L’analyse de l’introduction du changement dans les systèmes de santé des pays en développement : le cas d’un système de surveillance épidémiologique en Haïti

Les systèmes de santé des pays en développement font face à de nombreux enjeux organisationnels pour améliorer l’état de santé de leur population. Au nombre de ces enjeux, il est fréquemment mentionné la présence d’organisations internationales ayant des objectifs et caractéristiques peu convergents et qui interviennent de façon non nécessairement coordonnée. Cette thèse explore la thématique de l’introduction du changement dans ces systèmes de santé en mettant un accent spécifique sur l’enjeu lié à la présence de ces organisations internationales. La méthodologie utilisée est une analyse de concept. Cette approche méthodologique consiste à effectuer des revues critiques de la littérature sur des concepts, à mobiliser de nouvelles approches théoriques pour clarifier ces concepts et à réaliser des études de cas pour leur mise à l’épreuve empirique. En nous appuyant sur la théorie de l’action sociale de Parsons, la théorie de la complexité ainsi que les expériences d’introduction du changement dans différents systèmes de santé, nous avons développé un cadre théorique d’analyse de l’introduction du changement dans les systèmes de santé des pays en développement (1er concept). Ce cadre théorique, qui suggère de concevoir le processus d’introduction du changement comme un système d’action sociale complexe et émergent, a été appliqué à l’analyse de l’introduction d’un système de surveillance épidémiologique en Haïti. Plus précisément, nous avons analysé une étape ainsi que certains aspects du mécanisme sous-jacent au processus d’introduction du changement. Ce faisant, nous avons analysé, dans les deux premiers articles de la thèse, l’étape d’adoption du système de surveillance épidémiologique (2ème concept) ainsi que les déterminants de la collaboration entre les organisations impliquées dans le processus d’introduction du changement (3ème concept). Les résultats de ces analyses nous ont permis d’objectiver de faibles niveaux d’adoption, ainsi qu’une faible articulation des déterminants de la collaboration entre les différentes organisations impliquées dans le processus d’introduction du changement. Partant de ces constats, nous avons pu mettre en évidence, dans le troisième article, une phase de « chaos » dans le fonctionnement du système de santé d’Haïti. Cette phase de « chaos », qui pourrait expliquer les difficultés liées à l’introduction du changement dans les systèmes de santé des pays en développement en général et plus particulièrement en Haïti, était caractérisée par la présence d’un ordre sous-jacent au désordre apparent dans le fonctionnement de certaines composantes du système de santé d’Haïti, l’existence d’une instabilité, d’une imprédictibilité ainsi que d’une invariance structurelle aux différents niveaux de gouvernance. Par ailleurs, cette recherche a également permis de démontrer que les caractéristiques du « chaos » sont entretenues par la présence de trois groupes de systèmes d’action sociale bien articulés et bien cohérents à tous les échelons de la pyramide sanitaire en Haïti. Il s’agissait des systèmes d’action liés aux agences de coopération bilatérale, ceux liés aux initiatives ou fondations internationales de lutte contre le sida et finalement ceux associés aux organisations onusiennes. Ces systèmes d’action sociale sont en outre associés à d’autres systèmes d’action plus complexes qui sont situés à l’extérieur du système de santé d’Haïti. Au regard de ces résultats, nous avons proposé une nouvelle approche permettant de mieux appréhender l’introduction du changement dans les systèmes de santé des pays en développement et qui s’inscrit dans une logique permettant de favoriser une plus grande variété et une plus grande diversification. Cette variété et cette diversification étant soutenue par la création et la mise en place de plusieurs interconnections entre tous les systèmes d’action en présence dans les systèmes de santé qu’ils soient d’appartenance nationale, internationale ou qu’ils agissent au niveau central, départemental ou local. La finalité de ce processus étant l’émergence de propriétés systémiques issues non seulement des propriétés des groupes de systèmes d’action individuels qui interviennent dans la constitution du système émergent, mais aussi d’autres propriétés résultant de leur mise en commun.In an attempt to improve the health status of their population, health care systems in developing countries face several organizational issues. These issues include the presence of international organizations with different goals and characteristics, as well as little convergence and poor coordination. While focussing on this specific issue, the objective of this dissertation is to deeply explore the issues related to the process of introducing change in health care systems of developing countries. The research method for this study is a concept analysis that requires a literature review, the use of new theories to clarify these concepts as well as the use of case studies to empirically validate these concepts. Using Parsons’s social action theory and the complexity theory, a new theory of change (1st concept) was developed and applied to the process of introduction of an epidemiological surveillance system in Haiti. More specifically, in the first two articles, we have analysed the process of adopting the epidemiological surveillance system (2nd concept) and the determinants of collaboration among the different organizations involved in the change process (3rd concept). The results from these two articles enabled us to highlights the low level of adoption as well as the weak articulation of the determinants of collaborations between the various organizations involved in the change process. From these analyses, we were able to highlights the dynamics of chaos operating in Haiti’s health care system in the third article. This chaos stage which could enable us to show the difficulties associated with the introduction of change in health systems in developing countries in general, and Haiti in particular, was characterized by a hidden order underlying an apparent disorder in the operation of certain components of the Haitian’s health system, the existence of instability, unpredictability as well as structural invariance at various levels of governance. Moreover, this research also enabled us to show that these characteristics are maintained by the presence of three well articulated and coherent social action systems at all levels of the health pyramid. They are those related to bilateral cooperation agencies, those related to international foundations and global initiatives fighting against AIDS, and finally those associated with the United Nations Organizations. These social action systems are also associated with other more complex systems outside the Haiti’s health system. On the basis of these results, we proposed a new approach to understand the process of introducing change in health care systems of developing countries that would fit into the logic that supports the setting up a larger interconnections and diversification among various organizations involved

