An Integrated Primary Care Initiative for Child Health in Northern Togo.

OBJECTIVES: To determine if the Integrated Community-Based Health Systems-Strengthening (ICBHSS) initiative was effective in expanding health coverage, improving care quality, and reducing child mortality in Togo. METHODS: Population-representative cross-sectional household surveys adapted from the Demographic Household Survey and Multiple Indicator Cluster Surveys were conducted at baseline (2015) and then annually (2016-2020) in 4 ICBHSS catchment sites in Kara, Togo. The primary outcome was under-5 mortality, with health service coverage and health-seeking behavior as secondary outcomes. Costing analyses were calculated by using "top-down" methodology with audited financial statements and programmatic data. RESULTS: There were 10 022 household surveys completed from 2015 to 2020. At baseline (2015), under-5 mortality was 51.1 per 1000 live births (95% confidence interval [CI]: 35.5-66.8), and at the study end period (2020), under-5 mortality was 35.8 (95% CI: 23.4-48.2). From 2015 to 2020, home-based treatment by a community health worker increased from 24.1% (95% CI: 21.9%-26.4%) to 45.7% (95% CI: 43.3%-48.2%), and respondents reporting prenatal care in the first trimester likewise increased (37.5% to 50.1%). Among respondents who sought care for a child with fever, presenting for care within 1 day increased from 51.9% (95% CI: 47.1%-56.6%) in 2015 to 80.3% (95% CI: 74.6%-85.0%) in 2020. The estimated annual additional intervention cost was $8.84 per person. CONCLUSIONS: Our findings suggest that the ICBHSS initiative, a bundle of evidence-based interventions implemented with a community-based strategy, improves care access and quality and was associated with reduction in child mortality.

Sexual Relationship Power and Socio-demographic Factors Predicting Contraceptive Use, Antenatal Visits and Sick Child Health Service Use in Northern Togo.

INTRODUCTION: Implementation of community-based healthcare services offering effective contraception, antenatal care (ANC), and treatment for symptomatic children under five has reduced maternal and child mortality in Togo. However, understanding if women are utilizing these services differentially based on social or demographic factors is important. This study identifies whether sexual relationship and socio-demographic factors are associated with healthcare utilization in four health facility catchment areas. METHODS: We conducted a cross-sectional household survey of women aged 15-49 in four health facility catchment areas in 2016 (three rural sites, one urban site). We used multivariable Poisson regression to test whether socio-demographic factors and a validated sexual relationship power scale were associated with contraceptive use, ANC visits, and seeking treatment for symptomatic children under five. RESULTS: Among women not pregnant or desiring pregnancy, older age, lower education, and single relationship status were associated with lower use of effective contraception. Among women who gave birth in two years preceding survey, low relationship power and low wealth quintile were associated with being less likely to attend at least four ANC visits. Women in rural sites were slightly more likely than women in the urban site to report seeking treatment for child under five with malaria, pneumonia, and/or diarrhea symptoms in last 2 weeks. DISCUSSION: Interventions in low-resource settings should explore ways to reach women with low health-service utilization to improve contraceptive use, ANC visits, and treatment for sick children. Furthermore, age, education, marital status, wealth status and sexual relationship power must be considered when targeting maternal health behaviors. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03773913; Date of registration: 12 Dec. 2018.

Implementing an integrated community based health systems strengthening approach to improve HIV survival in Northern Togo.

To disseminate lessons learned from the implementation experience of a public-private sector partnership, we describe a comprehensive HIV/AIDS program including 5-year survival outcomes for individuals who initiated antiretroviral therapy (ART) treatment in Togo from 2010 to 2015. A retrospective case study analysis was conducted from a cohort of patients receiving ART at an HIV/AIDS care clinic in Kara Region, Togo. Kaplan-Meier curves with Log rank tests were used to compare estimated survival curves by demographic and clinical characteristics. Associations were described between survival probability and age, gender, World Health Organization (WHO) disease stage, and timing of ART initiation. Cox proportional hazard model was used to determine predictors of mortality. After approximately five-years since ART initiation (1780 days), there were 114 deaths, with a survival probability of 75.3% (95% CI: 70.3-80.6%). Participants with advanced WHO disease stage were more likely at risk of death relative to patients categorized as WHO Stage 1, with Stage 4 approximately 9 times more likely (aHR 9.22, 95% CI 4.29-19.84). Our study suggests that delivering comprehensive HIV care through a private-public partnership may serve as a model to expand and improve HIV/AIDS care as well as high quality primary care.

Assessing the Integrated Community-Based Health Systems Strengthening initiative in northern Togo: a pragmatic effectiveness-implementation study protocol.

