Secondary Level Health Facilities Research Articles

Challenges and Solutions for Keeping Maternity and Gynecology Services Functioning Comprehensively in Secondary Level Health Care Facility in COVID-19 Pandemic Situation Using a Clinical Spproach

OBJECTIVE: With the nationwide lockdown in India, and with a near-exclusive focus on the novel coronavirus disease (COVID-19) there has been a great deal of neglect in the management of other illnesses leading to significant mortality and morbidity. We aimed to assess the feasibility of keeping obstetrics & gynecology services in a secondary care hospital functioning (in terms of regional experiences and comprehensive patient care measures) in the COVID-19 pandemic situation using a clinical approach. STUDY DESIGN: All policies of the World Health Organization and other international obstetrics- gynecological recommendations or guidelines were followed in keeping the services functional. Hospital data of obstetrics and gynecology services were maintained and compared with the previous year’s data of the corresponding period (January to December) through a retrospective observational study. RESULTS: Compared to figures for 2019, in-patient admissions, surgeries, and daycare procedures performed, and deliveries conducted were reduced in total but almost approached previous levels. The number of out-patient attendance and gynecologic laparoscopic surgeries were significantly reduced mostly in the initial month of lockdown (April 2020) and thereafter. Only limited COVID-19 testing was done and there was no mortality in patients or health care workers (HCW) in the obstetrics and gynecological department. CONCLUSION: COVID-19 pandemic had caused an unprecedented global healthcare crisis. The experience and data collected from our hospital in the study period validate the ‘clinical’ working protocol that enables comprehensive maternity and gynecology care at secondary level care centers even in a pandemic situation without adverse outcomes on patients or the hospital staff.

Implementation status of national airborne infection control guidelines in the health care facilities of a North Indian State: A mixed method study

ObjectiveHealthcare-acquired infection (HCAIs), have become a significant cause of morbidity as well as mortality among the hospitalized patients and health care workers. The implementation of air-borne infection control measures play an important role in prevention of health care acquired infections (HCAIs). Hence, this study was planned to assess the implementation status of National Airborne Infection Control Guidelines in the health care settings of a North Indian State. Study designA mixed method study was planned in all the 13 health facilities of Himachal Pradesh having both the Anti-Retroviral Therapy (ART) Centre and Directly observed Treatment Short course (DOTS) for TB center in the same facility. MethodsThe implementation of airborne infection control measures was evaluated using a Standardized Health Care Facility Airborne Infection Risk Assessment Tool and an observational checklist. In-depth interviews are conducted with hospital staff. At all health facilities, risk assessment and implementation of airborne infection control was evaluated by using a pretested semi-structured questionnaire. The qualitative data was analyzed manually and transcripts prepared from hand written notes and audio tape records were analyzed thematically. ResultsOnly 5 out of 13 health facilities were having specially designated airborne infection control committee. The incidence of tuberculosis among hospital staff was 2.32% at secondary level health care facilities and 0.35% at tertiary care level health facilities. Among the tuberculosis cases, maximum were nursing staff (59.5%) as compared to other categories of health care workers. Improper functioning of health care system and individual factors were main reasons for deficiencies in the implementation of air-borne infection control measures. ConclusionThe health care facilities were not implementing the infection control measure to the fullest both at secondary and tertiary care health facilities. There is a need to set up the surveillance of airborne infections in the hospital and especially the passive surveillance of tuberculosis among health care workers.

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.

A Retrospective study of the pre-hospital trauma burden managed by the Western Cape Government Emergency Medical Services

Background: Trauma is one of the leading causes of premature death and disability in South Africa. There is a lack of data describing the pre-hospital trauma burden in sub-Saharan Africa. This study aimed to describe the epidemiology of common trauma emergencies managed by the Western Cape Government (WCG) emergency medical services (EMS) in South Africa. Methods: The WCG EMS call centre registry was retrospectively analysed for all trauma patients managed between 01 July 2017 to 30 June 2018. A descriptive analysis of the data was performed using standard procedures for all variables. To date, this Is the first analysis of this dataset or any prehospital trauma burden managed in the Western Cape of South Africa. Results: The WCG EMS managed 492 303 cases during the study period. Of these, 168 980 (34.3%), or 25.5 per 1000 population, were trauma related. However, only 91 196 met the inclusion criteria for the study. The majority of patients (66.4%) were men between the socio-economically active ages of 21–40 years (54.0%). Assaults were the most common cause of trauma emergencies, accounting for 50.2% of the EMS caseload. The patient acuity was categorised as urgent in 47.5% of the cases, and 74.9% of the prehospital trauma burden was transported to a secondary level health care facility for definitive care. Conclusion: This is the first report on the prehospital trauma burden managed in the Western Cape of South Africa. The Western Cape suffers a unique trauma burden that differs from what is described by the World Health Organization (WHO) or any other low- and middle-income countries (LMICs). It also provides the foundation for further research on emergency care needs in South Africa and support for Afrocentric health care solutions to address this public health crisis.

