Burden of depressive symptoms and non-alcohol substance abuse; and their association with alcohol use and partner violence: a cross-sectional study in four sub-Saharan Africa countries.

In sub-Saharan Africa, there are limited data on burden of non-alcohol substance abuse (NAS) and depressive symptoms (DS), yet potential risk factors such as alcohol and intimate partner violence (IPV) are common and NAS abuse may be the rise. The aim of this study was to measure the burden of DS and NAS abuse, and determine whether alcohol use and IPV are associated with DS and/or NAS abuse. We conducted a cross-sectional study at five sites in four countries: Nigeria (nurses), South Africa (teachers), Tanzania (teachers) and two sites in Uganda (rural and peri-urban residents). Participants were selected by simple random sampling from a sampling frame at each of the study sites. We used a standardized tool to collect data on demographics, alcohol use and NAS use, IPV and DS and calculated prevalence ratios (PR). We enrolled 1415 respondents and of these 34.6% were male. DS occurred among 383 (32.3%) and NAS use among 52 (4.3%). In the multivariable analysis, being female (PR  =  1.49, p  =  0.008), NAS abuse (PR  =  2.06, p  =  0.02) and IPV (PR  =  2.93, p < 0.001) were significantly associated with DS. Older age [odds ratio (OR) = 0.31, p < 0.001)], female (OR = 0.48, p  =  0.036) were protective of NAS but current smokers (OR = 2.98, p < 0.001) and those reporting IPV (OR  =  2.16, p  =  0.024) were more likely to use NAS. Longitudinal studies should be done to establish temporal relationships with these risk factors to provide basis for interventions.

High perceived social standing is associated with better health in HIV-infected Ugandan adults on highly active antiretroviral therapy.

Perceived social standing (PSS) was evaluated as a determinant of differences in health outcomes among Ugandan HIV-infected adults from Kampala using cross-sectional study design. PSS was defined using the MacArthur scale of subjective social status translated and adapted for the study setting. Socio-demographic and psychosocial correlates of PSS ranking at enrollment were determined using linear regression models. High versus low PSS was defined based on the median PSS score and evaluated as a determinant of body mass index, hemoglobin, quality of life (QOL) and frailty-related phenotype via linear regression. A log-binomial regression model estimated the relative-risk of good, very good or excellent versus fair or poor self-rated health (SRH) in relation to PSS. Older age, increasing social support and material wealth were correlated with high PSS ranking, whereas female sex, experience of multiple stigmas and multiple depressive symptoms were correlated with low PSS ranking. High PSS participants were on average 1.1 kg/m(2) heavier, had 4.7 % lower frailty scores and 3.6 % higher QOL scores compared to low PSS patients (all p < 0.05); they were also more likely to self-classify as high SRH (RR 1.4, 95 % confidence interval 1.1, 1.7) but had comparable hemoglobin levels (p = 0.634). Low PSS correlated with poor physical and psychosocial wellbeing in HIV-positive Ugandan adults. The assessment of PSS as part of clinical management, combined with efforts to reduce stigma and improve social support, may identify and possibly reduce PSS-associated health inequality in Ugandan adults with HIV.

Evidence-based monitoring and evaluation of the faith-based approach to HIV prevention among Christian and Muslim youth in Wakiso district in Uganda.

BACKGROUND: The Islamic Medical Association of Uganda, has been implementing the faith-based approach to HIV prevention without baseline data on expected positive outcomes. OBJECTIVES: To establish evidence-based baseline data on expected positive outcomes of the faith-based approach to HIV prevention. METHODS: A cross-sectional study of 15-24 year-old youths was analyzed for significant associations between HIV infections, risky behaviors, and religiosity RESULTS: HIV prevalence was 3.6% among Christians and 2.4% among Muslims. Abstaining from sex among teenagers was at 54% for Christians and 58% for Muslims. Being faithful in marriage among males was at 41% for Christians and 34% for Muslims and among females it was 65% for Christians and 69% for Muslims. Praying privately was associated with lower HIV infections and was observed among 60% of Christians. Sujda, the hyperpigmented marker of regular prayers on the forehead of Muslims was associated with lower HIV infections and observed in 42% of them. Ever drank alcohol was associated with higher HIV prevalence and observed in 52% of Christians and 17% of Muslims. Male circumcision rates were 15% for Christians and 98% for Muslims. CONCLUSION: A sero-behavioral-religiosity survey can provide evidence-based data for monitoring and evaluation of the faith-based approach to HIV prevention.

