Application of ICT in Strengthening Health Information Systems in Developing Countries in the Wake of Globalisation.

Information Communication Technology (ICT) revolution brought opportunities and challenges to developing countries in their efforts to strengthen the Health Management Information Systems (HMIS). In the wake of globalisation, developing countries have no choice but to take advantage of the opportunities and face the challenges. The last decades saw developing countries taking action to strengthen and modernise their HMIS using the existing ICT. Due to poor economic and communication infrastructure, the process has been limited to national and provincial/region levels leaving behind majority of health workers living in remote/rural areas. Even those with access do not get maximum benefit from ICT advancements due to inadequacies in data quality and lack of data utilisation. Therefore, developing countries need to make deliberate efforts to address constraints threatening to increase technology gap between urban minority and rural majority by setting up favourable policies and appropriate strategies. Concurrently, strategies to improve data quality and utilisation should be instituted to ensure that HMIS has positive impact on people's health. Potential strength from private sector and opportunities for sharing experiences among developing countries should be utilised. Short of this, advancement in ICT will continue to marginalise health workers in developing countries especially those living in remote areas

Adherence to artemether/lumefantrine treatment in children under real-life situations in rural Tanzania.

A follow-up study was conducted to determine the magnitude of and factors related to adherence to artemether/lumefantrine (ALu) treatment in rural settings in Tanzania. Children in five villages of Kilosa District treated at health facilities were followed-up at their homes on Day 7 after the first dose of ALu. For those found to be positive using a rapid diagnostic test for malaria and treated with ALu, their caretakers were interviewed on drug administration habits. In addition, capillary blood samples were collected on Day 7 to determine lumefantrine concentrations. The majority of children (392/444; 88.3%) were reported to have received all doses, in time. Non-adherence was due to untimeliness rather than missing doses and was highest for the last two doses. No significant difference was found between blood lumefantrine concentrations among adherent (median 286 nmol/l) and non-adherent [median 261 nmol/l; range 25 nmol/l (limit of quantification) to 9318 nmol/l]. Children from less poor households were more likely to adhere to therapy than the poor [odds ratio (OR)=2.45, 95% CI 1.35-4.45; adjusted OR=2.23, 95% CI 1.20-4.13]. The high reported rate of adherence to ALu in rural areas is encouraging and needs to be preserved to reduce the risk of emergence of resistant strains. The age-based dosage schedule and lack of adherence to ALu treatment guidelines by health facility staff may explain both the huge variability in observed lumefantrine concentrations and the lack of difference in concentrations between the two groups

Factors influencing adherence to referral advice following pre-referral treatment with artesunate suppositories in children in rural Tanzania

Objective: WHO recommends artemisinin suppository formulations as pre-referral treatment for children who are unable to take oral medication and cannot rapidly reach a facility for parenteral treatment. We investigated factors influencing caretakers’ adherence to referral advice following pre-referral treatment of their children with rectal artesunate suppositories. Methods: The study was nested within an intervention study that involved pre-referral treatment of all children who came to a community dispenser for treatment because they were unable to take oral medications because of repeated vomiting, lethargy, convulsions or altered consciousness. All patients who did not comply with referral advice were stratified by actions taken post-referral: taking their children to a drug shop, a traditional healer, or not seeking further treatment, and added to a random selection of patients who complied with referral advice. Caretakers of the children were interviewed about their socio-economic status (SES), knowledge about malaria, referral advice given and actions they took following pre-referral treatment. Interview data for 587 caretakers were matched with symptoms of the children, the time of treatment, arrival at a health facility or other actions taken post–pre-referral treatment. Results: The majority (93.5%) of caretakers reported being given referral advice by the community drug dispenser. The odds of adherence with this advice were three times greater for children with altered consciousness and/or convulsions than for children with other symptoms [odds ratio (OR) 3.47, 95% confidence interval (CI) 2.32–5.17, P \u3c 0.001]. When questioned, caretakers who remembered when (OR 2.19, 95% CI 1.48–3.23, P \u3c 0.001) and why (OR 1.77, 95% CI 1.07–2.95, P = 0.026) they were advised to proceed to health facility – were more likely to follow referral advice. Cost did not influence adherence except within a catchment area of facilities that charged for services. In these areas, costs deterred adherence by four to five times for those who had previously paid for laboratory services (OR = 0.25, 95% CI: 0.09–0.67, P = 0.006) or consultation (OR 0.20, 95% CI: 0.06–0.61, P = 0.005) compared with those who had not. Conclusion: When given referral advice, caretakers of patients with life-threatening symptoms adhere to referral advice more readily than other caretakers. Health service charges deter adherence

Primacy of effective communication and its influence on adherence to artemether-lumefantrine treatment for children under five years of age: a qualitative study.

