The role of universal health coverage and global health security nexus and interplay on SARS-CoV-2 infection and case-fatality rates in Africa : a structural equation modeling approach.

BACKGROUND: The Coronavirus Disease (COVID-19) caused by SARS-CoV-2 infections remains a significant health challenge worldwide. There is paucity of evidence on the influence of the universal health coverage (UHC) and global health security (GHS) nexus on SARS-CoV-2 infection risk and outcomes. This study aimed to investigate the effects of UHC and GHS nexus and interplay on SARS-CoV-2 infection rate and case-fatality rates (CFR) in Africa. METHODS: The study employed descriptive methods to analyze the data drawn from multiple sources as well used structural equation modeling (SEM) with maximum likelihood estimation to model and assess the relationships between independent and dependent variables by performing path analysis. RESULTS: In Africa, 100% and 18% of the effects of GHS on SARS-CoV-2 infection and RT-PCR CFR, respectively were direct. Increased SARS-CoV-2 CFR was associated with median age of the national population (ß = -0.1244, [95% CI: -0.24, -0.01], P = 0.031 ); COVID-19 infection rate (ß = -0.370, [95% CI: -0.66, -0.08], P = 0.012 ); and prevalence of obesity among adults aged 18 + years (ß = 0.128, [95% CI: 0.06,0.20], P = 0.0001) were statistically significant. SARS-CoV-2 infection rates were strongly linked to median age of the national population (ß = 0.118, [95% CI: 0.02,0.22 ], P = 0.024); population density per square kilometer, (ß = -0.003, [95% CI: -0.0058, -0.00059], P = 0.016 ) and UHC for service coverage index (ß = 0.089, [95% CI: 0.04,0.14, P = 0.001 ) in which their relationship was statistically significant. CONCLUSIONS: The study shade a light that UHC for service coverage, and median age of the national population, population density have significant effect on COVID-19 infection rate while COVID-19 infection rate, median age of the national population and prevalence of obesity among adults aged 18 + years were associated with COVID-19 case-fatality rate. Both, UHC and GHS do not emerge to protect against COVID-19-related case fatality rate.

Impact of good governance, economic growth and universal health coverage on COVID-19 infection and case fatality rates in Africa.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has disrupted lives across all countries and communities. It significantly reduced the global economic output and dealt health systems across the world a serious blow. There is growing evidence showing the progression of the COVID-19 pandemic and the impact it has on health systems, which should help to draw lessons for further consolidating and realizing universal health coverage (UHC) in all countries, complemented by more substantial government commitment and good governance, and continued full implementation of crucial policies and plans to avert COVID-19 and similar pandemic threats in the future. Therefore, the objective of the study was to assess the impact of good governance, economic growth and UHC on the COVID-19 infection rate and case fatality rate (CFR) among African countries. METHODS: We employed an analytical ecological study design to assess the association between COVID-19 CFR and infection rate as dependent variables, and governance, economic development and UHC as independent variables. We extracted data from publicly available databases (i.e., Worldometer, Worldwide Governance Indicators, Our World in Data and WHO Global Health Observatory Repository). We employed a multivariable linear regression model to examine the association between the dependent variables and the set of explanatory variables. STATA version 14 software was used for data analysis. RESULTS: All 54 African countries were covered by this study. The median observed COVID-19 CFR and infection rate were 1.65% and 233.46%, respectively. Results of multiple regression analysis for predicting COVID-19 infection rate indicated that COVID-19 government response stringency index (ß = 0.038; 95% CI 0.001, 0.076; P = 0.046), per capita gross domestic product (GDP) (ß = 0.514; 95% CI 0.158, 0.87; P = 0.006) and infectious disease components of UHC (ß = 0.025; 95% CI 0.005, 0.045; P = 0.016) were associated with COVID-19 infection rates, while noncommunicable disease components of UHC (ß = -0.064; 95% CI -0.114; -0.015; P = 0.012), prevalence of obesity among adults (ß = 0.112; 95% CI 0.044; 0.18; P = 0.002) and per capita GDP (ß = -0.918; 95% CI -1.583; -0.254; P = 0.008) were associated with COVID-19 CFR. CONCLUSIONS: The findings indicate that good governance practices, favourable economic indicators and UHC have a bearing on COVID-19 infection rate and CFR. Effective health system response through a primary healthcare approach and progressively taking measures to grow their economy and increase funding to the health sector to mitigate the risk of similar future pandemics would require African countries to move towards UHC, improve governance practices and ensure economic growth in order to reduce the impact of pandemics on populations.

