District Health Management Teams Research Articles

Cholera outbreak in districts around Lake Chilwa, Malawi: lessons learned.

Cholera is endemic in Malawi with seasonal outbreaks during the wet season. People living around Lake Chilwa rely on the lake for their water supply. From May 2009 to May 2010, a cholera outbreak occurred in fishing communities around Lake Chilwa. This paper describes the outbreak response and lessons learned for prevention and management of future outbreaks. Starting in January 2010, Médecins Sans Frontières (MSF) helped District Health Management Teams (DHMTs) to distribute educational materials, water disinfectant and hygiene supplies, and oral rehydration solution (ORS) in fishing communities. MSF also supported case management by mentoring health workers and providing equipment and supplies. A total of 1,171 cholera cases and 21 deaths were reported in the districts around the lake, with cases also being reported on the Mozambican side of the lake. The attack rate was highest among people living on or around the lake, particularly among fishermen. Samples of lake water had high turbidity conducive to the propagation of Vibrio cholerae. A number of practical measures could be taken to prevent future outbreaks and to manage outbreaks more effectively. These measures should address surveillance, environmental management, outbreak preparedness, and case management.

Expected to deliver: Alignment of regulation, training, and actual performance of emergency obstetric care providers in Malawi and Tanzania

Objective Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania. Methods A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities. Results A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery. Conclusion Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable.

Does supervision improve health worker productivity? Evidence from the Upper East Region of Ghana

To assess whether supervision of primary health care workers improves their productivity in four districts of Northern Ghana. We conducted a time-use study during which the activities of health workers were repeatedly observed and classified. Classification included four categories: direct patient care; documentation and reporting; staff development and facility operations; and personal time. These data were supplemented by a survey of health workers during which patterns of supervision were assessed. We used logistic regression models with health facility fixed effects to test the hypothesis that supervision increases the amount of time spent providing direct patient care (productivity). We further investigated whether these effects depend on whether or not supervision is supportive. Direct patient care accounted for <25% of observations. In bivariate analyses, productivity was higher among midwives and in facilities with a high volume of care. Supervisory visits were frequent in those four districts, but only a minority of health workers felt supported by their supervisors. Having been supervised within the last month was associated with a significantly higher proportion of time spent on direct patient care (OR = 1.57). The effects of supervision on productivity further depended on whether the health workers felt supported by their supervisors. Supportive supervision was associated with increased productivity. Investments in supervision could help maximize the output of scarce human resources in primary health care facilities. Time-use studies represent an objective approach in monitoring the productivity of health workers and evaluating the impact of health-system interventions on human resources.

Constraints to Implementing the Essential Health Package in Malawi

Increasingly seen as a useful tool of health policy, Essential or Minimal Health Packages direct resources to interventions that aim to address the local burden of disease and be cost-effective. Less attention has been paid to the delivery mechanisms for such interventions. This study aimed to assess the degree to which the Essential Health Package (EHP) in Malawi was available to its population and what health system constraints impeded its full implementation. The first phase of this study comprised a survey of all facilities in three districts including interviews with all managers and clinical staff. In the second and third phase, results were discussed with District Health Management Teams and national level stakeholders, respectively, including representatives of the Ministry of Health, Central Medical Stores, donors and NGOs. The EHP in Malawi is focussing on the local burden of disease; however, key constraints to its successful implementation included a widespread shortage of staff due to vacancies but also caused by frequent trainings and meetings (only 48% of expected man days of clinical staff were available; training and meetings represented 57% of all absences in health centres). Despite the training, the percentage of health workers aware of vital diagnostic and therapeutic approaches to EHP conditions was weak. Another major constraint was shortages of vital drugs at all levels of facilities (e.g. Cotrimoxazole was sufficiently available to treat the average number of patients in only 27% of health centres). Although a few health workers noted some improvement in infrastructure and working conditions, they still considered them to be widely inadequate. In Malawi, as in similar resource poor countries, greater attention needs to be given to the health system constraints to delivering health care. Removal of these constraints should receive priority over the considerable focus on the development and implementation of essential packages of interventions.

