Lower Level Health Facilities Research Articles

A lifesaving improvised peritoneal dialysis on a toddler with acute kidney injury following a swarm of bees’ sting at Iringa Regional Referral Hospital, Southern Highland—Tanzania: a case report

BackgroundPeritoneal dialysis as one of the nephrology services in children with acute kidney injury is a safe and cost-effective modality of treatment in low and lower-middle income countries. Despite evidence of its effectiveness in limited resource settings, the service is still provided only in tertiary level healthcare facilities in Tanzania.Case presentationIn this case report, we narrate the survival of a 22-month-old male patient of African descent with an acute kidney injury following a swarm of bees’ stings at home. A lifesaving, although low-quality and high-risk, peritoneal dialysis was performed for 5 days at Iringa Regional Referral Hospital, a secondary level health facility in rural Tanzania with lack of standard and recommended expertise, laboratory investigations, and equipment.ConclusionLower- and middle-income countries in collaboration with stake holders should ensure that this service is available, accessible, and safe in the lower-level health facilities, given that access to the tertiary-level facilities is inadequate and time limited, hence serving a larger population.

Diagnostic pattern of mental, neurological and substance use disorders at primary health care facilities in Uganda

Integration of diagnosis and treatment for mental, neurological, and substance use (MNS) disorders into primary health care is a recommended strategy to improve access to services in low-and middle-income countries. Despite numerous initiatives for integration of mental health care in Uganda, there has not been an evaluation of health management information system (HMIS) records to determine whether MNS disorders are routinely diagnosed. We sought to determine diagnostic pattern of MNS disorders at primary health facilities in Wakiso and Kampala districts, the most populous regions of Uganda. Lower-level primary health facilities were visited to obtain records from HMIS registers, to document diagnoses of MNS disorders. Secondary data analysis was conducted and descriptive statistics reported. A total of 40 primary health care facilities were visited representing 58.6% of the health facilities in the study districts. More than half (54.8%) and almost all (87.5%) of the lower-level health facilities in Wakiso district and Kampala district respectively were visited. The proportion of MNS disorders diagnosed at lower-level primary health facilities in Uganda is very low with Epilepsy the most common MNS diagnosis recorded. Reasons for such low numbers of diagnoses at primary health facilities are discussed as are possible solutions.

Providers and women’s perspectives on opportunities, challenges and recommendations to improve cervical cancer screening in women living with HIV at Mbarara Regional Referral Hospital: a qualitative study

BackgroundCervical cancer screening uptake remains low despite being a critical prevention method for adult women living with HIV(WLHIV). These women experience greater incidence and persistence of high-risk human papillomavirus (HPV) and severe outcomes, including cervical cancer comorbidity and death.ObjectiveWe explored the opportunities, challenges, and recommendations of clinical care providers and WLHIV to improve cervical cancer screening uptake among WLHIV in Southwestern Uganda.MethodsIn a cross-sectional qualitative study from January to June 2021 at Mbarara Regional Referral Hospital, we interviewed six key informant clinical care providers and held four focus group discussions with women living with HIV. Data was coded using Atlas ti software and analysed using thematic inductive analysis.ResultsThe participants identified several prevailing opportunities for cervical cancer screening, including skilled clinical care workers, public awareness for demand creation, optimized clinic flow, provider-led referrals, and peer-led information sharing that ease clinic navigation and shorten participant throughput. However, challenges occurred due to standalone services resulting in double queuing, longer clinic visit hours, missed chances for screening alongside unsupported lower health facilities leading to crowding at the referral hospital, and inadequate patient privacy measures leading to shame and stigma and the misconception that cervical cancer is incurable. Integrating HPV-DNA testing in HIV services was perceived with ambivalence; some participants worried about the quality of sample collection, while others valued the privacy it offered. Optimising self-collected DNA testing and sufficient counselling were recommended to improve cervical cancer screening uptake.ConclusionOpportunities for cervical cancer screening included trained clinical care professionals, increased public awareness, improved clinic flow, provider referrals, and peer education. Challenges, such as unsupported lower-level health facilities, misconceptions, inadequate patient privacy, and uncertainty about integrating HPV-DNA screening into HIV services, were cited. Adequate counselling and self-sample collection were recommended to foster screening. Our findings may guide healthcare programs integrating cervical cancer screening into HIV clinics to reach the 70% World Health Organisation targets by 2030.