Use of pulse oximetry during initial assessments of children under five with pneumonia: a retrospective cross-sectional study from 14 hospitals in Ethiopia.

BACKGROUND: Hypoxemia, a fatal condition characterized by low concentration of oxygen in the blood, is strongly associated with death among children with pneumonia. Ethiopia's Federal Ministry of Health launched its first National Oxygen and Pulse Oximetry Scale-up road map to improve access and utilization of pulse oximetry and oxygen. This study aimed to describe the use of pulse oximetry during the initial patient assessment among children under five diagnosed with pneumonia and serves as a benchmark to measure progress of the road map. METHODS: The study design was an observational study using retrospective review of patient medical records at 14 hospitals. Medical records of 443 children age 0-59 months with a primary diagnosis of pneumonia were randomly selected for review. The primary outcome was whether an arterial blood oxygen saturation (SpO2) measurement was recorded in the patient's medical record at the initial assessment. RESULTS: Overall, 10% (95% confidence interval CI = 4%-22%) of patient medical records had a SpO2 measurement. Admitted patients were more likely to have a SpO2 measurement recorded in their medical records than patients treated in the outpatient department (P<0.01). Among admitted patients, 19% (95% CI = 8%-38%) had a SpO2 measurement compared to 3% (95% CI = 1%-11%) of patients treated in the outpatient department. CONCLUSION: In Ethiopia, patients under five with a primary diagnosis of pneumonia are rarely screened for hypoxemia with a pulse oximeter, and hypoxemia may be severely underdiagnosed. Much needs to be done to improve the routine use of pulse oximetry.

Determinants of malnutrition among pregnant and lactating women under humanitarian setting in Ethiopia.

BACKGROUND: Despite significant gains and progress in the last decade, malnutrition remains a major public health problem in Ethiopia. Pregnant and lactating women (PLW), along with children, are among the most vulnerable groups of population during emergencies and droughts. Identifying and targeting of PLW with malnutrition is among the priorities in humanitarian emergencies. However, there is dearth of evidence on PLW nutritional status and its determinants in humanitarian context. METHODS: A community-based cross-sectional study was conducted in 10 kebeles of Rayitu district of Ethiopia in June 2013. A total of 900 PLW were assessed for malnutrition using mid-upper-arm circumference (MUAC). RESULT: Using MUAC < 21 cm as a criteria, 216 (24%) surveyed mothers were found to be malnourished. In multivariable logistic regression analysis, those mothers who did not received antenatal care (ANC) during their pregnancy had 1.83 higher odds of (adjusted odds ratio[AOR] = 1.83, 95% confidence interval [CI]:1.10,3.02) to be malnourished (MUAC < 21 cm) as compared to mothers who received ANC. Housewives had lower odds of (AOR = 0.59, 95 %CI: 0.37, 0.95) to be malnourished compared to those who engaged in as a pastoralist. Mothers belonging to families from which at least one person did not receive targeted supplementary feeding (TSF) in the 6 months before the study had lower odds of (AOR = 0.38, 95 %CI:0.23,0.62) to have acute malnutrition compared to those who lived in families who received TSF. CONCLUSIONS: Malnutrition is common among PLW in humanitarian settings, including those with ongoing interventions. Attending antenatal care, maternal occupational status and being a member of families who received TSF were factors associated with maternal nutritional status in this study. This signifies the need for sustainable solutions that address the high prevalence of malnutrition among PLW. Interventions targeting health system responses such as comprehensive nutrition education, support through antenatal care and women empowerment are recommended.

Reasons for defaulting from childhood immunization program: a qualitative study from Hadiya zone, Southern Ethiopia.

