Theoretical frameworks for project goal-setting: A qualitative case study of an organisational practice in Nigeria.

INTRODUCTION: Goal-setting in any practice context is vague unless the process is based on a framework that produces good goals. Popular goal-setting frameworks construct Specific, Measurable, Attainable, Realistic, and Time-bound (SMART) goal statements. Yet, research of how healthcare goals that are foundational to health plans are formulated is scanty. This case study explored the goal-setting practice of an organisation in Nigeria to discover the theoretical frameworks for setting the goals of their leprosy projects. METHODS: The study triangulated individual semi-structured interviews of 10 leprosy managers with a review of their project plans and a participant observation of the organisation's annual planning event. A five-stage thematic analysis was used to serially identify, code, and integrate goal-setting themes from the data collected. FINDINGS: This produced three final emergent themes: stakeholders, strategy, and goal statements, with 11 associated conceptual frameworks. All were further theoretically integrated into one general framework that illustrates the organisational goal-setting practice at the time of study. This revealed a practice with a four-staged linear centre-driven process that led to a top-down, problem-based goal formulation, and produced assigned project plans based on hierarchical non-SMART goal statements. CONCLUSION: Collaborative goal-setting process is proposed for Specific, Measurable, Attainable, Realistic, Timed, and Agreeable statements of project objectives and aims written with Change, Beneficiaries, Indicator, Target, Timeframe and Change, Beneficiaries, Location, and Timeframe models respectively.

En las comunidades en riesgo de lepra, la cobertura con vacunación BCG debería ser apoyada por las organizaciones de ILEP / No disponible

La principal tesis de este trabajo es que el planteamiento EPI de vacunación con BCG al nacer o durante el primer año de vida proporciona una protección parcial ya demostrada frente a la lepra y que las organizaciones ILEP deben estimular los servicios sanitarios de los distintos gobiernos para mantener una elevada cobertura de población vacunada. Una revisión de la información disponible en 12 estudios con controles presenta una eficacia media del 63% (rango 20-90%). Otros dos estudios de cohortes y dos ensayos comunitarios aleatorios ha n presentado una eficacia media del 70% (rango 42-80%). La duración de esta protección parcial es de entre 10-15 años. No se han llevado a cabo estudios sobre la protección BCG frente a la lepra a más largo plazo. Un ensayo demostró una reducción de la incidencia de la tuberculosis hasta 40 años después de la vacunación con BCG. Hay un consenso bastante generalizado de que la BCG produce un “incremento” de la respuesta inmunológica frente al M. Leprae derivando a los pacientes desde el polo lepromatoso de la escala de Ridley-Jopling hasta el extremo tuberculoide o incluso mantenerlo en estado de infección subclínica. Un análisis de las cifras de cobertura con BCG a nivel nacional, tal como se presentaron a la OMS reveló que la cobertura media incrementó desde un 58% en 1980 hasta 88% en 2003. Sólo cuatro países reportaron una cobertura inferior al 60% en el 2003. Veinte de los 53 países africanos reportaban coberturas inferiores al 80% en 2003 frente a cinco de 28 países asiáticos, cinco de 13 en Oceanía y dos de 27 en América Central y del Sur. Al compara los datos proporcionados por los gobiernos locales con los obtenidos en estudios específicos en distintas comunidades del país, se deduce que las cifras oficiales no reflejan adecuadamente la realidad local. Frecuentemente, las comunidades rurales presentan menor cobertura que las urbanas. Los hogares delos barrios pobres presentan menor cobertura que los de zonas mas prosperas. Existen bolsas de poca cobertura BCG en países donde la lepra es endémica y las organizaciones ILEP están trabajando de forma activa. Las organizaciones ILEP pueden colaborar no involucrándose en la vacunación misma, sino controlando la cobertura BCG y exigiendo servicios sanitarios adecuados en las zonas donde trabajan. Esto reduciría el riesgo de contraer lepra en los menores de 15 años, proporcionando otra serie de beneficios a las madres y niños comprometidos y contribuiría a reducir la incidencia de la lepra a largo plazo. Si la protección conferida por la BCG es de por vida, proporcionar una elevada cobertura BCG a los planteamientos rutinarios de detección y tratamiento precoz se podría reducir significativamente la incidencia de la lepra en el 2020 (AU)