Patterns of facility and patient related factors to the orthopedic and trauma admissions at the Kenyatta National Hospital: A qualitative assessment.

Inappropriate utilization of higher-level health facilities and ineffective management of the referral processes in resource-limited settings is increasingly becoming a concern in health care management in developing countries. This is characterized by self-referrals and frequent bypassing of nearest health facilities coupled with low formal referral mechanisms. This scenario lends itself to a situation where uncomplicated medical conditions are unnecessarily managed in a high-cost health facility. This situation compromises the ability and capacity of Kenyatta National Hospital (KNH) to function as a tertiary referral health facility as envisioned by Kenya Health Sector Referral Implementation Guidelines of 2014, Kenya 201 constitution and KNH legal statue of 1987. The study objective was to assess the patterns of facility and patient related factors to the orthopaedic and trauma admissions at the KNH. This was a descriptive qualitative study design. The study was conducted amongst the orthopaedic and trauma admission caseload for 2021. Data collection was done through a) data abstraction from 905 patients charts admitted during February to December 2021 and b) 10 (ten) semi-structured interviews with 10 major health facilities that refer to KNH to understand the reasons for referral to KNH. Quantitative data was analysed using Statistical Package for Social Science version 21.0 to calculate the frequency distribution. Qualitative data from the data abstraction and transcripts from the KIIs were analysed using NVivo version 12. The major facility and patient related factors to the orthopaedic and trauma admissions at KNH were inadequate human resource capacity and availability (42.7%), financial constraints (23.3%), inadequate Orthopaedic equipment's and implants availability (20.0%) and inadequate health facility infrastructure (6.3%) while the major patient related factor was patient's preference (23.4%). In conclusion, to decongest KNH requires that the lower-level health facilities need to be better equipped and resourced to handle essential orthopaedic and trauma care.

P16 Centre of excellence on antimicrobial stewardship in Central Uganda

Abstract Background Supported by a Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS 2) grant, our partnership team comprising members from Makerere University, Nottingham Trent University, Buckinghamshire Healthcare NHS Trust and Entebbe Regional Referral Hospital (ERRH) seeks to scale up and enhance sustainability on antimicrobial stewardship (AMS) in Central Uganda. Building on the achievements of our previous CwPAMS projects, this current initiative aims at strengthening, human, animal and environmental health practitioners’ capacity on AMS in health facilities and the community, as well as promoting increased use of microbiology and prescribing data to inform clinical decisions. Objectives To establish a centre of excellence on antimicrobial stewardship in Central Uganda using a One Health approach with a focus on capacity building, mentorship of lower-level facilities, and knowledge transfer. Methods This project uses a One Health approach involving professionals from the domains of human, animal and environmental health. ERRH, the project hub, is currently mentoring lower health facilities (spokes) in AMS. AMS champions have been identified in each of these health facilities who are leading ongoing activities. The project has also employed CwPAMS AMS assessment tools during scoping visits to assess the baseline conditions at seven lower-level health facilities (one regional referral hospital, two district hospitals, three health centre IIIs and two health centre IIs). AMS workshops have so far been held in two districts (Nakaseke and Butambala) including two general hospitals. Results The project held inception meetings that brought together different stakeholders in AMS. Scoping visits and AMS assessments have been successfully completed across seven health facilities, highlighting different AMS practices, challenges and intervention strategies. Furthermore, mentorship has so far resulted in establishment of AMS committees, identification of AMS champions, and adoption of the prescribing companion app at five of the seven mentored lower-level health facilities. AMS workshops held in the two districts resulted in increased knowledge on antimicrobial practices among the participants. The post assessments from the workshops showed that 73.4% of the participants had learnt the key importance of surveillance in AMS, 89.6% of the participants recognized the role of public awareness in promoting AMS, and 79.8% understood the value of infection prevention and control in promoting AMS in comparison with 51.7% at the pre-assessment (Figure 1). In addition, the online Community of Practice on AMS we established for health professionals in Uganda has seen a notable increase in membership, growing from 420 to over 600 members. Conclusions By engaging directly with front-line health practitioners using a hub and spoke mentorship model, the early stages of this project have provided more information on the prevailing AMS challenges in Uganda, particularly knowledge and training gaps, while revealing promising opportunities such as the existing health care structures and supportive policies. AMS capabilities of health practitioners have been improved by participation in the project, but further work is needed to limit the development of AMR in Uganda.