Religiosity for HIV prevention in Uganda: a case study among Christian youth in Wakiso district.

BACKGROUND: Utilization of religious institutions is one of the strategies for HIV prevention in Uganda. There is limited data on the association between religiosity and HIV infection rates. OBJECTIVE: To determine the association between religiosity and HIV prevalence rates among Christians. METHODS: An unmatched case-control study was done. Data from 106 HIV positive cases and 424 HIV negative controls between 15- 24 years were analyzed. RESULTS: Lower religiosity was associated with higher HIV infection rates when the following dimensions were analyzed: feeling guided by God in daily activities (odds ratio 1.90, 95%CI 1.03-3.50, p=0.035), feeling thankful for God's blessings (odds ratio 1.76, 95%CI 1.01-3.11, p=0.042), praying privately (odds ratio 2.02, 95%CI 1.30-3.11, p=0.001), trying hard to be patient in life (odds ratio1.74, 95%CI 1.07-2.84, p=0.024) and trying hard to love God (odds ratio 1.57, 95%CI 1.01-2.42, p=0.039). Higher HIV infection rates were associated with having multiple life-time sexual partners (odds ratio 5.37, 95%CI 1.86-15.47, p<0.001), ever drinking alcohol (odds ratio 2.28, 95%CI 1.43-3.65, p<0.001) and ever using narcotics for recreation (odds ratio 2.49, 95%CI 1.14-5.44, p=0.018). CONCLUSION: Lower levels of several dimensions religiosity are significantly associated with higher HIV infection rates. This data supports strengthening religiosity in HIV prevention strategies.

Religiosity for HIV prevention in Uganda: a case study among Muslim youth in Wakiso district.

BACKGROUND: Evidence for the association between religiosity and HIV infections is limited. Sujda, the hyper-pigmented spot on the forehead due to repeated prostration during prayers and fasting to worship, involving abstaining from food, drink and sex during daytime in Ramadhan and other specified days, are measures of religiosity among Muslims OBJECTIVES: To assess the association between religiosity and HIV infections. METHODS: This was an unmatched case-control study with 29 HIV positive cases and 116 HIV negative controls, from 1224 Muslims, 15-24 years. RESULTS: Respondents without Sujda had more HIV infections (odds ratio 2.90, 95% CI 1.07-7.86, p=0.029). Those with Sujda were more likely to abstain from sex (odds ratio 1.69, 95% CI 1.31-2.20, p<0.001) and be faithful in marriage (odds ratio 1.69, 95% CI 1.11-2.57, p=0.012). Respondents without Sujda were more likely to have ever taken alcohol before sex (odds ratio 5.00, 95% CI 1.39-17.95, p=0.006) and to have ever used narcotics (odds ratio 2.12, 95% CI, 1.11-4.05, p=0.019). Respondents who fasted less, had more HIV infections (odds ratio 2.46, 95% CI 1.07-5.67, p=0.028). CONCLUSION: Sujda and fasting were associated with lower HIV infections. Imams should use this information to intensify the Islamic approach to HIV prevention.

Prevalence factors associated with hypertension in Rukungiri district, Uganda--a community-based study.

BACKGROUND: Hypertension is a growing public health problem in Uganda and Africa as a whole. We conducted a study to determine the prevalence and identify factors associated withy hypertension among residents of the rural district of Rukungiri, Uganda. METHODS: A community-based cross-sectional study design was used to conduct this study. Between January and February 2006, a random sample of consenting district residents, aged 20 years or older were enrolled to participate in this study. Trained research assistants administered a standardized questionnaire and performed the physical measurements. The questionnaire collected data on demographics, social economic and exposure history to various potential risk factors for hypertension. Hypertension was defined as systolic blood pressure (BP) equal or greater than 140mmHg and/or diastolic BP equal or greater than 90mmHg, and/or being on regular anti-hypertensive therapy. Logistic regression analysis was used to identify factors associated with hypertension. RESULTS: Of the 842 study participants, 252 were hypertensive. The age-standardized prevalence of hypertension was 30.5%, with a 95% Confidence Interval (CI) of 26.6 - 34.3%. Factors found to be associated with hypertension included: past alcohol use, Odds Ratio (OR)=2.28, [1.42 - 3.64], present alcohol use OR=1.64 [1.12 - 2.43], being overweight OR=1.95 [1.37 - 2.79], obesity OR=5.07 [2.79 - 9.21], female sex OR=1.44 [1.03 - 2.06], having attained tertiary education OR=1.91 [1.03 - 3.56], and older age OR=1.42 [1.27 - 1.59]). CONCLUSION: The prevalence of hypertension in this rural Ugandan district is relatively high. The findings confirm the growing concern about hypertension as a public health problem in Uganda. More studies are however required to determine the distribution and determinants of hypertension in other parts of the country.

