Africa Health Systems Initiative Support to African Research Partnerships

PROGRAM RESULTS

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The Global Health Research Initiative

The Global Health Research Initiative (GHRI) is a partnership of Canadian government agencies with mandates spanning health, research and international development.

GHRI brings researchers and decision-makers together to tackle complex problems that have an impact on the health of people and communities around the world.

GHRI funds a wide range of global health research, capacity building and knowledge translation activities through several programs.

About this booklet

This booklet presents projects carried out as part of GHRI’s Africa Health Systems Initiative ~ Support to African Research Partnerships program. The program supported ten African-led research teams investigating ways to strengthen health systems in sub-Saharan Africa.

For more detailed research results, consult our supplements:

“Addressing the human resources for health crisis through task-shifting and retention: results from the Africa Health Systems Initiative’s research component” Human Resources for Health 2014.

“Uptake and impact of research for evidence-based practice: lessons from the Africa Health Systems Initiative’s research component” BMC Health Services Research 2014.

In partnership for health worldwide

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To learn more about the Global Health Research Initiative,

visit GHRI.CA

PROGRAM RESULTSAfrica Health Systems Initiative ~ Support

to African Research Partnerships

Table of Contents

Introduction 4

Project Results

Results of ten projects based in Burkina Faso, Kenya, 10 Malawi, Mali, Tanzania, Uganda and Zambia

Feature Stories

A role for telemedicine in Mali 22

Developing the PALM Plus diagnostic tool for Malawi 26

Making mental health services in Kenya accessible 30 through innovative task-shifting

Sources 34

Teams 36

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Strengthening health systems

In Africa, particularly across the sub-Saharan region, people and their communities continue to face a heavy burden of preventable and treatable illnesses despite the existence of effective tools, technologies and practices for prevention and treatment. One of the principal reasons for this are weak health systems.

Encompassing “all organizations, people and actions whose primary intent is to promote, restore or maintain health,” health systems are vital to human well-being. Health systems in sub-Saharan Africa face a number of major challenges, including critical human resource shortages and persistent inequities in access to health care.

In recent years, organizations involved in efforts to improve health in low- and middle-income countries have been moving away from disease-specific approaches to ones that view health problems and potential solutions in the context of health systems. According to the World Health Organization (WHO), “strengthening health systems and making them more equitable have been recognized as key strategies for fighting poverty and fostering development.”

The projects described in this booklet are all contributing to this important effort.

Source: WHO. 2005.

“A good health system improves people’s lives tangibly every day.”

Source: WHO. 2005.

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On the importance of health systems research

In her introductory remarks to Systems Thinking for Health Systems Strengthening (2009), the flagship report of the Alliance for Health Policy and Systems Research, WHO Director-General Dr. Margaret Chan underscores the importance of efforts to under-stand health systems in all their real-world complexity.

The report highlights the fact that many health systems, in particular those in low- and middle-income countries, “simply lack the capacity to measure or understand their own weaknesses and constraints, which effectively leaves policy-makers without scientifically sound ideas of what they can and should actually strengthen.” The report stresses that in these circumstances, “even the very simplest interventions often fail to achieve their goals” and that this may have less to do with the quality of the intervention itself than with “the often unpredictable behaviour of the system around it.”

Making a strong case for health systems research, the report’s authors argue that “as investments in health are expanding in low- and middle-income countries, and as funders increasingly support broader initiatives for health systems strengthening, we need to know not only what works but what works for whom and under what circumstances.” According to Dr. Chan, this context-rich research, and the “systems thinking” that informs it, are vital to the success of efforts “to strengthen systems, increase coverage, and improve health” around the world.

Source: de Savigny & Adam. 2009.

“We must know the health system in order to strengthen it.”

Source: de Savigny & Adam. 2009.

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The Africa Health Systems Initiative

Foreign Affairs, Trade and Development Canada’s (DFATD) Africa Health Systems Initiative (AHSI) aims to improve health outcomes and make progress toward the United Nations Millennium Development Goals (MDGs), particularly those related to child health (Goal 4) and maternal health (Goal 5).

AHSI provides support to train, equip and deploy new and existing health workers in Africa to make health care more accessible to the most vulnerable, particularly mothers and children. The majority of AHSI funding supports bilateral, country-led efforts in sub-Saharan Africa.

AHSI complements DFATD’s regular health programming in three areas: strengthening frontline health workers, improving health information systems—with a focus on better accountability and monitoring—and strengthening equity in health service delivery.

AHSI supported research on health systems issues through the Global Health Research Initiative’s Africa Health Systems Initiative ~ Support to African Research Partnerships program.

Source: CIDA. 2010.

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Africa Health Systems Initiative ~ Support to African Research Partnerships Program (2008-2014)

GHRI’s Africa Health Systems Initiative ~ Support to African Research Partnerships program supported ten African-led research teams investigating innovative ways to strengthen health systems in sub-Saharan Africa.