Community Medicine Outpatient Department: Patient profile and reasons for bypass of lower-level public health facilities

Background: The General OPD under the department of Community Medicine at LLRM Medical College, Meerut was inaugurated with the vision to improve quality of OPD services by reducing the patient burden and waiting time at specialist OPDs. Aim & Objective: To describe the profile of patients attending the Community Medicine OPD in LLRM Medical College, Meerut and to estimate the extent and reasons for bypass of lower-level public health facility by patients attending the general OPD. Settings and Design: A hospital based descriptive study was conducted in the general OPD. Methods and Material: Data of all patients from 1st July,2023 to 31st August,2023 was collected from the registers maintained in the OPD. A sample of 215 patients were selected by systematic random sampling to study the objective to assess bypass of lower-level public health facility. Statistical analysis used: Descriptive statistics. Results: A total of 2570 patients attended the general OPD from 1st July,2023 to 31st August,2023. Around 12.8% patients required referral to specialist OPDs. Most common presenting complaints were respiratory symptoms (29.8%). It was seen that 58.8% patients had bypassed the lower-level public health system and the most common reasons were non-availability of a facility nearby (26.8%), not satisfied with previous experience (23.7%), non-availability of treatment (21.6%) and investigations (17.5%), and lack of awareness of services available at the public health facility (15.4%). Conclusions: The general OPD serves as a model for other medical colleges to emulate and improve the quality of services at tertiary care centres.

Health Resource Gaps in Primary Health Care Facilities: Community Members’ Perspectives in the Era of Universal Health Coverage in Lawra Municipality, Ghana

Background. Health resources are key determinants of healthcare coverage. Community members who utilise healthcare have significant insights into the availability of health resources in providing healthcare. Aim. This study sought to explore community (health committee) members’ perspectives on health resource gaps in lower-level health facilities in the municipality. Methods. The qualitative descriptive study explored the perspectives of community members who served on the health committee. Thirty-four community health committee members at community-based health planning and services (CHPS) compounds, maternity-unit CHPS, and health centres were studied. Results. The study found three high-level categories of resource gaps deemed relevant to community members—infrastructural gaps, equipment gaps, and safety-quality gaps. Conclusion and Recommendation. There are perceived gaps in health resources from the community members’ perspective. It is recommended that the Lawra Municipal Health Directorate and other health directorates with similar health resource challenges take steps to fill health resource gaps to ensure universal health coverage.

The role of trust in the implementation and uptake of COVID-19 response measures: a qualitative study of health professionals’ experiences in Tanzania

BackgroundEven though trust is placed at the central point in ensuring proper functioning of the health systems, studies remain scant on how it affects both the implementation and uptake of COVID-19 response measures in low- and middle-income countries such as Tanzania. This study, therefore, explored the role of trust in the implementation and uptake of recommended COVID-19 response measures including vaccines from the perspective of health professionals in Tanzania.MethodsThis cross-sectional qualitative study was implemented in four of Tanzania’s thirty-one regions. Qualitative data was collected through 26 in-depth interviews held with regional and district disease outbreak response teams, district cold chain co-ordinators and health facility in-charges. In addition, five focus group discussions and seven group interviews were conducted with healthcare workers from the lower-level health facilities. Thematic analysis was conducted and applied the trust constructs.ResultsInterpersonal trust and health system trust emerged as two major themes in the study. Interpersonal trust was reported to stem from lack of transparency that instigated fear, worries, and confusion regarding the implementation and uptake of the recommended response measures. The distrust was mainly between health professionals in health facilities and those assigned to isolation centres as well as between patients and community members. On the other hand, the health system trust was shaped by mixed feelings regarding COVID-19 vaccine national decisions, and conflicting messages from national officials, politicians and religious leaders on COVID-19 responses, safety, and effectiveness of the vaccines. Questions surrounding the short duration of clinical trials, indeterminate post-vaccination protection duration, impotence-linked beliefs, freemasonry notion and unclear vaccinated cards information are other reported contributory factors to mistrust in the health system. However, after a comprehensive health education and experience in COVID-19 vaccination administration most professionals affirmed the effectiveness of the vaccines in limiting infections and its severe consequences.ConclusionParticipants indicated limited trust at both interpersonal and health system levels aggravated by lack of transparency, unclear and conflicting messages on COVID-19 infections and response measures. Enforced transparency on pandemics alongside standardised messages from the reliable sources is crucial in enhancing trust in implementation and uptake of the recommended response measures.

