Monitoring the referral system through benchmarking in rural Niger: an evaluation of the functional relation between health centres and the district hospital

BACKGROUND: The main objective of this study is to establish a benchmark for referral rates in rural Niger so as to allow interpretation of routine referral data to assess the performance of the referral system in Niger. METHODS: Strict and controlled application of existing clinical decision trees in a sample of rural health centres allowed the estimation of the corresponding need for and characteristics of curative referrals in rural Niger. Compliance of referral was monitored as well. Need was matched against actual referral in 11 rural districts. The referral patterns were registered so as to get an idea on the types of pathology referred. RESULTS: The referral rate benchmark was set at 2.5 % of patients consulting at the health centre for curative reasons. Niger's rural districts have a referral rate of less than half this benchmark. Acceptability of referrals is low for the population and is adding to the deficient referral system in Niger. Mortality because of under-referral is highest among young children. CONCLUSION: Referral patterns show that the present programme approach to deliver health care leaves a large amount of unmet need for which only comprehensive first and second line health services can provide a proper answer. On the other hand, the benchmark suggests that well functioning health centres can take care of the vast majority of problems patients present with

The weakest link: competence and prestige as constraints to referral by isolated nurses in rural Niger

BACKGROUND: For a health district to function referral from health centres to district hospitals is critical. In many developing countries referral systems perform well below expectations. Niger is not an exception in this matter. Beyond obvious problems of cost and access this study shows to what extent the behaviour of the health worker in its interaction with the patient can be a barrier of its own. METHODS: Information was triangulated from three sources in two rural districts in Niger: first, 46 semi-structured interviews with health centre nurses; second, 42 focus group discussions with an average of 12 participants – patients, relatives of patients and others; third, 231 semi-structured interviews with referred patients. RESULTS: Passive patients without 'voice' reinforce authoritarian attitudes of health centre staff. The latter appear reluctant to refer because they see little added value in referral and fear loss of power and prestige. As a result staff communicates poorly and show little eagerness to convince reluctant patients and families to accept referral proposals. CONCLUSIONS: Diminishing referral costs and distance barriers is not enough to correct failing referral systems. There is also a need for investment in district hospitals to make referrals visibly worthwhile and for professional upgrading of the human resources at the first contact level, so as to allow for more effective referral patterns

Changing cause of death profile in Morocco : The impact of child-survival programmes

This study was carried out to evaluate the trends in cause-specific mortality and the impact of child-survival programmes in Morocco. Two national surveys on causes and circumstances of child deaths were conducted in Morocco in 1988 and 1998 (ECCD-1 and ECCD-2 respectively). These surveys were based on a representative sample of deaths of children aged less than five years (432 and 866 respectively). Causes of death were assessed by verbal autopsy and were validated on a subsample of 94 cases. Data on causes of deaths were matched with death rates from demographic surveys (Enquete Nationale Demographique a Passages Repetes and Demographic and Health Survey) to compute cause-specific death rates. Morocco underwent a dramatic mortality decline since independence, and the decline in mortality among children aged less than five years was particularly rapid over the 1988-1997 period, at an average rate of -6% a year, and faster for children (aged 1-4 year(s)) than for infants. The decline in mortality varied markedly by causes of death and was most pronounced for causes due to vaccine-preventable diseases, such as neonatal tetanus, measles, whooping cough, tuberculosis, for diarrhoeal diseases and malnutrition, and for selected infectious diseases. However, mortality due to acute lower respiratory infection (ALRI) outside the neonatal period did not change significantly as was the case for some neonatal conditions (birth trauma and prematurity) and for accidents. The decline in cause-specific mortality could be attributed to the success of public-health programmes: the Expanded Programme on Immunization, the management of diarrhoeal diseases and malnutrition, and the use of antibiotics for selected infectious diseases. It is likely that improvements in living conditions, child-feeding practices, hygiene, and sanitation also contributed to the decline in mortality, although these could not explain the magnitude of the changes for target diseases. In contrast, the ALRI programme, which started after 1997, could not have any effect yet, and conditions of delivery and care of the newborn improved only marginally over the study period