Primary Level Health Facilities Research Articles

Is qualitative social research in global health fulfilling its potential?: a systematic evidence mapping of research on point-of-care testing in low- and middle-income contexts

BackgroundQualitative social research has made valuable contributions to understanding technology-based interventions in global health. However, we have little evidence of who is carrying out this research, where, how, for what purpose, or the overall scope of this body of work. To address these questions, we undertook a systematic evidence mapping of one area of technology-focused research in global health, related to the development, deployment and use of point-of-care tests (POCTs) for low-and middle-income countries (LMICs).MethodsWe conducted an exhaustive search to identify papers reporting on primary qualitative studies that explore the development, deployment, and use of POCTs in LMICs and screened results to identify studies meeting the inclusion criteria. Data were extracted from included studies and descriptive analyses were conducted.ResultsOne hundred thirty-eight studies met our inclusion criteria, with numbers increasing year by year. Funding of studies was primarily credited to high income country (HIC)-based institutions (95%) and 64% of first authors were affiliated with HIC-based institutions. Study sites, in contrast, were concentrated in a small number of LMICs. Relatively few studies examined social phenomena related to POCTs that take place in HICs. Seventy-one percent of papers reported on studies conducted within the context of a trial or intervention. Eighty percent reported on studies considering POCTs for HIV and/or malaria. Studies overwhelmingly reported on POCT use (91%) within primary-level health facilities (60%) or in hospitals (30%) and explored the perspectives of the health workforce (70%).ConclusionsA reflexive approach to the role, status, and contribution of qualitative and social science research is crucial to identifying the contributions it can make to the production of global health knowledge and understanding the roles technology can play in achieving global health goals. The body of qualitative social research on POCTs for LMICs is highly concentrated in scope, overwhelmingly focuses on testing in the context of a narrow number of donor-supported initiatives and is driven by HIC resources and expertise. To optimise the full potential of qualitative social research requires the promotion of open and just research ecosystems that broaden the scope of inquiry beyond established public health paradigms and build social science capacity in LMICs.

Healthcare system barriers and facilitators to hypertension management in Ghana.

Background: Hypertension continues to pose a significant burden on the health systems in Sub-Saharan Africa (SSA). Multiple challenges at the health systems level could impact patients' blood pressure outcomes. There is a need to understand the gaps in health systems to improve their readiness to manage the rising burden of hypertension Objective: To explore health system barriers and opportunities for improved management of hypertension in Ghana, West Africa. Methods: We conducted 5 focus group discussions involving 9 health facility leaders and 24 clinicians involved in hypertension treatment at 15 primary-level health facilities in Kumasi, Ghana. We held discussions remotely over Zoom and used thematic analysis methods. Results: Four themes emerged from the focus group discussions: (1) financial and geographic inaccessibility of hypertension services; (2) facilities' struggle to maintain the supply of antihypertensive medications and providers' perceptions of suboptimal quality of insured medications; (3) shortage of healthcare providers, especially physicians; and (4) patients' negative self-management practices. Facilitators identified included presence of wellness and hypertension clinics for screening and management of hypertension at some health facilities, nurses' request for additional roles in hypertension management, and the rising positive practice of patient home blood pressure monitoring. Conclusion: Our findings highlight critical barriers to hypertension service delivery and providers' abilities to provide quality services. Health facilities should build on ongoing innovations in hypertension screening, task-shifting strategies, and patient self-management to improve hypertension control. In Ghana and other countries, policies to equip healthcare systems with the resources needed for hypertension management could lead to a high improvement in hypertension outcomes among patients.