Analysis of public health-care facilities in rural India

PurposeThis paper aims to analyze the status of infrastructure, workforce and basic amenities at public health-care facilities in rural India and draw a comparison with its urban counterparts.Design/methodology/approachRural Health Statistics data and National Sample Survey Office Report for the period 2019–10 were used to analyze lower-level public health facilities, namely, subcenters, primary health centers and community health centers (CHCs). Selected tracer indicators under World Health Organization’s (WHO) Service Availability and Readiness Assessment (SARA) mechanism such as health center density, core health workforce density and basic amenities were used to carry out the analysis. The extent of facility coverage was measured using the National Rural Health Mission (NRHM) guidelines and the proportion of facilities satisfying the Indian Public Health Standards (IPHS) was measured to assess the service provision quality in rural public health-care facilities.FindingsResults indicated that the density of public health centers is higher in rural areas than in urban areas. Almost all public health-care facilities lack basic amenities in rural areas. Working positions for health specialists in CHCs barely meet the total requirement. Almost all of the public health facilities functioning in rural areas do not meet the IPHS norms.Originality/valueTo the best of the authors’ knowledge, the present paper is the first initiative to assess the status of rural public health-care facilities on the national level using WHO’s SARA indicators as well as NRHM and IPHS guidelines. The study is significant in terms of policy input for achieving universal health coverage in India.

Completeness and legibility of obstetric referral documents from peripheral public health facilities to a tertiary care facility in North India- a cross-sectional study

IntroductionIncomplete information in the referral letters may result in a delayed diagnosis, polypharmacy, and wasteful duplication of laboratory testing, which negatively impact patient care. The aim of the present study was to assess the quality (completeness and legibility) of obstetric referral documents sent by health personnel of lower-level public health facilities to a tertiary health care facility. MethodologyA cross-sectional study was conducted among 675 pregnant women referred to a tertiary care centre from public health facilities of Lucknow and other districts of the state of Uttar Pradesh, from October 2019 to September 2020. Systematic random sampling was used to select the study participants. Data was analysed using Statistical Package Social Sciences 24 and presented as frequencies, percentages, and graphs. A p-value <0.05 was considered statistically significant. ResultsAbout two-third (377/622) of the referrals had the information on the pre-referral treatment but it was not readable in (127/269) of those forms. Less than half (269/622) referral letters had information for the medication dosage but in only (142/269), it was clearly written. First referral unit-community health centres scored less for quality of referral letter in comparison to non-first referral unit-community health centres. ConclusionThe study concluded that there was poor documentation of the referral letters at all levels of healthcare facilities. Health personnel need to be sensitized for importance of completeness of information in the referral letters to improve the treatment as well as the outcome.

Public Primary Health Facilities Autonomy: Findings from Tanzania Star Rating Assessment

