District Health Team Research Articles

Development of Learning and Research Health Districts (LRHD) in the DR Congo: results

Abstract Issue There is great need in DRCongo for adequate training sites where national public health managers and workers can discover what is means to manage complex district healthcare delivery systems in a perspective of PHC and UHC. The development of such LRHD is coherent with the national policy in DRC advocating for demonstration districts. Description of the Problem The RIPSEC has launched three sites called LRHD, two of which are rural and one urban. A specialist in the organization and management of health services, from each of the three schools of public health, supervised the development and monitoring of those LRHDs. The Provincial Supervisor was also involved. Three approaches to solving priority problems have been defined: strengthening leadership at the HD level; transform health services into a learning and research framework. We analyze the transformation process obtained in these HD. Results Transformation processes in the district went through a strengthening of the capacity of the district health teams and via a process of action-research. The results of those LRHD after 4 years were mixed: the leadership of the management teams has improved. A reflexive attitude developed which contributes to more appropriate decision-making,monitoring and evaluation.At least one hospital service and 2 health centers have been transformed according to specific problems,improving the interaction between health structures, in order to quality of care has improved, the results of action research have made it possible to resolve local health problems. RIPSEC support to Provincial Supervisor to develop their working tools to better address their functions and responsibilities. However, the documentation of these changes induced by RIPSEC was not yet systematized. No residential internship could be carried out due to operational constraints. Lessons Mentoring, through its intellectual inputs, has contributed to a dynamic of change in the HD. Key messages The basis of the strategy is the improvement of the leadership of the HD management team,reinforced by mentoring and systematic documentation of complex decisions. This program could be continued to perpetuate these fragile achievements. This experience can be used elsewhere in different contexts. But,the residential internship requires other resources.

Institutional strengthening for evidence-based health policies in the DR Congo (RIPSEC): Impact

Abstract Issue In the DRC, the need to strengthen the health system for a more equitable charge of the health of the population in a perspective of universal health coverage proves to be relevant. Develop a culture that promotes decision-making based on scientific evidence, essential to improve the overall performance of the health system from this perspective Description of the Problem The RIPSEC program aims to (i) develop the capacity to manage health knowledge in the DRC through the creation of a Health Knowledge Center in the DRC, (CCSC- Asbl); to strengthen the scientific capacity of the Public Health Schools and the National Institute of Biomedical Research in health systems research and education and to strengthen the training capacity of the Public Health Schools by Development of Learning and Research Health Districts (LRHD). We assess the level of achievement of the results of this program. Results The majority of objectives have been reached.The CCSC-Asbl, created is an autonomous institution with legal personality. It produces scientific evidence and support for decision-making. The Ministry of Health has been strengthened and diversified. Institutional capacities and visibility have been strengthened through continuing education and the publication of scientific articles. But, no doctorals theses has been completed yet. Establishment of a consultation framework for health science training institutes: online training, short-term joint training on health system research. The third component concerns the development of LHRD; Transformation processes in the district went through a strengthening of the capacity of the district health teams and via a process of action-research. Lessons The RIPSEC program is increasingly becoming part of the Congolese health system as a strong partner. Key messages This experience can be used elsewhere in different contexts This program could be continued to perpetuate these fragile achievements. It corresponds to the felt needs and the priority of the health education system in the DRC or elsewhere.

Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods.

An intervention called ‘Optimising the Health Extension Program’, aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.

