Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu.

BACKGROUND: The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care. METHODS: A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes). RESULT: This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels. CONCLUSION: This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

Integrated Care for Crohn's Disease: A Plea for the Development of Clinical Decision Support Systems.

Evolution in the management of Crohn's disease [CD] has been characterized by recent paradigm changes. First, new biological therapies induce intestinal healing and full disease control in a substantial number of patients, particularly when introduced early in the disease course. However, they are expensive and associated with potentially severe side effects, raising the question of optimal treatment duration. Secondly, progress in biomarkers and medical imaging performance has enabled better refinement of the definition and prediction of remission or relapse of the disease through monitoring [tight control]. This progress may help to improve tailoring treatment in relation to target ['treat-to target' approach], applying patient-centred and collaborative perspectives, consistent with other chronic disease management. Such an approach requires the integration of a potentially large number of parameters coming from different stakeholders. This integration would be difficult based solely on implementation of classical guidelines and the clinician's intuition. To this end, clinical decision support systems should be developed that integrate a combination of various outcomes to facilitate the treatment decision and to share information between patients, primary care specialists, and health insurance companies or health authorities. This should ease complex therapeutic decisions and serve as a basis for continued research into effectiveness of CD management.

A critique of the Uganda district league table using a normative health system performance assessment framework.

BACKGROUND: In 2003 the Uganda Ministry of Health (MoH) introduced the District League Table (DLT) to track district performance. This review of the DLT is intended to add to the evidence base on Health Systems Performance Assessment (HSPA) globally, with emphasis on Low and Middle Income Countries (LMICs), and provide recommendations for adjustments to the current Ugandan reality. METHODS: A normative HSPA framework was used to inform the development of a Key Informant Interview (KII) tool. Thirty Key Informants were interviewed, purposively selected from the Ugandan health system on the basis of having developed or used the DLT. KII data and information from published and grey literature on the Uganda health system was analyzed using deductive analysis. RESULTS: Stakeholder involvement in the development of the DLT was limited, including MoH officials and development partners, and a few district technical managers. Uganda policy documents articulate a conceptually broad health system whereas the DLT focuses on a healthcare system. The complexity and dynamism of the Uganda health system was insufficiently acknowledged by the HSPA framework. Though DLT objectives and indicators were articulated, there was no conceptual reference model and lack of clarity on the constitutive dimensions. The DLT mechanisms for change were not explicit. The DLT compared markedly different districts and did not identify factors behind observed performance. Uganda lacks a designated institutional unit for the analysis and presentation of HSPA data, and there are challenges in data quality and range. CONCLUSIONS: The critique of the DLT using a normative model supported the development of recommendation for Uganda district HSPA and provides lessons for other LMICs. A similar approach can be used by researchers and policy makers elsewhere for the review and development of other frameworks. Adjustments in Uganda district HSPA should consider: wider stakeholder involvement with more district managers including political, administrative and technical; better anchoring within the national health system framework; integration of the notion of complexity in the design of the framework; and emphasis on facilitating district decision-making and learning. There is need to improve data quality and range and additional approaches for data analysis and presentation.

Cost-effectiveness of screening for active cases of tuberculosis in Flanders, Belgium.

OBJECTIVE: To assess the cost-effectiveness of the tuberculosis screening activities currently funded by the Flemish government in Flanders, Belgium. METHODS: After estimating the expenses for 2013-2014 of each of nine screening components - which include high-risk groups, contacts and people who are seeking tuberculosis consultation at a centre for respiratory health care - and the associated costs per active case of tuberculosis identified between 2007 and 2014, we compared the cost-effectiveness of each component. The applied perspective was that of the Flemish government. FINDINGS: The three most cost-effective activities appeared to be the follow-up of asylum seekers who were found to have abnormal X-rays in initial screening at the Immigration Office, systematic screening in prisons and contact investigation. The mean costs of these activities were 5564 (95% uncertainty interval, UI: 3791-8160), 11 603 (95% UI: 9010-14 909) and 13 941 (95% UI: 10 723-18 201) euros (€) per detected active case, respectively. The periodic or supplementary initial screening of asylum seekers and the screening of new immigrants from high-incidence countries - which had corresponding costs of €51 813 (95% UI: 34 855-76 847), €126 236 (95% UI: 41 984-347 822) and €418 359 (95% UI: 74 975-1 686 588) - appeared much less cost-effective. Between 2007 and 2014, no active tuberculosis cases were detected during screening in the juvenile detention centres. CONCLUSION: In Flanders, tuberculosis screening in juvenile detention centres and among new immigrants and the periodic or supplementary initial screening of asylum seekers appear to be relatively expensive ways of detecting people with active tuberculosis.