BACKGROUND: Reduction of mortality and morbidity from vaccine-preventable diseases in developing countries involves successfully implementing strategies that ensure high coverage and minimize drop-outs and missed opportunities. Achieving maximum coverage, however, has been a challenge due to many reasons, including high rates of defaulters from the program. The objective of this study was to explore the reasons behind defaulting from the immunization program. METHODS: A qualitative study was conducted in two districts of Hadiya zone, Southern Ethiopia between November 2014 and April 2015. A total of twenty-six in-depth interviews were held with mothers of defaulted children aged 6-11months old and key informants from the communities, health centers, and health offices. Observations and review of relevant documents were also conducted. Thematic analysis was used to analyze the data. RESULTS: In this study, the main reason for defaulting from the immunization was inadequate counseling of mothers that led to a lack of information about vaccination schedules and service arrangements, including in unusual circumstances such as after missed appointment, loss of vaccination card and when the health workers failed to make home visits. Provider-client relationships are poor with mothers reporting fear of mistreatment and lack of cooperation from service providers. Contrary to what health workers and managers believe, mothers were knowledgeable about the benefits of vaccination. The high workload on mothers compounded by the lack of support from male partners was also found to contribute to the problem. Health system factors that contributed to the problem were poorly arranged and coordinated immunization services, vaccine and supplies stock outs, and lack of viable defaulter tracking systems in the health facilities. CONCLUSIONS: The main reasons for defaulting from the immunization program are poor counseling of mothers, unsupportive provider-client relationships, poor immunization service arrangements, and lack of systems for tracking defaulters. Efforts to reduce defaulter rates from the immunization program need to focus on improving counseling of mothers and strengthening the health systems, especially with regards to service arrangements and tracking of defaulters.

Chronic viral hepatitis: policy, regulation, and strategies for its control and elimination in Ethiopia.

BACKGROUND: Hepatitis B and C are silent killers not yet recognized as major public health challenges in many developing countries with huge disease burden. In Ethiopia, Hepatitis B is endemic with an average prevalence of 10.8 %, and the prevalence of Hepatitis C is 2 %. The prevalence of both infections, however, is likely to be underreported due to the lack of diagnostic facilities and appropriate surveillance systems. Ethiopia is also among the many Sub-Sahara African countries lacking a coordinated and systematic national response to chronic viral hepatitis. The objective of this study is to examine the current level of response to viral Hepatitis B & C in Ethiopia with the aim to bring identified gaps to the attention of relevant stakeholders and policy makers. METHODS: This cross-sectional qualitative study was based on semi-structured in-depth interviews with 21 key informants from health facilities, health offices, pharmaceutical companies, regulatory bodies, professional association and blood bank units. Participants were selected purposively based on their role in the national hepatitis response. The investigators also reviewed available policy and strategy documents, standards of practice and surveys, and paid visits to pharmaceutical premises to check the availability of antiviral drugs. Thematic analysis was employed to make sense of the data. During the data analysis process, all the authors critically read the materials, and data was triangulated by source, interpreter view and thematic perspective to ensure accurate representation and comprehensiveness, and validation of the interviewees' responses. Once each investigator reviewed the data independently, the team reached a common understanding of the scope and contexts of the information attained. Data were subsequently reduced to key concepts, and case stories were taken with successive revisions. The key concepts were later coded into most basic meaningful categories. The World Health Organization (WHO) global hepatitis response framework was used to organize the analysis. RESULTS: Ethiopia is in the process of preparing strategic plan and guidelines for viral hepatitis. However, the country still lacks the required partnerships, and resource mobilization as a national health response is limited. Community awareness on the disease transmission and its sequel is poor. Viral hepatitis screening services are not widely available except for the occasional mandatory medical checkups for work or travel purposes. Healthcare providers often take no further action after diagnosing patients with viral hepatitis due to lack of treatment guidelines and strategic frameworks for screening, diagnosis, and treatment. Besides, drugs that are effective in the treatment of viral hepatitis are not available, mainly due to regulatory challenges. CONCLUSIONS: Viral hepatitis and its disease burden are getting little attention in Ethiopia and many low-income countries. The levels of technical guidance and financial support from the international community are low. To date, the response to the infections in Ethiopia is patchy. Thus, the country needs to formulate policy and strategies in the areas of disease surveillance, risk group identification and screening, use of the birth dose of hepatitis B vaccine, and care and treatment. Improving availability of data on viral hepatitis, access to low-cost generic drugs and developing and dissemination of treatment guidelines are also critical. Leveraging the successful Health Extension Program for a hepatitis response, and exploring ways to learn from and integrate into the HIV/AIDS program should also be considered.

Adapting HIV patient and program monitoring tools for chronic non-communicable diseases in Ethiopia.