BACKGROUND\ud \ud Prompt access to artemesinin-combination therapy (ACT) is not adequate unless the drug is taken according to treatment guidelines. Adherence to the treatment schedule is important to preserve efficacy of the drug. Although some community based studies have reported fairly high levels of adherence, data on factors influencing adherence to artemether-lumefantrine (AL) treatment schedule remain inadequate. This study was carried-out to explore the provider's instructions to caretakers, caretakers' understanding of the instructions and how that understanding was likely to influence their practice with regard to adhering to AL treatment schedule.\ud \ud METHODS\ud \ud A qualitative study was conducted in five villages in Kilosa district, Tanzania. In-depth interviews were held with providers that included prescribers and dispensers; and caretakers whose children had just received AL treatment. Information was collected on providers' instructions to caretakers regarding dose timing and how to administer AL; and caretakers' understanding of providers' instructions.\ud \ud RESULTS\ud \ud Mismatch was found on providers' instructions as regards to dose timing. Some providers' (dogmatists) instructions were based on strict hourly schedule (conventional) which was likely to lead to administering some doses in awkward hours and completing treatment several hours before the scheduled time. Other providers (pragmatists) based their instruction on the existing circumstances (contextual) which was likely to lead to delays in administering the initial dose with serious treatment outcomes. Findings suggest that, the national treatment guidelines do not provide explicit information on how to address the various scenarios found in the field. A communication gap was also noted in which some important instructions on how to administer the doses were sometimes not provided or were given with false reasons.\ud \ud CONCLUSIONS\ud \ud There is need for a review of the national malaria treatment guidelines to address local context. In the review, emphasis should be put on on-the-job training to address practical problems faced by providers in the course of their work. Further research is needed to determine the implication of completing AL treatment prior to scheduled time

Managing malaria in under-fives : Prompt access, adherence to treatment and referral in rural Tanzania

Background: Nearly a million people die of malaria each year, the majority are children in rural African settings. These deaths could be reduced if children had prompt access to artemisinin-based combination therapy (ACTs), demonstrated adherence to treatment and to referral advice for severe malaria. However, health systems are weak to deliver the interventions. Although many African countries, including Tanzania, changed malaria treatment policy to ACTs in the last decade, few children reportedly get prompt access to ACTs. Main aim: To determine factors influencing prompt access to effective antimalarials; adherence to treatment schedules and to referral advice among children under five, in rural settings. Methods: Community-based studies were conducted in rural villages in Kilosa (I,II) and Mtwara rural (II,IV) districts, in Tanzania. Study I and II were prospective designed while study III and IV were nested in a community-based rectal-artesunate deployment intervention study. In study I, a total of 1,235 children from 12 randomly selected villages were followed up for six months. Caretakers of children reported to have fever were interviewed at home about the type and source of treatment using a questionnaire. In study II, all children (3918) in five selected villages were followed-up for 12 months, to determine adherence to treatment when they had malaria, diagnosed using Rapid Diagnostic Test (RDT) and treated with artemether-lumefantrine (ALu). In study III, 587 children who received pre-referral rectal artesunate during the deployment study were traced home and caretakers interviewed on a number of factors likely to influence adherence to referral advice, using a questionnaire. Study IV was qualitative, 12 focus group discussions were conducted in three purposively selected villages to explore reasons for non-adherence to referral advice. Results: Only one-third (37.6%) of febrile children had prompt access to ALu, the recommended ACTs in Tanzania, mainland (I). Lack of prompt access was mostly (>80 percent) attributed to receiving non-recommended drugs. Less than half of the febrile children were taken to government facilities, where they were 17-times more likely to have prompt access compared to those who went elsewhere. Less than 10% (41/607) of febrile children had access to ALu (I) from faith-based organisation facilities and accredited drug dispensing outlets, despite having subsidized ALu. Reported adherence to treatment schedules was high (>80 percent) and non-adherence was attributed mainly to untimely dosing, rather than taking a fewer number of doses (II). While social economic status influenced prompt access to ALu and adherence to treatment, basic education did not (I, II). Caretakers of children with altered consciousness and convulsion were almost 4-times more likely to adhere to referral advice than those whose children had less severe symptoms (III). They seemed to weigh child condition against obstacles to accessing care at health facilities, if the condition was less severe prior to or improved after rectal artesunate dose, caretakers were likely to be deterred from adhering to referral advice (IV). Detailed understanding of provider’s advice was likely to lead to adherence to the treatment schedule (II) and to referral advice (III, IV). Conclusion: This thesis has shown that once a child had access to ALu, caretakers were likely to adhere to treatment schedule; and to referral advice, if child had severe symptoms or not improved after pre-referral treatment. More efforts should therefore be directed towards increasing access to ALu by strengthening the public health sector to reach rural remote areas. A wide coverage in prompt access to ALu will also reduce the need for the rectal artesunate strateg

