The simultaneous introduction of the district health system and performance-based funding: the Burundi experience

Burundi recently introduced two fundamental reforms to its health system: a district health system (DHS) and performance-based financing (PBF) of the healthcare facilities. The authors of this article set out the salient points of a trial simultaneous implementation of DHS and PBF. The assessment refers to the six building blocks of health systems proposed by the WHO, and demonstrates that PBF can either have a leverage effect or hinder the following functional elements of the DHS: the group dynamics of the District Health Management Team (DHMT), the way the district hospital functions in relation to the primary health care level , the curative and preventive health services provided by health centers to provide health cover for a target population, the provision of essential medication by a fully-functional district pharmacy, the action-focused on the health management information system (HMIS) and funding that ensures fair provision and guaranteed resupply, supported by a transparent organization. The authors recommend that these aspects receive the attention they deserve as part of initiatives that combine both reforms, especially in the start-up stage. The health system regulator – the Ministry of Health – must remain vigilant to make any necessary adjustments and to avoid negative consequences.Le Burundi a introduit récemment deux réformes fondamentales dans son système de santé : la mise en place d’un système de santé de district (SSD) et le financement basé sur la performance (FBP) des structures sanitaires. Les auteurs de cet article relatent les points saillants d’une expérience de mise en œuvre simultanée  du SSD et du FBP sur le terrain L’appréciation est faite par rapport aux six piliers du système de santé tels que proposés par l’OMS, l’article montre que le FBP peut aussi bien exercer un effet de levier  qu’entraver les éléments de fonctionnalités suivants du SSD:  la dynamique du groupe de l’Equipe Cadre de District (ECD),  le fonctionnement de l’hôpital de district par rapport au premier niveau de soins, les soins curatifs et préventifs organisés par les centres de santé dans une optique de couverture sanitaire d’une population cible,  l’approvisionnement en médicaments essentiels par une pharmacie de district fonctionnelle,  le système d’information sanitaire orienté vers l’action et le financement permettant l’équité, garantissant le réapprovisionnement et soutenu par une  organisation transparente. Les auteurs recommandent que ces aspects reçoivent l’attention qu’ils méritent lors des interventions qui combinent les deux réformes plus particulièrement dès la phase de démarrage. Le régulateur du système de santé, c’est-à-dire le Ministère de la Santé, doit rester vigilant pour procéder aux ajustements et veiller à éviter tout dérapage.Burundi ha introducido recientemente dos reformas fundamentales en su sistema sanitario: la implementación de un sistema sanitario de distrito (SSD) y la financiación basada en los resultados (FBP) de las estructuras sanitarias. Los autores de este artículo relatan los puntos destacados de un experimento de implementación simultánea de SSD y de FBP en el terreno. La evaluación se realiza con respecto a los seis pilares del sistema sanitario que propone la OMS. El artículo muestra que la FBP puede ejercer tanto un efecto incentivador como obstaculizar las siguientes funcionalidades del SSD: la dinámica del grupo del Equipo de Gestión del Distrito (ECD), el funcionamiento del hospital de distrito con respecto al primer nivel de cuidado, los cuidados curativos y preventivos organizados por los centros de salud en un enfoque de cobertura sanitaria de una población diana, el aprovisionamiento de medicamentos esenciales por una farmacia de distrito funcional, el sistema de información sanitaria orientado a la acción y la financiación que permite la equidad, garantizando el reaprovisionamiento y sostenida por una organización transparente. Los autores recomiendan que estos aspectos reciban la atención que merecen durante intervenciones que combinen las dos reformas, más particularmente desde la fase de puesta en marcha. El regulador del sistema sanitario, es decir el Ministerio de Sanidad, debe permanecer atento para proceder a los ajustes y procurar evitar cualquier desliz

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

The simultaneous introduction of the district health system and performance-based funding: the Burundi experience

Burundi recently introduced two fundamental reforms to its health system: a district health system (DHS) and performance-based financing (PBF) of the healthcare facilities. The authors of this article set out the salient points of a trial simultaneous implementation of DHS and PBF. The assessment refers to the six building blocks of health systems proposed by the WHO, and demonstrates that PBF can either have a leverage effect or hinder the following functional elements of the DHS: the group dynamics of the District Health Management Team (DHMT), the way the district hospital functions in relation to the primary health care level , the curative and preventive health services provided by health centers to provide health cover for a target population, the provision of essential medication by a fully-functional district pharmacy, the action-focused on the health management information system (HMIS) and funding that ensures fair provision and guaranteed resupply, supported by a transparent organization. The authors recommend that these aspects receive the attention they deserve as part of initiatives that combine both reforms, especially in the start-up stage. The health system regulator – the Ministry of Health – must remain vigilant to make any necessary adjustments and to avoid negative consequences

L'épilepsie au Burundi (problème de santé publique méconnu)

LIMOGES-BU Médecine pharmacie (870852108) / SudocPARIS-BIUP (751062107) / SudocSudocFranceF

Association between cysticercosis/neurocysticercosis and epilepsy: an update.