Integrating acute malnutrition interventions into national health systems: lessons from Niger.

BACKGROUND: Since 2007, integrated care of acute malnutrition has been promoted in Niger, a country affected by high burden of disease. This policy change aimed at strengthening capacity and ownership to manage the condition. Integration was neither defined nor planned but assumed to have been achieved. This paper studied the level and progress of integration of acute malnutrition interventions into key health system functions. METHODS: The qualitative study method involved literature searches on acute malnutrition interventions for children under 5 in low-income countries to develop a matrix of integration. Integration indicators defined three levels of integration of acute malnutrition interventions into health system functions-full, partial or none. Indicators of health services and health status were added to describe health system improvements. Data from qualitative and quantitative studies conducted in Niger between 2007 and 2013 were used to measure the indicators for the years under study. RESULTS: Results showed a mosaic of integration levels across key health system functions. Four indicators showed full integration, 22 showed partial integration and three showed no integration. Two-thirds of system functions showed progress in assimilating acute malnutrition interventions, while six persistently stagnated over time. There was variation within and across health system domains, with governance and health information functions scoring highest and financing lowest. Steady improvements were noted in geographic coverage, access and under-5 mortality risk. CONCLUSIONS: This study provided useful information to inform policy makers and guide strategic planning to improve integration of acute malnutrition interventions in Niger. The proposed method of assessing the extent of integration and monitoring progress may be adapted and used in Niger and other low-income countries that are integrating or intending to integrate acute malnutrition interventions.

[Potentially inappropriate medication use in elderly care in Burkina Faso]. / Utilisation des médicaments potentiellement inappropriés dans les soins gériatriques au Burkina Faso.

These results suggest approaches to encourage the development of care provider skills, standardized practices and rational prescription to help improve medication use in the elderly..

Referral hospitals in the Democratic Republic of Congo as complex adaptive systems: similar program, different dynamics.

INTRODUCTION: In many African countries, first referral hospitals received little attention from development agencies until recently. We report the evolution of two of them in an unstable region like Eastern Democratic Republic of Congo when receiving the support from development aid program. Specifically, we aimed at studying how actors' network and institutional framework evolved over time and what could matter the most when looking at their performance in such an environment. METHODS: We performed two cases studies between 2006 and 2010. We used multiple sources of data: reports to document events; health information system for hospital services production, and "key-informants" interviews to interpret the relation between interventions and services production. Our analysis was inspired from complex adaptive system theory. It started from the analysis of events implementation, to explore interaction process between the main agents in each hospital, and the consequence it could have on hospital health services production. This led to the development of new theoretical propositions. RESULTS: Two events implemented in the frame of the development aid program were identified by most of the key-informants interviewed as having the greatest impact on hospital performance: the development of a hospital plan and the performance based financing. They resulted in contrasting interaction process between the main agents between the two hospitals. Two groups of services production were reviewed: consultation at outpatient department and admissions, and surgery. The evolution of both groups of services production were different between both hospitals. CONCLUSION: By studying two first referral hospitals through the lens of a Complex Adaptive System, their performance in a context of development aid takes a different meaning. Success is not only measured through increased hospital production but through meaningful process of hospital agents'" network adaptation. Expected process is not necessarily a change; strengthened equilibrium and existing institutional arrangement may be a preferable result. Much more attention should be given in future international aid to the proper understanding of the hospital adaptation capacities.

Obstetric Fistula "Disease" and Ensuing Care: Patients' Views in West-Africa.

We explored obstetric fistula patients' real-life experience of care in modern Health System. Our aim was to analyze how these women's views impacted their care uptake and coping. We conducted 67 in-depth interviews with 35 fistula patients or former patients in 5 fistula repair centers within referral hospitals in Mali and Niger. Perceptions of obstetric fistula influenced the care experience and vice versa. Obstetric fistula was viewed as a severe chronic disease due to length of care process, limitation of surgery and persisting physical and moral suffering. We highlight the opportunity to build on patients' views on obstetric fistula trauma and care in order to implement an effective holistic care process.