Post-acute care in China: development, challenges, and future prospects

Introduction: Post-acute care has been proved to be a crucial component of the health care system which promotes autonomous living functions, reduce unnecessary hospitalization, prevent unnecessary placement in a long-term care facility, and coordinate care between different levels of care.Different countries have built various forms of a PAC systems for decades. In light of the ongoing payment reform and population aging, PAC is becoming increasingly important as a part of the integrated health system in China. Based on comprehensive literature review, this paper summarizes Chinese health policies and progress that addressed PAC system in recent decades and provides outlook for future development.
 Methods: We based our review on published work and grey literature, including reports (international and domestic) and government policy documents. We searched PubMed, Google Scholar, EconLit, MEDLINE, Social Science Research Network, Wiley Online Library, and China Knowledge Resource Integrated Database for relevant research published since January 2009, until June 2022. We restricted our search to works published in English or Chinese and used the search terms “post-acute care”, “rehabilitation”, “nursing care”, “intermediate/transitional care”, “continuous medical/healthcare”, AND “China”, and combinations of these terms.
 Results: In the past decade, China has released various policies to support and regulate the development of rehabilitative and nursing facilities, in order to meet the increasing demand for PAC, including the building of rehabilitation and nursing facilities, strengthening PAC at the primary care level, constructing a tiered rehabilitative network, and experimenting innovative payment methods. However, the challenges and gaps remain. China lacks clinical consensus for PAC delivery and continues to face a severe shortage of PAC resources, both in terms of facilities and professionals. Moreover, quality of PAC at the primary level health facilities needs improvement for the hierarchical care system to function well. The development of a sound financing and payment mechanism for PAC services is still at the initial stage.
 Conclusions: This is the first paper comprehensively examining the current development progress of PAC as a whole, and point direction for future PAC system development in China.In its overall health system design, although the name of PAC is not explicitly stated in domestic policy documents, it is considered as an integral part towards a more continuous system, and a preliminary framework of the PAC system has been established through various efforts. To promote the further development of China’s PAC system, attention should be given to setting up of official definition and clinical guidelines, development of sound financing and payment models, increasing public and private investment in PAC infrastructures, establishing health provider requirements, strengthening the training and retaining of professionals and development of unified information system for PAC based on functional assessment. 
 

Design and techno-economic evaluation of hybrid renewable energy system for an Upazilla Health Complex (UHC) in Bangladesh

Upazilla Health Complex (UHC) offers the primary level health care facilities for rural communities. Every day thousands of patients come here for health care. The Health complex needs 24 hours electric supply. The national Grid cannot provide continuous electricity supply. Rural areas face various disturbance such as load shedding, blackouts problems and bad weather situation. In this paper, we report on the techno-economic assessment of net metering based On-grid photovoltaic system for Kaunia Upazila Health Complex in Rangpur District, Bangladesh. The analysis is based on the grid-connected photovoltaic system without battery storage. The HOMER software is used to obtain the overall analysis and the load study is carried out by HOMER powering tools. It suggests that the selected health complex requires a 34 kW PV system. The system’s net present cost (NPC) and the levelized cost of energy (COE) are $35,524 and $0.048 respectively. In this proposed system, renewable energy provides 99% of the total power requirements, while the generator and grid provide only 1%. The system produces 53,736 kWh a year of electricity where the system’s surplus electricity is 3226 kWh per year which can be sold to the national grid using a net-metering system.

Analysing the implementation of infection prevention and control measures in health care facilities during the COVID-19 pandemic in the African Region

BackgroundThe declaration of SARS-CoV-2 as a public health emergency of international concern in January 2020 prompted the need to strengthen infection prevention and control (IPC) capacities within health care facilities (HCF). IPC guidelines, with standard and transmission-based precautions to be put in place to prevent the spread of SARS-CoV-2 at these HCFs were developed. Based on these IPC guidelines, a rapid assessment scorecard tool, with 14 components, to enhance assessment and improvement of IPC measures at HCFs was developed. This study assessed the level of implementation of the IPC measures in HCFs across the African Region during the COVID-19 pandemic.MethodAn observational study was conducted from April 2020 to November 2022 in 17 countries in the African Region to monitor the progress made in implementing IPC standard and transmission-based precautions in primary-, secondary- and tertiary-level HCFs. A total of 5168 primary, secondary and tertiary HCFs were assessed. The HCFs were assessed and scored each component of the tool. Statistical analyses were done using R (version 4.2.0).ResultsA total of 11 564 assessments were conducted in 5153 HCFs, giving an average of 2.2 assessments per HCF. The baseline median score for the facility assessments was 60.2%. Tertiary HCFs and those dedicated to COVID-19 patients had the highest IPC scores. Tertiary-level HCFs had a median score of 70%, secondary-level HCFs 62.3% and primary-level HCFs 56.8%. HCFs dedicated to COVID-19 patients had the highest scores, with a median of 68.2%, followed by the mixed facilities that attended to both COVID-19 and non-COVID-19 patients, with 64.84%. On the components, there was a strong correlation between high IPC assessment scores and the presence of IPC focal points in HCFs, the availability of IPC guidelines in HCFs and HCFs that had all their health workers trained in basic IPC.ConclusionIn conclusion, a functional IPC programme with a dedicated focal person is a prerequisite for implementing improved IPC measures at the HCF level. In the absence of an epidemic, the general IPC standards in HCFs are low, as evidenced by the low scores in the non-COVID-19 treatment centres.

