theGlobal Health Watch 2 (People’s Health Movement et al.2008).The World Health Report 2008 revisits the Alma Atavision as a set of values and principles for guiding thedevelopment of health systems: ‘Primary Health Care –Now More Than Ever’. The report thoroughly analyseshealth systems and identifies the need for major reforms infour areas: universal coverage, people-centred servicedelivery, ‘healthy public policies’ and leadership. Thereport suggests that primary health care, underpinned bysocial justice, equity and solidarity, is feasible and urgesgovernments and the international community to moreseriously consider people’s needs and to adapt servicedelivery to changing epidemiological patterns.A bit earlier a report commissioned by WHO on socialdeterminants of health, ‘Closing the Gap in a Generation’,was published. The final report summarises the work andrecommendation of a diverse international group ofscientists and practitioners. Formally launched in 2005, theCommission was organised in knowledge networks tocompile evidence on policies and interventions to addressinequalities and social determinants of health. Its recom-mendations cover three areas: daily living conditions; theinequitable distribution of power, money and resources;and methods to measure and understand the problems andassess the impact of action.The third report, ‘Global Health Watch 2’, is oftenlabelled ‘The Alternative World Health Report’. TwoNGO movements, the People’s Health Movement and theGlobal Equity Gauge Alliance, together with a largenumber of individuals and institutions wrote their secondreport aimed to draw attention to often neglected drivers ofill-health, the ‘political and economic choices, or thecurrent form of globalisation’. The report concludes thatthe current dominant model of development, based onmarket liberalisation and commercial globalisation, hasnot only failed to deliver ‘health for all’, but also places theworld at the brink of an environmental crisis.The three reports have been written with distinctivemotives, have different backgrounds and use differentperspectives. WHR 2008 concentrates mainly on the healthsystem and health policies. CSDH provides a broad range

Improving tuberculosis care in low income countries – a qualitative study of patients' understanding of "patient support" in Nepal

BackgroundIn the new Stop TB Strategy for Tuberculosis (TB) Care, direct observation of treatment has been replaced by "supervision and patient support". However, it is still unclear what patient support means and how it is to be best implemented. The objective of this study was to accurately document patients' support needs during TB treatment from their own perspectives, to inform development of appropriate support and supervision strategies that meet patients' needs.MethodsIn-depth individual interviews and focus group discussions were conducted in three districts in Nepal. Analysis took place concurrently with data collection to allow emerging issues to guide selection of subsequent interviewees. In total 23 patients, 15 male and 8 female, were interviewed and six focus group discussions were held. Issues from these interviews were grouped into emergent themes.ResultsRespondents reported that the burden of treatment for TB was high, particularly in terms of difficulties with social and psychological aspects of undergoing treatment. They saw three main areas for support during their treatment: relevant information for them and their families about their disease, its treatment, potential side-effects and what they should do if side-effects arise; approachable and supportive healthcare staff with whom patients feel comfortable discussing (often non-medical) problems that arise during treatment; and some flexibility in treatment to allow essential elements of patients' lives (such as income generation, food-growing and childcare) to continue. They were anxious to ensure that family support did not absolve healthcare workers from their own support responsibilities.ConclusionIn order to support people with TB more during their treatment, health policy and practice must appreciate that TB affects all aspects of TB patients' lives. A focus on caring for each patient as an individual should underlie all aspects of treatment. Improved communication between healthcare providers and patients and increased patient knowledge and understanding of the treatment programme would give those receiving treatment a sense of individual empowerment and raise their confidence in treatment.