Enhancing the routine health information system in rural southern Tanzania: successes, challenges and lessons learned

To describe and evaluate the use of handheld computers for the management of Health Management Information System data. Electronic data capture took place in 11 sentinel health centres in rural southern Tanzania. Information from children attending the outpatient department (OPD) and the Expanded Program on Immunization vaccination clinic was captured by trained local school-leavers, supported by monthly supervision visits. Clinical data included malaria blood slides and haemoglobin colour scale results. Quality of captured data was assessed using double data entry. Malaria blood slide results from health centre laboratories were compared to those from the study's quality control laboratory. The system took 5 months to implement, and few staffings or logistical problems were encountered. Over the following 12 months (April 2006-March 2007), 7056 attendances were recorded in 9880 infants aged 2-11 months, 50% with clinical malaria. Monthly supervision visits highlighted incomplete recording of information between OPD and laboratory records, where on average 40% of laboratory visits were missing the record of their corresponding OPD visit. Quality of microscopy from health facility laboratories was lower overall than that from the quality assurance laboratory. Electronic capture of HMIS data was rapidly and successfully implemented in this resource-poor setting. Electronic capture alone did not resolve issues of data completeness, accuracy and reliability, which are essential for management, monitoring and evaluation; suggestions to monitor and improve data quality are made.

Fairness and legitimacy of decisions during delivery of malaria services and ITN interventions in zambia

BackgroundMalaria is the leading cause of morbidity and the second leading cause of mortality in Zambia. Perceptions of fairness and legitimacy of decisions relating to treatment of malaria cases within public health facilities and distribution of ITNs were assessed in a district in Zambia. The study was conducted within the framework of REsponse to ACcountable priority setting for Trust in health systems (REACT), a north-south collaborative action research study, which evaluates the Accountability for Reasonableness (AFR) approach to priority setting in Zambia, Tanzania and Kenya.MethodsThis paper is based on baseline in-depth interviews (IDIs) conducted with 38 decision-makers, who were involved in prioritization of malaria services and ITN distribution at district, facility and community levels in Zambia, one Focus Group Discussion (FGD) with District Health Management Team managers and eight FGDs with outpatients' attendees. Perceptions and attitudes of providers and users and practices of providers were systematized according to the four AFR conditions relevance, publicity, appeals and leadership.ResultsConflicting criteria for judging fairness were used by decision-makers and patients. Decision-makers argued that there was fairness in delivery of malaria treatment and distribution of ITNs based on alleged excessive supply of free malaria medicines, subsidized ITNs, and presence of a qualified health-provider in every facility. Patients argued that there was unfairness due to differences in waiting time, distances to health facilities, erratic supply of ITNs, no responsive appeal mechanisms, inadequate access to malaria medicines, ITNs and health providers, and uncaring providers. Decision-makers only perceived government bodies and donors/NGOs to be legitimate stakeholders to involve during delivery. Patients found government bodies, patients, indigenous healers, chiefs and politicians to be legitimate stakeholders during both planning and delivery.ConclusionPoor status of the AFR conditions of relevance, publicity, appeals and leadership corresponds well to the differing perceptions of fairness and unfairness among outpatient attendees and decision-makers. This may have been re-enforced by existing disagreements between the two groups regarding who the legitimate stakeholders to involve during service delivery were. Conflicts identified in this study could be resolved by promoting application of approaches such as AFR during priority setting in the district.

Expansion of antiretroviral treatment to rural health centre level by a mobile service in Mumbwa district, Zambia.

Despite the Government's effort to expand services to district level, it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages. The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa. Mumbwa is a rural district with an area of 23 000 km² and a population of 167 000. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital. The mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases "lost to follow-up". This might be due to the closer involvement of the community and the better support offered by these services to rural clients. These mobile ART services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.