BACKGROUND: Chronic non-communicable diseases (NCDs) have become a huge public health concern in developing countries. Many resource-poor countries facing this growing epidemic, however, lack systems for an organized and comprehensive response to NCDs. Lack of NCD national policy, strategies, treatment guidelines and surveillance and monitoring systems are features of health systems in many developing countries. Successfully responding to the problem requires a number of actions by the countries, including developing context-appropriate chronic care models and programs and standardization of patient and program monitoring tools. METHODS: In this cross-sectional qualitative study we assessed existing monitoring and evaluation (M&E) tools used for NCD services in Ethiopia. Since HIV care and treatment program is the only large-scale chronic care program in the country, we explored the M&E tools being used in the program and analyzed how these tools might be adapted to support NCD services in the country. Document review and in-depth interviews were the main data collection methods used. The interviews were held with health workers and staff involved in data management purposively selected from four health facilities with high HIV and NCD patient load. Thematic analysis was employed to make sense of the data. RESULTS: Our findings indicate the apparent lack of information systems for NCD services, including the absence of standardized patient and program monitoring tools to support the services. We identified several HIV care and treatment patient and program monitoring tools currently being used to facilitate intake process, enrolment, follow up, cohort monitoring, appointment keeping, analysis and reporting. Analysis of how each tool being used for HIV patient and program monitoring can be adapted for supporting NCD services is presented. CONCLUSION: Given the similarity between HIV care and treatment and NCD services and the huge investment already made to implement standardized tools for HIV care and treatment program, adaptation and use of HIV patient and program monitoring tools for NCD services can improve NCD response in Ethiopia through structuring services, standardizing patient care and treatment, supporting evidence-based planning and providing information on effectiveness of interventions.

Challenges to the Scaling of Computer- Based Patient Record System for Antiretroviral Therapy Program in Ethiopia

Drawing upon interpretive paradigm and an action research approach, this study investigated the challenges to the scaling of computer-based health information systems in the public health sector of Ethiopia. The research was situated within a broader action research project by HISP (Health Information System Program) Ethiopia which was aimed at developing and implementing an integrated HIV/AIDS management system in the country. The ART module of the system was developed and implemented in two pilot sites in the capital city, Addis Ababa. The research problem was addressed using this system; specifically through participation in its scaling (both in functionality and geographically). The fieldwork was conducted in two logically connected phases between July 2006 and January 2007. In the first phase, I studied how the computerized system was functioning at the pilot sites with the aim to understand what needs to be done when it is implemented elsewhere; and identify any problems with it which might need to be addressed before its deployment to other sites (geographic scaling). The second phase of the study was the actual deployment of the system to the main case study site, the Southern Nations Nationalities and People's Region. Efforts to deploy the system to other clinics within Addis Ababa; and Amhara, Oromia, and Somali regions were also investigated. Qualitative data collection techniques including interviews, observation, and document review were used to collect the empirical data. The findings were analyzed using qualitative techniques. Analysis of the findings concerning the geographic scaling of the system (through the processes of adoption and implementation) was informed by a theoretical framework which was developed by combining key concepts from the diffusion of innovations and institutional theories; and findings of previous information systems implementation studies. The framework was developed in way that facilitates an integrated analysis of the challenges to the geographic scaling, including the technological factors, organizational issues, and external influences on the public health organizations. The research identified frequent changes in the requirements (information needs) of users, differences in work practices, lack of technical workforce, and the use of complicated pilot sites as the key challenges to the scaling in functionality of the system. A variety of technological, organizational, and environmental factors were found to influence the adoption and implementation of the system by public health organizations. Functionality of the system; and perceived characteristics of the system, specifically perceived benefits, technical compatibility with the existing systems, perceived complexity, trialability (the possibility of trying it before the decision to implement is made), and perceived reliability were the technology-related factors which influenced the adoption and implementation processes. The major organizational factors which affected the processes were inadequate organizational readiness, and the administrative structure of public health organizations. In addition, coercive influences from the NGOs supporting the Antiretroviral Therapy program had significant impact. Analysis of the findings also revealed that the lack of formal rules (such as IS implementation guidelines), which could provide a framework for the actions of iii the decision-makers and the implementers, to be the key problem, and a possible explanation for most of the observed challenges. It is argued that the influences on the adoption and implementation of the system are complex and inter-related; and thus cannot be fully understood in isolation. The research proposes a holistic approach to the investigation and understanding of challenges to computer-based health information systems development and implementation in developing countries. The major implications of the findings for the public health sector in developing countries are also outlined. In the context of the ART program, and the current massive scale-up of the treatment in developing countries, the need to anticipate the information management challenges and strengthen the health information system ­ including the development of clear strategic directions for the adoption of innovative solutions, the strengthening of the manual system and its infrastructure base; and alignment between various stakeholders ­ are emphasized.