An audit of Zimbabwean public sector diagnostic ultrasound services.

Introductionthe provision of basic diagnostic imaging services is pivotal to achieving universal health coverage. An estimated two-thirds of the world's population have no access to basic diagnostic imaging. Accurate data on current imaging equipment resources are required to inform health delivery strategy and policy at national level. This is an audit of Zimbabwean public sector diagnostic ultrasound resources and services.Methodsutilising the Ministry of Health and Child Care (MHCC) database, sequential interviews were conducted with provincial health authorities and local facility managers. Ultrasound equipment, personnel and services in all hospitals and clinics, nationally were recorded, collated, and analysed for the whole country, and by province.Resultsof the 1798 Zimbabwean public sector healthcare facilities, sixty-six (n=66, 3.67%) have ultrasound equipment. Ninety-nine (n=99) ultrasound units are distributed across the sonar facilities, representing a national average of 8 units per million people. More than half the equipment units (n=53, 54%) are in secondary-level healthcare facilities (district and mission hospitals), and approximately one-fifth (n=22, 22%) in the central hospitals (quaternary level). The best-resourced province has twice the resources of the least resourced. One-hundred and forty-two (n=142) healthcare workers, from six different professional groups, provide the public sector ultrasound service. Most facilities with sonar equipment (n=64/66, 97%) provide obstetrics and gynaecology services, while general abdominal scanning is available at one third (n=22, 33%). Two facilities with ultrasound equipment have no capacity to offer a sonography service.Conclusionin order to reach the WHO recommendation of 20 sonar units per million people, an estimated 140 additional sonar units are required nationally. The need is greatest in Masvingo, Midlands and Mashonaland East Provinces. Task-shifting plays a key role in the provision of Zimbabwean sonar services. Consideration should be given to formal training and accreditation of all healthcare workers involved in sonar service delivery.

Status of Infection Prevention and Control in Selected Hospitals in Sierra Leone

Background: Improved infection prevention and control (IPC) reduces healthcare-associated infections (HAIs). Following the Ebola virus disease (EVD) outbreak in West Africa (2014–2016), Sierra Leone made substantial investments in strengthening IPC in health facilities. The WHO identified 8 core components of IPC and developed an accompanying assessment framework (IPCAF) to monitor IPC capacity and progress. The IPCAF reflects the 8 WHO core components of IPC. The core component constitute a consistent universal outline that supports guidance to healthcare decision makers and service providers at national and international levels. We conducted an in-depth assessment of IPC practices in Sierra Leone using the IPCAF tool. Methods: This assessment was conducted in in July 2019 over a 2-week period. Data were collected through interview with IPC focal persons as well as observations and corroboration of document and immediate feedback on findings given to facilities through brief exit meetings. All areas of the facility were assessed (ie, all wards, operation theatres, laboratories maternity units, sterile service departments, waste management units, etc). The main objective was to identify the gaps and challenges faced by health facilities. Each component was scored based on the responses and observations, with the scores ranging from zero to 100 and the maximum score was 800. The IPCAF allocated hospitals to 4 different “IPC levels”: inadequate, basic, intermediate, and advanced. Results: Moreover, 13 hospitals were assessed, including 12 primary level hospitals and 1 secondary level hospital. The median score was 367. 5 (IQR, 110), which corresponds to a basic level of IPC. Primary-level hospitals scored higher (median, 373; IQR, 112.5) compared to secondary-level hospitals (median, 280; IQR, 0). The lowest score was in healthcare-associated infection surveillance (median, 0; IQR, 5), and the highest score was in the built environment, availability of materials, and equipment to support IPC (median, 62.5; IQR, 22.5). Conclusions: The assessment provides a baseline of the status of IPC in Sierra Leone in the post-EVD period using the IPCAF tool. These results can be used to guide healthcare facilities and policy makers in developing strategies for IPC quality improvement projects to improve low-performing healthcare facilities. Significant gaps were observed in key IPC areas, especially in secondary-level health facilities. There is need to establish national surveillance for healthcare-associated infections, to institutionalize monitoring of IPC practices, and to ensure an appropriate staffing–workload ratio in health facilities.Funding: NoneDisclosures:If I am presenting research funded by a commercial company, the information presented will be based on generally accepted scientific principals and methods, and will not promote the commercial interest of the Funding: company. DisagreeAnna MarutaIf I am discussing specific healthcare products or services, I will use generic names to extent possible. If I need to use trade names, I will use trade names from several companies when available, and not just trade names from any single company.DisagreeChristiana Kallon