A proposed framework for the implementation of community based health initiatives(CBHI)in the context of reforms in TANZANIA:enabling households and communities to take effective for the improvement of their own health development

\ud A team of I 0 local and one external consultants was contracted to review the implementation of CBHI in Tanzania. The objective of the review was to develop a framework for the implementation of CBHI in the districts; in the wake of Health and Local Government Reforms. Specifically, the team set out to review: Conununity Based Management of CDHC (Situation analysis, Planning, Implementation, Monitoring, Evaluation, and Feedback), Community Based Health Information Systems, Community Based Resource mobilization, Community Based Human resource management, Community Based provision of the essential health service package,Community Based Communication Strategy for Health development and behavior change, Community Based Coordination and linkage for health initiatives.\ud \ud In the course of the review, the team visited 11 districts with the aim of identifying best practice in Community Based Health Initiatives (CBHI) in Tanzania. Lessons derived from district experiences were to be included in this framework so as to guide the scaling up of this appro:!ch throughout the country, as a key element of the Health Sector Reform (HSR) process.\ud \ud Information gathering was undertaken through desk review, key informant interviews, and group discussions as well as observation of ongoing activities at National, District, Ward and Village levels. Visits were made to a total of 11 Districts (and 40 villages, 21\ud Wards). A second visit was paid to two Districts to validate the findings and. s s relevance of strategic actions-suggested by the team. Key infonnants and groups interviewed included: District Management Team (DMT), District Health Management Team (DHMT), Ward Development Committee (WDC) members, Village Chairpersons and Executive Officers, Kitongoji Chairpersons, other Village leaders and ordinary community people at Village Assemblies.\ud \ud In general, the Review Team found that CBHI implemented in whole Districts over a long period of time were associated with a series of indicators of improved health status, household health behaviour, and community services.\ud \ud In Mufmdi District, for example, quarterly pregnancy monitoring reports submission increased from 72% to 88%. Maternal Mortality dropped from 900/100,000 in 1991 to\ud 397 in 1993. Child mortality from 107/1000 to 90/1000 live births. Immunization\ud coverage reached 92% in 1990 and stabilized at 80% from 1994 to date. Family Planning acceptance has reached 75% in some villages. Severe malnutrition had gone down from an average of7 to 1 case per quarter in one of the villages visited. The number ofhouses constructed using pennanent materials had also increased eight-fold during the project\ud period indicating the possibility of an improving economic base. Access to water sources had improved to the level of 80% of households having access to safe water within 30 minutes walk. The villages visited had not experienced an outbreak of cholera for the past three years. In addition, roads to the villages had been improved anmaintained in good condition.\ud \ud There was increased proportion of women in Village committees reaching up to one third (8/20) in some of the villages. These achievements were attributed to the use of participatory approach in planning and implementation of CBHI.\u

Understanding caretakers' dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate

BACKGROUND: Malaria kills. A single rectal dose of artesunate before referral can reduce mortality and prevent permanent disability. However, the success of this intervention depends on caretakers' adherence to referral advice for follow-up care. This paper explores the dilemma facing caretakers when they are in the process of deciding whether or not to transit their child to a health facility after pre-referral treatment with rectal artesunate. METHODS: Four focus group discussions were held in each of three purposively selected villages in Mtwara rural district of Tanzania. Data were analysed manually using latent qualitative content analysis. RESULTS: The theme "Caretakers dilemma in deciding whether or not to adhere with referral advice after pre-referral treatment with rectal artesunate" depicts the challenge they face. Caretakers' understanding of the rationale for going to hospital after treatment--when and why they should adhere--influenced adherence. Caretakers, whose children did not improve, usually adhered to referral advice. If a child had noticeably improved with pre-referral treatment however, caretakers weighed whether they should proceed to the facility, balancing the child's improved condition against other competing priorities, difficulties in reaching the health facilities, and the perceived quality of care at the health facility. Some misinterpretation were found regarding the urgency and rationale for adherence among some caretakers of children who improved which were attributed to be possibly due to their prior understanding. CONCLUSION: Some caretakers did not adhere when their children improved and some who adhered did so without understanding why they should proceed to the facility. Successful implementation of the rectal artesunate strategy depends upon effective communication regarding referral to clinic

Institutional capacity for health systems research in East and Central African Schools of Public Health: strengthening human and financial resources

BACKGROUND: Despite its importance in providing evidence for health-related policy and decision-making, an insufficient amount of health systems research (HSR) is conducted in low-income countries (LICs). Schools of public health (SPHs) are key stakeholders in HSR. This paper, one in a series of four, examines human and financial resources capacities, policies and organizational support for HSR in seven Africa Hub SPHs in East and Central Africa. METHODS: Capacity assessment done included document analysis to establish staff numbers, qualifications and publications; self-assessment using a tool developed to capture individual perceptions on the capacity for HSR and institutional dialogues. Key informant interviews (KIIs) were held with Deans from each SPH and Ministry of Health and non-governmental officials, focusing on perceptions on capacity of SPHs to engage in HSR, access to funding, and organizational support for HSR. RESULTS: A total of 123 people participated in the self-assessment and 73 KIIs were conducted. Except for the National University of Rwanda and the University of Nairobi SPH, most respondents expressed confidence in the adequacy of staffing levels and HSR-related skills at their SPH. However, most of the researchers operate at individual level with low outputs. The average number of HSR-related publications was only <1 to 3 per staff member over a 6-year period with most of the publications in international journals. There is dependency on external funding for HSR, except for Rwanda, where there was little government funding. We also found that officials from the Ministries of Health often formulate policy based on data generated through ad hoc technical reviews and consultancies, despite their questionable quality. CONCLUSIONS: There exists adequate skilled staff for HSR in the SPHs. However, HSR conducted by individuals, fuelled by Ministries’ of Health tendency to engage individual researchers, undermines institutional capacity. This study underscores the need to form effective multidisciplinary teams to enhance research of immediate and local relevance. Capacity strengthening in the SPH needs to focus on knowledge translation and communication of findings to relevant audiences. Advocacy is needed to influence respective governments to allocate adequate funding for HSR to avoid donor dependency that distorts local research agenda.DFI

Understanding the Rural–Rural Migration of Health Workers in Two Selected Districts of Tanzania

Globally, rural–urban migration has been the focus in addressing the question of availability of health workers in rural areas. Often, the rural–rural migration of health workers, another important dimension is neglected. This study aimed to analyze the magnitude and the underlying factors for rural–rural migration of health workers in two rural districts of Tanzania. An exploratory comparative cross-sectional study adopting both quantitative and qualitative approaches was carried out in two districts of Kilwa in Lindi region, southern Tanzania, and Rombo in Kilimanjaro region, northern Tanzania. In a quantitative approach, 174 health workers (both clinicians and nonclinicians) filled in a self-administered questionnaire between August 2015 and September 2016. For the qualitative sub-study, 14 key informants that included health facilities in-charges and district health managers from the two districts were interviewed. In addition, three focus group discussions were conducted with members of the health facilities committee, in the two districts. Over 40% of health workers migrated from one workstation to another between 2011 and 2015. Close to 70% of the migrated health workers, migrated within the same districts. The proportion of health workers migrated was higher in Kilwa compared to Rombo. However, the difference was not statistically significant. The major underlying factors for migration in both districts were: Caring for the family and Unfavorable working and living conditions. In Kilwa, unlike Rombo, rejection by the community, superstitious beliefs, and lack of social services, were the other major factors underlying migration of the health workers. While addressing rural–urban migration, attention should be paid also to the rural–rural migration of health workers. Lastly, addressing the migration of health workers is a multi-dimensional issue that needs the engagement of all stakeholders within and beyond the health sector