Malaria outbreak investigation in a rural area south of Zimbabwe: a case\u2013control study

BackgroundNinety percent of the global annual malaria mortality cases emanate from the African region. About 80–90% of malaria transmissions in sub-Saharan Africa occur indoors during the night. In Zimbabwe, 79% of the population are at risk of contracting the disease. Although the country has made significant progress towards malaria elimination, isolated seasonal outbreaks persistently resurface. In 2017, Beitbridge District was experiencing a second malaria outbreak within 12 months prompting the need for investigating the outbreak.MethodsAn unmatched 1:1 case–control study was conducted to establish the risk factors associated with contracting malaria in Ward 6 of Beitbridge District from week 36 to week 44 of 2017. The sample size constituted of 75 randomly selected cases and 75 purposively selected controls. Data were collected using an interviewer-administered questionnaire and Epi Info version 7.2.1.0 was used to conduct descriptive, bivariate and multivariate analyses of the factors associated with contracting malaria.ResultsFifty-two percent of the cases were females and the mean age of cases was 29 ± 13 years. Cases were diagnosed using rapid diagnostic tests. Sleeping in a house with open eaves (OR: 2.97; 95% CI 1.44–6.16; p < 0.01), spending the evenings outdoors (OR: 2.24; 95% CI 1.04–4.85; p = 0.037) and sleeping in a poorly constructed house (OR: 4.33; 95% CI 1.97–9.51; p < 0.01) were significantly associated with contracting malaria while closing eaves was protective (OR: 0.45; 95% CI 0.20–1.02; p = 0.055). After using backward stepwise logistic regression, sleeping in a poorly constructed house was associated with five-fold odds of getting sick from malaria (AOR: 8.40; 95% CI 1.69–41.66; p = 0.009). Those who had mosquito nets did not use them consistently. The district health team and the rural health centre were well prepared to response despite having limited human resources.ConclusionHealth promotion messages should emphasize the importance of closing the entry points of the malaria vector, and the construction of better houses in the future. Residents had to be educated in the importance of consistent use of mosquito nets. The district had to improve malaria preventive measures like distribution of mosquito nets and lobby for more human resources to assist with malaria surveillance thus, curbing the recurrence of malaria outbreaks.

Managing possible serious bacterial infection of young infants where referral is not possible: Lessons from the early implementation experience in Kushtia District learning laboratory, Bangladesh.

BackgroundSerious infections account for 25% of global newborn deaths annually, most in low-resource settings where hospital-based treatment is not accessible or feasible. In Bangladesh, one-third of neonatal deaths are attributable to serious infection; in 2014, the government adopted new policy for outpatient management of danger signs indicating possible serious bacterial infections (PSBI) when referral was not possible. We conducted implementation research to understand what it takes for a district health team to implement quality outpatient PSBI management per national guidelines.MethodsPSBI management was introduced as part of the Comprehensive Newborn Care Package in 2015. The study piloted this package through government health systems with limited partner support to inform scale-up efforts. Data collection included facility register reviews for cases seen at primary level facilities; facility readiness and provider knowledge and skills assessments; household surveys capturing caregiver knowledge of newborn danger signs and care-seeking for newborn illness; and follow-up case tracking, capturing treatment adherence and outcomes. Analysis consisted of descriptive statistics.ResultsOver the 15-month implementation period, 1432 young infants received care, of which 649 (45%) were classified as PSBI. Estimated coverage of care-seeking increased from 22% to 42% during the implementation period. Although facility readiness and providers’ skills increased, providers’ adherence to guidelines was not optimal. Among locally managed PSBI cases, 75% completed the oral antibiotic course and 15% received the fourth day follow-up. Care-seeking remained high among private providers (95%), predominantly village health doctors (over 80%).ConclusionsFacility readiness, including health care provider knowledge and skills were strengthened; future efforts should focus on improving provider adherence to guidelines. Social and behavior change strategies targeting families and communities should explore shifting care-seeking from private, possibly less-qualified providers. Strategies to improve private sector management of PSBI cases and improved linkages between private and public sector providers could be explored.

