[Does the National HIV /AIDS Control programme provide support for district hospitals in Cameroon?]. / Le programme national de lutte contre le VIH/sida renforce-t-il les hôpitaux de district au Cameroun?

The aim of this study was to investigate the effects of the national HIV/AIDS control programme on district hospitals in Cameroon. A multiple case study was conducted in two district hospitals- one public and one faith-based. Data were collected by document review, semi-structured interviews and observation of managerial processes and health care delivery. Programme interventions result in a series of positive and negative effects on the functioning of district hospitals and local health systems. High input and support of staff skills were observed for antiretroviral therapy and the management of opportunistic infections. However, the impact of the programme on the stewardship function is problematic. The low implication of district management teams in the implementation of HIV /AIDS activities reduces their structural capacity to run the local health systems. Programme and health system managers failed to take advantage of opportunities to develop synergies between the HIV/AIDS programme and local health systems. The HIV/AIDS programme weakens the systemic and structural capacity of local health systems. Managers of both programmes and general health systems should analyse and adapt their interventions in order to effective' strengthen health systems. One of the research questions is to understand why health system stakeholders do not seize opportunities to develop synergies between programmes and the general system and to strengthen health systems.

A systematic review of missed opportunities for improving tuberculosis and HIV/AIDS control in Sub-saharan Africa: what is still missed by health experts?

In sub-Saharan Africa, HIV/AIDS and tuberculosis are major public health problems. In 2010, 64% of the 34 million of people infected with HIV were reported to be living in sub-Saharan Africa. Only 41% of eligible HIV-positive people had access to antiretroviral therapy (ART). Regarding tuberculosis, in 2010, the region had 12% of the world's population but reported 26% of the 8.8 million incident cases and 254000 tuberculosis-related deaths. This paper aims to review missed opportunities for improving HIV/AIDS and tuberculosis prevention and care. We conducted a systematic review in PubMed using the terms 'missed'(Title) AND 'opportunities'(Title). We included systematic review and original research articles done in sub-Saharan Africa on missed opportunities in HIV/AIDS and/or tuberculosis care. Missed opportunities for improving HIV/AIDS and/or tuberculosis care can be classified into five categories: i) patient and community; ii) health professional; iii) health facility; iv) local health system; and v) vertical programme (HIV/AIDS and/or tuberculosis control programmes). None of the reviewed studies identified any missed opportunities related to health system strengthening. Opportunities that are missed hamper tuberculosis and/or HIV/AIDS care in sub-Saharan Africa where health systems remain weak. What is still missing in the analysis of health experts is the acknowledgement that opportunities that are missed to strengthen health systems also undermine tuberculosis and HIV/AIDS prevention and care. Studying why these opportunities are missed will help to understand the rationales behind the missed opportunities, and customize adequate strategies to seize them and for effective diseases control.

Profile of suicide in rural Cameroon: are health systems doing enough?

OBJECTIVES: To describe the characteristics of suicide and assess the capacity of health services at the district level in Cameroon to deliver quality mental health care. METHODS: The study covered the period between 1999 and 2008 and was carried out in Guidiguis health district which had a population of 145 700 inhabitants in 2008. Data collection was based on psychological autopsy methods. To collect data, we used documentary review of medical archives, semi-structured interviews of relatives of suicide completers, a focus group discussion of health committee members and a survey to consulting nurses working at the primary health care level. RESULTS: Forty-seven suicides were recorded from 1999 to 2008: 37 (78.7%) males and 10 (21.3%) females, yielding rates of reported suicides that ranged from 0.89 to 6.54 per 100 000 inhabitants. The most frequently used suicide method was the ingestion of toxic agricultural chemicals (in 76.6% of cases). According to the relatives, the suicides were due to an ongoing chronic illness (31.9%), sexual and marital conflicts (25.5%), witchcraft (14.9%), financial problems (8.5%) or unknown cause (25.5%). In 25 (53.2%) cases, suicide victims exhibited symptoms suggestive of a mental disorder but only six of the suicide committers who presented behavioural symptoms sought health care. Only two of the 15 consulting nurses were able to cite at least three symptoms of depression and were aware that depression can lead to suicide. All of the nurses acknowledged that they had never received any specific training or supervision in mental health care. CONCLUSIONS: Suicides are not a rare event in rural settings in Cameroon. The health district capacity to provide quality mental care is almost insignificant. The integration of minimal mental health care services at the community and primary health care levels should be considered a priority in sub-Saharan Africa.