The central thesis of this paper is that the EPI policy of a BCG vaccination at birth or in the first year of life provides proven partial protection against leprosy and that ILEP organizations should actively encourage government health services to maintain a high coverage. A literature review identified 12 case-control studies showing a median vaccine efficacy of 63% (range 20-90%). Two prospective studies and two randomized community trials showed a median efficacy of 70% (range 42-80%). The duration of this partial protection is at least 10-15 years. Studies of the long-term protective effect of BCG vaccination against leprosy have not been conducted. One trial has demonstrated a reduction of tuberculosis incidence up to 40 years after vaccination with BCG. There is a growing consensus that BCG works by “upgrading” the immune response to M. leprae, moving leprosy cases form the lepromatous end of the Ridley-Jopling classification to the tuberculoid end or even make it possible for infection to remain subclinical. An analysis of national BCG coverage figures as reported to WHO showed that the global mean coverage increased form 58% in 1980 to 88% in 2003. The absolute number of countries reporting less than 80% coverage has decreased from 78 out of 105 in 1981 to 32 of 157 in 2003. Only four countries reported coverage’s below 60% in 2003. Twenty of the 53 African countries reported coverage’s below 80% in 003 against five of 38 countries in Asia, five of 13 countries in Oceania and two of 27 in Central and South America. Comparison of officially reported national coverage to estimates of coverage form special surveys clearly shows that the national figure may not adequately reflect the local situation. Rural communities often have lower coverage than urban populations. Slum households have lower coverage than non-slum households. Remote areas may not be touched by modern health services. Pockets of low BCG coverage exist in countries where leprosy is endemic and ILEP organisations are active. ILEP organisations can make an impact, not by getting involved in vaccination work directly, but by monitoring the BCG coverage and advocating for adequate provision of MCH services in the communities in which they work. This will reduce the risk of leprosy in children up to 15 years of age, provide a number of other benefits to the mothers and children involved and potentially contribute to a reduction of leprosy incidence on the longer term. If the partial protection imparted by BCG is life-long, adding a consistently high BCG coverage to the usual strategy of early case detection and treatment could result in a halving of the leprosy incidence in 2020 (AU)

ILEP organisations should strive for high BCG coverage in communities at risk of leprosy.

The central thesis of this paper is that the EPI policy of a BCG vaccination at birth or in the first year of life provides proven partial protection against leprosy and that ILEP organisations should actively encourage government health services to maintain a high coverage. A literature review identified 12 case-control studies showing a median vaccine efficacy of 63% (range 20-90%). Two prospective studies and two randomised community trials showed a median efficacy of 70% (range 42-80%). The duration of this partial protection is at least 10-15 years. Studies of the long-term protective effect of BCG vaccination against leprosy have not been conducted. One trial has demonstrated a reduction of tuberculosis incidence up to 40 years after vaccination with BCG. There is a growing consensus that BCG works by 'upgrading' the immune response to M. leprae, moving leprosy cases from the lepromatous end of the Ridley-Jopling classification to the tuberculoid end or even makes it possible for infection to remain subclinical. An analysis of national BCG coverage figures as reported to WHO showed that the global mean coverage increased from 58% in 1980 to 88% in 2003. The absolute number of countries reporting less than 80% coverage has decreased from 78 out of 105 in 1981 to 32 of 157 in 2003. Only four countries reported coverages below 60% in 2003. Twenty of the 53 African countries reported coverages below 80% in 2003 against five of 38 countries in Asia, five of 13 countries in Oceania and two of 27 in Central and South America. Comparison of officially reported national coverage to estimates of coverage from special surveys clearly shows that the national figure may not adequately reflect the local situation. Rural communities often have lower coverage than urban populations. Slum households have lower coverage than non-slum households. Remote areas may not be touched by modem health services. Pockets of low BCG coverage exist in countries where leprosy is endemic and ILEP organisations are active. ILEP organisations can make an impact, not by getting involved in vaccination work directly, but by monitoring the BCG coverage and advocating for adequate provision of MCH services in the communities in which they work. This will reduce the risk of leprosy in children up to 15 years of age, provide a number of other benefits to the mothers and children involved and potentially contribute to a reduction of leprosy incidence on the longer term. If the partial protection imparted by BCG is life-long, adding a consistently high BCG coverage to the usual strategy of early case detection and treatment could result in a halving of the leprosy incidence in 2020.

