Innovations in Monitoring Vital Events:Mobile Phone SMS Support to Improve Coverage of Birth and Death Registration: A Scalable Solution

Civil Registration (CR) of births and deaths is an essential component of any health information system.\ud Globally, across low income countries, CR suffers from unacceptably poor quality coverage. This Health\ud Information Systems Knowledge Hub (HIS Hub) working paper summarises and reports the results, conclusions and outlook from a small six-month project that investigated the potential of introducing a mobile phone step into the routine CR system in a rural district in Tanzania. The project developed a computer application that could receive SMS messages—from existing basic mobile phones of community-based CR officers—and feed them directly to the District Registrar’s office and computer. The message contained the details from the birth or death notification form. The system provided instant access to notifications and automatic feedback to the Village Executive Officer (VEO) if the family that experienced the birth or death event failed to register the event for certification. It also prompted the VEO to follow up with the family by conducting a questionnaire, administered by mobile phone, to determine and communicate the reasons for the non-registration. The District Civil Registrar was also able to monitor trends in these notifications via a user-friendly webbased browser and dashboard. The system was tested for six months and validated against an independent prospective household surveillance system that monitors pregnancies, births and deaths in the same period. In summary, the findings showed that the routine CR system notified only 28% of total births in the period. Adding the SMS step increased this to 51% of births. The routine CR system notified only 2.1% of deaths in the period. Adding the SMS step increased this to 14% of deaths. The SMS step therefore made significant improvements in the notification step (and modest improvements in the registration step) of routine CR. However, both notifications and registrations still fell well short of reality at community level. The most important finding of this pilot is that the current CR system in at least the study district, and likely in most of rural Tanzania, is essentially unable to provide adequate registration coverage for births and deaths, and that coverage is so low that even log order improvements are insufficient to lift it to satisfactory levels (in excess of 90%). This, as yet, says nothing regarding the quality of the data. No overwhelming reason is provided by families for the low reporting rate, suggesting that the problems are highly systemic and will need a radical redesign of CR processes to solve. To the extent that similar problems prevail in other low-income countries, it is clear that whatever these processes will be, some form of scalable real-time mobile communication such as SMS will greatly facilitate coverage levels. This pilot shows\ud that such technology is feasible. But these results also emphasise the need for an end-to-end overhaul of the\ud architecture and processes of how CR systems are built and integrated into the information fabric of a country. Small incremental technical fixes will not suffice\u

Effective coverage and systems effectiveness for malaria case management in sub-saharan african countries

Scale-up of malaria preventive and control interventions over the last decade resulted in substantial declines in mortality and morbidity from the disease in sub-Saharan Africa and many other parts of the world. Sustaining these gains will depend on the health system performance. Treatment provides individual benefits by curing infection and preventing progression to severe disease as well as community-level benefits by reducing the infectious reservoir and averting emergence and spread of drug resistance. However many patients with malaria do not access care, providers do not comply with treatment guidelines, and hence, patients do not necessarily receive the correct regimen. Even when the correct regimen is administered some patients will not adhere and others will be treated with counterfeit or substandard medication leading to treatment failures and spread of drug resistance. We apply systems effectiveness concepts that explicitly consider implications of health system factors such as treatment seeking, provider compliance, adherence, and quality of medication to estimate treatment outcomes for malaria case management. We compile data for these indicators to derive estimates of effective coverage for 43 high-burden Sub-Saharan African countries. Parameters are populated from the Demographic and Health Surveys and other published sources. We assess the relative importance of these factors on the level of effective coverage and consider variation in these health systems indicators across countries. Our findings suggest that effective coverage for malaria case management ranges from 8% to 72% in the region. Different factors account for health system inefficiencies in different countries. Significant losses in effectiveness of treatment are estimated in all countries. The patterns of inter-country variation suggest that these are system failures that are amenable to change. Identifying the reasons for the poor health system performance and intervening to tac them become key priority areas for malaria control and elimination policies in the region

Control of Neglected Tropical Diseases: Integrated Chemotherapy and Beyond

Utzinger and de Savigny discuss the implications of a new policy paper, which argues that the control of "the big three" diseases (HIV, TB, and malaria) should be integrated with control of the neglected tropical diseases

Costing the supply chain for delivery of ACT and RDTs in the public sector in Benin and Kenya