Drawing on a range of knowledge and experience, the teams funded by this Global Health Research Initiative program focused on two main areas. The first area of focus was the recruitment and retention of health workers and the delegation of some tasks to less specialized health workers, an approach known as ‘task-shifting’.* The second area of focus was the role of health information systems and management in efforts to make health care more accessible and focused on the population’s needs.

The ten teams supported by this program worked to connect research, policy and action to improve health decision-making and programming in the sub-Saharan region. They paid particular attention to the needs of disadvantaged segments of the population. The teams were based in Burkina Faso, Kenya, Malawi, Mali, Tanzania, Uganda and Zambia. They were led jointly by an African researcher and an African decision-maker and included several Canadian researchers.

* According to the World Health Organization, task-shifting is “the name given to a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers.” (WHO, 2008)

4%A 2011 survey found that only 4% of health policy and systems researchcarried out in low- and middle-income countries over the last decade was led by researchers fromthose countries.

Source: Adam et al. 2011.

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~ PROJECT RESULTS ~

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Burkina Faso

Kenya

Malawi

Mali

Tanzania

Zambia

Uganda

Project teams based in:

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Assessing the impact of regionalization of health care worker recruitment in Burkina Faso on national and regional distribution of health care human resources Burkina Faso ~ CA$352,600 (2009-2013)

Burkina Faso’s health system is burdened by critical human resource shortages and an inequitable distribution of existing health care personnel. Shortages are especially acute in rural and remote areas of the country, where recruiting and retaining health care providers is particularly challenging.

This team assessed the impact of government efforts to regionalize health personnel recruitment on the distribution of health workers throughout Burkina Faso. Researchers noted that regionalized recruitment led to a significant increase both in the numbers of nurses and midwives in remote areas since 2006 and in the ratio of health workers to population in rural areas from 2002 to 2009. The rate of retention in remote areas is also positive, with over 90% staying in the regions they were recruted to. The policy did have some negative effects on performance; regional staff were more likely to be absent and felt some injustice compared to health workers in urban areas. However, a reduction in inequity of health worker distribution between the urban and rural zones was demonstrated.

The study has produced evidence on the regionalized recruitment policy, which is as-sisting decision-makers with evidence-based planning. The research also contributed to a review of the conditions for regionalized health workers, whose obligation to stay in the region they were recruited to has been decreased to six years.

7.3Number of nursing and midwifery personnel per 10,000 people in Burkina Faso in 2008.

100.5 Number of nursing and midwifery personnel per 10,000 people in Canada in 2008.

Source: WHO. 2011a.

Burkina Faso

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Linking a community-based health information system and an institutional health information system to make decision-making more effective

Kenya ~ CA$320,570 (2009-2013)

This project tested an approach that links health information collected at the community level to health facility information systems. The team piloted the approach in three different types of communities in Kenya: rural villages, peri-urban settlements and among nomadic herders.

The approach was built on local health registers prepared and updated every six months by community health workers. These registers are linked to the institutional health information system. This system enables service providers to compare health data, and will better support decision-making, planning, and resource allocation.

“Community health workers can accurately and reliably collect household data which can be used for health decisions and actions, especially in resource poor settings”.*

Kenya

The team showed that Kenya’s Community Health Strategy (CHS) is effective in improving utilization of health interventions. CHS is cost-effective; saving a life through maternal health services using this approach costs less than one tenth compared to without CHS. The study suggests that task shifting is accepted by communities, service providers, and managers but recognition, identification, and regulation is required. The team also demonstrated that community-based workers are effective and collect accurate data and can be used for dialogue, decisions, and actions for health improvement.

*Source: Otieno et al. 2012.

Kakamega County Health Management Team members discussing findings presentated by Charles Wafula (Photo credit: Joseph Video Production Inc)

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Investigating the impact and reproducibility of Healthy Child Uganda, a program that mobilizes village health volunteers to provide vital child health services in southwest Uganda

Uganda ~ CA$336,200 (2009-2013)

Children in sub-Saharan Africa continue to die from diarrhoea, acute respiratory illness and malaria despite the existence of inexpensive and highly effective treat-ments. Part of the reason for this is a shortage of trained rural health care providers.

86%Percentage of Healthy Child Uganda volunteers who have been with the program for more than 18 months.*

Uganda

Healthy Child Uganda (HCU) trained almost 200 community health workers (CHW) to provide treatment for fever (malaria), diarrhoea, and acute respiratory illness to children in their home villages. The approach is called iCCM, or ‘integrated community case management’. The team showed that iCCM significantly increased the proportion of children receiving treatment. The proportion of children treated with antibiotics for pneumonia doubled, compared with controls. A mobile phone application also strengthened CHW reporting and links with health facilities.