Background: In many countries, health facility autonomy has been a crucial component of health sector reform. Reducing direct government control over public health facilities and increasing their exposure to the market and market-like forces are part of this reform strategy. The degree of financial independence is a crucial characteristic that determines health facility financing and it has an impact on how well public health facilities function. This study aims at ascertaining Primary Health Facilities autonomy in the context of Star Rating Assessment (SRA) in Tanzania. Methods: This is a quantitative secondary data analysis using the SRA re-assessment data collected in the fiscal year 2017/18. Facility autonomy was measured by the desirable performance of six indicators, namely submission of a health facility plan, having operational bank account, competent handling of funds and financial reporting, deposit of self-generated funds in a facility bank account, health facility receiving any part of budgeted funds for Other Charges (OC) or Health Sector Basket Funds (HSBF) and appropriate expenditure on health commodities as stipulated in Health Facility Plans guidelines. The proportions were compared by using one and two sample proportion Z and chi-square tests. We employed Poisson regression to ascertain factors influencing facility autonomy among public primary health facilities. Results: This study involved 3,666 PHC facilities, the majority of which were dispensaries (97.6%) and rural located (85.9%). On average, 23.3% of health facilities were autonomous. 60.8% of urban located health facilities (95% CI=56.6%- 65.0%) are autonomous which is higher than 56.7% of health facilities that are located in rural areas (95% CI=55.0%- 58.5%), this difference is statistically significant (p=0.008). On the other hand, 84.6% of district hospitals were autonomous (95% CI=73.3%-96.0%) which is significantly higher compared to 57.0% of autonomous lower-level health facilities (health centers and dispensaries) (95% CI=55.4%-58.7%, p&lt;0.001). Conclusions: In Tanzanian PHC facilities, public primary health facility autonomy is a challenge. The challenge is more prevalent in rural located health facilities and lower-level PHC facilities (dispensaries and Health centers). Enhancing the effectiveness of Quality Improvement Teams (QITs) and Health Management Teams (HMTs) should be one of the measures considered in order to increase the autonomy of PHC facilities

Maternal mortality, stillbirths, and neonatal mortality: a transition model based on analyses of 151 countries

Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning. In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000-20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase. Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards. The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths. Bill & Melinda Gates Foundation.

Assessing the Readiness to Provide Integrated Management of Cardiovascular Diseases and Type 2 Diabetes in Kenya: Results from a National Survey.

Integrated chronic disease management is the desired core function of a responsive healthcare system. However, many challenges surround its implementation in Sub-Saharan Africa. The current study assessed the readiness of healthcare facilities to provide integrated management of cardiovascular diseases (CVDs) and type 2 diabetes in Kenya. We used data from a nationally representative cross-sectional survey of 258 public and private health facilities conducted in Kenya between 2019 and 2020. Data were collected using a standardised facility assessment questionnaire and observation checklists modified from the World Health Organization Package of Essential Non-communicable Diseases. The primary outcome was the readiness to provide integrated care for CVDs and diabetes-defined as the mean availability of tracer items comprising trained staff and clinical guidelines, diagnostic equipment, essential medicines, diagnosis, treatment and follow-up. A cut-off threshold of ≥70% was used to classify facilities as 'ready'. Gardner-Altman plots and modified Poisson regression were used to examine the facility characteristics associated with care integration readiness. Of the surveyed facilities, only a quarter (24.1%) were ready to provide integrated care for CVDs and type 2 diabetes. Care integration readiness was lower in public versus private facilities [aPR = 0.6; 95% CI 0.4 to 0.9], and primary healthcare facilities were less likely to be ready compared to hospitals [aPR = 0.2; 95% CI 0.1 to 0.4]. Facilities located in Central Kenya [aPR = 0.3; 95% CI 0.1 to 0.9], and the Rift Valley region [aPR = 0.4; 95% CI 0.1 to 0.9], were less likely to be ready compared to the capital Nairobi. There are gaps in the readiness of healthcare facilities particularly primary healthcare facilities in Kenya to provide integrated care services for CVDs and diabetes. Our findings inform the review of current supply-side interventions for integrated management of CVDs and type 2 diabetes, especially in lower-level public health facilities in Kenya.

Readiness of health facilities to manage individuals infected with COVID-19, Uganda, June 2021

