Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia.

Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme. The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance

Development of processes allowing near real-time refinement and validation of triage tools during the early stage of an outbreak in readiness for surge: the FLU-CATs Study

BACKGROUND: During pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circumstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study. OBJECTIVES: (1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools 'Community Assessment Tools' and 'Pandemic Medical Early Warning Score' to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons. DESIGN: Prospective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs. SETTING: Thirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink. PARTICIPANTS: All people presenting with ILI. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Study outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital - if admitted, the need for higher levels of care and length of hospital stay. DATA SOURCES: Linked anonymised data from a web-based structured clinical assessment and primary care EHRs. RESULTS: In the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation. CONCLUSIONS: We have developed processes that allow capture and near real-time automated analysis of GP's clinical assessments and management decisions of people presenting with ILI. FUTURE WORK: We will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak. STUDY REGISTRATION: This study is registered as ISRCTN87130712 and UK Clinical Research Network 12827. FUNDING: The National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections

A step forward for understanding the morbidity burden in Guinea: a national descriptive study

<p>Abstract</p> <p>Background</p> <p>Little evidence on the burden of disease has been reported about Guinea. This study was conducted to demonstrate the morbidity burden in Guinea and provide basic evidence for setting health priorities.</p> <p>Methods</p> <p>A retrospective descriptive study was designed to present the morbidity burden of Guinea. Morbidity data were extracted from the National Health Statistics Report of Guinea of 2008. The data are collected based on a pyramid of facilities which includes two national hospitals (teaching hospitals), seven regional hospitals, 26 prefectural hospitals, 8 communal medical centers, 390 health centers, and 628 health posts. Morbidity rates were calculated to measure the burden of non-fatal diseases. The contributions of the 10 leading diseases were presented by sex and age group.</p> <p>Results</p> <p>In 2008, a total of 3,936,599 cases occurred. The morbidity rate for males was higher than for females, 461 versus 332 per 1,000 population. Malaria, respiratory infections, diarrheal diseases, helminthiases, and malnutrition ranked in the first 5 places and accounted for 74% of the total burden, respectively having a rate of 148, 64, 33, 32, and 14 per 1,000 population. The elderly aged 65+ had the highest morbidity rate (611 per 1,000 population) followed by working-age population (458 per 1,000 population) and children (396 per 1,000 population) while the working-age population aged 25-64 contributed the largest part (39%) to total cases. The sex- and age-specific spectrum of morbidity burden showed a similar profile except for small variations.</p> <p>Conclusion</p> <p>Guinea has its unique morbidity burden. The ten leading causes of morbidity burden, especially for malaria, respiratory infections, diarrheal diseases, helminthiases, and malnutrition, need to be prioritized in Guinea.</p

International service trade and its implications for human resources for health: a case study of Thailand

This study aims at analysing the impact of international service trade on the health care system, particularly in terms of human resources for health (HRH), using Thailand as a case study. Information was gathered through a literature review and interviews of relevant experts, as well as a brainstorming session. It was found that international service trade has greatly affected the Thai health care system and its HRH. From 1965 to 1975 there was massive emigration of physicians from Thailand in response to increasing demand in the United States of America. The country lost about 1,500 physicians, 20% of its total number, during that period. External migration of health professionals occurred without relation to agreements on trade in services. It was also found that free trade in service sectors other than health could seriously affect the health care system and HRH. Free trade in financial services with free flow of low-interest foreign loans, which started in 1993 in Thailand, resulted in the mushrooming of urban private hospitals between 1994 and 1997. This was followed by intensive internal migration of health professionals from rural public to urban private hospitals. After the economic crisis in 1997, with the resulting downturn of the private health sector, reverse brain drain was evident. At the same time, foreign investors started to invest in the bankrupt private hospitals. Since 2001, the return of economic growth and the influx of foreign patients have started another round of internal brain drain

Analysis of factors influencing the outpatient workload at Chinese health centres

<p>Abstract</p> <p>Background</p> <p>Although the community health service system is now established in China, the utilisation of the community health service institutions is low due to the lack of a gate-keeping role of the primary health service providers and referrals among the three-tiered health service institutions. In addition to this, patients who can afford to pay, often seek best services in big hospitals to guarantee the quality of care. Thus, the need of guiding the patients to the community health services and increasing the utilisation of the community health service institutions is becoming an urgent problem, which hinders the future development of community health services. This study focuses on the question of how to increase the utilisation of Chinese community health centres (HCs).</p> <p>Methods</p> <p>A cross-sectional Base-line Survey of Chinese City Community Health Service System Building using the multi-staged cluster sampling was conducted to collect data from all HCs in 28 key contact cities. Relevant indicators of totally 1790 HCs were analysed. The statistical methods included ANONVA and logistic regression.</p> <p>Results and Conclusions</p> <p>The analysis suggested several key factors for increasing the outpatient workload (OW) at the HCs: establishing an adequate referral system among the different levels of the health system; enhancing the qualification of health personnel and increasing the compensation by the health insurance for services provided at HCs. Other key factors with a positive effect on the OW included: the government ownership of the HCs, the scale of the institutions, the medical equipment used, the mix of health services provided, and the women in childbearing age in the residence.</p

Rethinking health sector procurement as developmental linkages in East Africa

Health care forms a large economic sector in all countries, and procurement of medicines and other essential commodities necessarily creates economic linkages between a country's health sector and local and international industrial development. These procurement processes may be positive or negative in their effects on populations' access to appropriate treatment and on local industrial development, yet procurement in low and middle income countries (LMICs) remains under-studied: generally analysed, when addressed at all, as a public sector technical and organisational challenge rather than a social and economic element of health system governance shaping its links to the wider economy. This article uses fieldwork in Tanzania and Kenya in 2012–15 to analyse procurement of essential medicines and supplies as a governance process for the health system and its industrial links, drawing on aspects of global value chain theory. We describe procurement work processes as experienced by front line staff in public, faith-based and private sectors, linking these experiences to wholesale funding sources and purchasing practices, and examining their implications for medicines access and for local industrial development within these East African countries. We show that in a context of poor access to reliable medicines, extensive reliance on private medicines purchase, and increasing globalisation of procurement systems, domestic linkages between health and industrial sectors have been weakened, especially in Tanzania. We argue in consequence for a more developmental perspective on health sector procurement design, including closer policy attention to strengthening vertical and horizontal relational working within local health-industry value chains, in the interests of both wider access to treatment and improved industrial development in Africa