Understanding implementation barriers in the national scale-up of differentiated ART delivery in Uganda

BackgroundAlthough Differentiated Service Delivery (DSD) for anti-retroviral therapy (ART) has been rolled-out nationally in several countries since World Health Organization (WHO)‘s landmark 2016 guidelines, there is little research evaluating post-implementation outcomes. The objective of this study was to explore patients’ and HIV service managers’ perspectives on barriers to implementation of Differentiated ART service delivery in Uganda.MethodsWe employed a qualitative descriptive design involving 124 participants. Between April and June 2019 we conducted 76 qualitative interviews with national-level HIV program managers (n = 18), District Health Team leaders (n = 24), representatives of PEPFAR implementing organizations (11), ART clinic in-charges (23) in six purposively selected Uganda districts with a high HIV burden (Kampala, Luwero, Wakiso, Mbale, Budadiri, Bulambuli). Six focus group discussions (48 participants) were held with patients enrolled in DSD models in case-study districts. Data were analyzed by thematic approach as guided by a multi-level analytical framework: Individual-level factors; Health-system factors; Community factors; and Context.ResultsOur data shows that multiple barriers have been encountered in DSD implementation. Individual-level: Individualized stigma and a fear of detachment from health facilities by stable patients enrolled in community-based models were reported as bottlenecks. Socio-economic status was reported to have an influence on patient selection of DSD models. Health-system: Insufficient training of health workers in DSD delivery and supply chain barriers to multi-month ART dispensing were identified as constraints. Patients perceived current selection of DSD models to be provider-intensive and not sufficiently patient-centred. Community: Community-level stigma and insufficient funding to providers to fully operationalize community drug pick-up points were identified as limitations. Context: Frequent changes in physical addresses among urban clients were reported to impede the running of patient groups of rotating ART refill pick-ups.ConclusionThis is one of the first multi-stakeholder evaluations of national DSD implementation in Uganda since initial roll-out in 2017. Multi-level interventions are needed to accelerate further DSD implementation in Uganda from demand-side (addressing HIV-related stigma, community engagement) and supply-side dimensions (strengthening ART supply chain capacities, increasing funding for community models and further DSD program design to improve patient-centeredness).

Strengthening District Health Teams Capacity in Surveillance Systems and Response to Public Health Threats in Western Uganda through Field Epidemiology Training Program (FETP)

Aim: To strengthen the District Capacity in surveillance for effective detection, Reporting and Response to Public Health threats. Background: The overall aim of a good surveillance system is to strengthen the capacity of a Health system through training of health personnel who can conduct effective surveillance activities. A good surveillance system is achieved through improved use of complete and timely health information to detect changes in time to institute a rapid response to the suspected outbreak of Public Health events. This assessment followed a 3-month Field Epidemiology Training program undertaken by the investigator who applied the acquired knowledge and skills in completion of the assessment. Study Design: It was a descriptive cross-sectional, institutional based epidemiological investigation conducted at district level and Health Centre 1V in Kabarole from 15th December 2019-March 2020. eReports were retrieved from DHIS-2 for epidemiological weeks 44 in 2019 to week 3 in 2020. Data analysis: Micro soft word excel program was used to determine the reporting rates, epidemic disease trends and construction of malaria channel. SWOT analysis was done to identify poor HMIS reporting as the lead surveillance quality challenge and route cause analysis done to determine underlying causes. Results: Weekly reports analyzed were from a total of 53 Health facilities and one Health Centre four for malaria channel construction. Of the 53 functional Health facilities assessed in the district, the average reporting Timeliness was 32% and Completeness at 63% from week 44 in 2019 to week 3 in 2020. This finding shows that the district was not achieving the 80% Timeliness and 80% Completeness national target. The poor reporting situation implies that the district may not detect an emerging Public Health Event and respond in time. Poor reporting rate was linked to knowledge gap among reporting staff in completion of the newly revised HMIS tools and lack of support supervision. The analyzed data revealed that the district had increased dysentery, measles and typhoid fever cases. The dysentery and typhoid fever cases had reached and surpassed the Alert and Action thresh hold levels however there was no reported death from these diseases. Further inquiry revealed that Typhoid fever was being diagnosed using WIDAL test as opposed to WHO recommendation of stool or blood culture. The noted typhoid fever outbreak in the district was therefore being based on wrong laboratory tests hence regarded by the researcher as speculative. Findings on malaria channel revealed a normal and expected trend of malaria in Kabarole district in 2020. Conclusion: knowledge and skills from FETP-training enabled the investigator to establish the fact that the district’s surveillance system was less sensitive in detecting Public Health events for a quick response. Intensified targeted support supervision and mentorships of all health workers on reporting could help improve the districts surveillance system.