International audienc

Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi?

Abstract Background The Integrated Management of Childhood Illness (IMCI) strategy was adopted in Burundi in 2003. Our aim was to evaluate to what extent the malnutrition component of the IMCI guidelines is implemented at health facilities level. Methods We carried out direct observations of curative outpatient consultations for children aged 6–59 months in 90 health centres selected randomly. We considered both the child and the health worker (HW) as units of analysis and used bivariate analysis to explore characteristics of HWs associated with tasks systematically or never performed. Results A total of 514 consultations carried out by 145 HWs were observed. Among the 250 children under two years, less than 30% were asked questions on breastfeeding. None of them had all seven nutrition-related questions asked to their caregivers and none of the 200 children over the age of two years had all five nutrition-related questions asked to their caregivers. Only 13 cases (3%) had all of the six examinations/tasks (weight, height/length, mid-upper arm circumference, oedema, filling in and discussing the growth curve and calculating the weight for height z-score) performed as part of their care. 393 cases (76%) reported that they had not being given any nutrition advice. With regards to HWs, among 99 of them who had received children under two, only 21 (21.2%)[14.2–30.5%) systematically asked the question regarding ‘ongoing breastfeeding’. Only 56 (38.6%)[31–46.9%] weighed or discussed the weight taken prior the consultation for each child they reviewed, only 38 (26.2%)[19.6–34.1%] measured the height/length or discussed it for each child reviewed and 23 (15.9%)[10.7–22.8%] performed (systematically?) the WHZ-score. More than 50% never gave nutrition advices to any child reviewed. HWs who daily manage severe acute malnutrition were the most likely to systematically ask the question regarding ‘ongoing breastfeeding’ and to perform a ‘weight examination’. Those who had not received supervision visit on the topic of malnutrition predominantly never performed a ‘weight examination’. The ‘height/length’ examination’ was predominantly performed by female HWs and those who have ‘contract with the government. Conclusion This study has found poor compliance by HWs to IMCI in Burundi. This indicates that a substantial proportion of children do not receive early and appropriate care, especially that pertaining to malnutrition. This alarming situation calls for strong action by actors committed to child health in the country. Trial registration Clinical Trials.gov Identifier: NCT02721160; March 2016 (retrospectively registered)

Relationship between cysticercosis and epilepsy in Kiremba, Burundi.

International audienc

LETTER - KENYA : A NEW HUMAN CYSTICERCOSIS FOCUS

When the larval form (Cysticercus cellulosae   ) of Taenia solium   migrates to the brain, partial or secondarily generalized seizures may develop. In some countries in Africa (4) and the south American sub-continent (5) cysticercosis may be responsible for epilepsy in up to 50% of the cases

Epilepsy and toxocariasis: a case-control study in Burundi.

International audiencePURPOSE: A case-control study to assess the relationship between epilepsy and toxocariasis was carried out in the Kiremba population, Burundi. METHODS: People with epilepsy (PWE) were diagnosed according to the definition proposed by the International League Against Epilepsy (ILAE). Seizures were classified according to the classification proposed by ILAE in 1981. One control per case was selected matched by age (+/-5 years). Control subjects also lived in Kiremba, had neither neurological disorders nor kinship with the PWE. Cases and controls were assessed serologically for antibodies against Toxocara canis by an immunoblotting assay. Odds ratios (ORs) and 95% CI were determined using conditional regression analysis for matched case-control study. RESULTS: One hundred ninety-one PWE (99 men and 92 women) and 191 age-matched controls (72 men and 112 women) were enrolled in the study. Of the 191 PWE, 113 presented partial seizures while 73 generalized seizures and five were unclassifiable. Antibodies anti T. canis were found in 114 PWE (59.7%) and in 97 controls (50.8%). Multivariate analysis (conditional logistic regression) showed a significant association between positivity for T canis and epilepsy with an adjusted OR of 2.13 (95% CI 1.18-3.83; p-value 0.01). CONCLUSIONS: We found a significant association between toxocariasis and epilepsy. In agreement with a previous study, our finding suggests that toxocariasis may increase the risk of developing epilepsy in endemic areas and could participate to the high burden of epilepsy in tropical areas