Effect of the eQuality Health Bwindi Scheme on Utilization of Health Services at Bwindi Community Hospital in Uganda

Introduction: eQuality Health Bwindi (eQHB), a Community Based Health Insurance (CBHI) scheme was launched in March 2010 with the aim of generating income to maintain high quality care as well as increasing access to and utilization of health services at Bwindi Community Hospital (BCH). The main objective of this study was to explore evidence showing that eQHB scheme affected access and utilization of health services at BCH. The evidence generated would be used to inform decision making, policy and scale up of the scheme.Methods and Materials: This study applied qualitative and quantitative research methods. It involved a review of hospital records for the period July 2009–June 2014, a survey of 272 households, four focus group discussions, and six key informant interviews. Both quantitative and qualitative analysis techniques were applied for the analysis.Results: Outpatient attendance, inpatient admissions, and deliveries at the hospital increased by 65, 73, and 27%, respectively between FY 2009/10 and FY 2012/13. Utilization of health services by sick children from insured participants was greater than that of the uninsured members of the community (p-value = 0.0038). BCH services became more affordable. However, opting out of the scheme at a later stage in the review period was attributed to rising unaffordable premiums and co-payments. Failure to afford scheme membership, residing far from BCH and limited understanding of health insurance led to reduced BCH service utilization.Conclusions: eQHB has potential to increase access and utilization of health services at BCH. The challenges are; limited understanding of the concept of health insurance and unaffordable premiums and co-payments set to enable provision of high quality services.Recommendations: Based on these findings, intensified community sensitization on health insurance, establishment of satellite health facilities by BCH to bring services closer to members and transformation of eQHB to a savings/credit society in order to grow savings and subsequently reduce premiums are recommended. Government of Uganda should engage CBHIs countrywide to discuss achievement of UHC and establishment of a national health insurance scheme. A further study to guide setting of affordable premiums and copayments for eQHB is also recommended

Estimating the costs of responding to a measles outbreak: Buvuma Islands, Lake Victoria, Uganda, February-May 2017

Introduction: Despite the strong prevention efforts by the Uganda Ministry of Health (MOH), measles outbreaks continue to occur. The MOH responded to a measles outbreak in the hard to reach areas of Buvuma Islands, identifying 54 case-patients, 4 of whom developed complications and were hospitalized. We defined a measles case as; Any suspected case with a positive measles IgM antibodies or detection of measles viral RNA by PCR in a suspected case. We estimated the provider cost of responding to this outbreak, cost of prevention, and the cost the government would have saved with effective prevention. Methods: We interviewed health facility in charges, record clerks, and measles cases to collect information on patient management and days of illness. Using an itemized form, we systematically collected data on quantities and unit costs of all the resource inputs for both direct and indirect costs at national, district, and facility levels. Medical costs referred to hospital and clinic costs for medications, supplies, utilities, transport, and personnel; non-medical costs included those associated with person-hours spent on the outbreak investigation and control effort. Results: The overall cost of investigating and controlling this outbreak was $16,459.50 (including$5,526.30) of medical costs, $10,733.20 of non-medical costs) and the cost per capita of number of children 6months-5years was$117.80 (16,259.5/138 (number of children 6months-5years. This is the target for measles intensified immunization following an outbreak). Conclusion: The total cost incurred in this outbreak is four fold the amount needed to vaccinate all children in Buvuma which would have averted the outbreak. We recommended strengthening vaccination services in the entire country, especially hard-to-reach areas, to enable the government forego the extra cost and morbidity associated with outbreak control

Exploring the effect of implementation and context on a stepped-wedge randomised controlled trial of a vital sign triage device in routine maternity care in low-resource settings