Integration of the UNHCR Refugee Health Information System into the National Health Information Management System for Uganda.

The Uganda Government, together with development partners, has provided continuing support services (including protection, food, nutrition, healthcare, water and sanitation) to refugee-hosting Districts to successfully manage refugees from different neighbouring countries in established settlements. This service has increased the need for timely and accurate information to facilitate planning, resource allocation and decision-making. Complexity in providing effective public health interventions in refugee settings coupled with increased funding requirements has created demands for better data and improved accountability. Health data management in refugee settings is faced with several information gaps that require harmonisation of the Ugandan National Health Management Information System (UHMIS) and United Nations High Commission for Refugees (UNHCR) Refugee Health Information System (RHIS). This article discusses the rationale for harmonisation of the UNHCR RHIS, which currently captures refugee data, with the UHMIS. It also provides insights into how refugee health data management can be harmonised within a country's national health management information system. A consultative meeting with various stakeholders, including the Ugandan Ministry of Health, district health teams, representatives from UNHCR, the United Nations Children Education Fund (UNICEF), United States Government and civil society organisations, was held with an aim to review the UHMIS and UNHCR RHIS health data management systems and identify ways to harmonise the two to achieve an integrated system for monitoring health service delivery in Uganda. Several challenges facing refugee-hosting district health teams with regard to health data management were identified, including data collection, analysis and reporting. There was unanimous agreement to prioritise an integrated data management system and harmonisation of national refugee stakeholder data requirements, guided by key recommendations developed at the meeting. This article outlines a proposed model that can be used to harmonise the UNHCR RHIS with the UHMIS. The national refugee stakeholder data requirements have been harmonised, and Uganda looks forward to achieving better health data quality through a more comprehensive national UHMIS to inform policy planning and evidence-based decision-making.

Preference and uptake of different community-based HIV testing service delivery models among female sex workers along Malaba-Kampala highway, Uganda, 2017

IntroductionFemale Sex workers (FSW) and their clients accounted for 18% of the new HIV infections in 2015/2016. Special community-based HIV testing service delivery models (static facilities, outreaches, and peer to peer mechanism) were designed in 2012 under the Most At Risk Populations Frame work and implemented to increase access and utilization of HIV care services for key populations like female sex workers. However, to date there is no study that has been done to access the preference and uptake of different community-based HIV testing service delivery models used to reach FSW. We assessed preference and uptake of the current community-based HIV testing services delivery models that are used to reach FSW and identified challenges faced during the implementation of the models.MethodsWe conducted a cross-sectional study design using quantitative (interview with the health workers in facilities providing services to female sex workers and interviews with FSWs) and qualitative (interviews with Ministry of Health staff, health workers, district health team members, program staff at different levels involved in delivery of HIV care services, FSWs and political leaders to assess for the enabling environment created to deliver the different community-based HIV testing services to FSWs along the Malaba-Kampala highway. Malaba – Kampala high way is one of the major high ways with many different hot spots where the actual buying and selling of sex takes place. We defined FSWs as any female, who undertakes sexual activity after consenting with a man for money or other items/benefits as an occupation or as a primary source of livelihood irrespective of site of operation within the past six months.We assessed the preference and uptake of different community based HIV testing services delivery model among FSWs based on two indicators, i.e., the proportion of FSWs who had an HIV Counseling and Testing (HCT) in the last 12 months and the proportion of FSWs who were positive and linked to care.ResultsOverall, 86% (390/456) of the FSWs had taken an HIV test in the last 12 months. Of the 390 FSWs, 72% (279/390) had used static facilities, 25% (98/390) had used outreaches, and 3.3% (13/390) used peer to peer mechanisms to have an HIV test. Overall, 35% (159/390) of the FSWs who had taken an HIV test were HIV positive. Of the 159, 83% (132/159) were successfully linked into care. Ninety one percent (120/132) reported to have been linked into care by static facilities. Challenges experienced included; lack of trust in the results given during outreaches, failure to offer other testing services including hepatitis B and syphilis during outreaches, inconsistent supply of testing kits, condoms, STI drugs, and unfriendly health services due to the infrastructure and non-trained health workers delivering KP HIV testing services.ConclusionsMost of the FSWs had HCT services and were linked to care through static facilities. Community-based HIV testing service delivery models are challenged with inconsistent supply of HIV testing commodities and unfriendly services.. We recommended strengthening of all HIV testing community-based HIV testing service deliverymodels by ensuring constant supply of HIV testing/AIDS care commoditiesoffering FSW friendly services, and provision of comprehensive HIV/AIDS health care package.