The interface between the national tuberculosis control programme and district hospitals in Cameroon: missed opportunities for strengthening the local health system -a multiple case study.

BACKGROUND: Tuberculosis remains a major public health problem in sub-Saharan Africa. District hospitals (DHs) play a central role in district-based health systems, and their relation with vertical programmes is very important. Studies on the impact of vertical programmes on DHs are rare. This study aims to fill this gap. Its purpose is to analyse the interaction between the National Tuberculosis Control Programme (NTCP) and DHs in Cameroon, especially its effects on the human resources, routine health information system (HIS) and technical capacity at the hospital level. METHODS: We used a multiple case study methodology. From the Adamaoua Region, we selected two DHs, one public and one faith-based. We collected qualitative and quantitative data through document reviews, semi-structured interviews with district and regional staff, and observations in the two DHs. RESULTS: The NTCP trained and supervised staff, designed and provided tuberculosis data collection and reporting tools, and provided anti-tuberculosis drugs, reagents and microscopes to DHs. However, these interventions were limited to the hospital units designated as Tuberculosis Diagnostic and Treatment Centres and to staff dedicated to tuberculosis control activities. The NTCP installed a parallel HIS that bypassed the District Health Services. The DH that performs well in terms of general hospital care and that is well managed was successful in tuberculosis control. Based on the available resources, the two hospitals adapt the organisation of tuberculosis control to their settings. The management teams in charge of the District Health Services are not involved in tuberculosis control. In our study, we identified several opportunities to strengthen the local health system that have been missed by the NTCP and the health system managers. CONCLUSION: Well-managed DHs perform better in terms of tuberculosis control than DHs that are not well managed. The analysis of the effects of the NTCP on the human resources, HIS and technical capacity of DHs indicates that the NTCP supports, rather than strengthens, the local health system. Moreover, there is potential for this support to be enhanced. Positive synergies between the NTCP and district health systems can be achieved if opportunities to strengthen the district health system are seized. The question remains, however, of why managers do not take advantage of the opportunities to strengthen the health system.

The interface between health systems and vertical programmes in Francophone Africa: the managers' perceptions.

OBJECTIVE: To explores the interface between vertical programmes (VPs) and general health services (GHS) in sub-Saharan Africa. METHODS: Using semi-structured interviews, we analysed the perceptions of a selection of experienced mid-level managers of health systems and of VP originating in francophone Africa on the nature and quality of this interface. RESULTS: The respondents acknowledged that VPs lead to both positive and negative effects on the functioning of GHS. The overall result, however, cannot be viewed as a simple summation of the positive effects possibly compensating for the negative ones. Indeed, some of the negative effects have a profound impact on the management and operation of the health care delivery system and may undermine the long-term institutional capacity of the general health systems. The quality and the nature of the interface between VP and GHS strongly vary in time, between settings and programmes. CONCLUSION: We argue for more systematic monitoring of the interface between VP and GHS, so as to identify and address, in a timely manner, significant disruptive effects and deficiencies in a perspective of systemic capacity building of health systems.

Hematuria and dysuria in the self-diagnosis of urinary schistosomiasis among school-children in Northern Cameroon.