Clinical characteristics and health care received among patients with type 2 diabetes attending secondary and tertiary healthcare facilities in Mwanza Region, Tanzania: a cross-sectional study

BackgroundTanzania is among the sub-Saharan African countries facing a tremendous increase in the burden of type 2 diabetes mellitus. In order to provide diabetes health care services, the government has established diabetes care clinics in secondary and tertiary healthcare facilities. However, previous studies have demonstrated a disparity in availability of supplies and equipment for provision of diabetes health care services at these healthcare facilities. This study aims to assess the clinical characteristics and health care received among patients with type 2 diabetes attending secondary and tertiary healthcare facilities in Mwanza Region, Tanzania.MethodsA cross-sectional study was conducted in Mwanza Region from June to September, 2018.Three hundred and thirty patients were selected by systematic random sampling from three healthcare facilities. A structured questionnaire was utilized to collect information on patient characteristics, health care received and patient perception of care. Patient blood pressure, blood glucose, weight and height were measured during the study. Percentages, chi-square tests and multivariable analysis were conducted to obtain the proportions, make comparisons and determining the correlates of tertiary-level healthcare facility.ResultsApproximately half of respondents (54.5%) were from secondary healthcare facilities. The prevalence of hypertension (63.3%), hyperglycemia (95.8%) and obesity (93.3%) were high. The prevalence of hyperglycemia was slightly higher at secondary-level healthcare facility (p = 0.005). The proportion of respondents recently diagnosed with diabetes (≤ 10 years) was significantly higher at tertiary-level healthcare facility (p = 0.000). The prevalence of diabetes related complications was higher at tertiary-level healthcare facility (80.7% versus 53.3%, p = 0.000). Assessments of body weight, blood pressure, blood glucose, feet and eye examination were conducted on a monthly basis at all facilities. None of the respondents had undergone lipid profile testing. All of the respondents (100%) received care from a nurse during diabetes clinic visits and half of the respondents (49.7%) also received care from a clinician. Relatively young patients, married and recently diagnosed patients were more likely to attend clinic at tertiary facilities. Tertiary-level healthcare facilities were more likely to have patients with complications and to have a dietitian available at the clinic.

Knowledge and adherence to isoniazid preventive therapy among people living with HIV in multilevel health facilities in South-East, Nigeria: baseline findings from a quasi-experimental study.

Introductionisoniazid preventive therapy is a crucial component of TB/HIV collaborative program and patient good knowledge and adherence to this preventive treatment are essential in improving implementation. The aim of this study was to determine the knowledge and adherence to isoniazid preventive therapy among patients receiving HIV care.Methodsthis is a baseline result of a quasi-experimental study which was carried out among 200 patients receiving HIV care in six high patient load health facilities providing comprehensive HIV care in Ebonyi State. This included a tertiary health facility and five secondary level health facilities. We used structured interviewer-administered questionnaire to collect information from the participants. Adherence was assessed by self-reports. Descriptive, bivariate and multivariate logistic regression analyses were conducted using SPSS version 20 at 5% level of significance.Resultsmajority (65%) of the respondents were between 30 and 49 years and most (73.5%) were females. Majority (85%) had been on antiretroviral therapy (ART) for more than one year. More than half of the respondents had ever received and had been counselled on IPT (55%, 62% respectively) while only 17.5% were on IPT during the study. More than half (60.5%) of the respondents had low level of knowledge. Marital status was the only predictor of knowledge. Unmarried respondents were 2 times more likely to have knowledge of IPT compared with the married (AOR = 2.11, CI = 1.10-4.06). Among the 35 patients who were on IPT, 32 (91%) reported good adherence in the 30 days preceding the survey. Conclusion: there was poor knowledge of IPT among the respondents however self-reported adherence was high. We recommend intensification of general and personalized education of PLHIV on IPT by health workers.