Feasibility and acceptability of a midwife-led health education strategy to reduce exposure to biomass smoke among pregnant women in Uganda, A FRESH AIR project

ABSTRACTBiomass smoke exposure is a threat to child and maternal health in many resource-limited countries and is associated with poor pregnancy outcomes and serious lung diseases in the offspring. We aimed to assess the feasibility, acceptability and impact of a midwife-led education programme on biomass risks and prevention for women attending maternity clinics in Uganda. Education materials were co-developed through an iterative process by midwives and other stakeholders. The materials were serially tested and approved by the Ministry of Health and used by midwives and village health teams (VHTs). The district health team, 12 midwives and 40 VHTs were sensitised on biomass smoke. Two hundred and forty-four women were educated about biomass smoke by midwives; pre- and post-session questionnaires showed major improvements in knowledge of biomass smoke risks. Qualitative interviews with women three months after the sessions showed that they made behavioural changes such as avoiding smoke while cooking, using dry wood, solar power for lighting and improved ventilation. The major barrier to behavioural changes was poverty, but some improvements cost no money. The programme delivered by midwives was feasible and acceptable; implementing this programme has the potential to reduce exposure to smoke with major benefits to mother, foetus, and children throughout their lives.

Outbreak of Cyanide Poisoning Caused by Consumption of Cassava Flour - Kasese District, Uganda, September 2017.

Cassava (Manihot esculenta), an edible tuberous root that is resistant to drought, diseases, and pests, is a major source of carbohydrates in tropical areas, the second most widely grown and consumed food in Uganda after bananas, and a staple in the diet for approximately 57% of the Uganda population (Figure 1) (1). On September 5, 2017, a funeral was held in Kasese District in western Uganda. Following the funeral, 33 persons with symptoms that included diarrhea, vomiting, and abdominal pains were admitted to Bwera Hospital in Kasese District. On September 8, the Uganda Ministry of Health received notification from the Kasese District health team regarding this outbreak of suspected food poisoning. An investigation to determine the cause of the outbreak and recommend control measures revealed that the outbreak resulted from consumption of a cassava dish made by combining hot water with cassava flour. The implicated batch of cassava flour was traced back to a single wholesaler and found to contain high cyanogenic content. Informed by the investigation findings, police confiscated all cassava flour from retailers identified as the patients' source of the flour. Health education about cyanide poisoning from cassava and the need to adequately process cassava to reduce cyanogenic content was conducted by public health officials.