DETERMINANTS OF SELF-REFERRAL FROM PRIMARY TO SECONDARY LEVEL HEALTH FACILITIES AMONG OUTPATIENTS IN TANZANIA

Introduction 
 In Tanzania, self-referrals have been one of the sources of underutilization of primary-level health facilities resulting in the overutilization and overburdening of secondary-level health facilities. A significant number of patients receiving services at the outpatient departments in the secondary-level health facilities could have been served at the primary health facilities. Understanding of determinants of self-referral is critical to informing important interventions to improve the referral processes and rational utilization of health facilities at the two levels. 
 Methods
 A cross-sectional study was conducted among 230 outpatients at Katavi Regional Referral Hospital in Tanzania. A convenient sampling method was used to enroll study participants. An interviewer-administered questionnaire was used to collect data. STATA version 15 was used to analyze data descriptively while the chi-square test was performed to establish the association between dependent and independent variables at a p-value of less than 0.05.
 Results
 The magnitude of self-referral was 66.5%. The perceived determinants of self-referral were quality of care offered (90.8 %), availability of medicine (89.4%), proximity of health facility (88.8%), and patient-perceived severity of the disease (86.7%). The availability of medicine (p= 0.015), quality of care offered (p=0.00), location of the facility (p=0.044), place of residence (p=0.04), and patient-perceived severity of disease (p=0.017) were statistically significantly associated with the self-referral practices.
 Conclusion
 The magnitude of self-referral practice was high. Availability of essential medicines, quality of care offered by the hospital, hospital proximity, patient-perceived severity of the disease, and availability of barriers to accessing healthcare in lower-level facilities were factors significantly associated with the self-referral practice. It is recommended that continuous investment should be made in lower-level facilities to ensure patients receive the care they need at every point of care.

Are conversation and whispered voice hearing tests comparable to pure tone audiometry for assessment of hearing loss? A retrospective analysis

BackgroundPure tone audiometry (PTA) is considered the standard method of hearing assessment. However, technical and logistical challenges preclude its usage for hearing screening at primary healthcare facilities. Free field hearing (FFH) tests such as conversation voice (CV) and whispered voice (WV) tests have been used for hearing assessment. However, their correlation to PTA and accuracy in detection of hearing loss are doubtful. This study aims to determine if FFH tests can be used for estimation of hearing thresholds. MethodsA retrospective analytical study was conducted at the otorhinolaryngology department. Spearman's correlation coefficient (ρ) was determined between FFH recognition distance and average air conduction PTA thresholds. A statistical regression model was developed to estimate hearing thresholds from the FFH recognition distance. The FFH tests were studied for their accuracy in detection of hearing loss. ResultsThe audiometric records of 437 persons (874 ears) were analysed. The CV and WV tests were found to have a high correlation (ρ = −0.757 and −0.758, respectively) with average PTA thresholds in persons with hearing loss. The WV test was found to have a 94.7% sensitivity, 90.8% specificity, 97.6% positive predictive value, 80.9% negative predictive value, and 93.9% accuracy in detection of hearing loss. ConclusionFFH tests such as WV test can be used to estimate the hearing thresholds and screen for hearing loss when audiometric tests are not logistically feasible, such as at primary-level healthcare facilities, remote locations, and in schools. However, such tests should not be regarded as a substitute to PTA.