Risk factors towards self-destructive behaviour among fresh students at Makerere University

It has been suggested that some individuals are suicide prone; and that such individuals can be detected long before they commit suicide. This paper reports the risk factors associated with potential self-destructive behaviour among a group of freshwomen at Makerere University. A suicide proneness questionnaire; the Umzimkulu suicide Proneness Inventory (USPI); was completed by 619 students admitted to the University in the academic year 1992/93. The results indicate that students' propensity to self-destructive behaviour was significantly related to the history of suicide behaviour among the students; or their relatives; and the presence of a probable depressive disorder as indicated by scores above at least 60 on each of SR; AL; AS; and PDW; scales on the questionnaire. The paper describes in detail the development of the USPI; and the theory underlying the study. Implications for improving counselling services for students at Makerere University are highlighted

A re-examination of the potential impact of preventive therapy on the public health problem of tuberculosis in contemporary sub-Saharan Africa.

BACKGROUND: To estimate the effect size of tuberculosis preventive therapy (PT) on the public health problem of tuberculosis in contemporary sub-Saharan Africa. METHODS: A compartmental flow model that considers high levels of tuberculosis and human immunodeficiency virus (HIV) infection in contemporary sub-Saharan Africa was used to assess the impact of PT on the prevalence of tuberculosis and tuberculosis-associated mortality. RESULTS: Model implementation shows that giving PT to 25% of HIV-positive individuals with latent tuberculosis infection (LTBI) leads to a 3.9% reduction in the prevalence of tuberculosis in 10 years and a 5.1% reduction in 20 years. This intervention also prevents a cumulative total of 3.0% of tuberculosis-associated deaths in a decade and 5.5% in two decades. Doubling PT coverage to 50% approximately doubles the effect size, suggesting a linear relationship within the 20-year period. The effect size is slightly sensitive to changes in level of HIV transmission, level of tuberculosis transmission, and level of case detection and treatment cure rates in the population. CONCLUSIONS: Contrary to suggestions by previous authors that PT can significantly reduce the public health problem of tuberculosis in sub-Saharan Africa, this model-based analysis suggests that the impact of PT on tuberculosis in the population is likely to be small.

Tuberculosis in household contacts of infectious cases in Kampala, Uganda.

Tuberculosis remains a serious threat to public health, especially in sub-Saharan Africa. To determine the host and environmental factors responsible for tuberculosis in African households, the authors performed a prospective cohort study of 1,206 household contacts of 302 index cases with tuberculosis enrolled in Uganda between 1995 and 1999. All contacts were systematically evaluated for active tuberculosis and risk factors for active disease. Among the 1,206 household contacts, 76 secondary cases (6%) of tuberculosis were identified. Of these cases, 51 were identified in the baseline evaluation, and 25 developed during follow-up. Compared with index cases, secondary cases presented more often with minimal disease. The risk for secondary tuberculosis was greater among young children than adults (10% vs. 1.9%) and among human immunodeficiency virus-seropositive than -seronegative contacts (23% vs. 3.3%). Host risk factors could not be completely separated from the effects of environmental risk factors, suggesting that a household may represent a complex system of interacting risks for tuberculosis.

Mycobacterium africanum subtype II is associated with two distinct genotypes and is a major cause of human tuberculosis in Kampala, Uganda.