NEWHINTS cluster randomised trial to evaluate the impact on neonatal mortality in rural Ghana of routine home visits to provide a package of essential newborn care interventions in the third trimester of pregnancy and the first week of life: trial protocol

BackgroundTackling neonatal mortality is essential for the achievement of the child survival millennium development goal. There are just under 4 million neonatal deaths, accounting for 38% of the 10.8 million deaths among children younger than 5 years of age taking place each year; 99% of these occur in low- and middle-income countries where a large proportion of births take place at home, and where postnatal care for mothers and neonates is either not available or is of poor quality. WHO and UNICEF have issued a joint statement calling for governments to implement "Home visits for the newborn child: a strategy to improve survival", following several studies in South Asia which achieved substantial reductions in neonatal mortality through community-based approaches. However, their feasibility and effectiveness have not yet been evaluated in Africa. The Newhints study aims to do this in Ghana and to develop a feasible and sustainable community-based approach to improve newborn care practices, and by so doing improve neonatal survival.MethodsNewhints is an integrated intervention package based on extensive formative research, and developed in close collaboration with seven District Health Management Teams (DHMTs) in Brong Ahafo Region. The core component is training the existing community based surveillance volunteers (CBSVs) to identify pregnant women and to conduct two home visits during pregnancy and three in the first week of life to address essential care practices, and to assess and refer very low birth weight and sick babies. CBSVs are supported by a set of materials, regular supervisory visits, incentives, sensitisation activities with TBAs, health facility staff and communities, and providing training for essential newborn care in health facilities.Newhints is being evaluated through a cluster randomised controlled trial, and intention to treat analyses. The clusters are 98 supervisory zones; 49 have been randomised for implementation of the Newhints intervention, with the other 49 acting as controls. Data on neonatal mortality and care practices will be collected from approximately 15,000 babies through surveillance of women of child-bearing age in the 7 districts. Detailed process, cost and cost-effectiveness evaluations are also being carried out.Trial registrationhttp://www.clinicaltrials.gov (identifier NCT00623337)

Communication challenges in implementing health sector decentralisation at district level in Ghana

PurposeThe aim of this paper is to examine how internal communication of reform objectives to health workforces and stakeholders has influenced the implementation of Ghana's health sector decentralisation at district level.Design/methodology/approachData collection involved in‐depth interviews with district public health officials, private health providers, local government officials and health‐related non‐government organisations which had been working in the district for at least two years.FindingsThe study's findings showed that communication (the sharing of information) about reform objectives were centralised among the top hierarchy of the District Health Management Teams; and the process of transferring reform information to district health workforces and stakeholders was through a top‐downward approach. This vertical style of communication resulted in limited information getting through to district health workforces tasked with the implementation. This impacted negatively on reform implementation.Originality/valueThe paper reveals that there is a connection between the level of comprehension of the objectives for decentralisation reform both by the health workforce and stakeholders, particularly the expected new roles they are supposed to play. A lack of effective transfer of information affects commitment and ownership of the decentralisation reform at district level; contributing significantly to the poor implementation of the reform programme.

The challenges of budgeting in a newly introduced district health system: A case study

Background: Nigeria operates a three-tier political system consisting of a national government: 36 states, Federal Capital Territory and 768 local governments. There are three levels of health care: primary, secondary and tertiary levels corresponding to and funded by local, state and national governments, respectively. A budget prepared at the district level was not possible until 2006 when the 2007 annual budget was prepared. Aim: The goal of this study was to identify the key challenges of budgeting in a newly introduced District Health System and to share our experience with other scholars. Methodology: This study is a descriptive case study using interviews and focus group discussions of district and local health officers and the District Health Management Team as well as field notes made from participant observers and reviews of relevant documents. Findings and discussion: The study showed that a bottom-up approach was used at the district level, while the concept of business planning was introduced to underscore the seriousness of health planning and efficient resource allocation. The two systems of expenditure classifications, i.e., functional and economic classification, were used in a complementary manner. The capacity for planning and budgeting was found to be lacking among the district health officers. The crosscutting contextual issues constraining budgeting included the inadequate Health Management Information System (HMIS), a non-functional Financial Management System (FMS) and an unreliable Human Resources Management System (HRMS). Recommendations: There is a need for further study to be carried out to determine the factors that constrain the collection, analysis and dissemination of HMIS. In addition, there is a need to study the constraints to proper implementation of the FMS, HRMS and the linkage between the quality of the essential data-set with the efficiency of resource allocation in budgeting.