Revitalization of integrated disease surveillance and response in Sierra Leone post Ebola virus disease outbreak

BackgroundThe Ministry of Health and Sanitation (MOHS) in Sierra Leone partially rolled out the implementation of Integrated Disease Surveillance and Response (IDSR) in 2003. After the Ebola virus disease outbreak in 2014–2015, there was need to strengthen IDSR to ensure prompt detection and response to epidemic-prone diseases. We describe the processes, successes and challenges of revitalizing public health surveillance in a country recovering from a protracted Ebola virus disease outbreak.MethodsThe revitalization process began with adaptation of the revised IDSR guidelines and development of customized guidelines to suit the health care systems in Sierra Leone. Public health experts defined data flow, system operations, case definitions, frequency and channels of reporting and dissemination. Next, phased training of IDSR focal persons in each health facility and the distribution of data collection and reporting tools was done. Monitoring activities included periodic supportive supervision and data quality assessments. Rapid response teams were formed to investigate and respond to disease outbreak alerts in all districts.ResultsSubmission of reports through the IDSR system began in mid-2015 and by the 35th epidemiologic week, all district health teams were submitting reports. The key performance indicators measuring the functionality of the IDSR system in 2016 and 2017 were achieved (WHO Africa Region target ≥80%); the annual average proportion of timely weekly health facility reports submitted to the next level was 93% in 2016 and 97% in 2017; the proportion of suspected outbreaks and public health events detected through the IDSR system was 96% (n = 87) in 2016 and 100% (n = 85) in 2017.ConclusionWith proper planning, phased implementation and adequate investment of resources, it is possible to establish a functional IDSR system in a country recovering from a public health crisis. A functional IDSR system requires well trained workforce, provision of the necessary tools and guidelines, information, communication and technology infrastructure to support data transmission, provision of timely feedback as well as logistical support.

WhatsApp: a supplementary tool for improving bed nets universal coverage campaign in Mozambique

BackgroundWhatsApp (WA) is the most recent and attractive applicative among Smartphone users. The use of WA in healthcare environment has been shown of multiple benefices. Mozambique team involved in 2017 bed nets universal coverage campaign (UCC) implemented a distant mentoring strategy using WA. This study aims to perform a descriptive analysis of the use of WA as a supplementary tool for mentoring provincial and district health teams during bed nets universal coverage campaign in Mozambique.MethodsUsing WA, a qualitative study was carried out between March and July 2017. Seven WA groups were created. One group for central-level team, and six groups corresponding to each implementation province. The WA content was analyzed, grouped into separate themes, and subject to information triangulation among researchers and group participants. Saturation guided the quantity and quality of information.ResultsA total of 511 members were included in all WA groups. Of these, 96% were provincial WA groups. A total of 24,897 messages (text and images) were exchanged in all WA groups. The main communication form was text (22,660–91%), followed by images (2237–9%). Five themes emerged from content analyses: 1) administrative/financial, 2) logistic, 3) planning and implementation, 4) monitoring and evaluation, and 5) best practice.ConclusionsThe use of WA during universal coverage bed nets campaign implementation in Mozambique fostered central-level coordination, providing implementation support to district and provincial teams, and promoting wider and timely information sharing among group members.

Knowledge, attitude, and beliefs on epilepsy among adults in Erute South, Lira District, Uganda.

SummaryObjectiveTo assess the knowledge, attitudes, and beliefs of adults on epilepsy in Erute South County, Lira District, Uganda.MethodsA cross‐sectional study was conducted in rural Erute South County. Two hundred seventeen of 220 randomly selected adults 18 years or older participated in the study. A standardized self‐administered questionnaire (Attitudes towards persons with Epilepsy “ATPE”) was used for data collection. Protocol approval was sought from International Health Sciences University, and informed consent was obtained from participants at all times.ResultsTwo hundred seventeen of 220 invited community members completed the study. Females comprised the majority 51.6%.. Most of the respondents had a low level of knowledge on epilepsy. The mean ATPE scale knowledge score was 4.57 (standard deviation [SD] = 3.24) of a maximum score of 11. The male respondents almost had mean knowledge scores almost equal to their female counterparts (4.23, SD = 2.48; 4.51, SD = 2.54, respectively). Most respondents had negative attitudes toward epilepsy, with a mean ATPE attitude score of 73.2 (SD = 2.11) of a possible maximum score of 126. The mean attitude scores for the male and female respondents were 58.18 (SD = 4.23) and 86.62 (SD = 5.23), respectively. Most respondents had negative beliefs such as attributing epilepsy to supernatural spirits, heredity, and preference of traditional medicine and healers to conventional medicine as a treatment for epilepsy. A significant number of respondents expressed sympathetic feelings toward people living with epilepsy, specifically tolerance and kindness to those living with epilepsy.SignificanceFindings could benefit policymakers, the district health team, researchers, community members, affected families, and people with epilepsy in designing awareness strategies. Knowledge on epilepsy could improve the quality of life and care for people living with epilepsy, through reducing misconceptions and stigmatization in the communities where they live.