[Does the National HIV /AIDS Control programme provide support for district hospitals in Cameroon?]. / Le programme national de lutte contre le VIH/sida renforce-t-il les hôpitaux de district au Cameroun?

The aim of this study was to investigate the effects of the national HIV/AIDS control programme on district hospitals in Cameroon. A multiple case study was conducted in two district hospitals- one public and one faith-based. Data were collected by document review, semi-structured interviews and observation of managerial processes and health care delivery. Programme interventions result in a series of positive and negative effects on the functioning of district hospitals and local health systems. High input and support of staff skills were observed for antiretroviral therapy and the management of opportunistic infections. However, the impact of the programme on the stewardship function is problematic. The low implication of district management teams in the implementation of HIV /AIDS activities reduces their structural capacity to run the local health systems. Programme and health system managers failed to take advantage of opportunities to develop synergies between the HIV/AIDS programme and local health systems. The HIV/AIDS programme weakens the systemic and structural capacity of local health systems. Managers of both programmes and general health systems should analyse and adapt their interventions in order to effective' strengthen health systems. One of the research questions is to understand why health system stakeholders do not seize opportunities to develop synergies between programmes and the general system and to strengthen health systems.

Medico-social pathways of obstetric fistula patients in Mali and Niger: an 18-month cohort follow-up.

OBJECTIVES: To gain understanding of care pathways and induced mobility patterns of obstetric fistula patients in French-speaking West African fistula repair centres. METHODS: We followed prospectively during 18 months a cohort of obstetric fistula patients in Mali and Niger (2008-2009). 120 patients were recruited at different stages of their care process in 5 reference fistula repair centres. Follow-up was carried out in repair centres and communities. Quantitative data were collected through close-ended questionnaires at three time points. Medico-social pathways were explored through a longitudinal analysis focusing on six indicators: fistula duration, care process duration, patients' mobility, marital status, number of surgeries and continence status. RESULTS: Patients' pathways were characterised by their length: fistula duration (median 4 years), care process duration (median 2.7 years), aggregated time spent in repair centres during study (median 7 months). Patients developed four mobility patterns (homebound, itinerant, institutionalised and urbanised). Adverse marital status change continued over time. Sample stratification according to number of previous surgeries revealed differences in care process duration and outcome: 23/31 new cases (≤1 surgery) gained continence with a mean of 1.5 surgeries in a median of 0.6 year while only 17/78 old cases (≥2 surgeries) became continent with a mean of 4 surgeries in a median time of 4.9 years. CONCLUSION: The quest for continence does not end with admission to a fistula repair centre. Analysing fistula care experience across time within the varying settings highlights the twofold population and mixed medico-social outcomes that should prompt new development in obstetric fistula care management and research.

Using classification tree modelling to investigate drug prescription practices at health facilities in rural Tanzania.

BACKGROUND: Drug prescription practices depend on several factors related to the patient, health worker and health facilities. A better understanding of the factors influencing prescription patterns is essential to develop strategies to mitigate the negative consequences associated with poor practices in both the public and private sectors. METHODS: A cross-sectional study was conducted in rural Tanzania among patients attending health facilities, and health workers. Patients, health workers and health facilities-related factors with the potential to influence drug prescription patterns were used to build a model of key predictors. Standard data mining methodology of classification tree analysis was used to define the importance of the different factors on prescription patterns. RESULTS: This analysis included 1,470 patients and 71 health workers practicing in 30 health facilities. Patients were mostly treated in dispensaries. Twenty two variables were used to construct two classification tree models: one for polypharmacy (prescription of ≥3 drugs) on a single clinic visit and one for co-prescription of artemether-lumefantrine (AL) with antibiotics. The most important predictor of polypharmacy was the diagnosis of several illnesses. Polypharmacy was also associated with little or no supervision of the health workers, administration of AL and private facilities. Co-prescription of AL with antibiotics was more frequent in children under five years of age and the other important predictors were transmission season, mode of diagnosis and the location of the health facility. CONCLUSION: Standard data mining methodology is an easy-to-implement analytical approach that can be useful for decision-making. Polypharmacy is mainly due to the diagnosis of multiple illnesses.