Rashtriya Swasthya Bima Yojana (RSBY) and outpatient coverage.

The healthcare industry worldwide is undergoing a radical transformation. An enthusiastic healthcare system of the Government of India (GOI) continually tries to tackle numerous challenges facing the system. The Rashtriya Swasthya Bima Yojana (RSBY) program has provided secondary level healthcare facilities to more than 36 million families across most states in India. This particular health insurance initiative was taken by the GOI with the purpose to safeguard the pitiable or marginalized Indian population or those households who are facing economic risks due to hospitalization and their everyday expenditures. RSBY provides affordable and accessible healthcare services along with insurance coverage for secondary care. However, it is limited to inpatient treatment or hospitalization. For outpatient coverage many strategies have been applied but low enrolment is still an existing flaw under this streamer. The present paper discusses various features of RSBY, outpatient projects undertook, and various obstacles that can be removed to integrate this insurance scheme with primary healthcare in India.

Knowledge and Practices of Doctors About Patient Safety Working at Primary and Secondary Level Health Care Facilities in Bangladesh

Aim: This descriptive type of cross sectional study was conducted with an objective to evaluate the views of doctors regarding knowledge and practices about patient safety working at primary and secondary level health care facilities in Bangladesh.
 Methods: Study period was from August 2016 to December 2016. Multistage, convenience sampling was done . Sample size was 550. Self administered semi structured questionnaire was used for data collection after pre testing. Data was collected by principle investigator , co-investigator & data collectors. Data was also collected by sending questionnaire by postage followed by a focal group discussion.
 Results: Result showed 70 % were male and 57% were primary level medical officers. 44.9% understands patients safety. 51.1% understands medical errors . 37.5% agreed that less duty hours will reduce medical errors . 62% strongly agreed that Learning about patient safety will enhance competency. 44.5% agreed that undergraduate course prepared them to ensure patient safety. 37.5 % agreed that they learned about medical errors during their undergraduate course. 40.6% stated that they were assigned to perform the tasks for which they were not trained competently, 34% said that they were assigned to perform the tasks which could have resulted easily in medical errors . Most of the respondents strongly agreed that teaching about patient safety should be an important priority. 46% stated that these should be in clinical teaching and 40% stated the same to be in bed side teaching . 24% stated that there were not enough topics in the existing curriculum regarding patient safety. 46% confessed that they made medical errors during their practices. 33% stated that they want patient safety education in their professional practice, 76.9% strongly agreed that patient safety is an important issue in their professional practices and 44% sensitizes their colleagues about patient safety to learn & practices. 54.7% stated that they did not have error reporting system/ death review/ medical audit in their hospital, 89.7% did not have attended any training on patient safety . 90% thought that training on patient safety is essential for doctors 67.2% respondents opined that there should be a competent organization / body who can take care of patient safety & medical errors in Bangladesh.
 Conclusion: The study reflects that many primary level medical officers do not understand patients safety and medical errors. The study also showed that most of them has a positive attitude torwards patient safety. Study recommended that doctors serving at primary and secondary level healthcare facilities to be oriented/ trained on different aspects of patient safety
 J Bangladesh Coll Phys Surg 2020; 38(1): 5-11

A 19 Month Old Male Child with Xeroderma Pigmentosum-A Case Report

Background: Xeroderma Pigmentosum (XP) is a rare autosomal recessive genodermatosis characterized by pigmentary abnormalities, solar skin damage and cutaneous malignancies on sun exposed area of skin and eyes. XP occurs in subjects with molecular defects in the genes involved in nucleotide excision repair (NER) of ultraviolet-induced DNA lesions leading to premature skin and ocular ageing consequent upon cellular apoptosis and other UV-induced degenerative changes. If sufficient DNA damage occurs, there will be cellular transformation and the development of malignancies. Both genetic, as well as environmental factor, play an important role in XP. XP has a >1000-fold increased risk of a cutaneous basal cell or squamous cell carcinoma or malignant melanoma. Case history: In this case report, we mentioned about a 19 month old boy who was diagnosed clinically as a case of Xeroderma Pigmentosum and presented with pigmentary skin changes (generalized hypo and hyper pigmented macule), eye problems, developmental delay, acute respiratory infection and failure to thrive. A multidisciplinary team involving the Pediatrician, Dermatologist and Ophthalmologist evaluated, diagnosed and treated the patient. In this case, XP was diagnosed clinically due to lack of all investigation facilities. This genetic premalignant condition is rarely diagnosed at the district level hospitals in Bangladesh. We report this case to upgrade the knowledge of pediatricians working in the rural areas (primary and secondary level health care facilities) regarding the diagnosis, counseling, treatment modalities and appropriate referral for Xeroderma Pigmentosum. Recommended management should be focused on educating the patient and the parents about effective sun protection and early recognition of cancers. Genetic counseling should be offered for families at risk