Options for the Delivery of Intermittent Preventive Treatment for Malaria to Children: A Community Randomised Trial

BackgroundIntermittent preventive treatment for malaria in children (IPTc) is a promising new intervention for the prevention of malaria but its delivery is a challenge. We have evaluated the coverage of IPTc that can be achieved by two different delivery systems in Ghana.MethodsIPTc was delivered by volunteers in six villages (community-based arm) and by health workers at health centres or at Expanded Programme on Immunisation outreach clinics (facility based) in another six communities. The villages were selected randomly and drugs were administered in May, June, September and October 2006. The first dose of a three-dose regimen of amodiaquine plus sulphadoxine-pyrimethamine was administered under supervision to 3–59 month-old children (n = 964) in the 12 study villages; doses for days 2 and 3 were given to parents/guardians to administer at home.ResultsThe proportion of children who received at least the first dose of 3 or more courses of IPTc was slightly higher in the community based arm (90.5% vs 86.6%; p = 0.059). Completion of the three dose regimen was high and similar with both delivery systems (91.6% and 91.7% respectively).ConclusionSeasonal IPTc delivered through community-based or facility-based systems can achieve a high coverage rate with the support and supervision of the district health management team. However, in order to maximise the impact of IPTc, both delivery systems may be needed in some settings. Trial RegistrationClinicalTrials.gov NCT00119132

Retention of health workers in Malawi: perspectives of health workers and district management

BackgroundShortage of human resources is a major problem facing Malawi, where more than 50% of the population lives in rural areas. Most of the district health services are provided by clinical health officers specially trained to provide services that would normally be provided by fully qualified doctors or specialists. As this cadre and the cadre of enrolled nurses are the mainstay of the Malawian health service at the district level, it is important that they are supported and motivated to deliver a good standard of service to the population. This study explores how these cadres are managed and motivated and the impact this has on their performance.MethodsA quantitative survey measured health workers' job satisfaction, perceptions of the work environment and sense of justice in the workplace, and was reported elsewhere. It emerged that health workers were particularly dissatisfied with what they perceived as unfair access to continuous education and career advancement opportunities, as well as inadequate supervision. These issues and their contribution to demotivation, from the perspective of both management and health workers, were further explored by means of qualitative techniques.Focus group discussions were held with health workers, and key-informant interviews were conducted with members of district health management teams and human resource officers in the Ministry of Health. The focus groups used convenience sampling that included all the different cadres of health workers available and willing to participate on the day the research team visited the health facility. The interviews targeted district health management teams in three districts and the human resources personnel in the Ministry of Health, also sampling those who were available and agreed to participate.ResultsThe results showed that health workers consider continuous education and career progression strategies to be inadequate. Standard human resource management practices such as performance appraisal and the provision of job descriptions were not present in many cases. Health workers felt that they were inadequately supervised, with no feedback on performance. In contrast to health workers, managers did not perceive these human resources management deficiencies in the system as having an impact on motivation.ConclusionA strong human resource management function operating at the district level is likely to improve worker motivation and performance.

Can VISION 2020 be implemented in rural government settings? Findings from two programmes in Tanzania

To generate information on essential components and the cost recovery potential of VISION 2020 programmes in rural Africa. We took a structured approach to planning, training, implementation and supervision of programmes in Singida and Mara regions, Tanzania involving both government and non-government partners. Extensive mentoring was provided to monitor activities and costs. Annual numbers of patients receiving eye care increased sevenfold, cataract surgeries by a factor of 2.6 and spectacles dispensed by a factor of 16. Running costs were shared; the government provided 40-60%, non-government organisations (NGOs) 25-45%, and patient fees 15%. Comprehensive eye care can be delivered with cooperation among partners. However, continued coordination and cooperation from government and NGOs are critical to reach VISION 2020 goals.

