Human resources for primary health care in sub-Saharan Africa: progress or stagnation?

BACKGROUND: The World Health Organization defines a "critical shortage" of health workers as being fewer than 2.28 health workers per 1000 population and failing to attain 80% coverage for deliveries by skilled birth attendants. We aimed to quantify the number of health workers in five African countries and the proportion of these currently working in primary health care facilities, to compare this to estimates of numbers needed and to assess how the situation has changed in recent years. METHODS: This study is a review of published and unpublished "grey" literature on human resources for health in five disparate countries: Mali, Sudan, Uganda, Botswana and South Africa. RESULTS: Health worker density has increased steadily since 2000 in South Africa and Botswana which already meet WHO targets but has not significantly increased since 2004 in Sudan, Mali and Uganda which have a critical shortage of health workers. In all five countries, a minority of doctors, nurses and midwives are working in primary health care, and shortages of qualified staff are greatest in rural areas. In Uganda, shortages are greater in primary health care settings than at higher levels. In Mali, few community health centres have a midwife or a doctor. Even South Africa has a shortage of doctors in primary health care in poorer districts. Although most countries recognize village health workers, traditional healers and traditional birth attendants, there are insufficient data on their numbers. CONCLUSION: There is an "inverse primary health care law" in the countries studied: staffing is inversely related to poverty and level of need, and health worker density is not increasing in the lowest income countries. Unless there is money to recruit and retain staff in these areas, training programmes will not improve health worker density because the trained staff will simply leave to work elsewhere. Information systems need to be improved in a way that informs policy on the health workforce. It may be possible to use existing resources more cost-effectively by involving skilled staff to supervise and support lower level health care workers who currently provide the front line of primary health care in most of Africa.

A "reverse pharmacology" approach for developing an anti-malarial phytomedicine.

A "reverse pharmacology" approach to developing an anti-malarial phytomedicine was designed and implemented in Mali, resulting in a new standardized herbal anti-malarial after six years of research. The first step was to select a remedy for development, through a retrospective treatment-outcome study. The second step was a dose-escalating clinical trial that showed a dose-response phenomenon and helped select the safest and most efficacious dose. The third step was a randomized controlled trial to compare the phytomedicine to the standard first-line treatment. The last step was to identify active compounds which can be used as markers for standardization and quality control. This example of "reverse pharmacology" shows that a standardized phytomedicine can be developed faster and more cheaply than conventional drugs. Even if both approaches are not fully comparable, their efficiency in terms of public health and their complementarity should be thoroughly considered.

Is parasite clearance clinically important after malaria treatment in a high transmission area? A 3-month follow-up of home-based management with herbal medicine or ACT.

Argemone mexicana (AM), a validated herbal medicine for uncomplicated malaria, seems to prevent severe malaria without completely clearing parasites in most patients. This study, in a high transmission area of South Mali, explores whether residual parasitaemia at day 28 was associated with subsequent malaria episodes and/or anaemia. Three hundred and one patients were randomly assigned to AM or artesunate/amodiaquine as first line treatment, of whom 294 were followed up beyond the standard 28 days, to 84 days. From day 29 to day 84, there were no significant differences between treatment groups in new clinical episodes of uncomplicated malaria (0.33 vs 0.31 episodes/patient), severe malaria (< 6% per month of patients aged ≤ 5 years) or moderate anaemia (hematocrit < 24%: 1.1% in both groups at day 84). Total parasite clearance at day 28 was not correlated with incidence of uncomplicated or severe malaria or of moderate anaemia over the subsequent two months. Total parasite clearance at day 28 was not clinically important in the context of high transmission. If this finding can be confirmed, some antimalarials which are clinically effective but do not completely clear parasites could nevertheless be appropriate in high transmission areas. Such a policy could be tested as a way to delay resistance to artemisinin combination therapies.

Argemone mexicana decoction versus artesunate-amodiaquine for the management of malaria in Mali: policy and public-health implications.

A classic way of delaying drug resistance is to use an alternative when possible. We tested the malaria treatment Argemone mexicana decoction (AM), a validated self-prepared traditional medicine made with one widely available plant and safe across wide dose variations. In an attempt to reflect the real situation in the home-based management of malaria in a remote Malian village, 301 patients with presumed uncomplicated malaria (median age 5 years) were randomly assigned to receive AM or artesunate-amodiaquine [artemisinin combination therapy (ACT)] as first-line treatment. Both treatments were well tolerated. Over 28 days, second-line treatment was not required for 89% (95% CI 84.1-93.2) of patients on AM, versus 95% (95% CI 88.8-98.3) on ACT. Deterioration to severe malaria was 1.9% in both groups in children aged 5 years) and 0% had coma/convulsions. AM, now government-approved in Mali, could be tested as a first-line complement to standard modern drugs in high-transmission areas, in order to reduce the drug pressure for development of resistance to ACT, in the management of malaria. In view of the low rate of severe malaria and good tolerability, AM may also constitute a first-aid treatment when access to other antimalarials is delayed.

[Study of the consumption of the Improved Traditional Phytomedicines in the health district of Kadiolo (Region of Sikasso, Mali)]. / Etude de la consommation des Medicaments Traditionnels Ameliores dans le district sanitaire de Kadiolo (Region de Sikasso, Mali).