Psychological wellbeing in a resource-limited work environment: examining levels and determinants among health workers in rural Malawi

BackgroundA competent, responsive, and productive health workforce is central to a well-performing health system capable of providing universal access to high-quality care. Ensuring health workers’ psychological wellbeing is critical to sustaining their availability and productivity. This is particularly true in heavily constrained health systems in low- and lower-middle-income countries. Research on the issue, however, is scarce. This study aimed to contribute to filling the gap in knowledge by investigating levels of and factors associated with psychological wellbeing of mid-level health workers in Malawi.MethodsThe study relied on a cross-sectional sample of 174 health workers from 33 primary- and secondary-level health facilities in four districts of Malawi. Psychological wellbeing was measured using the WHO-5 Wellbeing Index. Data were analyzed using linear and logistic regression models.ResultsTwenty-five percent of respondents had WHO-5 scores indicative of poor psychological wellbeing. Analyses of factors related to psychological wellbeing showed no association with sex, cadre, having dependents, supervision, perceived coworker support, satisfaction with the physical work environment, satisfaction with remuneration, and motivation; a positive association with respondents’ satisfaction with interpersonal relationships at work; and a negative association with having received professional training recently. Results were inconclusive in regard to personal relationship status, seniority and responsibility at the health facility, clinical knowledge, perceived competence, perceived supervisor support, satisfaction with job demands, health facility level, data collection year, and exposure to performance-based financing.ConclusionsThe high proportion of health workers with poor wellbeing scores is concerning in light of the general health workforce shortage in Malawi and strong links between wellbeing and work performance. While more research is needed to draw conclusions and provide recommendations as to how to enhance wellbeing, our results underline the importance of considering this as a key concern for human resources for health.

Pattern of Ruptured Ectopic Pregnancy in a Secondary Level Healthcare Facility

Tubal rupture following an ectopic pregnancy is usually associated with profound hemorrhage which can lead to an unstable hemodynamic state that can risk the life of the patient. To explore the pattern of ruptured ectopic pregnancy in a secondary level healthcare facility, this Cross-sectional study was conducted among 100 ruptured ectopic pregnancy cases at 250 Bedded General Hospital, Tangail from January to November 2017. Cases were diagnosed by taking history (short period of amenorrhoea, acute lower abdominal pain and per-vaginal bleeding), clinical examination and relevant investigations (per-abdominal ultrasonography, TVS, CBC, serum ß-hCG level). Postoperatively, all the patients were followed up meticulously till discharge. The mean age of patients was 33.5(±7.8) years and the highest incidence (43%) was recorded in the age group of 26-30 years. All the patients were managed surgically with no record of case fatality. The most common site for the extra-uterine pregnancy was the tubal area (80%), 13% were ovarian pregnancy, 2% were abdominal and 5% were in other sites (rudimentary horn of uterus, cessarian scar). Chronic pelvic inflammatory disease was the most common risk factor (70%). Other risk factors such as, H/O receiving subfertility treatment (assisted reproduction/ ovulation inducing drugs), previous ectopic pregnancy, developmental errors of uterus, caesarean scar pregnancy and unknown cause were 10.0%, 6.0%, 3.0%, 3.0% and 8.0% respectively. The rise of serum ß-hCG level was found ≤1500 IU/L in 72% and >1500 IU/L in 28% of patients. Tubal area found to be the most common site of ruptured ectopic pregnancy in this study and chronic pelvic inflammatory disease was the most common risk factor followed by undergoing subfertility treatment. Surgical intervention was the choice of treatment in all cases with zero fatality recorded.
 Bangladesh Med J. 2019 May; 48 (2): 20-23

ABC-VEN Matrix Analysis of the Pharmacy Store in a Secondary Level Health Care Facility in Arbaminch Town, Southern Ethiopia