Community-directed treatment of lymphatic filariasis in Kenya and its role in the national programmes for elimination of lymphatic filariasis

We conducted a prospective, cross-sectional study to examine and compare treatment coverage of lymphatic filariasis by the health system (HST) and a health system implemented, community-directed treatment for the control of lymphatic filariasis (ComDT / HS) in 44 randomly selected villages in coastal Kenya. Demographic information on the villages and peripheral health facilities to guide design and implementation was obtained from a situation analysis phase of this study. A series of interactive training sessions on basic biology of lymphatic filariasis, concept and philosophy of ComDT / HS were given to members of the District Health Management Team (DHMT), peripheral health staff, community leaders and community drug distributors (CDDs) prior to ivermectin distribution. An intensive sensitization process of the community by the trained peripheral health staff and community leaders followed before selection of the CDDs. Quantitative and qualitative data for evaluation of the study were collected by coverage surveys of randomly selected households, focus group discussions and interviews, immediately after the drug distribution. Treatment coverage of all eligible persons was 46.5 and 88 % in HST and ComDT/HS villages, respectively, P < 0.001. In comparing treatment coverage by the two study arms in relationship to the distance from a health facility, coverage among HST and not ComDT / HS villages was influenced by distance. In Kenya, ComDT / HS can effectively be implemented by the regular health system and can attain coverage levels compatible with the global filariasis elimination goal.

Training needs for mid-level managers and immunisation coverage in western Kenya

To determine the current status of immunisation coverage in Western Kenya before intervention, to identify strengths and weaknesses of the existing programme in order to design educational interventions that could improve the services provided and find out the training needs of the mid-level managers of Kenya Expanded Programme of Immunisation. Cross-sectional descriptive study. All thirty nine districts in Rift Valley, Western and Nyanza provinces. Mid-level managers of Kenya Expanded Programme on Immunisation in the 39 districts and the provinces. These included Provincial Logisticians, Provincial Medical Officers of Health, District Medical Officers of Health, District Public Health Nurses, District Records and Health Information Officers, District Disease Surveillance Officers, and District Public Health Officers. Number of staff trained on EPI, coverage rates and perceived training needs of the mid-level managers. A total of eighty eight mid-level managers participated in the interviews. Most of these were District Public Health Nurses (40.9%) and District Health Information and Records Officers (23.9%). Only 49 (25%) of the District Health Management Team members had undergone training at the supervisory level. Eighteen districts (43.6%) had no member of the District Health Management Team that had ever been trained at the supervisory level. Using rates of Pentavalent 1 and measles coverage, Nyanza Province had the highest immunisation dropout rate (Pentavalent 1--measles) whereas Rift Valley Province had the lowest. The annual cumulative coverage for all the provinces by antigen was 80% for Pentavalent 1 and 2 and 60% for measles. The most requested need for inclusion in the training curriculum was maintenance of the cold chain equipment. Most of the members in the study area have not been trained on Expanded Programme on Immunisation and may be ill-equipped to manage the complicated programmes needed to maximise delivery of services. The immunisation coverage in this area is low while the dropout rates are high. We therefore recommend that all the mid-level managers of Expanded Programme on Immunisation in this area be trained comprehensively through the Merck Vaccine Network--Africa programme using the World Health Organisation approved mid-level managers course.