© 2019 The Author(s). Background: Interventions aimed at reducing maternal mortality are increasingly complex. Understanding how complex interventions are delivered, to whom, and how they work is key in ensuring their rapid scale-up. We delivered a vital signs triage intervention into routine maternity care in eight low- and middle-income countries with the aim of reducing a composite outcome of morbidity and mortality. This was a pragmatic, hybrid effectiveness-implementation stepped-wedge randomised controlled trial. In this study, we present the results of the mixed-methods process evaluation. The aim was to describe implementation and local context and integrate results to determine whether differences in the effect of the intervention across sites could be explained. Methods: The duration and content of implementation, uptake of the intervention and its impact on clinical management were recorded. These were integrated with interviews (n = 36) and focus groups (n = 19) at 3 months and 6-9 months after implementation. In order to determine the effect of implementation on effectiveness, measures were ranked and averaged across implementation domains to create a composite implementation strength score and then correlated with the primary outcome. Results: Overall, 61.1% (n = 2747) of health care providers were trained in the intervention (range 16.5% to 89.2%) over a mean of 10.8 days. Uptake and acceptability of the intervention was good. All clusters demonstrated improved availability of vital signs equipment. There was an increase in the proportion of women having their blood pressure measured in pregnancy following the intervention (79.2% vs. 97.6%; OR 1.30 (1.29-1.31)) and no significant change in referral rates (3.7% vs. 4.4% OR 0.89; (0.39-2.05)). Availability of resources and acceptable, effective referral systems influenced health care provider interaction with the intervention. There was no correlation between process measures within or between domains, or between the composite score and the primary outcome. Conclusions: This process evaluation has successfully described the quantity and quality of implementation. Variation in implementation and context did not explain differences in the effectiveness of the intervention on maternal mortality and morbidity. We suggest future trials should prioritise in-depth evaluation of local context and clinical pathways. Trial registration: Trial registration: ISRCTN41244132. Registered on 2 Feb 2016

The Potential for Sustainability of Malaria in Pregnancy Initiatives in East and Southern Africa: Kenya and Malawi

This study was possible through the generous support of the people of the United States through the United States Agency for International Development (USAID), under the terms of Cooperative Agreement No. HRNA-00-98-00012-00 and In-house project 8012 53905. The contents are the responsibility of the FRONTIERS Program and do not necessarily reflect th

Two Clusters of Meningococcal Meningitis in Bunyangabu District, Uganda: October, 2017

Introduction: On 13 November 2017, the Uganda Ministry of Health through the Public Health Emergency Operations Centre was notified of an unknown illness that caused sudden deaths of 3 children in Bunyangabu District. The case-patients presented with fever, convulsions, loss of consciousness and neck stiffness. We investigated to establish the cause, scope of outbreak and recommend preventive measures. Methods: We defined a suspected case as onset of fever, neck stiffness and any of the following: convulsions, loss of consciousness, headache, vomiting, nausea in a resident of Kabonero or Kateebwa sub-counties, Bunyangabu District from 1 September to 30 November 2017. We reviewed medical records and conducted active case finding in affected communities. We analyzed case data by person, place and time and assessed vaccination status of the case-patients. A cerebro spinal fluid (CSF) sample from one case-patient for laboratory analysis was collected and tested using standard gram staining procedure. Results: Between 1 September and 30 October 2017, 5 cases with 3 deaths (case fatality rate = 60%) occurred in Bunyangabu District. The mean age of case-patients was 4 years. Two sub-counties of Kabonero and Kateebwa were affected. Of the 5 case-patients, one (20%) had laboratory confirmation of meningococcal meningitis. One (20%) had proof of full vaccination with Pneumococcal Conjugate Vaccine, one (20%) was partially vaccinated and three (60%) had not received any vaccination. Conclusion: These were two unrelated clusters of meningococcal meningitis outbreak caused by Neisseria meningitides. We recommended that the Ministry of Health extends vaccination to susceptible sub-populations in districts outside the meningitis belt

Two clusters of meningococcal meningitis in Bunyangabu District, Uganda: October, 2017