IMPROVING THE ABILITY OF DISTRICTS IN UGANDA TO MONITOR THEIR HIV PROGRAMS

BACKGROUND&#x0D; Although district health teams (DHT) in Uganda are supposed to monitor and support facilities to ensure quality HIV data collection, reporting and use, they are often ill-equipped to do so. We implemented a program designed to build the capacity of districts to manage and use their own HIV-related program data and to assist facilities to collect and evaluate their own data.&#x0D; METHODS&#x0D; We conducted a baseline assessment of the monitoring and evaluation (M&amp;E) capacity of 38 districts. In the 10 worst-performing districts, we identified and trained district-level staff to become M&amp;E mentors who in turn trained and supervised facility-level staff. We collected information on action plans developed by facilities to address major issues of concern. Following the intervention, we reassessed M&amp;E capacity of the 10 targeted districts.&#x0D; RESULTS&#x0D; Among the 38 districts assessed, one-half did not have a biostatistician, less than one-quarter had staff trained in the basics of M&amp;E or data analysis, and less than one-quarter had an M&amp;E plan. The main concerns of facilities included lack of updated data collection tools, lack of supervision, inaccurate data recording, and limited ability to analyze and use data. In the 10 targeted districts, comparison before and after the intervention showed that the number of districts with trained M&amp;E staff increased (4 to 9), the number of M&amp;E plans increased (3 to 6), and the number using data for programming increased (4 to 8). Implementation of action plans by facilities successfully addressed many issues and led to improved programming.&#x0D; CONCLUSION&#x0D; Challenges of district M&amp;E in Uganda mainly result from a lack of skilled human resources. On-the-job training and direct involvement of district staff to provide support to facilities can lead to improvements in data quality and use.

Unexplained cluster of deaths - Nana Kru Community, Dugbe River District, Liberia, January 2017

Introduction: an unexplained cluster of deaths (UCD) is deaths from unknown cause occurring closely together. In Liberia, UCD is one of the 14 priority events requiring immediate reporting and investigation. On 11th January, 2017, the Dugbe River District Health Team was notified of five unexplained deaths in Nana Kru Community. We investigated to describe the events, establish the causes of death, implement control measures and make recommendations.

Acute Flaccid Paralysis case investigation, Butaw District, Sinoe County, Liberia, August 2016

Introduction: Acute Flaccid Paralysis (AFP) is characterized by sudden onset of weakness in one or more limbs. It is a common sign of acute poliomyelitis which is targeted for eradication by World Health Organization. AFP is used for surveillance of poliomyelitis but is also associated with a number of other pathogenic agents including enteroviruses, echoviruses, West Nile virus, and adenoviruses, among others. AFP is among the 14 priority conditions requiring immediate reporting in Liberia. On 28 September, 2016 a community health volunteer informed the Butaw District Health Team about a case of AFP. An investigation was conducted to verify the report, determine the cause and extent of the disease and take response actions or make recommendations.