Obstetric emergencies in the maternity ward of the Ignace Deen national hospital CHU of Conakry: sociodemographic, therapeutic and maternal fetal prognosis aspects

Background: Despite government efforts to reduce maternal mortality, the risk of a woman dying from obstetric complications is about one in six in the poorest regions of the world compared to one in thirty thousand in North Europe. The objective was therefore to describe the clinical socio-demographic aspects and to establish the maternal and fetal prognosis of obstetric emergencies.Methods: This was a descriptive cross-sectional prospective study over a 6-month period from January 1 to June 30, 2020 carried out at the maternity ward of the Ignace Deen national hospital (Conakry university hospital) in Guinea. The study looked at a continuous series of 662 obstetric emergency cases.Results: The frequency of admission of obstetric emergencies was 22.62%. They concerned young women (29.5 years old) on average, first-time mothers (53.32%), with low income professional activities, evacuated from a peripheral maternity unit (63.14%), no schooling (44.9%), married (92.3%), using the more often a means of public transport (66.5%) and whose pregnancies were poorly monitored (63.9%). Fetal emergencies were dominated by acute fetal distress (91.3%) and maternal emergencies were dominated by hypertensive emergencies (pre-eclampsia and eclampsia 37.44%) followed by hemorrhagic emergencies (last trimester hemorrhage and postpartum hemorrhage 34.34%). Pregnant and parturient women were more frequently admitted to labor (62.7%) and gave birth more frequently by caesarean section (86.70%). the staff reacted promptly to make a treatment decision in 75.5% of cases within fifteen minutes. emergency procedures were performed in less than fifteen minutes in almost all cases (97.4%), specific treatment was carried out in less than an hour in the majority of cases (68.3%). The maternal case fatality rate was 4.1% with the main cause of death being hemorrhagic shock of 51.8%. The stillbirth rate was 17.4%.Conclusions: The anticipation of emergency obstetric care (SOU) and close collaboration between the obstetrician, the anesthesiologist-resuscitator are essential in the management of obstetric emergencies

Recours a la Médecine Traditionnelle chez les Rhumatisants en Guinée

Aim: To determine the frequency and pattern of use of traditional medicine in rheumatic patients at Ignace Deen National Hospital in Conakry, Guinea. Patients and methods: Descriptive cross-sectional study in the rheumatology department of HNID between January and March 2018 Results: Of the 108 patients interviewed, 40 had used traditional medicine (37.03%). There was a female predominance (21 women, 52.5%) with a sex ratio of 0.90. The mean age of the patients was 44.75 ± 17.24 years. Rheumatoid arthritis and knee osteoarthritis were the main rheumatic diseases observed with 41.86% and 16.27% respectively. The diagnostic delay was 6.54 ± 1.25 years. The nature of the treatment used was dominated by taking a decoction (57.50%) and the reason for using traditional treatment was to relieve pain (85%). The oral route was the main mode of use of traditional treatment (67.5%). More than half of the patients (52.50%) were not satisfied with the outcome of traditional treatment received and did not know the name of the treatment used in their vernacular language. In 47.50% of cases they thought that traditional treatment had adverse effects and had possible interactions with modern drug therapy. Conclusion: More than a third of rheumatology consulting patients use traditional medicine even though they believe it has side effects. This phenomenon leads to a delay in consultation with the rheumatologist, hence the need for better communication between the different actors.Objectif : Déterminer la fréquence et le profil de l’utilisation de la médecine traditionnelle chez les patients souffrant de rhumatisme à l'hôpital national Ignace Deen de Conakry (Guinée). Patients et méthodes : Etude transversale de type descriptif dans le service de rhumatologie de l'HNID entre janvier et mars 2018. Résultats : Sur 108 patients interrogés, 40 avaient eu recours à la médecine traditionnelle soit 37,03 %. On notait une prédominance féminine (21 femmes ; 52,5 %) avec un sexe ratio de 0,90 H/F. L’âge moyen des patients était de 44,75 ± 17,24 ans. La polyarthrite rhumatoïde et la gonarthrose étaient les principales affections rhumatologiques observées avec respectivement 41,86% et 16,27%. Le délai diagnostique était de 6,54 ±1,25 ans. La nature du traitement utilisé était dominée par la prise de décoction (57,50%) et le motif d’utilisation du traitement était de soulager la douleur (85%). La voie orale était le principal mode d’utilisation (67,5%). Plus de la moitié des patients (52,50%) n’étaient pas satisfaits du résultat du traitement traditionnel reçu et ne connaissaient pas le nom du traitement utilisé dans leur langue vernaculaire. Ils pensaient dans 47,50% des cas que le traitement traditionnel entrainait des effets indésirables et avait de possibles interactions avec le traitement médicamenteux moderne. Conclusion : Plus du tiers des patients consultant en rhumatologie ont recours à la médecine traditionnelle même s’ils croient qu’elle a des effets indésirables. Ce phénomène entraîne un retard à la consultation chez le rhumatologue, d’où la nécessité d’une meilleure communication entre les différents acteurs