The population structure of 234 Mycobacterium tuberculosis complex strains obtained during 1995 and 1997 from tuberculosis patients living in Kampala, Uganda (East Africa), was analyzed by routine laboratory procedures, spoligotyping, and IS6110 restriction fragment length polymorphism (RFLP) typing. According to biochemical test results, 157 isolates (67%) were classified as M. africanum subtype II (resistant to thiophen-2-carboxylic acid hydrazide), 76 isolates (32%) were classified as M. tuberculosis, and 1 isolate was classified as classical M. bovis. Spoligotyping did not lead to clear differentiation of M. tuberculosis and M. africanum, but all M. africanum subtype II isolates lacked spacers 33 to 36, differentiating them from M. africanum subtype I. Moreover, spoligotyping was not sufficient for differentiation of isolates on the strain level, since 193 (82%) were grouped into clusters. In contrast, in the IS6110-based dendrogram, M. africanum strains were clustered into two closely related strain families (Uganda I and II) and clearly separated from the M. tuberculosis isolates. A further characteristic of both M. africanum subtype II families was the absence of spoligotype spacer 40. All strains of family I also lacked spacer 43. The clustering rate obtained by the combination of spoligotyping and RFLP IS6110 analysis was similar for M. africanum and M. tuberculosis, as 46% and 49% of the respective isolates were grouped into clusters. The results presented demonstrate that M. africanum subtype II isolates from Kampala, Uganda, belong to two closely related genotypes, which may represent unique phylogenetic branches within the M. tuberculosis complex. We conclude that M. africanum subtype II is the main cause of human tuberculosis in Kampala, Uganda.

Citywide trauma experience in Kampala, Uganda: a call for intervention.

OBJECTIVES: To describe injuries and their emergency care at five city hospitals. SETTING: Data were collected between January and December 1998 from casualty departments of the five largest hospitals of Kampala city, Uganda, with bed capacity ranging from 60 to 1200. METHODS: Registry forms were completed on trauma patients. All patients with injuries were eligible. Outcome at two weeks was determined for admitted patients. RESULTS: Of the 4359 injury patients, 73% were males. Their mean age was 24.2 years, range 0.1-89, and a 5-95 centile of 5-50 years. Patients with injuries were 7% of all patients seen. Traffic crashes caused 50% of injuries, and were the leading cause for patients > or = 10 years. Fifty eight per cent of injuries occurred on the road, 29% at home, and 4% in a public building. Falls, assaults, and burns were the main causes in homes. Fourteen per cent of injuries were intentional. Injuries were severe in 24% as determined with the Kampala trauma score. One third of patients were admitted; two thirds arrived at the hospital within 30 minutes of injury, and 92% were attended within 20 minutes of arrival. CONCLUSIONS: Injuries in Kampala are an important public health problem, predominantly in young adult males, mostly due to traffic. The majority of injuries are unintentional. Hospital response is rapid, but the majority of injuries are minor. Without pre-hospital care, it is likely that patients with serious injuries die before they access care. Preventive measures and a pre-hospital emergency service are urgently needed.

Injury patterns in rural and urban Uganda.

OBJECTIVES: To describe and contrast injury patterns in rural and urban Uganda. SETTINGS: One rural and one urban community in Uganda. METHODS: Community health workers interviewed adult respondents in households selected by multistage sampling, using a standardized questionnaire. RESULTS: In the rural setting, 1,673 households, with 7,427 persons, were surveyed. Injuries had an annual mortality rate of 92/100,000 persons, and disabilities a prevalence proportion of 0.7%. In the urban setting 2,322 households, with 10,982 people, were surveyed. Injuries had an annual mortality rate of 217/100,000, and injury disabilities a prevalence proportion of 2.8%. The total incidence of fatal, disabling, and recovered injuries was 116/1,000/year. Leading causes of death were drowning in the rural setting, and road traffic in the city. CONCLUSION: Injuries are a substantial burden in Uganda, with much higher rates than those in most Western countries. The urban population is at a higher risk than the rural population, and the patterns of injury differ. Interventions to control injuries should be a priority in Uganda.