Introduction: On 13 November 2017, the Uganda Ministry of Health through the Public Health Emergency Operations Centre was notified of an unknown illness that caused sudden deaths of 3 children in Bunyangabu District. The case-patients presented with fever, convulsions, loss of consciousness and neck stiffness. We investigated to establish the cause, scope of outbreak and recommend preventive measures. Methods: We defined a suspected case as onset of fever, neck stiffness and any of the following: convulsions, loss of consciousness, headache, vomiting, nausea in a resident of Kabonero or Kateebwa sub-counties, Bunyangabu District from 1 September to 30 November 2017. We reviewed medical records and conducted active case finding in affected communities. We analyzed case data by person, place and time and assessed vaccination status of the case-patients. A cerebro spinal fluid (CSF) sample from one case-patient for laboratory analysis was collected and tested using standard gram staining procedure. Results: Between 1 September and 30 October 2017, 5 cases with 3 deaths (case fatality rate = 60%) occurred in Bunyangabu District. The mean age of case-patients was 4 years. Two sub-counties of Kabonero and Kateebwa were affected. Of the 5 case-patients, one (20%) had laboratory confirmation of meningococcal meningitis. One (20%) had proof of full vaccination with Pneumococcal Conjugate Vaccine, one (20%) was partially vaccinated and three (60%) had not received any vaccination. Conclusion: These were two unrelated clusters of meningococcal meningitis outbreak caused by Neisseria meningitides. We recommended that the Ministry of Health extends vaccination to susceptible sub-populations in districts outside the meningitis belt

Multidrug-resistant tuberculosis outbreak associated with poor treatment adherence and delayed treatment: Arua District, Uganda, 2013–2017

Abstract Background In August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities’ capacity to manage MDR-TB, and recommend evidence-based control measures. Methods We defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013–2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January–August 2017 with the same months in 2013–2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities’ capacity to manage TB. Results We identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January–August 2017 was 10, compared with 3–4 cases in January–August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p  15 months from symptom onset (aOR = 11, 95% CI: 1.5–87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients. Conclusion The number of cases during January–August in 2017 was significantly higher than during the same months in 2013–2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH

Sporadic outbreaks of crimean-congo haemorrhagic fever in Uganda, July 2018-January 2019.

IntroductionCrimean-Congo haemorrhagic fever (CCHF) is a tick-borne, zoonotic viral disease that causes haemorrhagic symptoms. Despite having eight confirmed outbreaks between 2013 and 2017, all within Uganda's 'cattle corridor', no targeted tick control programs exist in Uganda to prevent disease. During a seven-month-period from July 2018-January 2019, the Ministry of Health confirmed multiple independent CCHF outbreaks. We investigated to identify risk factors and recommend interventions to prevent future outbreaks.MethodsWe defined a confirmed case as sudden onset of fever (≥37.5°C) with ≥4 of the following signs and symptoms: anorexia, vomiting, diarrhoea, headache, abdominal pain, joint pain, or sudden unexplained bleeding in a resident of the affected districts who tested positive for Crimean-Congo haemorrhagic fever virus (CCHFv) by RT-PCR from 1 July 2018-30 January 2019. We reviewed medical records and performed active case-finding. We conducted a case-control study and compared exposures of case-patients with age-, sex-, and sub-county-matched control-persons (1:4).ResultsWe identified 14 confirmed cases (64% males) with five deaths (case-fatality rate: 36%) from 11 districts in western and central region. Of these, eight (73%) case-patients resided in Uganda's 'cattle corridor'. One outbreak involved two case-patients and the remainder involved one. All case-patients had fever and 93% had unexplained bleeding. Case-patients were aged 6-36 years, with persons aged 20-44 years more affected (AR: 7.2/1,000,000) than persons ≤19 years (2.0/1,000,000), p = 0.015. Most (93%) case-patients had contact with livestock ≤2 weeks before symptom onset. Twelve (86%) lived ConclusionsCCHF outbreaks occurred sporadically during 2018-2019, both within and outside 'cattle corridor' districts of Uganda. Most cases were associated with tick exposure. The Ministry of Health should partner with the Ministry of Agriculture, Animal Industry and Fisheries to develop joint nationwide tick control programs and strategies with shared responsibilities through a One Health approach

Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial

Summary: Background: In 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy). Methods: We did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132. Findings: Between April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86–0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73–2·06; p=0·45). Interpretation: There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials. Funding: Newton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development