: Objective: This study was aimed to analyze Arbaminch Secondary level Hospital inventories by using ABC-VED matrix analysis and to identify the medicines requiring strict management control. Method: The ABC, VEN and ABC-VEN matrix analysis of the medicines used by Arbaminch Hospital, Arbaminch, Ethiopia for the year 2015-2017. Results: The medicine store inventory of Arbaminch Secondary Level Hospital consisted of a total of 218 products. The total annual drug expenditure of the store on products issued in 2013-2015 was found to be 259049.4 USD. In the year 2015-2017, 15.14%, 22.47% and 62.39% items were placed into A, B and C category medicines respectively, costing to 70.08 %, 19.87% and 10.05 % of drug expenditure. On VED analysis, 31.19%, 67.43% and 1.38% products were placed into the vital, essential and non-essential categories and the hospital had spent 45.05%, 52.62% and 2.33% of drug expenditure respectively. On ABC-VEN reconciliation analysis, 39.91%, 59.17% and 0.92% medicines were in group I, II and III respectively and amounting for 80.86%, 18.79% and 0.35% of drug expenditure respectively. Conclusion: The study showed that medicines belonging to category I need strict inventory control, also medicines belonging to categories II and III which need control by middle and lower managerial level respectively. ABC-VEN techniques should be applied for efficient use of resources and taking away of wastage and out-of-stock in the secondary level health care facility.Key words: ABC analysis, ABC-VEN analysis, Pharmacy store, Secondary Level, VED analysis.

Patient satisfaction with pharmaceutical care services provided at primary-level and secondary-level health facilities in Indonesia’s health coverage system

Purpose The purpose of this paper is to determine patient expectation and perception of pharmaceutical care services in order to measure the level of patient satisfaction provided by Indonesia’s health coverage (IHC) system. Design/methodology/approach A patient satisfaction survey was conducted at primary-level and secondary-level health facilities operating under IHC system. The assessment was performed using a closed-ended questionnaire that had been tested for validity and reliability. The patients’ point of view was evaluated based on their expectation and perception of six dimensions of the pharmaceutical care services they had received. Patient satisfaction was calculated based on the gap between their expectation and their perception. Findings A total of 602 patients participated in this research. The levels of the patients’ expectation of the pharmaceutical care services provided at primary-level health facilities range from high (3.39) to very high (3.54), whereas at secondary-level health facilities, the range was from low (2.04) to very high (3.75). This indicates that patients have a higher expectation of the provided pharmaceutical care services compared to the actual experience of the healthcare services that they received, resulting in a low value in the measurement of patient satisfaction levels. Originality/value The high level of patient expectation is an opportunity for pharmacists at both primary-level and secondary-level health facilities to continue developing pharmaceutical care services. Improving drug information service, patient counseling and reducing patient waiting time can be good ways to increase patient satisfaction within pharmaceutical care services.

Health workforce availability and competency to manage noncommunicable diseases at secondary care level hospitals of Delhi

Context: Health system strengthening is a major component of the national strategy to address noncommunicable diseases (NCDs). Human resource (HR) is an important building block of health system, and its capacity to address NCDs needs to be assessed. Aims: We assessed the availability, training, and self-rated competencies of available staff in secondary-level health facilities under the Government of Delhi for NCD services. Settings and Design: This study was conducted in a secondary care hospital in Delhi; this was a cross-sectional study. Subjects and Methods: Fifteen hospitals listed by the Directorate of Health Services, Delhi, were assessed through personal visits. Medical superintendents provided information regarding the availability of workforce and their training. Self-rated competency was assessed among doctors, nurses, and laboratory workers using a self-administered questionnaire. Results: A total of 85 doctors, 66 nurses and 52 laboratory technicians were interviewed. Shortage of staff ranged from 7.2% for staff nurse to 42.5% for medicine specialist. None of the staff had undergone special training for providing NCD-related services. 96.5% of doctors and 83.3% of nurses reported being aware of standard treatment guidelines for diabetes and hypertension. Key reported deficiencies were seen in doctors and nurses in managing diabetes complications. Cancer was not being managed in any hospital. Proficiency in cardiovascular disease management was reported by 24.7% and COPD management by 83.5% of doctors. There was major gap in competencies related to stroke management. Conclusions: Availability of trained and competent workforce was a limiting step in delivering NCD care in secondary-level public health facilities of Delhi, indicating the need for strengthening the HR capacity.