The Impact of HIV on Transmission of Tuberculosis in Ugandan Households

To examine the effect of HIV infection old infectiousness of TB. Design: Cross-sectional prevalence study of household contacts to smear positive TB patients. Methods: HIV-infected and non-infected index TB cases with sputum smear positive TB; were enrolled from a major TB clinic at Mulago Hospital in Kampala; Uganda. All full-time household contacts of the index cases were evaluated by: medical history and physical examination; Mantoux purified protein derivative (PPD) skin tests; chest x-ray; BCG vaccination status; HIV test (in consenting subjects); TB symptoms and demographic and household environment. a contact with signs and/or symptoms of TB underwent a complete work-up for active TB. The main outcome measures were PPD positively and active TB. APPD skin-test readingor=5mm was considered positive. Results: 699 contacts of 170 index TB cases were included in this analysis. 319 (46) were contacts of 82 HIV+index TB cases. No significant differences were noted in the proportion of PPD positively; between contacts of HIV-infected and those pf the HIV-non-infected index cases [79versus 79; P=0.984]. Risk factors for PPD-positivity in contacts were: AFB smear grade of the index case [Odds Ratio (OR) = 1.7; 95CI: 1.16-2.37]; cavitary disease in the index case [OR=5.9; 95CI: 2.53-14.0]; age of the contact [OR = 1.1; 95CI: 1.05-1.10]; and household size [OR=0.9;95CI:0.85-0.96]. Risk factors for active TB in contacts were: cavitary disease in the index case [OR = 2.0;95CI: 1.07-3.58]; age of the contact [OR = 1.1; 95CI:0.89-0.96]; HIV status of the contact [OR=5.9;95CI:1.69-21.9]; and sharing of bed or bedroom with the index case [OR=2.5; 95CI: 1.54-3.92]. Conclusion: Transmission of M. tuberculosis within households was comparable among HIV-infected and non-infected index TB cases. However; transmission differed depending on: whether the index case had cavitary disease; the sputum AFB smear; household sixe and age of the contact. HIV-infected contacts; children and intimate contacts of the index cases were at increased risk of having active TB at the time of household evaluation

The effect of bacille Calmette-Guérin vaccination at birth on tuberculin skin test reactivity in Ugandan children.

SETTING: In Uganda, bacille-Calmette Guerin (BCG) vaccination coverage at birth is between 82 and 84%. OBJECTIVE: To evaluate the effect of neonatal BCG vaccination on tuberculin skin test positivity in Ugandan children exposed to infectious cases. DESIGN: As part of an ongoing prevalence study of household contacts of new tuberculosis cases, 365 children were evaluated to determine if BCG vaccination at birth had an impact on tuberculin skin testing. The children were classified as contacts (179) and non-contacts (186) depending on the presence of a sputum acid-fast bacilli (AFB) smear-positive adult tuberculosis case in the household. RESULTS: Regardless of prior BCG vaccination, children exposed to a smear-positive adult were more likely to have a positive skin test (purified protein derivative >5mm) (68% versus 36%, P < 0.01). BCG-vaccinated children below 1 year of age without a known household contact with active tuberculosis had a lower frequency of tuberculin skin reactions (29%) compared to their counterparts in the contact households (65%, P = 0.031). CONCLUSION: BCG vaccination at birth had no important effect on the interpretation of the tuberculin skin test reactivity in this group of Ugandan children. The tuberculin skin test remains a valuable tool for the evaluation of household contacts and suspected cases of tuberculosis in BCG-vaccinated children.

The challenge to restoring basic health care in Uganda.

This paper presents the results of a health facility survey conducted in Uganda between June 1992 and December 1993. The survey covered both government and non-government organisation (NGO) facilities from 10 districts in the five regions of the country. The main objective of the survey was to assess resource use, costs and financing of health facilities. The survey found differences between resource levels of NGOs and government facilities. Government facilities were inadequately maintained, and mostly in a state of disrepair. The user fee scheme that had been recently introduced in some government units to meet running costs was not only inadequate, but was not being used to meet the needs of consumers. In addition, most available resources, including human resources, were concentrated in hospitals. As a result, there was heavy demand for hospital services and less use of services in the lower level facilities. And furthermore, staff in government facilities were paid much less than staff working for NGOs, who not only got better pay but also in-kind forms of rewards, which made them better motivated to work. The number of qualified staff, particularly for primary health care, was grossly inadequate, and most of the work in local facilities was being done by unqualified employees, such as ward maids and dressers. In order to alleviate some of the problems identified, particularly in government facilities, there is a need to explore ways in which more can be done with the available resources to improve the efficiency of health services. The user charge system could be effective in improving the resource base of the health facilities, but it must result in visible improvement in the quality of services for consumers to be willing to pay. Collection methods should be standardised, and expenditures supervised. As part of the government's decentralisation programme, districts should be given the power to recruit and fire personnel. Once this authority is in place, the district should consider employing fewer personnel at all levels and aim to pay them a living wage.

