Multimethod evaluation of health services integration for neglected tropical diseases requiring case management in Liberia.

INTRODUCTION: The WHO neglected tropical disease (NTD) roadmap stresses the importance of integrating NTDs requiring case management (CM) within the health system. The NTDs programme of Liberia is among the first to implement an integrated approach and evaluate its impact. METHODS: A retrospective study of three of five CM-NTD-endemic counties that implemented the integrated approach was compared with cluster-matched counties with non-integrated CM-NTD. We compared trends in CM-NTD integrated versus non-integrated county clusters. We conducted a pre-post comparison of WHO high-level outcomes using data collected during intervention years compared with baseline in control counties. Changes in health outcomes, effect sizes for different diseases and rate ratios with statistically significant differences were determined. Complementary qualitative research explored CM-NTD stakeholders' perceptions, analysed through the framework approach, which is a transparent, multistage approach for qualitative thematic interdisciplinary data analysis. RESULTS: The detection rates for all diseases combined improved significantly in the intervention compared with the control clusters. Besides leprosy, detection rates improved with large effects, over fourfold increase with statistically significant effects for individual diseases (p<0.000; 95% CI 3.5 to 5.4). Access to CM-NTD services increased in integrated counties by 71 facilities, compared with three facilities in non-integrated counties. Qualitative findings highlight training and supervision as inputs underpinning increases in case detection, but challenges with refresher training, medicine supply and incentives negatively impact quality, equity and access. CONCLUSIONS: Integrating CM-NTDs improves case detection, accessibility and availability of CM-NTD services, promoting universal health coverage. Early case detection and the quality of care need further strengthening.

The burden of surgical complications from unsafe abortion treated at the John F. Kennedy Maternity Center (JFKMC), Monrovia, Liberia.

Background: The burden of surgical complications from unsafe abortion affects both health facilities and patients in most developing countries. This study aimed to determine the nature of surgical complications from unsafe abortion treated at the JFKMC, Liberia, and the estimated cost burden on facility and patient. Method: This was a retrospective study of the medical records of patients who had exploratory laparotomy for complications of induced abortion and presented at the JFKMC from June 15, 2018, to December 15, 2019. Results: The medical records of 44 out of the 49 patients who had exploratory laparotomy for unsafe abortion were captured and analyzed. Surgical complications from unsafe abortion accounted for 17.8% out of the 276 gynaecological surgeries at the JFKMC, Liberia. The case fatality was 22.4%. The mean age of subjects was 29.00 ±6.06 years. About 1/3 of the subjects were in their teens, over 4/5 were single, and half were students. Almost 60.0% of the subjects terminated their pregnancies in private health facilities. Ten subjects had a hysterectomy for necrotic/septic uterus. The mean cost of managing a patient with surgical complications from unsafe abortion at the JFKMC was $331.50, in contrast with $22.00, for spontaneous or induced abortion with mild complications treated as a day case. Conclusion: This study showed a cost burden on the facility, and patients as a result of surgical complications from induced abortion. A shift in current practice by health facilities in Liberia to medical management of abortion and MVA, training of health personnel on the use of MVA, and a less restrictive abortion law with effective contraceptive services are recommended.