The study, which received the support of the Development and Co-operation Management of the Swiss Confederation in the frame of the Socio-Sanitary Support Program Mali-Switzerland, proceeded from February to March 2004. The goal was to evaluate the impact of a workshop of formation of the prescribers on the Improved Traditional Phytomedicines (ITP), carried out in October 2001, on the consumption of the ITP in the medical structures of the District of Kadiolo. The study required the data-gathering of consumption, starting from the cards of stock of the years 2001, 2002 and 2003 of the Distributor Warehouse of the Reference Health Center and of the Pharmacies of the Community Health Centers. To evaluate the appreciation of the ITP, the investigations were carried out near the prescribers and the users. The overall consumption of ITP in CSRéf and 16 CSCom of the District knew a progressive increase, while passing from 2 565 480 F CFA in 2001 to 4 307 760 F CFA in 2003. The consumption of ITP during the year 2003 was of 27.83 F CFA per capita. The ITP in general were well appreciated by the prescribers and the consumers. Various projections of the consumption data recorded in Kadiolo allowed considering the potential market of the ITP currently available in Mali with a value ranging between 414 and 560 millions of F CFA.

Cultural adaptation and application of the IBS-QOL in China: a disease-specific quality-of-life questionnaire.

BACKGROUND: Irritable bowel syndrome (IBS) is a chronic and episodic illness characterized by altered bowel habits and associated abdominal pain. At present, IBS is one of the most common functional gastrointestinal and motility disorders affecting countries around the world. Surveys have found that patients with IBS have a significantly lower health-related quality of life. OBJECTIVES: The aim of this study was to translate and examine the validity of the Irritable Bowel Syndrome-Quality of Life questionnaire (IBS-QOL) in patients suffering from IBS in China. METHODS: A structured procedure was used for the translation and cultural adaptation of the original English IBS-QOL into Chinese. The questionnaire was administered to 73 clinical patients with IBS and 70 healthy individuals. Psychometric testing for reliability, validity and responsiveness followed standardized procedures. Test-retest reliability (10-20 hours) was assessed using the clinical patients. Follow-up (4 weeks) was collected for 61 clinical patients. All enrolled patients also completed the Short Form-36 Health Survey (SF-36) at the baseline visit. Responsiveness to treatment (Venlafaxine and traditional Chinese herbal medicine) was assessed by one-way ANOVA methods. RESULTS: The average length of time required to complete the questionnaire was short (5.63 min for IBS patients and 5.54 min for healthy subjects by self-administration). Internal consistency (Cronbach's alpha) values ranged from 0.722 to 0.914 for the Chinese IBS-QOL subscales and test-retest reliability coefficients were higher than 0.920 on all subscales. The convergent and discriminate validity results comparing the Chinese translation of the IBS-QOL overall score and the SF-36 subscales confirmed our predicted hypotheses. The Chinese IBS-QOL scores are more highly correlated with social functioning, vitality and general health (SF-36) and show weaker associations with physical functioning, role physical, mental health, and bodily pain (SF-36). The Chinese translation of the IBS-QOL was responsive to treatment. CONCLUSION: In general, the Chinese translation of the IBS-QOL, after cultural adaptation and revision, possesses good reliability, validity and responsiveness. It is a reliable and valid instrument to assess the quality of life in Chinese patients suffering from IBS and is an appropriate measure to use in further clinical trials or for related research projects in China.

[Knowledge of traditional healers on malaria in Kendi (Bandiagara) and Finkolo (Sikasso) in Mali ]. / La prise en charge du paludisme par les therapeutes traditionnels dans les aires de sante de Kendie (Bandiagara) et de Finkolo (Sikasso) au Mali.

The survey has been carried out in the context of the project "Traditional Practices and Primary Health Care", developed by the Traditional Medicine Department (DMT) of the INRSP and the Swiss Ngo Antenna Technologies, with the support of Aidemet Ngo. The objective was to evaluate the knowledge, attitudes and practices of traditional healers on uncomplicated and severe malaria, in the perspective of collaboration between traditional and modern medicine for the optimal care of the critical cases. The investigation has been conducted from January to February 2003 in the health areas of Kendié (Bandiagara District, Mopti Region) and Finkolo (Sikasso District and Region). The interviews concerned in total 79 traditional healers, 9 of which were women. The survey showed that the traditional healers have a good knowledge of the symptomatology of uncomplicated and severe malaria, and their diagnosis corresponds with that of the health workers who do not have access to laboratory analyses. On the other hand, the traditional etiology doesn't always correspond with the modern one, even if the traditional healers mention, among the causes of malaria, the mosquito bites. Most treatments were based on plant substances. We identified 66 medicinal species in total. The majority of them had already been studied for anti-plasmodial activity. We therefore investigated 8 of these plants, which had not previously been thoroughly studied. Extracts of different parts of these plants were tested on standard chloroquine-resistant strains of Plasmodium falciparum; the most active plants were Argemone mexicana, Securinega virosa, Spondias mombin and Opilia celtidifolia, with IC50 ranging from 1.00 to 4.01 microg/ml.

Malaria treatment in remote areas of Mali: use of modern and traditional medicines, patient outcome.

Use of official health services often remains low despite great efforts to improve quality of care. Are informal treatments responsible for keeping a number of patients away from standard care, and if so, why? Through a questionnaire survey with proportional cluster samples, we studied the case histories of 952 children in Bandiagara and Sikasso areas of Mali. Most children with reported uncomplicated malaria were first treated at home (87%) with modern medicines alone (40%), a mixture of modern and traditional treatments (33%), or traditional treatment alone (27%). For severe episodes (224 cases), a traditional treatment alone was used in 50% of the cases. Clinical recovery after uncomplicated malaria was above 98% with any type of treatment. For presumed severe malaria, the global mortality rate was 17%; it was not correlated with the type of treatment used (traditional or modern, at home or elsewhere). In the study areas, informal treatments divert a high proportion of patients away from official health services. Patients' experience that outcome after standard therapeutic itineraries is not better than after alternative care may help to explain low use of official health services. We need to study whether some traditional treatments available in remote villages should be considered real, recommendable first aid.