Abstract P191: Health Services Availability And Readiness For Management Of Hypertension And Diabetes In Primary Level Healthcare Facilities In Ghana

Background: Hypertension (HTN) and diabetes (DM) are the leading cause of adult morbidity and mortality in Ghana and other African countries. We explored the service availability (SA) and readiness (SR) of health systems for managing HTN and DM in the Bono Region, Ghana. Methods: We conducted a multi-center cross-sectional study of four primary health facilities between June 2022 and July 2022. We modified the World Health Organization (WHO) Service Availability and Readiness Assessment tool to focus on management of HTN and DM. We computed composite scores for SR based on domains of functional equipment, diagnostic capacity, medications, and clinical guidelines & protocols; SA based on service-specific domains and stratified by facility ownership (Mission vs Government). At a cutoff value of 70%, services were considered "available" or facility "ready" to manage HTN and DM based on previous studies. Results: The median number of HCWs was 7 (IQR 2-7). The overall average SR and SA scores were 75.5% and 63% respectively (Fig A & B). SR scores were higher at mission hospitals (84.5%) than at government hospitals. SA scores were generally lower than SR Scores for both Mission and Government facilities. Half of the health facilities had guidelines and had CVD training in the last 2 years (n = 2; 50%), and all (n=4,100%) had received supervisory visits regarding CVD care in the last three months. Conclusion: There are gaps in diagnostic capacity, basic equipment, clinical guidelines, and a limited number of physicians accounting for low scores, particularly in government facilities. Improving resource allocation and implementing a team-based care policy may enhance HTN and DM care in Ghana .

Use of a digital job-aid in improving antenatal clinical protocols and quality of care in rural primary-level health facilities in Burkina Faso: a quasi-experimental evaluation

ObjectiveWe assessed the impact of a digital clinical decision support (CDS) tool in improving health providers adherence to recommended antenatal protocols and service quality in rural primary-level health facilities in...

Assessment of the distribution of human and material resources for eye health in the public sector in Nampula, Mozambique

BackgroundThe unavailability of human and material resources can affect access to eye health services, constituting an obstacle in the fight against avoidable visual impairment. This study aimed to assess the availability and distribution of human and material resources for eye health in the public sector in Nampula province.MethodsA mixed method approach was used, which included document reviews (to extract information regarding the number of professionals and inhabitants in each district) and application of a questionnaire to heads of the ophthalmology department in each health facility (to obtain the list of available equipment). The ratios of eye health professionals per population in Nampula province and each of its districts were calculated and evaluated taking into account the recommendations of the World Health Organization (WHO). Based on the level of care of each health facility, the availability of equipment was evaluated.ResultsNampula Province has not reached the recommended ratio of eye health professionals per population in the different categories (ophthalmic technicians with 0.8 per 100 thousand inhabitants; optometrists and ophthalmologists with 0.4 and 0.2 per 250 thousand inhabitants, respectively). Most districts of Nampula did not reach the recommended ratio in the three categories of professionals, except Nampula City (provincial capital). However, there was a greater concentration of professionals and facilities with eye health services in the provincial capital. Primary and secondary level health facilities lacked some equipment to provide eye health services within their scope.ConclusionsThere is an unequal distribution of the workforce in Nampula and the centralization of surgical services at the Central Hospital of Nampula level. Therefore, there is a need to review resource distribution strategies and decentralization policy of eye health services in Nampula.

Quantitative assessment of umbilical cord care practices amongst mothers in Jos, Plateau State, Nigeria.

A newly cut neonatal umbilical stump is a potential portal of pathogen entry leading to omphalitis. Neonatal sepsis can complicate omphalitis, but good cord care practices can reduce this risk. The objective of this study was to assess umbilical cord care practices in tertiary-, secondary- and primary-level healthcare facilities in Jos, Nigeria. A multi-centre, cross-sectional study of 284 mothers of infants aged 3-6 weeks old attending immunisation clinics in the three-level healthcare facilities using multistage sampling technique between April and September 2019. Data were analysed using SPSS version 23.0. Pearson's Chi-squared test was used to compare categorical variables. Adjusted odds ratios (AORs) and 95% confidence interval (CI) were used as point and interval estimates, respectively. P < 0.05 was adjudged to be statistically significant. The mean age of the mothers and infants was 25 ± 6 years and 5 ± 1 week, respectively. Only 2.2% of mothers used chlorhexidine (CHX) gel for cord care. Mothers showed good knowledge but poor practice of cord care. A significant positive relationship was observed between quality of cord care practices and level of healthcare facility (χ2 = 15.213; df = 2; P < 0.001). Good cord care practices were predicted by mothers' age 30-46 (AOR = 3.6; CI: 1.4-9.1) and good knowledge of cord care (AOR = 4.7; 95% CI: 2.2-9.9). The study has highlighted the good knowledge but poor practices of cord care by mothers and the need to scale up the uptake of CHX gel in Jos. Mother's age and good knowledge of cord care are predictors of good cord care practices.