The present study was designed to assess the value of self reported hematuria and dysuria in the diagnosis of urinary schistosomiasis at the individual level. A sample of 964 school children of grade 5 and 6 from 15 schools of the French speaking educational system in the Sudano-sahelian zone of northern Cameroon were submitted to a questionnaire related to hematuria and dysuria, and provided a urine sample each. The urine samples were processed using the dip stick and sedimentation methods, and the degree of microhematuria and oviuria determined. In all 964 questionnaires were collected, 843 urine samples examined for microhematuria and 871 for oviuria. The percentage of children reporting hematuria increased with the degree of microhematuria and the intensity of infection. Among the various indicators of urinary schistosome infection, microhematuria had the highest sensitivity (76%), followed by self reported hematuria or dysuria (65%), and dysuria (52%). The specificity was highest for self reported hematuria, and lowest for self reported hematuria or dysuria. The efficiency of self reported hematuria or dysuria increased with the intensity of infection and was highest (100%) for heavy infections (> 400 eggs/ml g urine). We advocate the use of self reported hematuria or dysuria for the assessment of S. haematobium at the individual level.

Some social determinants of urinary schistosomiasis in Northern Cameroon: implications for schistosomiasis control.

The present study was designed to assess the perceptions of hematuria, the most conspicuous sign of urinary schistosomiasis, in selected communities of the sudano-sahelian zone of Cameroon. Study questionnaires related to knowledge, beliefs and stigma associated with hematuria were administered to 964 pupils from 15 randomly selected schools. In order to ascertain children perceptions, we interviewed 143 adults living less than 2 kilometers from the target school. School children provided urine samples that were examined using the dip stick and sedimentation methods. Exposure to sun was the most reported cause of hematuria (53% adult and 62% children respondents), followed by drinking of dirty water (18% adults and 41% children). Only 15% of adult and 26% school children could relate hematuria to wading, a common means of exposure to urinary schistosomiasis. More than half of the school children stated that hematuria was a sign of disease (56%). Few pupils perceived hematuria to be a sign of strength (6%), while others related it to puberty (30%). Most pupils (80%) reported that hematuria was preventable while others (20% ) ascribed it to witchcraft. Pupils reported that hematuria could be cured in the hospital (65%), by the traditional healer (21%), or by reading Holy Scriptures (14%). Some respondents (35% of adult, and 40% of school children) stated that it was shameful to have blood in urine. Almost half of the adult respondents and 26% of the school children reported that hematuria was contagious. Boys and girls had similar levels of oviuria (OR=0.79 p>0.05), but boys were 4 times more likely to report hematuria (OR= 3.62, p<0.001). There was a poor understanding of the means of exposure, transmission and treatment of hematuria. Some aspects of the perceptions of hematuria reported herein corroborate with previous studies carried out in Cameroon, Niger, Ghana, Kenya and Tanzania. They should be considered, together with other socioeconomic and cultural determinants in the design of educational messages applicable to the study region.

Rapid assessment method for prevalence and intensity of Loa loa infection.

OBJECTIVE: To assess the validity of observations on eye worm and Calabar swellings for the rapid assessment of the prevalence and intensity of loiasis at the community level. METHOD: A total of 12895 individuals over the age of 15 years living in 102 communities in Cameroon and Nigeria took part in the study. A standardized questionnaire was administered to participants from whom finger-prick blood samples were collected and examined for Loa loa microfilariae. Rapid assessments of the prevalence and intensity of loiasis were made on the basis of a history of eye worm or Calabar swellings. FINDINGS: There was a strong correlation between the indices of the rapid assessment procedures and the parasitological indices of L. loa endemicity. The rapid assessment indices were effective in diagnosing high-risk communities (sensitivity 94-100%; specificity 66-92%). The highest sensitivity (100%) and specificity (92%) were obtained with a rapid assessment procedure based on a history of eye worm lasting 1-7 days together with confirmation by the guided recognition of a photograph of adult L. loa in the eye. CONCLUSION: Rapid assessment of the prevalence and intensity of loiasis at the community level can be achieved using a procedure based on the history of eye worm lasting 1-7 days together with confirmation by the guided recognition of a photograph of an adult L. loa in the eye.