Transitioning the COVID-19 response in the WHO African region: a proposed framework for rethinking and rebuilding health systems

The onset of the pandemic revealed the health system inequities and inadequate preparedness, especially in the African continent. Over the past months, African countries have ensured optimum pandemic response. However, there is still a need to build further resilient health systems that enhance response and transition from the acute phase of the pandemic to the recovery interpandemic/preparedness phase. Guided by the lessons learnt in the response and plausible pandemic scenarios, the WHO Regional Office for Africa has envisioned a transition framework that will optimise the response and enhance preparedness for future public health emergencies. The framework encompasses maintaining and consolidating the current response capacity but with a view to learning and reshaping them by harnessing the power of science, data and digital technologies, and research innovations. In addition, the framework reorients the health system towards primary healthcare and integrates response into routine care based on best practices/health system interventions. These elements are significant in building a resilient health system capable of addressing more effectively and more effectively future public health crises, all while maintaining an optimal level of essential public health functions. The key elements of the framework are possible with countries following three principles: equity (the protection of all vulnerable populations with no one left behind), inclusiveness (full engagement, equal participation, leadership, decision-making and ownership of all stakeholders using a multisectoral and transdisciplinary, One Health approach), and coherence (to reduce the fragmentation, competition and duplication and promote logical, consistent programmes aligned with international instruments)

Response to the Ebola epidemics in Guinea: Public Health Organisational issues and possible solutions

Because of its magnitude and changing dynamics, the Ebola epidemics currently affecting some West African countries constitutes one of the most serious public health problems in recent decades. Conceptualised as a case study with two levels of analysis, this article aims at analysing the response to the Ebola epidemics in Guinea in order to ultimately highlight the public health organisational issues related to this response and to propose some possible solutions to improve the efficiency of this response. This article is based on documentary analysis, observation and a three month participating immersion conducted in Guinea from June 2014 to August 2014. Using certain elements of Parsons’ social action theory, this study has shown the existence of 4 systems of social intervention in the organisation and management of the response to the Ebola epidemics in Guinea. They are the WHO, MSF, the Red Cross and the Ministry of Health. Each of these systems of social intervention has specific characteristics and specificities and interacts actively at several levels of the healthsystem of Guinea. Having completed the analysis of the interventions undertaken by these 4 systems of social action, and using the conceptual basis of the complexity theory, we propose some avenues for reflection and action for improving the quality of the response to the Ebola epidemics in Guinea, in order to finally restrain and stop its propagation in other African countries and other continents

The Induction Team Member Training Course Fitted to the Scope and Background of the Participants: A Case Study of the African Setting