Diabetes mellitus patients in Indonesia: management in a tertiary hospital compared to primary health care

Background The increasing prevalence of diabetes mellitus (DM) requires that patients have greater access to care, which is yet lacking in many low- and middle-income countries and the quality of which varies between health care facilities. We compare the characteristics, complications, and risk profile of diabetes in patients receiving care in primary and tertiary level health facilities in Bandung, Indonesia. MethodsAdult DM patients were recruited from 25 community health centres (CHCs) and the outpatient clinic at one referral hospital. Key data collected and compared to national guidelines were DM history, treatment, complications, blood pressure, height, weight, and laboratory examinations on glycated haemoglobin (HbA1c), lipid profile, and creatinine. Data analysis was by chi-square test. ResultsOf the 809 DM patients (median age 59 years, 63% female, 98% type 2 DM), 318 (39%) were from CHCs and 491 (61%) from the hospital. Overall median HbA1c was 8.3%, with no difference between CHC and hospital patients. Only 32% of patients with HbA1c ≥10% were on insulin (CHCs 5.9%, hospital 42.9%), and only 18% of those on insulin had glycaemic control. Hypertension was common (CHCs 62%, hospital 51%, p&lt;0.001), and only 44% of CHC and 34% of hospital patients received antihypertensive therapy. Among those with macrovascular complications, only 32% (CHCs) and 26% (hospital) were receiving aspirin. The numbers reaching the treatment targets were low for those on antihypertensives and lipid-lowering medications (80/251 and 11/105, respectively). ConclusionGlycaemic control and management of complications of DM patients at both health care levels need considerable improvement.

Utilization of The Chronic Disease Management Program (Prolanis) of BPJS Kesehatan in Gowa District-Indonesia

The Chronic Disease Management Program (Prolanis) is an effort of the government and BPJS Kesehatan to carry out health care for BPJS Kesehatan participants who suffer from chronic diseases to achieve optimal quality of life with health care costs effective and efficient. Primary Level Health Facilities (PLHF) such as Puskesmas, Family Doctors, and primary care clinics that have collaborated with BPJS Kesehatan are obliged to implement Prolanis. This study aims to determine the relationship between enabling factors and need factors on the use of Prolanis. This research is a type of analytic survey research with a cross sectional approach which is carried out in several PLHFs, namely; Gentungan Health Center, Manuju Health Center and Tinggi Moncong Health Center. The population in this study were participants in the prolanis activities at the PLHF. The number of samples in this study were 107 people. The results of this study indicate that the factors that influence the use of prolanis in PLHF are; Educational history (0.001), income (0.029), BPJS Kesehatan membership class (0.019), role of health workers (0.001) and timeliness of implementation of prolanis activities (0.048). Factors that do not affect the use of prolanis in PLHF are; Gender (0.369), Age (0.169), Occupation (0.103), Distance from house to PLHF (0.353), Family support (0.413), Knowledge (0.145), Need for prolanis (0.400) and disease control (0.315)

Assessing provider performance of intrapartum care using simulated encounters and clinical vignettes: A comparison study from Tanzania

ObjectiveTo compare clinical vignettes and objective structured clinical examinations (OSCE) as methods for assessing the quality of intrapartum care among skilled providers in rural primary‐level health facilities in Tanzania.MethodsCross‐sectional study conducted at six health facilities in the Simiyu region of Tanzania. Providers were assessed using OSCE and clinical vignettes in spontaneous delivery, neonatal resuscitation, and management of postpartum hemorrhage. Trained researchers used a structured clinical checklist. The frequencies of items are presented as percentages and the agreement of the methods of assessment are reported using kappa statistics (high: kappa > 0.80, moderate: kappa = 0.60–0.80, low: kappa < 0.60).ResultsMost healthcare providers were female (60.7%), registered nurses by training (29.0%), and worked in a dispensary (56.1%), with an average age of 33 years and an average of 7.4 years of experience in their respective professions. Five items had high agreement between OSCE and clinical vignettes: postpartum vital signs every 15 min, oxytocin within 1 min of birth, diagnosis of postpartum hemorrhage, elevating legs of the mother, and deciding on manual compression of the uterus.ConclusionOSCE and clinical vignettes should be viewed as complimentary to one another in the assessment of provider knowledge and skill, with priority given to OSCE, particularly in intrapartum care.