BackgroundThe COVID-19 pandemic overwhelmed the capacity of health facilities globally, emphasizing the need for readiness to respond to rapid increases in cases. The first wave of COVID-19 in Uganda peaked in late 2020 and demonstrated challenges with facility readiness to manage cases. The second wave began in May 2021. In June 2021, we assessed the readiness of health facilities in Uganda to manage the second wave of COVID-19.MethodsReferral hospitals managed severe COVID-19 patients, while lower-level health facilities screened, isolated, and managed mild cases. We assessed 17 of 20 referral hospitals in Uganda and 71 of 3,107 lower-level health facilities, selected using multistage sampling. We interviewed health facility heads in person about case management, coordination and communication and reporting, and preparation for the surge of COVID-19 during first and the start of the second waves of COVID-19, inspected COVID-19 treatment units (CTUs) and other service delivery points. We used an observational checklist to evaluate capacity in infection prevention, medicines, personal protective equipment (PPE), and CTU surge capacity. We used the “ReadyScore” criteria to classify readiness levels as > 80% (‘ready’), 40–80% (‘work to do’), and < 40% (‘not ready’) and tailored the assessments to the health facility level. Scores for the lower-level health facilities were weighted to approximate representativeness for their health facility type in Uganda.ResultsThe median (interquartile range (IQR)) readiness scores were: 39% (IQR: 30, 51%) for all health facilities, 63% (IQR: 56, 75%) for referral hospitals, and 32% (IQR: 24, 37%) for lower-level facilities. Of 17 referral facilities, two (12%) were ‘ready’ and 15 (88%) were in the “work to do” category. Fourteen (82%) had an inadequate supply of medicines, 12 (71%) lacked adequate supply of oxygen, and 11 (65%) lacked space to expand their CTU. Fifty-five (77%) lower-level health facilities were “not ready,” and 16 (23%) were in the “work to do” category. Seventy (99%) lower-level health facilities lacked medicines, 65 (92%) lacked PPE, and 53 (73%) lacked an emergency plan for COVID-19.ConclusionFew health facilities were ready to manage the second wave of COVID-19 in Uganda during June 2021. Significant gaps existed for essential medicines, PPE, oxygen, and space to expand CTUs. The Uganda Ministry of Health utilized our findings to set up additional COVID-19 wards in hospitals and deliver medicines and PPE to referral hospitals. Adequate readiness for future waves of COVID-19 requires additional support and action in Uganda.

Factors influencing health workers’ compliance with the WHO intermittent preventive treatment for malaria in pregnancy recommendations in the Northern Region, Ghana

BackgroundAlthough IPTp-SP is a lifesaving World Health Organization (WHO) recommended preventive intervention for pregnant women in malaria-endemic regions, IPTp-SP uptake in the Northern region of Ghana is much lower than the sub-optimal national coverage level. Assessing the extent of health workers’ compliance and its associated factors will generate valuable pointers to be targeted at the program level. The study examined the factors influencing health workers’ compliance with the WHO recommended guidelines for IPTp-SP in the Northern Region.MethodsA cross-sectional study among 315 health workers in the Northern region was conducted. Semi-structured questionnaires were used to collect data on health workers’ sociodemographic characteristics, facility-based factors and knowledge level. Data were collected on health workers’ compliance with the recommended practices through covert observations using a checklist. Facility observations were carried out using a checklist. Crude and adjusted logistic regression were used to determine predictors of health workers’ compliance, at a 5% significance level adjusting for clustering.ResultsOf the 315 health workers studied, the median age was 29 years (26–34 years). Females constituted (80.5%; 252) of the 313 workers. The majority (47.4%;148) of the 312 health workers were midwives. Overall, 56.2% (CI 51.0 – 62.0) were adequately complying with the recommended guidelines. Lower levels of compliance were recorded in health centres 15.6% (5.0 – 33.0) and CHPS compounds 21.2% (11.0 – 35.0). The factors associated with compliance included health workers’ knowledge (aOR = 7.64, 95% CI 4.21 – 13.87, p < 0.001), job satisfaction (aOR 10.87, 95% CI 7.04 – 16.79, p < 0.001), in-service training (aOR 10.11, 95% CI 4.53 – 22.56, p < 0.001), supervision (aOR 4.01, 95% CI 2.09 – 7.68, p < 0.001), availability of job aids (aOR 3.61, 95% CI 2.44 – 5.35, p < 0.001), health workers experience (aOR = 10.64, 95% CI 5.99 – 18.91, p < 0.001) and facility type (aOR 0.03, 95% CI 0.01–0.07, p < 0.001).ConclusionCompliance with the recommended IPTp-SP guidelines is suboptimal in the region, with lower-level health facilities recording the least compliance levels. Health centres and CHPS facilities should be prioritized in distributing limited resources to improve health worker quality of care for antenatal care clients.