Studies have shown that supply chain costs are a significant proportion of total programme costs. Nevertheless, the costs of delivering specific products are poorly understood and ballpark estimates are often used to inadequately plan for the budgetary implications of supply chain expenses. The purpose of this research was to estimate the country level costs of the public sector supply chain for artemisinin-based combination therapy (ACT) and rapid diagnostic tests (RDTs) from the central to the peripheral levels in Benin and Kenya.MethodsA micro-costing approach was used and primary data on the various cost components of the supply chain was collected at the central, intermediate, and facility levels between September and November 2013. Information sources included central warehouse databases, health facility records, transport schedules, and expenditure reports. Data from document reviews and semi-structured interviews were used to identify cost inputs and estimate actual costs. Sampling was purposive to isolate key variables of interest. Survey guides were developed and administered electronically. Data were extracted into Microsoft Excel®, and the supply chain cost per unit of ACT and RDT distributed by function and level of system was calculated.ResultsIn Benin, supply chain costs added USD 0.2011 to the initial acquisition cost of ACT and USD 0.3375 to RDTs (normalized to USD 1). In Kenya, they added USD 0.2443 to the acquisition cost of ACT and USD 0.1895 to RDTs (normalized to USD 1). Total supply chain costs accounted for more than 30% of the initial acquisition cost of the products in some cases and these costs were highly sensitive to product volumes. The major cost drivers were found to be labour, transport, and utilities with health facilities carrying the majority of the cost per unit of product. Accurate cost estimates are needed to ensure adequate resources are available for supply chain activities. Product volumes should be considered when costing supply chain functions rather than dollar value. Further work is needed to develop extrapolative costing models that can be applied at country level without extensive micro-costing exercises. This will allow other countries to generate more accurate estimates in the future

Case studies in public-private-partnership in health with the focus of enhancing the accessibility of health interventions

Various definitions have been framed for public-private partnerships (PPPs) in health depending on the desired relationship and the characteristics of the respective sectors. These relationships span from a continuum of loose relationships with narrow objectives, lack of a legalstatus and an absence of a formalized membership or governing body to high level institutionalization. The latter includes concrete objectives, the presence of a legal status and permanent multi-sectoral membership. The study used qualitative research methods including case studies, literature review and interview with key informants. The research undertakes an extensive literature review of various PPP models in health in scale and in scope which are aimed at advancing public health goals in developing countries. The major emphasis is on a qualitative description of some of the PPPs in the planning and implementation phases, including the challenges encountered. This background is used to analyse in-depth two case studies which are both health oriented; the first one is a national level NGO consortium with a focus on malaria and the second one is an international advocacy group with an overarching goal of protecting children against malaria through an innovative mechanism. The case study approach is used to analyze why the PPP approach was used to address malaria control and how it was implemented. Both PPPs demonstrated that relationships between the public and private sector may begin from very humble and loose beginnings. However, with perseverance from committed individuals, a vision and trustworthiness may become powerful advocates for meeting prescribed health agendas. In conclusion, three key themes (trust, sacrifice and championship) run vividly through the case studies and are significant for developing countries to emulate.Keywords: public-private partnership, malaria, insecticide treated nets, champio

Paludisme, le tsunami silencieux d'Afrique

Version anglaise disponible dans la Bibliothèque numérique du CRDI : Malaria : Africa's silent tsunam

Beyond Antimalarial Stock-outs: Implications of Health Provider Compliance on Out-of-Pocket Expenditure during Care-Seeking for Fever in South East Tanzania.

To better understand how stock-outs of the first line antimalarial, Artemisinin-based Combination Therapy (ACT) and other non-compliant health worker behaviour, influence household expenditures during care-seeking for fever in the Ulanga District in Tanzania. We combined weekly ACT stock data for the period 2009-2011 from six health facilities in the Ulanga District in Tanzania, together with household data from 333 respondents on the cost of fever care-seeking in Ulanga during the same time period to establish how health seeking behaviour and expenditure might vary depending on ACT availability in their nearest health facility. Irrespective of ACT stock-outs, more than half (58%) of respondents sought initial care in the public sector, the remainder seeking care in the private sector where expenditure was higher by 19%. Over half (54%) of respondents who went to the public sector reported incidences of non-compliant behaviour by the attending health worker (e.g. charging those who were eligible for free service or referring patients to the private sector despite ACT stock), which increased household expenditure per fever episode from USD0.14 to USD1.76. ACT stock-outs were considered to be the result of non-compliant behaviour of others in the health system and increased household expenditure by 21%; however we lacked sufficient statistical power to confirm this finding. System design and governance challenges in the Tanzanian health system have resulted in numerous ACT stock-outs and frequent non-compliant public sector health worker behaviour, both of which increase out-of-pocket health expenditure. Interventions are urgently needed to ensure a stable supply of ACT in the public sector and increase health worker accountability