District-based malaria epidemic early warning systems in East Africa: Perceptions of acceptability and usefulness among key staff at health facility, district and central levels

Malaria epidemics represent a significant public health problem in the highlands of Africa. Many of these epidemics occur in low resource settings, where the development of an effective system for malaria surveillance has been a key challenge. Between 2001 and 2006, the Highland Malaria Project (HIMAL) established a programme to develop and test a district-based surveillance system for the early detection and control of malaria epidemics in four pilot districts in Kenya and Uganda. An innovative feature of the programme was the devolution of responsibility for the detection of epidemics from the central Ministry of Health to District Health Management Teams. The implementation of the programme offered the opportunity to test both the technical aspects of the system and to examine the practical issues relating to the operation of the programme in the context of the existing health system. To investigate the attitude of key staff towards the programme, and their perceptions of its impact on their working practices, interviews were carried out among 52 health staff at district level and in the Ministries of Health in Kenya and Uganda. The transfer of responsibility for the early detection of epidemics to the districts had resulted in perceptions of individual empowerment among district-based staff. This, together with improved support supervision, was a key factor in sustaining motivation and improved surveillance. The enhanced support supervision also produced capacity benefits that extended beyond improved malaria surveillance. However, these improvements occurred in the context of increased logistical support (the provision of transport, fuel and travel allowances) which the participants believed was essential to the functioning of an effective system. With this proviso, the district-based malaria early warning system was perceived to be manageable, effective and sustainable in the context of the current health system.

Why don't health workers prescribe ACT? A qualitative study of factors affecting the prescription of artemether-lumefantrine

BackgroundKenya recently changed its antimalarial drug policy to a specific artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). New national guidelines on the diagnosis, treatment and prevention were developed and disseminated to health workers together with in-service training.MethodsBetween January and March 2007, 36 in-depth interviews were conducted in five rural districts with health workers who attended in-service training and were non-adherent to the new guidelines. A further 20 interviews were undertaken with training facilitators and members of District Health Management Teams (DHMTs) to explore reasons underlying health workers' non-adherence.ResultsHealth workers generally perceived AL as being tolerable and efficacious as compared to amodiaquine and sulphadoxine-pyremethamine. However, a number of key reasons for non-adherence were identified. Insufficient supply of AL was a major issue and hence fears of stock outs and concern about AL costs was an impediment to AL prescription. Training messages that contradicted the recommended guidelines also led to health worker non-adherence, compounded by a lack of follow-up supervision. In addition, the availability of non-recommended antimalarials such as amodiaquine caused prescription confusion. Some health workers and DHMT members maintained that shortage of staff had resulted in increased patient caseload affecting the delivery of the desirable quality of care and adherence to guidelines.ConclusionThe introduction of free efficacious ACTs in the public health sector in Kenya and other countries has major potential public health benefits for Africa. These may not be realized if provider prescription practices do not conform to the recommended treatment guidelines. It is essential that high quality training, drug supply and supervision work synergistically to ensure appropriate case management.

Can District-Level tuberculosis case-finding in Malawi be improved? a qualitative study of healthcare worker perceptions in Dedza District

Objectives: This study aimed to identify, from healthcare workers' (HCWs') perspectives, barriers to tuberculosis (TB) case-finding that can be targeted to aid rapid TB diagnosis within Dedza district. Design: In-depth interviews were conducted with staff routinely involved in the diagnosis and treatment of TB patients. Those identified worked at the district hospital or community healthcare centres. Results: There was a consensus amongst HCWs that barriers to TB case-finding in the district health system include logistical problems. HCWs identified the tendency of patients with TB to seek traditional and private healthcare services, the association of TB with HIV/AIDS, difficulties in traveling to healthcare facilities and poverty as major patient-related barriers to diagnosis. Conclusion: This study identified perceptions of both health system and patient-related barriers to TB case-finding. Health-system related barriers highlight the need to further integrate TB case-finding into routine district service provision, particularly at peripheral health units. The Malawi National TB Programme and District Health Management Team must share responsibility for overcoming such barriers. There are also broader implications for providing healthcare in general and preventing the exclusion of certain members of the population from health services. Malawi Medical Journal Vol. 18 (2) 2006: pp. 66-71

Delayed cord clamping and haemoglobin levels in infancy: a randomised controlled trial in term babies