Demand sensing and digital tracking for maternal child health (MCH) in Uganda: a pilot study for ‘E+TRA health’

BackgroundThirteen essential maternal child health (MCH) commodities, identified by the UN Commission on Life-Saving Commodities for Women and Children, could save the lives of more than 6 million women and children in Low-and-Middle-Income Countries (LMICs) if made available at the point of care. To reduce stockout of those commodities and improve the health supply chains in LMICs, the Electronic TRAcking system for healthcare commodities (E+TRA Health), an all-in-one out-of-box solution, was developed to track and manage medical commodities at lower-level health facilities in rural areas. It aims to support real-time monitoring and decision-making to (1) reduce the time needed to prepare orders, (2) reduce stockout and overstock cases of targeted medical supplies, (3) help improve patient outcomes. In this study, we adopted an integrated approach to analyze the process of information flow, identify and address critical paths of essential supplies associated with maternal health in the Ugandan health system.MethodsWe apply system engineering principles and work with community partners in hospitals to develop care process workflow charts (based on essential services) for the lifecycle of maternal health continuum of care. Based on this chart, we develop a cloud-based offline-compatible smart sync platform named “E+TRA Health” to triangulate (1) patient admission, diagnoses, delivery information, testing reports from laboratories, (2) inventory information from main store, stores in MCH unit, and (3) lab, to identify the critical list of medical and laboratory supplies, their lead times for procurement and then generate reports and suggested procurement plans for real time decision-making.ResultsThe E+TRA Health platform was piloted in two Healthcare Center IV facilities in Uganda over a period of 6 months. The system collected more than 5000 patient records and managed more than 500 types of medicines. The pilot study demonstrated the functionalities of E+TRA Health and its feasibility to sense demand from point of care.ConclusionE+TRA Health is the first to triangulate supply and demand data from three different departments (main store, lab, and MCH) to forecast and generate orders automatically to meet patient demands. It is capable of generating reports required by Ministry of Health in real time compared to one-week lead-time using paper-based systems. This prompts frontline stakeholders to generate efficient, reliable and sustainable strategic healthcare plans with real time data. This system improves patient outcomes through better commodity availability by sensing true patient demands.

Application of the hub and spokes model in improving access to cervical cancer screening in Ghana.

To examine the contribution of lower-level health facilities in increasing access to cervical cancer screening in the North Tongu District. A descriptive cross-sectional study design was used. The Cervical Cancer Prevention and Training Centre (CCPTC) of the Catholic Hospital, Battor, served as the hub, and six health facilities (3 health centres and 3 CHPS compounds) served as the spokes. From April 2018 to September 2019, the well-resourced CCPTC trained 6 nurses at selected Community-based Health Planning and Services (CHPS) / Health Centres (HCs) (spokes) to provide cervical cancer screening services. The nurses, after training, started screening with VIA and HPV DNA testing. A total of 3,451women were screened by the trained nurses. This comprised 1,935 (56.1%) from the hub and 1,516 (43.9%) from the spokes. The detection of screen positives. The screen positives were 19.4% (375/1935) at the hub and 4.9% (74/1516) at the spokes. We have demonstrated that a hub and spokes model for cervical cancer screening is possible in limited resource settings. Designating and resourcing a 'hub' that supports a network of 'spokes' could increase women's access to cervical cancer screening. This approach could create awareness about cervical cancer screening services and how they can be accessed. None declared.

Readiness of the primary health care units and associated factors for the management of hypertension and type II diabetes mellitus in Sidama, Ethiopia.

BackgroundIn low-income nations such as Ethiopia, noncommunicable diseases (NCDs) are becoming more common. The Ethiopian Ministry of Health has prioritized NCD prevention, early diagnosis, and management. However, research on the readiness of public health facilities to address NCDs, particularly hypertension and type II diabetes mellitus, is limited.MethodsThe study used a multistage cluster sampling method and a health facility-based cross-sectional study design. A total of 83 health facilities were evaluated based on WHO’s Service Availability and Readiness Assessment (SARA) tool to investigate the availability of services and the readiness of the primary health care unit (PHCU) to manage type II diabetes and Hypertension. Trained data collectors interviewed with PHCU head or NCD focal persons. The study tried to investigate (1) the availability of basic amenities and the four domains: staff and guidelines, basic equipment, diagnostic materials, and essential medicines used to manage DM and HPN, (2) the readiness of the PHCU to manage DM and HPN. The data were processed by using SPSS version 24. Descriptive statistics, including frequency and percentage, inferential statistics like the chi-square test, and logistic regression models were used to analyze the data.ResultsOf the 82 health facilities, only 29% and 28% of the PHCU identified as ready to manage HPN and DM. Facility type, facility location, presence of guidelines, trained staff, groups of antihypertensive and antidiabetic medicines had a significant impact (P < 0.05) on the readiness of the PHCU to manage HPN and DM at a 0.05 level of significance. Facilities located in urban were 8.2 times more likely to be ready to manage HPN cases than facilities located in rural (AOR = 8.2, 95% CI [2.4–28.5]) and P < 0.05.Conclusion and recommendationThe results identified comparatively poor and deprived readiness to offer HPN and DM services at lower-level health facilities(health centers). Equipping the lower-level health facilities with screening and diagnostic materials, essential medicines, and provision of basic training for the health care providers and NCD guidelines should be available, especially in the lower health care facilities.