Background/Introduction: The Induction Team Member (ITM) course is compulsory training for teams setting up an EMT. It encapsulates elements around safety and security, protocols and procedures, and familiarization with equipment and should happen in countries that have undergone the awareness session.1 Tailoring the ITM course to fit different countries settings and professional backgrounds is imperative, particularly in Africa, because countries have heterogeneous characteristics. Objectives: To describe the changes to the ITM Course curriculum adapted to the different professional backgrounds and technical scopes of potential team members (TM) and African countries. Method/Description: This is an After-Action Review (AAR) of in-depth feedback (n = 10) received from participants in the five trainings that have been conducted at the WHO African Regional EMT Training Center (TC) since 2021 to date. All analyses were done thematically. Results/Outcomes: The training experiences in the region have shown the need for three imperative modifications to the ITM course based on the type of EMTs and the background of the participants. These include ITM courses focusing on health workers (Doctors and Nurses); team leads, security, and logistics officials; and support staff that can work during deployment and pre-deployment tasks. An interactive ten steps to building an operational national EMTs initiative developed to fit the context has been shown as significant. Conclusion: Conceptualizing ITM course training for EMTs based on teams' backgrounds, cultural circumstances, and political will is imperative for enhancing the capacity of regional countries' EMTs. A pragmatic modification to the training to fit the context that captures the countries' needs is key

Review of the Senegalese Military Emergency Medical Team (EMT) Deployment Following a Tanker Explosion in Freetown, Sierra Leone

Background/Introduction: In November 2021, a tanker exploded in Freetown, injuring and killing people. The WHO facilitated a seven-week first deployment of the Senegalese military to support the Ministry of Health (MOH) in providing care to the wounded in three referral hospitals. Objectives: Review the deployed team’s processes and outputs of medical care provided to burns patients. Method/Description: This is a cross-sectional After-Action Review (AAR) debrief of the deployment, including the WHO and MOH staff (n =14) in a virtual workshop. Six thematic areas: mobilization, deployment, coordination, case management activities, national capacity, and community acceptance were analyzed. Results/Outcomes: The WHO facilitated the team’s deployment and mobilized medical supplies and equipment whilst the MOH provided accommodation and logistics through collaboration. The team dispensed their functions with professionalism, adapted to the environment and available resources, and augmented the care provided by the available health workers. They offered additional care: reconstructive surgery, pain management, palliative and wound care, rehabilitation, physiotherapy, and psychosocial counselling, which were initially inadequate. 87 out of 155 patients were discharged home at the end, the national clinicians acquired additional skills, and the community appreciated the team. Despite being perceived as a weakness, the language barrier did not hinder the patient-doctor/nurse relationship or the provision of clinical care. Conclusion: This sub-regional response had significant benefits, including speed, political acceptability, and health context experience to support rapid and safe deployment. Mechanisms to facilitate rapid and quality-assured deployment of EMTs at regional and sub-regional levels in collaboration with WHO should be strengthened in region to support future responses

Tendances et Perceptions de la Pauvreté en Guinée de 1994 à 2003

Sur la période 1994-2002, la Guinée a enregistré des taux de croissance du PIB par tête de près de 2% par an. Cette croissance qui a notamment été tirée par le secteur des produits primaires a conduit à une baisse substantielle de la pauvreté. Après un traitement harmonisé des enquêtes auprès des ménages réalisées en 1994/95 et 2002/03, on observe qu’alors que plus de six personnes sur dix étaient pauvres en 1994, la moitié de la population du pays vit cette situation huit ans plus tard. La situation du pays s’est cependant sensiblement dégradée depuis 2002, et cela se remarque dans les perceptions des ménages sur leur statut de bien-être. Cette étude présente une analyse des tendances de la pauvreté en Guinée, ainsi qu’un profil de la pauvreté et une analyse des perceptions des ménages vis-à-vis de la pauvreté.

A Systematic Literature Review of the Determinants of a Good National Civil-Military Partnership for Rapid Management and Response of Health Emergencies: Lessons for Africa

Background/Introduction: Civil-military collaboration in response to an epidemic or health crisis could strengthen countries’ capacities to provide adequate medical care and limit casualties. Many countries have received the support of military medical services during an emergency,1 guided by their multi-disciplinary human resources, with a strong background in rapid deployment, logistics and trauma management, and the civilian teams with a good capacity in epidemic management.1,2 Objectives: This study analyzes the determinants of a good civil-military partnership for rapid management of health emergencies on the African continent. Method/Description: We conducted a systematic review of literature from published (PUBMED, Hinari, and Google Scholar) and grey databases guided by the PRISMA guideline. Results/Outcomes: A good collaboration requires a formal agreement with a defined institutional anchor structure between the two institutions.1,3 The coordination should remain flexible with the co-leadership of each institution.1,3,4 The roles of all participating teams should be defined at the onset,1-5 and plans instituted based on the type of emergency to enhance cooperation. Both civilian and military teams need to know and understand the approved management protocols. Military health services are better experienced in trauma management, while civilians are more equipped to manage epidemics.1,4 Besides, there is a need for periodic evaluation of patient outcomes, resource management, challenges, and lessons learned after the response. Conclusion: Civil-military teams jointly responding to emergencies can be challenging but should be built around four defined pillars: collaboration, coordination, capacity building, and evaluation to capitalize on the teams’ strengths