Is 'Health for All' synonymous with 'antibiotics for all': changes in antibiotic prescribing in a performance-based financing pilot in Zanzibar.

Universal Health Coverage, to meet the Sustainable Development Goal of 'Health for All', aims to increase the access of preventative and curative care services, particularly to the poor and vulnerable. However, the very provision of curative services by health providers in the primary care setting in low-income countries is considered one of the major drivers of antimicrobial resistance. The Zanzibar Ministry of Health introduced performance-based financing (PBF) in 2 of 10 Health Districts in July 2013. Payments to health facilities and staff were on a fee-for-service basis using 'direct quality indicators'. Results of an evaluation of secondary data of two indicators, 'treatment according to guidelines' and 'antibiotics prescribed according to guidelines' from 31 Primary Health Care Units in the two PBF pilot districts are compared with 28 in non-PBF districts. The proportion of patients treated with an antibiotic not in accordance with treatment guidelines after the introduction of PBF fell to 2%, 6% and 5% in 2014, 2015 and 2016, respectively, compared with an increase from 25% (2013) to 31% (2014) and 22% (2015, 2016) in non-PBF facilities. The key take-home messages from this evaluation are firstly that 'direct quality indicators' to improve the use of treatment guidelines, introduced into a national PBF reform that includes financial incentives and rigorous verification of register entries, have the potential to significantly reduce inappropriate use of antibiotics in high population density settings in Africa. Secondly, for a sustained reduction in the overall proportion of unnecessary antibiotic prescriptions rigorous monitoring of health worker behaviour is required to address changes in prescribing practice. A well-designed and monitored PBF with 'direct quality indicators' has the potential to ensure that 'Health for All', in terms of increased access to primary health services is not synonymous with 'antibiotics for all'.

Local problems; local solutions: an innovative approach to investigating and addressing causes of maternal deaths in Zambia's Copperbelt.

BACKGROUND: Maternal mortality in developing countries is high and international targets for reduction are unlikely to be met. Zambia's maternal mortality ratio was 591 per 100,000 live births according to survey data (2007) while routinely collected data captured only about 10% of these deaths. In one district in Zambia medical staff reviewed deaths occurring in the labour ward but no related recommendations were documented nor was there evidence of actions taken to avert further deaths. The Investigate Maternal Deaths and Act (IMDA) approach was designed to address these deficiencies and is comprised of four components; identification of maternal deaths; investigation of factors contributing to the deaths; recommendations for action drawn up by multiple stakeholders and monitoring of progress through existing systems. METHODS: A pilot was conducted in one district of Zambia. Maternal deaths occurring over a period of twelve months were identified and investigated. Data was collected through in-depth interviews with family, focus group discussions and hospital records. The information was summarized and presented at eleven data sharing meetings to key decision makers, during which recommendations for action were drawn up. An output indicator to monitor progress was included in the routine performance assessment tool. High impact interventions were identified using frequency analysis. RESULTS: A total of 56 maternal deaths were investigated. Poor communication, existing risk factors, a lack of resources and case management issues were the broad categories under which contributing factors were assigned. Sixty three recommendations were drawn up by key decision-makers of which two thirds were implemented by the end of the pilot period. Potential high impact actions were related to management of AIDS and pregnancy, human resources, referral mechanisms, birth planning at household level and availability of safe blood. CONCLUSION: In resource constrained settings the IMDA approach promotes the use of existing systems to reduce maternal mortality. In turn the capacity of local health officers to use data to determine, plan and implement relevant interventions that address the local factors contributing to maternal deaths is strengthened. Monitoring actions taken against the defined recommendations within the routine performance assessment ensures sustainability. Suggestions for further research are provided.

Nursing in Bangladesh: rhetoric and reality.

In the past decade concern has been raised through independent channels that nurses in Bangladesh do not provide active hands on care directly to patients as envisioned when the British nursing model was first introduced decades ago. The objective of the study was to observe the activities nurses engaged in during their working hours on major medical and surgical wards. A total of 24,587 min of nursing activities were recorded by three observers in 18 hospitals between the hours of 05.00 and 23.00 h over a 3 month period. These were compared with reports of the nurses about their activities, and indirectly with the activities outlined in the nursing curriculum. Nurses in government hospitals spent only 5.3% of their working time in direct contact with their patients. Paperwork and indirect patient care occupied nurses for 32.4% of their time while 50.1% fell under the category of unproductive time such as time away from the ward and chatting with other nurses. Hospital support workers and patients' relatives acted as nurse surrogates. When asked how they spent their day, nurses reported what the curriculum specifies but not what was observed. As a consequence policy decisions have not consistently reflected this reality. By contrast, nurses in the hospitals outside the government system were found to spend 22.7% directly with patients. A deeper understanding of nurse's behaviour on the wards is required to determine the desired role of the nurse that will, in turn, feed into nursing policy and decisions related to resource allocation.

Why Bangladeshi nurses avoid 'nursing': social and structural factors on hospital wards in Bangladesh.

In response to concerns that nurses spend less than 6% of their time on direct patient care, this study explored factors that influence nurses' behaviour in the provision of 'hands on' care in hospitals in Bangladesh. Through in-depth interviews with female nurses and patients and their co-workers in six hospitals, we identified conflicts between the inherited British model of nursing and Bangladeshi societal norms. This was most evident in the areas of night duty, contact with strangers, and involvement in 'dirty' work. The public was said to associate nursing activities with commercial sex work. As a consequence, their value on the 'bride market' decreases. To minimise the stigma associated with their profession, nurses in government hospitals distance themselves from patients, using nurse surrogates in the form of patients' relatives and hospital support workers to carry out their work. These adaptations are supported and sustained through unofficial activities developed over time within hospitals. In contrast nurses in NGO hospitals give more direct patient care themselves and do not rely on carers as much because of tight supervision and limited visitor hours. Initiatives undertaken to improve the quality of patient care, such as enlarging the nursing workforce or providing clinical instruction, which do not take into account the prevailing culture in hospitals and social conflicts faced by nurses, are unlikely to succeed. Fundamental decisions on how to care for the sick in Bangladesh are required. If the present nursing curriculum is followed, adequate supplies, supervision and accountability are prerequisites for its implementation.