Progress towards the elimination of leprosy in Nigeria: a review of the role of policy implementation and operational factors.

The annual reports of the national leprosy control programme in Nigeria were reviewed to study the trends of the indices of leprosy control from 1992 to 2003 and determine the influence of operational and policy factors. By 2003, both national prevalence and case detection rates had reached below 0.5 per 10,000. Sub-nationally, all except three contiguous States in the Southeast, had prevalence rates below one case per 10,000. Over the 12 years, the prevalence rate decreased by 94-1%, from 7.14 to 0.42 per 10,000, with two periods of rapid decline: 1992-1994 and 1998. Remarkable surges of discharges from multi-drug therapy (MDT) occurred in these same periods. The period 1992-1994 corresponds to the years of introduction of MDT, case reviews, and clean-up of leprosy registers nationwide, while 1998 corresponds to the year the programme adopted the shortened 12-month MDT regime for multibacillary (MB) leprosy. The overall trend of case detection since 1992 was relatively stable, but had three significant periods of initial increase (1992-1994), stability (1994-1999) and recent decline (1999-2003), apparently related to the changing levels of activeness of the national programme. The pattern of new cases detected revealed increasing MB classification and lower disability, but a relatively stable child rate since 1992. The trend of MB proportion was also related to the years of MDT introduction and the adoption of a new leprosy case definition and classification policies. Thus, Nigeria has attained a low leprosy endemic status-mainly through operational and policy influences. The challenges that remain include reducing the relatively high leprosy burden in the Southeastern States and evolving effective case detection interventions that will make an observable impact on the incidence of leprosy.

Integrating leprosy control into general health service in a war situation: the level after 5 years in eastern Congo.

South Kivu Province of the Democratic Republic of Congo, plagued by a turbulent civil war, started a process of integrating leprosy into general health services in 1995. A questionnaire survey was carried out in September 2000 to assess the level of structural and functional integration, after 5 years of the integration process, in nine of its 14 health districts. The survey revealed that a total of 76 clinic nurses remained of those trained in leprosy since 1993. In all, 33-6% of the total 226 health facilities had a trained nurse, but according to the district supervisors who filled the questionnaires, nurses in only 28.3% of health facilities could diagnose leprosy. Less than 40% of the total 226 health facilities were structurally integrated with MDT and other leprosy services. Functionally, the clinic nurses were involved in dispensing MDT drugs and keeping leprosy records in 90.8 and 81.6%, respectively, of the integrated facilities, and diagnostic activities in 43.7%. The degree of involvement put health facilities into four grades of functional integration: 1) fully-functional integrated, 2) semi-functional integrated, 3) semi-integrated (structural but not functional), 4) not integrated (vertical). On this scale, 80% of 107 health facilities reported by the supervisors had some form of integration and 20% were not integrated. Treatment activities were significantly more functionally integrated than the diagnostic and POD activities, which require more skills. The presence of a trained nurse in a health facility made no significant difference to the involvement of clinic nurses in dispensing MDT drugs and performing POD activities, but significantly affected their performance of diagnostic activities and records keeping. The endemic districts had higher levels of structural integration, were not more likely to be functionally integrated. The levels of structural integration after 5 years are considered low in South Kivu Province, and reflect the significant negative effect of civil conflicts on integration of leprosy programmes in Africa.