Availability and distribution of phototherapy services and health care providers for neonatal jaundice in three local government areas in Jos, North - Central Nigeria

Background: Severe neonatal jaundice remains common in Nigeria. Phototherapy is the most commonly used inhospital treatment for neonatal hyperbilirubinaemia. Objectives: To describe the availability and distribution of phototherapy services as an essential neonatal service in hospitals in Jos, North-Central Nigeria. Methods: This was a crosssectional study of all secondary and tertiary level health facilities in Jos-North, Jos-South and Jos-East Local government Areas (LGAs) between January and March 2015. Results: There were 30 (90.9%) secondary and three (9.1%) tertiary health facilities. Twenty – eight (84.8%) were privately owned. Fourteen (42.4%) of the 33 hospitals provided phototherapy services, of which 11 (78.6%) were private. Phototherapy services were available in all the tertiary facilities and in only 11 (36.7%) of the secondary level health facilities. Most (10; 71.4%) of the hospitals with phototherapy were located in Jos-North LGA. There were 38 phototherapy units in all the 14 hospitals that offered phototherapy, consisting of 8 (21.1%) light emitting diodes (LED) and 30(78.9%) conventional units of which 25(83.3%) were locally fabricated. In all the hospitals that provided phototherapy, jaundiced neonates were managed by physicians of whom only 12% were fulltime paediatricians. All hospitals that offered phototherapy had laboratory facilities to assay bilirubin. Conclusions: Phototherapy services in Jos, Nigeria are inadequate and are concentrated in the urban private sector. An increase in phototherapy services especially in secondary public facilities is needed. Keywords: Health Care Provider, Hyperbilirubinaemia, Jos, Neonatal Jaundice, Nigeria, Phototherapy

Factors associated with perinatal mortality among Referred Obstetric Emergencies in the Accra-Tema Metropolitan Areas, Ghana, 2017

Introduction : perinatal mortality rate (PNMR) in developing countries, particularly Sub-Sahara Africa and Ghana is unacceptably high. Most perinatal mortalities (PNM) occur among women referred for obstetric complications (Khanam et al,2017). Maternity referral system challenges limit access to emergency obstetric care needed to prevent maternal and perinatal mortalities. Much studies have focused on access to Emergency Obstetric Care (EmOC) and its association with maternal health, but few have focused on foetal outcomes and the role of referral system gaps on perinatal health. This study thus sought to find factors associated with PNM among referred obstetric emergencies in the Accra and Tema Metropolitan Areas, Ghana. Methods : this study is descriptive cross-sectional study conducted at four secondary level health facilities within the Accra and Tema metropolitan areas. Data was collected by interviewing mothers referred as obstetric emergencies or their relations using an interviewer administered structured questionnaire, and via data abstraction using a data abstraction template. Data obtained from 240 respondents was entered into SPSS v22 and analysed using STATA version 14. Univariate analysis, simple logistic regression and multivariate logistic regressions were carried out to determine factors associated with PNM. Results : most of the respondents (38.3%) were referred on account of Pregnancy Induced Hypertension (PIH). About 17% % were referred for non-clinician reasons, most due to non-availability of a doctor/ midwife. Most referred clients were unaccompanied by a health worker (55.0%) and no prior notification was given the receiving facility (70.8%), although most came with referral letters (92.7%). Perinatal mortality rate was high (21.7%). On simple logistic regression, means of transport, accompanied by health worker (HW), marital status, number of Ante-natal care (ANC) attendance, birth weight, gestational age and antepartum haemorrhage were found to be significantly associated with PNM (p Conclusion : referral guideline adherence is poor. Prevalence of PNM among referred obstetric emergencies is high. Independent risk factors for PNM are APH, low ANC visit and accompanied by HW. There is the need for a review of the current referral guidelines by the Ministry of Health to help address current challenges. Clinicians must attend quickly and have a low thresh-hold for lifesaving interventions for referred emergencies with APH, accompanied by a HW and with poor ANC attendance record. Further research on referral systems and their role in determining perinatal outcomes are needed.

Self-reported acute febrile illness, malaria and anemia among pregnant women in communities surrounding the Lagoon of Lagos, South-west Nigeria.