This study was carried out to assess whether delaying umbilical cord clamping is effective in improving the haematological status of term infants living in a malaria-endemic area, and whether this is associated with complications in infants and mothers. We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to delayed cord clamping (DCC, n = 46) or immediate cord clamping (controls, n = 45) and followed their infants on a bi-monthly basis until the age of 6 months. We compared the haemoglobin (Hb) change from cord values and the proportion of anaemic infants. Secondary outcomes related to infant and maternal safety. Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls than in the DCC group [difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI) 0.2; 2.1]. By 6 months, this difference had disappeared (0.0 g/dl, 95% CI -0.9; 0.8). The odds ratio for iron deficiency anaemia in the DCC group at 4 months was 0.3 (95% CI 0.1; 1.0), but no differences were found between the groups at 6 months. No adverse events were seen in infants and mothers. Our findings indicate that DCC could help improve the haematological status of term infants living in a malaria-endemic region at 4 months of age. However, the beneficial haematological effect disappeared by 6 months. This simple, free and safe delivery procedure might offer a strategy to reduce early infant anaemia risk, when other interventions are not yet feasible.

Enhancing disease surveillance reporting using public transport in Dodoma District, Central Tanzania

An efficient disease surveillance system is a prerequisite for an effective disease control programme. It is only when correct and timely reports about disease outbreaks reaches the responsible persons that prompt actions can be taken. Tanzania is in the process of strengthening its infectious disease surveillance system using an integrated approach. However, several constraints hamper the smooth implementation of the new strategy (Miller et al., 2003). Under the current Integrated Disease Surveillance and Response (IDSR) strategy, health facilities in Tanzania are required to immediately notify the district when they suspect an outbreak, and to provide week-ending reports for 7 outbreak-prone diseases, and monthlyreports for 13 priority diseases (Mboera, 2004). Vital epidemiological information available at most health facilities in Tanzania are not often readily available for decision making at the district and national levels. This is due to lack of adequate information exchange facilities and systems that allow for a rapid access of information available at one level or both levels. Epidemiological reporting between facility and district levels of health delivery system has remained poor due to lack of effective and efficient means of communication (Miller et al., 2003; Kajeguka & Mboera, 2003). In a recent study in 12 districts of Tanzania, the overall timeliness reporting from facility to district level was found to be 8% (0-19%) for weekly reports and 24% (3-56%) for montly reports (Gueye et al., 2005). Some routine paper reports are currently being picked up during supervision and outreach visits, but these visits are quite irregular. Some reports are sent by radio call and hard copies delivered in person. In this paper, we report the use of a participatory process in solving weekly epidemiological surveillance reporting problem in Dodoma Rural district in Tanzania. Dodoma Rural District (6o, 30’ to 8o0’S, 35o, 30’ to 37o 0’E) is located in the central plateaus in Tanzania at an elevation of about 800-1200m above sea level. The district consists of a number of mountain chains, between which are low-lying flat areas. A number of depressions are associated with these lower areas, which are generally waterlogged during the rainy season and have a tendency of salinity because of their limited outflow. The district has a dry Savannah type of climate characterised by a long dry season lasting between April and November. The average annual rainfall is 500800mm, which is normally a short single wet season lasting between December and March. The district is made up of 8 divisions, 48 wards, and 128 villages covering an area of 14,004 km. The district population is 495,176 made up of 96,686 households. The district is served by 81 health facilities (1 hospital, 6 health centres and 74 dispensaries). The nearest and furthest health facilities are 37 km and 145 km from the district capital, respectively (Mboera et al., 2005). The participatory process approach involved researchers from the National Institute for Medical Research, district council health management team (CHMT) and the in-charges of all facilities in the district. The CHMT and health workers were trained to carry out problem-solving participatory approach in the area of communication. Following the discussions, strategies were developed and documented. Eighty-one health facilities were involved in the discussion in four different sessions. During the discussion several means of communication were suggested by the participants. These included: public bus transport, radio calls, passenger train, mobile phones and bicycles. The use of public buses was given the highest priority.