Using the workload indicators of staffing need method to determine the staffing requirements for primary healthcare service delivery in Nigeria

Background Weak health governance mechanisms and inequitable distribution of health investments exist in Nigeria, and this is negatively affecting the health system, and health workforce availability and performance. This is evident at the primary level of care and necessitates the need to ensure that staffing levels are informed by workloads. Methods This study applied the workload indicators of staffing need (WISN) method to determine the staffing requirements for nurses, midwives, community health officers (CHO), community health extension workers (CHEWS), and junior community health extension workers (JCHEWS). It was conducted in 11 purposefully selected primary-level health facilities in two local government areas in Cross River State, Nigeria. Results Eighteen health service activities were identified for the primary level of care across the life course. Whilst nurses, midwives, CHO and CHEWS perform all the activities, the JCHEWS performed 10 of these functions. The staffing requirement findings for the facilities in Calabar Municipal indicated that there were staffing shortages for nurses and midwives in 4 of the 5 sampled facilities, three facilities had sufficient or excess numbers of CHO/CHEWS, and 4 facilities had sufficient or excess numbers of JCHEWS. In Calabar South local government area, the calculated requirement showed a cumulative shortage of 5 nurses/midwives and 26 CHO/CHEW, and appropriate staffing of JCHEWS in 4 facilities. Conclusions The results of this study illustrate the staffing needs of nurses, midwives, CHO, CHEWS and JCHEWS in the sampled facilities and indicate the need for using evidence for staffing decisions. This is pertinent considering it ultimately contribute to improvements in service delivery and health indices. The evidence from the application of the WISN tool and the scale-up of its application has the potential of contributing to the achievement of national goals as well as universal health coverage and sustainable development goals.

NATIONAL HEALTH INSURANCE BASED TELEMEDICINE APPLICATION FOR HYPERTENSION MANAGEMENT IN PRIMARY LEVEL OF HEALTH FACILITIES

Hypertension nowadays still becomes one of the severe problems in Indonesia, with a prevalence of 34% in 2018. The complication of hypertension causes the most deaths and disabilities in Indonesia and cost 75% of The Social Security Organizing Agency (BPJS) budget or IDR 15 trillion in 2019. This problem was probably caused by patients' lack of knowledge and limited personnel at the primary health centre (PHC). Telemedicine is a health care provider without any direct contact, which has various methods. Today, telemedicine in Indonesia is growing rapidly along with technology and legal regulation in its implementation, increasing users by 700% in the first year of 2020. Despite the rise of those numbers, telemedicine in PHC is still limited. Recently, the Ministry of Health and various organizations have issued telemedicine regulations at primary level health facilities in collaboration with The Social Security Organizing Agency. This review aims to discuss the current implementation and the potential future of telemedicine-based hypertension management in collaboration with the Social Security Organizing Agency in PHC.

Assessing service availability and readiness to manage cervical cancer in Bangladesh

BackgroundThe second most common cancer among females in Bangladesh is cervical cancer. The national strategy for cervical cancer needs monitoring to ensure that patients have access to care. In order to provide accurate information to policymakers in Bangladesh and other low and middle income countries, it is vital to assess current service availability and readiness to manage cervical cancer at health facilities in Bangladesh.MethodsAn interviewer-administered questionnaire adapted from the World Health Organization Service Availability and Readiness Assessment Standard Tool was used to collect cross-sectional data from health administrators of 323 health facilities in Bangladesh. Services provided were categorized into domains and service readiness was determined by mean readiness index (RI) scores. Data analysis was conducted using STATA version 13.ResultsThere were seven tertiary and specialized hospitals, 118 secondary level health facilities, 124 primary level health facilities, and 74 NGO/private hospitals included in the study. Twenty-six per cent of the health facilities provided services to cancer patients. Among the 34 tracer items used to assess cancer management capacity of health facilities, four cervical cancer-specific tracer items were used to determine service readiness for cervical cancer. On average, tertiary and specialized hospitals surpassed the readiness index cutoff of 70% with adequate staff and training (100%), equipment (100%), and diagnostic facilities (85.7%), indicating that they were ready to manage cervical cancer. The mean RI scores for the rest of the health facilities were below the cutoff value, meaning that they were not prepared to provide adequate cervical cancer services.ConclusionThe health facilities in Bangladesh (except for some tertiary hospitals) lack readiness in cervical cancer management in terms of guidelines on diagnosis and treatment, training of staff, and shortage of equipment. Given that cervical cancer accounts for more than one-fourth of all female cancers in Bangladesh, management of cervical cancer needs to be available at all levels of health facilities, with primary level facilities focusing on early diagnosis. It is recommended that appropriate standard operating procedures on cervical cancer be developed for each level of health facilities to contribute towards attaining sustainable developmental goals.