Background: Maternal febrile illness is often linked with undesirable adverse consequences of pregnancy and of fetal development. Objective: The objective of this study was to assess the prevalence of malaria parasitemia and anemia among pregnant women who gave a self-report of febrile illness within 48 hours of presentation at antenatal clinics in semi-urban Lagoon communities in Lagos, Southwest Nigeria where malaria preventive strategies have been carried out. Subjects and methods: A total of 113 pregnant women receiving antenatal care at two secondary-level health facilities in Ikorodu Local Government Area of Lagos State, were recruited into this crosssectional. Relevant information such as age, gravidity, trimester of pregnancy, febrile illness within the past 48 hours and use of malaria commodities were extracted from them. Laboratory analysis was conducted for anemia and malaria parasitemia. Results: In all, 32 (28.3%), 32 (28.3%) and 49 (43.4%) of the study subjects were pregnant for the first time, second time and many times respectively. The overall means (± sd) of age (years) and of PCV (%) were 29.9 (5.8) and 30.0 (6.3) respectively while the mean age of those in 1st 2nd and >2 pregnancies were 26.8 (5.2), 27.3 (3.7) and 33.7 (5.1) years respectively. Also, 38 (33.6%) of the 113 study subjects gave a self-report of febrile illness (SERFI) 48 hours prior to presentation at Antenatal clinic. Laboratory investigation showed that 22 (19.5%) of the study subjects were malaria parasite positive, whose mean Packed Cell Volume (26.8 ± 6.6%) was significantly lower (t=2.64, P-value=0.007) than that of the 91 (80.5%) without malaria parasitemia (30.8 ± 6.0%). The mean (± sd) PCV% of the 38 pregnant women who gave a SERFI (28.4 ± 5.2) was significantly lower (t=-2.13, P-value=0.018) than that of the 75 (66.4%) who did not (30.9 ± 6.6). Women in their first pregnancy were over 2½ times as likely to present with febrile illness than those in their second or more pregnancies (χ²=5.36, Pvalue= 0.02, OR=2.65, 995% CI: 1.15, 6.27). In all 36.8%, 27.8% and 40.0% of those in 1st, 2nd and 3rd trimester presented with febrile illness. Very few of the study subjects slept under Long-lasting Insecticide-treated nets (LLINs) night before the survey or used Sulphadoxine-pyrimethamine (SP) for Intermittent Preventive Treatment of malaria in pregnancy (IPTpp). Conclusion: The prevalence of malaria and anemia among those who gave SERFI in pregnancy was moderately high in Ikorodu Local Government Area of Lagos State, Nigeria. More penetrating stronger health education should be given to pregnant women to report within 24-48 hours of any febrile illness in pregnancy. Efforts should also be intensified to identify cause(s) of maternal febrile illness to reduce maternal and neonatal morbidity and mortality in semi-urban settings of Lagos State specifically and throughout Nigeria in general.

'The money can be a motivator, to me a little, but mostly PBF just helps me to do better in my job.' An exploration of the motivational mechanisms of performance-based financing for health workers in Malawi.

Performance-based financing (PBF) is assumed to improve health care delivery by motivating health workers to enhance their work performance. However, the exact motivational mechanisms through which PBF is assumed to produce such changes are poorly understood to date. Although PBF is increasingly recognized as a complex health systems intervention, its motivational effect for individual health workers is still often reduced to financial 'carrots and sticks' in the literature and discourse. Aiming to contribute to the development of a more comprehensive understanding of the motivational mechanisms, we explored how PBF impacted health worker motivation in the context of the Malawian Results-based Financing for Maternal and Newborn Health (RBF4MNH) Initiative. We conducted in-depth interviews with 41 nurses, medical assistants and clinical officers from primary- and secondary-level health facilities 1 and 2years after the introduction of RBF4MNH in 2013. Six categories of motivational mechanisms emerged: RBF4MNH motivated health workers to improve their performance (1) by acting as a periodic wake-up call to deficiencies in their day-to-day practice; (2) by providing direction and goals to work towards; (3) by strengthening perceived ability to perform successfully at work and triggering a sense of accomplishment; (4) by instilling feelings of recognition; (5) by altering social dynamics, improving team work towards a common goal, but also introducing social pressure; and (6) by offering a 'nice to have' opportunity to earn extra income. However, respondents also perceived weaknesses of the intervention design, implementation-related challenges and contextual constraints that kept RBF4MNH from developing its full motivating potential. Our results underline PBF's potential to affect health workers' motivation in ways which go far beyond the direct effects of financial rewards to individuals. We strongly recommend considering all motivational mechanisms more explicitly in future PBF design to fully exploit the approach's capacity for enhancing health worker performance.