Prediction of self-destructive behaviour among Makerere University students.

Student suicides at Makerere University have occurred sporadically and no systematic programme of suicide prevention has been developed. In addition, no clear guidelines have been worked out to guide the operations of the university counselling centre. A study on the possible predictability of suicide behaviour among students was conducted from October 1992 to June 1995. Study objectives included the identification of possible characteristics of suicidal students; the determination of the proportion of students who will seek counselling services at the university hospital in the course of their studies; and the identification of characteristics of counsellees. Study participants were the entire group of the 1992/93 academic year intake. Six hundred and nineteen students consented to complete a self-administered questionnaire, especially designed to identify suicidal and or depressed persons. The students were then followed up for three years during which data on student attendance at the counselling centre were collected. The results were analysed using the EPI INFO computer software. The results indicated that some students (at least 5.5%) who enrolled at Makerere university annually will probably require counselling services in the course of their studies; and it is possible to recognise students who might require counselling services early at the time of their enrollment at the university. The following recommendations are made to improve counselling services for students: all students should be inducted at the time of their entry into the university; counselling services should be made attractive to students; students should be involved in providing counselling services, particularly at emergency level; a prompt and attractive referral system for students requiring psychiatric care should be established; a telephone hot-line to be managed by the students should be established and; further research is needed to improve counselling services for students at Makerere university.

Prediction of self-destructive behavior among Makerere University students

Student suicides at Makerere University have occured sporadically and no systematic programme of suicide prevention has been developed. In addition; no clear guidelines have been worked out to guide the operations of the University counselling centre. A study on the predictability of suicide behaviour among students was conducted from October 1992 to June 1995. Study objectives included the identification of possible characteristics of suicidal students; the determination of the proportion of students who will seek counselling services at the University hospital in the course of their studies; and the identification of characteristics of counsellees. Study participants were the entire group of the 1992/93 academic year intake. Six hundred and nineteen students consented to complete a self-adminsitered questionnaire; especially designed to identify suicidal and or depressed persons. The students were then followed up for three years during which data on student attendance at the counselling centre were collected. The results were analysed using the EPIINFO computer software. The results indicated that some students (at least 5.5) who enrolled at Makerere University annually will probably require counselling services early at the time of their enrollment at the University. The following recommendations are made to improve counselling services for students: all students should be inducted at the time of their entry the University; counselling services should be made attractive to students; students should be involved in providing counselling services; particularly at emergency level; a prompt and attractive referral system for students requiring psychiatric care should be established; a telephone hot-line to be managed by the students should be established and; further research is needed to improve counselling services for students at Makerere University

Risk factors towards self-destructive behaviour among fresh students at Makerere University.

It has been suggested that some individuals are suicide prone, and that such individuals can be detected long before they commit suicide. This paper reports the risk factors associated with potential self-destructive behaviour among a group of freshmen and freshwomen at Makerere University. A suicide proneness questionnaire, the Umzimkulu Suicide Proneness Inventory (USPI), was completed by 619 students admitted to the university in the academic year 1992/93. The results indicate that students' propensity to self-destructive behaviour was significantly related to the history of suicide behaviour among the students, or their relatives, and the presence of a probable depressive disorder as indicated by scores above at least 60 on each of SR, AL, AS, and PDW, scales on the questionnaire. The paper describes in detail the development of the USPI, and the theory underlying the study. Implications for improving counselling services for students at Makerere University are highlighted.

Low bed occupancy rates in Uganda's peripheral health units: is it a policy problem?

A survey of 71 government and non-governmental health units ranging from hospitals to dispensaries was made to determine the utilisation of available beds in these units. In addition, an assessment of consumer practices on the use of beds was made using qualitative methods. The major finding of the study was the very low bed occupancy rates at the primary health care (PHC) level, ranging from 0.2-42%; compared to very high bed occupancy rates at the hospitals, ranging from 54-153%. Most patients referred themselves directly to the hospitals, travelling very long distances of up to 80 km. The reason for low bed occupancy rates at the primary health care level are multifactorial, including lack of medically trained personnel at this level, sporadic supply of drugs and other medical supplies and a complete breakdown in the transfer and referral system. In order to implement the policy of PHC which government has adopted, there is need to redirect resources to the PHC level and revive the referral system.