BACKGROUND: Over the past decade, prevalence of maternal and child morbidity and mortality in Togo, particularly in the northern regions, has remained high despite global progress. The causes of under-five child mortality in Togo are diseases with effective and low-cost prevention and/or treatment strategies, including malaria, acute lower respiratory infections, and diarrheal diseases. While Togo has a national strategy for implementing the integrated management of childhood illness (IMCI) guidelines, including a policy on integrated community case management (iCCM), challenges in implementation and low public sector health service utilization persist. There are critical gaps to access and quality of community health systems throughout the country. An integrated facility- and community-based initiative, the Integrated Community-Based Health Systems Strengthening (ICBHSS) initiative, seeks to address these gaps while strengthening the public sector health system in northern Togo. This study aims to evaluate the effect and implementation strategy of the ICBHSS initiative over 48 months in the catchment areas of 21 public sector health facilities. METHODS: The ICBHSS model comprises a bundle of evidence-based interventions targeting children under five, women of reproductive age, and people living with HIV through (1) community engagement and feedback; (2) elimination of point-of-care costs; (3) proactive community-based IMCI using community health workers (CHWs) with additional services including family planning, HIV testing, and referrals; (4) clinical mentoring and enhanced supervision; and (5) improved supply chain management and facility structures. Using a pragmatic type II hybrid effectiveness-implementation study, we will evaluate the ICBHSS initiative with two primary aims: (1) determine effectiveness through changes in under-five mortality rates and (2) assess the implementation strategy through measures of reach, adoption, implementation, and maintenance. We will conduct a mixed-methods assessment using the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. This assessment consists of four components: (1) a stepped-wedge cluster randomized control trial using a community-based household survey, (2) annual health facility assessments, (3) key informant interviews, and (4) costing and return-on-investment assessments for each randomized cluster. DISCUSSION: Our research is expected to contribute to continuous quality improvement initiatives, optimize implementation factors, provide knowledge regarding health service delivery, and accelerate health systems improvements in Togo and more broadly. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03694366 , registered 3 October 2018.

Closing the delivery gap.

Purpose The purpose of this paper is to describe the authors' experience operationalizing the care delivery value chain (CDVC) as a management and continuous quality improvement (QI) approach to strengthen HIV/AIDS services provided in Northern Togo through addressing gaps across a care continuum. Design/methodology/approach The authors led a series of discussions to develop a CDVC specific to existing HIV/AIDS services in Northern Togo. Using the CDVC framework, 28 specific gaps in service delivery were identified and integrated into a strategic QI plan. Findings At 12 months, 92 percent of delivery gaps had demonstrated improvement. The CDVC framework proved to be valuable in the following ways. First, it facilitated the first comprehensive mapping of HIV/AIDS services in the Kara region of Togo. Second, it enabled the identification of gaps or insufficiencies in the currently available services across the full continuum of care. Third, it catalyzed the creation of a strategic QI plan based on identified gaps. Research limitations/implications This case description is the authors' experience in one setting and should not be considered comparative in nature. Furthermore, the approach described may not be applicable to all initiatives and/or organizations. As described, the lack of sophisticated and comprehensive data collection systems limited the authors' ability to collect reliable data on some of the QI initiatives planned. Practical implications The operationalization of the CDVC framework is an effective approach to drive continuous QI. Originality/value Through the operationalization of the CDVC, the authors developed a new approach for assessing existing services, identifying gaps in service delivery and directing continuous QI initiatives in a strategic manner.

A tale of two countries: HIV among core groups in Togo.

OBJECTIVE: To describe the epidemiology of HIV among core groups in Togo. METHODS: We enumerated sex workers (SWs) and conducted cross-sectional surveys of SWs and their clients in 2003 in Lomé and in 2005 in the whole country. RESULTS: Sex work was concentrated in Lomé, which comprised 15% of the population, but 52% of the 5397 SWs enumerated in Togo in 2005 and 68% of the estimated 101,376 men who had bought sex in the year before the 2005 survey. HIV prevalence among SWs was highest in Lomé (45.4% in 2005) and progressively decreased from south to north. A similar geographical pattern was seen for clients (8.3% were HIV infected in Lomé in 2005) and had already been reported for pregnant women. In Lomé, the population attributable fraction of prevalent cases of HIV acquired during transactional sex was estimated at 32%; in the rest of the country, this was only 2%. CONCLUSIONS: This is the first study quantifying sex work at a national level in Africa. Variations in HIV prevalence within Togo, with a north-south gradient among SWs, their clients, and pregnant women, may to a large extent reflect the concentration of the sex trade within Lomé. Prostitution played only a modest a role in HIV dynamics outside Lomé.

Additional health and development activities for community-directed distributors of ivermectin: threat or opportunity for onchocerciasis control?

We studied the involvement of community-directed distributors (CDDs) of ivermectin for onchocerciasis control in other health and development activities in Nigeria, Togo and Cameroon. Most CDDs (82%) were involved in additional activities, especially EPI, water and sanitation and community development projects. These activities did not take up much time and were not considered an important burden. Ivermectin treatment coverage did not decline with increasing number of additional activities. Other health programmes are interested in building on the experiences and structures of community-directed treatment with ivermectin and involving CDDs in their health programmes. Some, such as EPI, provide financial incentives. Incentives by other programmes may enhance the performance of CDDs when they are selected on the basis of their CDD status. CDDs, health personnel and community members have very positive attitudes towards greater involvement of CDDs in additional health and development activities. We conclude that additional activities for CDDs do not pose a threat to but rather provide an opportunity to strengthen sustainability and effectiveness of ivermectin treatment.