Suspected neonatal death investigation, Jaedae District, Sinoe County, February 2017

Introduction : neonatal death is death of a baby at birth or within first 28 days of life. Neonates account for 45% of deaths among children under five. Liberia recorded 534 neonatal deaths in 2016 with 2.4% (13) from Sinoe County. The District Health Team received report of neonatal death in Jarkupen community on 2nd February, 2017. We investigated to confirm the event, establish the cause and take public health action. Methods : jarkupen community has 765 inhabitants. It is hard to reach; requiring about 9 hours footing to access health facility. We compared the series of events with the standard case definition to confirm the event. We interviewed community leaders, family members and health workers to establish the cause and took public health action based on findings. Results : the mother was primiparous, aged 22 years. She never sought antenatal care. Labour was at term and managed by a trained traditional midwife (TTM) at home. The second stage of labour (delivery) was delayed to a point that TTM could no longer hear the foetal heartbeat. A male baby was eventually delivered vaginally but with no breathing and no heartbeat, although it was pink. The event did not meet the case definition of neonatal death but rather fresh still birth. Conclusion : inadequate delivery and neonatal resuscitation skills of TTM could have contributed. TTMs are not supposed to conduct deliveries but a long distance from the community to the facility poses a challenge for compliance. We conducted community sensitization on maternal health and health-seeking behavior. Upon our recommendation, preparations are underway to build a maternal waiting home close to a health facility where pregnant women can reside when they are almost term.

Schistosomiasis outbreak investigation - Bokomu District, Gbarpolu County, Liberia, 2016

Introduction : schistosomiasis is an acute and chronic disease caused by parasitic worm Schistosoma. There are urogenital and intestinal forms of schistosomiasis, leading to chronic ill-health, anaemia and end-organ damage, including renal failure. Transmission is by contact with water infested by infected water snail. Schistosoma haematobium and Schistosoma mansoni are prevalent in Liberia. On August 23, 2016, the Bokomu District Health Team received reports of increased cases of haematuria in Gbarnga, Bokomu District from a community volunteer after two suspected cases from the community reported to the hospital. We investigated to confirm the outbreak, identify the causative agent, determine the extent of the disease, and identify the source of transmission and to control the spread. Methods : the total population of Gbarnga community was 2,100. We screened community members who availed themselves by conducting laboratory testing of their urine samples. We conducted an environmental assessment of water bodies. We analyzed the data using Microsoft Excel. Results : of 256 persons screened, 96% (247) tested positive for S. haematobium. More community members declined to report for screening although some were symptomatic. Median age of screened persons was 14 (range 1.8 to 43years). Majority (64%) of these were of school-going age. Duration of symptoms ranged from 1 week to 3 years. The main source of water is a swamp; for bathing, farming activities and recreational swimming. We observed some water snails around the swamp but could not test the water for cercaria worms. Conclusion : an outbreak of urinary schistosomiasis was confirmed, caused by S. haematobium. Prevalence was at least 11.8% (247 out of 2100). The community swamp was the likely reservoir of the infection. The County Health Team conducted mass education and treatment and recommended that the Government provide the community with potable water. Surveillance is ongoing.

Study on Epidemiology of Chronic Obstructive Pulmonary Disease (COPD) at Western Regional Hospital, Pokhara

According to the curriculum of Bachelor of Medicine and Bachelor of Surgery (MBBS) program of the Tribhuvan University (TU), Institute of Medicine (IOM), the Department of Community Medicine of Gandaki Medical College (GMC) has been conducting the District Health System Management (DHSM) study for the students of MBBS, third phase (4th year). This program provides us an opportunity for clinical and community orientation to develop skills to become a competent medical professional to work at different levels of hospitals and district health system. This course enables us to assess resource potentials and constraints, prioritize the health problems and set strategies for solving them. It also enables us to be able to work in promotive, preventive, curative and rehabilitative health services as part of district health team. The program begins with theory classes on management and orientation classes at the college and placement of the students in three different places with rotation along with field supervisions in between. Here we are presenting our investigations on epidemiology of chronic obstructive pulmonary disease made at Western Regional Hospital during our District Health System Management (DHSM) study in third phase (Fourth year).Journal of Gandaki Medical College Volume, 09, Number 2, July December 2016, Page: 65-69