The RE-AIM framework-based evaluation of the implementation of the Maternal and Child Health Handbook program in Angola: a mixed methods study

BackgroundThe World Health Organization recommends the Maternal and Child Health Handbook (MCH-HB) to promote health service utilization from pregnancy to early childhood. Although many countries have adopted it as a national health policy, there is a paucity of research in MCH-HB’s implementation. Thus, this study aimed to evaluate the MCH-HB’s implementation status based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance), and identify facilitators of, and barriers to its implementation in Angola to understand effective implementation strategies.MethodsA cross-sectional survey was conducted targeting all health facilities which implemented MCH-HB, subsamples of health workers, and officers responsible for the MCH-HB at the municipality health office. Using the 14 indicators based on the RE-AIM framework, health facilities’ overall implementation statuses were assessed. This categorized health facilities into optimal-implementation and suboptimal-implementation groups. To identify barriers to and facilitators of MCH-HB implementation, semi-structured interviews were conducted among health workers and municipality health officers responsible for MCH-HB. The data were analyzed via content analysis.ResultsA total of 88 health facilities and 216 health workers were surveyed to evaluate the implementation status, and 155 interviews were conducted among health workers to assess the barriers to and facilitators of the implementation. The overall implementation target was achieved in 50 health facilities (56.8%). The target was achieved by more health facilities in urban than rural areas (urban 68.4%, rural 53.6%) and by more health facilities of higher facility types (hospital 83.3%, health center 59.3%, health post 52.7%). Through the interview data’s analysis, facilitators of and barriers to MCH-HB were comprehensively demonstrated. MCH-HB’s content advantage was the most widely recognized facilitator and inadequate training for health workers was the most widely recognized barrier.ConclusionsStrengthening education for health workers, supervision by municipality health officers, and community sensitization were potential implementation strategies. These strategies must be intensified in rural and lower-level health facilities.

Prevalence of keratoconus in Ghana: A hospital-based study of tertiary eye care facilities.

To estimate the prevalence of keratoconus in tertiary eye care facilities in Ghana. In this hospital-based retrospective cohort study, medical records of patients from tertiary/referral eye care facilities in Ghana were reviewed. Included in the study were records of individuals who visited the eye care facilities and were diagnosed of keratoconus within the period of January 2016 to December 2019 inclusive. Data on patients' demographics, severity of keratoconus, mode of diagnosis, treatment, and visual acuity outcomes were analysed. Out of the total of 142,209 records reviewed, 75 patients were diagnosed of keratoconus in at least one eye (127 eyes; 86.8% bilateral cases), representing a prevalence estimate of 53 per 100000 (95% confidence interval (CI): 41 to 65 per 100000). The mean ± SD age of patients at the time of diagnosis was 21.1 ± 9.5 years (66.2% males). The mean ± SD keratometry in keratoconus patients was 52.1 ± 7.0: majority (76.5%) of the cases were moderate to severe keratoconus. The main primary treatment regimen was corneal transplant (58.8%) followed by spectacles (25.0%), crosslinking (8.8%) and rigid contact lens (7.3%). There was a significant association between post-treatment visual acuity outcomes and treatment type (p < 0.001). Our study represents the first prevalence estimate of keratoconus in Ghana. The prevalence of keratoconus estimated in our study is lower than that reported in countries with tropical climates. This could be due to lower uptake of referrals, underdiagnosis and/or misdiagnosis of the condition in lower-level health facilities.