Tools for measuring the impact of informal caregiving of the elderly: a literature review.

OBJECTIVES: (1) Describe available tools to assess the impact of informal caregiving of home-dwelling elderly, (2) identify an acceptable and appropriate tool for a study aiming at the evaluation of the impact of innovative projects for care and support of care for elderly at home, on their main informal caregiver and (3) find a definition of 'main informal caregiver'. STUDY DESIGN: Literature review by searches of the following electronic databases: MEDLINE, CINAHL, EMBASE, using firstly keywords and exclusion criteria, then citations and reference search. RESULTS: This review has identified 105 scales assessing the impact of informal caregiving of the elderly. Those scales were described in terms of characteristics of the care receiver population, content and psychometric properties. Most retrieved scales are intended to measure the impact of caregiving on caregivers' health of elderly with dementia (n=49), overall elderly (n=21), cancer patients (n=7), chronically ill patients (n=7), psychiatric patients (n=7) and stroke patients (n=3). Dimensions of the impact of caregiving were classified into its positive (n=34), negative (n=55) or neither positive nor negative (n=16) consequences on the informal caregiver's health. Internal consistency varied from 0.48 to 0.99 and in half of the cases (n=52), construct validity was reported. Scales comprised 1-200 questions. The Zarit Burden Interview (ZBI-12) was selected for the study and an operational definition of the concept of "main informal caregiver" was constructed. CONCLUSION: This review identified a large number of scales that can be used to assess the impact of caregiving, viewed through different dimensions. The Zarit Burden Interview can be a useful tool for researchers and clinicians due to its user-friendliness, extensively validation and international use, making comparisons between groups possible. Despite the fact that only the original version of each scale was selected, this inventory should be a useful tool for intervention studies and even clinicians work.

Public purchasers contracting external primary care providers in Central America for better responsiveness, efficiency of health care and public governance: issues and challenges.

Several national health systems in Latin America initiated health reforms to counter widespread criticisms of low equity and efficiency. For public purchasing agencies, these reforms often consisted in contracting external providers for primary care provision. This paper intends to clarify both the complex and intertwined issues characterizing such contracting as well as health system performances within the context of four Central American countries. It results from a European Commission financed project lead between 2002 and 2005, involving participants from Costa Rica, Guatemala, Nicaragua, Salvador, United Kingdom, Netherlands and Belgium, whose aim was to promote exchanges between these participants. The findings presented in this paper are the results of a two stage process: (a) the design of an initial analytical framework, built upon findings from the literature, interlinking characteristics of contractual relation with health systems performances criteria and (b) the use of that framework in four case studies to identify cross-cutting issues. This paper reinforces two pivotal findings: (a) contracting requires not only technical, but also political choices and (b) it cannot be considered as a mechanical process. The unpredictability of its evolution requires a flexible and reactive approach. This should be better assimilated by national and international organizations involved in health services provision, so as to progressively come out of dogmatic approaches in deciding to initiate contractual relation with external providers for primary care provision.

Informing the TB suspect for sputum sample collection and communicating laboratory results in Nicaragua: a neglected process in tuberculosis case finding

OBJETIVO: valorar el proceso de información del paciente antes de la producción de esputo, la calidad de la muestra de esputo, y la transmisión de los resultados del examen microscópico del esputo a los sospechosos de tuberculosis (TB) en tres áreas de Nicaragua. MATERIAL Y MÉTODOS: (a) entrevistas dirigidas a sospechosos de TB cuya expectoración ha sido examinada para BK; (b) entrevistas dirigidas al personal de salud de tres áreas de estudio (c) la evaluación de la calidad de la expectoración. RESULTADOS: Un total de 115 sospechosos de TB y 33 trabajadores de la salud fueron entrevistados; 625 muestras de esputo fueron examinadas. Los resultados muestran varias debilidades en el proceso de información a los sospechosos antes de la producción de esputo. CONCLUSIÓN: Este estudio revela un aspecto del proceso de diagnóstico de la TB demasiado ignorado. Los resultados ilustran la importancia de evaluar de forma rutinaria el proceso completo de diagnóstico de la TB. Informing the TB suspect for sputum sample collection and communicating laboratory results in Nicaragua: a neglected process in tuberculosis case finding.