Initiation of hepatitis C treatment in two rural Rwandan districts: a mobile clinic approach

BackgroundTo eliminate hepatitis C, Rwanda is conducting national mass screenings and providing to people with chronic hepatitis C free access to Direct Acting Antivirals (DAAs). Until 2020, prescribers trained and authorized to initiate DAA treatment were based at district hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We implemented a mobile clinic to provide DAA treatment initiation at primary-level health facilities among people with chronic hepatitis C identified through mass screening campaigns in rural Kirehe and Kayonza districts.MethodsThe mobile clinic team was composed of one clinician authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care.ResultsPrior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD.ConclusionThe mobile clinic was a feasible strategy for providing rapid treatment initiation among people chronically infected by hepatitis C, identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-centre level.

Closing delivery gaps in the treatment of tuberculosis infection: Lessons from implementation research in Peru.

BackgroundTargeted testing and treatment of TB infection to prevent disease is a pillar of TB elimination. Despite recent global commitments to greatly expand access to preventive treatment for TB infection, there remains a lack of research on how best to expand preventive treatment programs in settings with high TB burdens.MethodsWe conducted implementation research in Lima, Peru, around a multifaceted intervention to deliver TB preventive treatment to close contacts of all ages, health care workers, and people in congregate settings. Key interventions included use of the interferon gamma release assay (IGRA), specialist support for generalist physicians at primary-level health facilities, and treatment support by community health workers. We applied a convergent mixed methods approach to evaluate feasibility and acceptability based on a care cascade framework.FindingsDuring April 2019-January 2020, we enrolled 1,002 household contacts, 148 non-household contacts, 107 residents and staff of congregate settings, and 357 health care workers. Cumulative completion of the TB preventive care cascade was 34% for contacts <5 years old, 28% for contacts 5–19 years old, 18% for contacts ≥20 years old, 0% for people in congregate settings, and 4% of health care workers. IGRA testing was acceptable to adults exposed to TB. Preventive treatment was acceptable to contacts, but less acceptable to physicians, who frequently had doubts about prescribing preventive treatment for adults. Community-based treatment support was both acceptable and feasible, and periodic home-visits or calls were identified as facilitators of adherence.ConclusionsWe attempted to close the gap in TB preventive treatment in Peru by expanding preventive services to adult contacts and other risk groups. While suboptimal, care cascade completion for adult contacts was consistent with what has been observed in high-income settings. The major losses in the care cascade occurred in completing evaluations and having doctors prescribe preventive treatment.

Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system

In the initial phase of the coronavirus disease 2019 crisis, Bangladesh’s health systems faced competing demands to respond to the pandemic and concurrently maintain the continuity of essential health service delivery, particularly at the primary care level. Bangladesh’s established network of primary care health facilities, the country’s backbone for delivering essential health services, routinely feed data into the national health information system, the District Health Information Software 2 platform, which provides near real-time data on the utilization of essential health services, visualized through user-friendly integrated dashboards. Trend analyses of these data showed that by April and May 2020 there had been sharp reductions in the utilization of key essential health services across all levels of care.Early and continuous monitoring and analysis of these data informed public health policy-makers and health facility managers on rapid response strategies to restore the availability and use of essential health services. Through corrective policy measures and targeted interventions, Bangladesh’s primary health care network provided a critical platform for Bangladesh to build back most of its essential health services by October 2020. Bangladesh’s experience highlights the critical role of primary-level health facilities as a touchpoint for monitoring population access to services and as a staging point for implementation of strategies and interventions that rebuild and strengthen health service delivery towards achieving universal health coverage and more resilient health systems.