This research demonstrates that CHWs’ health promotion and curative roles need to be explored and defined. The lessons learned will help Ugandan and other sub-Saharan African policymakers as they plan for iCCM scale-up.

*Source: Brenner et al. 2011.A child in southwestern Uganda receives treatment from a community health worker (Photo credit: Ilia Horsburgh)

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Investigating the potential of mobile phones to prevent mother-to-child transmission of HIV in Kenya

Kenya ~ CA$341,100 (2010-2013)

Mobile phones are spreading rapidly in Africa. In Kenya, 92% of men and 86% of women are regular mobile phone users.* A study published in 2010 reported that text messages improved adherence to HIV antiretroviral therapy.† This team, which includes several researchers from the 2010 study, investigated whether text messages could help prevent mother-to-child transmission of HIV.‡ Text messages were used to remind women to take prescribed medications, and improve care for both mothers and infants after birth.

The team found no differences (number of prenatal clinic appointments and Nevirapine use) between pregnant, HIV-positive women who received the text messages and those who did not. However, some women felt more supported during their pregnancy due to the messages. Results also highlighted other challenges to PMTCT, including late presentation for first prenatal visit, care accessed at multiple sites, low disclosure rates and poor screening for TB. Health workers thought text messages could be used to improve service delivery and client satisfaction, provide appointment reminders, and improve adherence, although they cautioned about stigma and missing the most vulnerable who may not read or have access to a phone. These results have important policy implications in highlighting issues to be addressed as well as limitations of interventions to do so.

Sources: *AudienceScapes 2010; † Lester et al. 2010; ‡ Prevention of mother-to-child transmission of HIV (PMTCT) “provides drugs, counselling and psychological support to help mothers safeguard their infants against the virus.” (UNICEF, 2011)

47%Estimated percentageof pregnant women living with HIV in sub-Saharan Africa not receiving treatment to prevent transmission of HIV to their child.

Source: WHO. 2011b.

370,000Estimated number of children infected with HIV through mother-to-child transmission in 2009.

Source: UNAIDS. 2010.

Kenya

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Assessing the productivity and quality of eye care services to assist health human resource decision-making in Eastern Africa

Kenya, Tanzania and Malawi ~ CA$316,100 (2009-2013)

A joint effort of the World Health Organization and the International Agency for the Prevention of Blindness, Vision 2020 seeks to eliminate avoidable blindness* globally by the year 2020. One promising strategy to achieve this goal is task-shifting, whereby health care workers are trained to perform cataract surgery and other primary eye care services typically provided by physicians.

The project team investigated the impact of task-shifting on the productivity and retention of eye care personnel. In addition, the team evaluated the quality of eye care services in Eastern Africa following the implementation of task-shifting.

The team found that, while task shifting may be effective for some aspects of eye health services, it has limitations in dealing with the major causes of visual impairment. These findings have already encouraged some questioning and redefinition of the concept of primary eye care.

* Avoidable blindness is defined as “blindness that can be either treated or prevented by known, cost-effective means.” (Vision 2020, 2011)

285 millionNumber of people world-wide who are visually impaired. Of these, 90%live in developing countries.

80%Percentage of global visual impairment that can be prevented, treated or cured.

Source: Vision 2020. 2011.

Tanzania Kenya Malawi

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Strengthening human resources for health through simplified clinical tools and educational outreach

Malawi ~ CA$233,300 (2009-2013)

While an estimated 6.6 million people in low- and middle-income countries are receiving antiretroviral therapy (ART) for HIV, the majority are still without treatment.* Providing treatment close to where people live is crucial to expanding ART coverage, but weak health systems remain a significant barrier.

The team piloted the PALM Plus† tool in health centres in Zomba District. This tool provides symptom-based, user-friendly guidelines for disease management of TB, malaria, asthma, HIV/AIDS and other sexually transmitted infections. Using an approach known as a cluster-randomized trial, health centres were randomly assigned to two groups, one of which used the PALM Plus tool. The study compared the two groups to determine whether there were any differences in staff retention and satisfaction, as well as patient outcomes in HIV/AIDS, TB, malaria and other primary care conditions.

The results showed that health workers using the PALM Plus tool were more likely to remain in their original place of work. On the other hand, overall job satisfaction and patient outcomes were not significantly different between the groups.

* WHO. 2011d; † PALM Plus: ‘Practical Approach to Lung Health and HIV/AIDS in Malawi’.

Malawi

219%Percentage increase in appropriate referrals for severely ill patients in South Africa using the PALSA-PLUS tool.

Source: Fairall et al. 2005.

FEATURE STORY on page 26

PALM Plus tool

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Understanding how information and communication technologies can increase access to health professionals in francophone Africa

Mali ~ CA$327,800 (2009-2013)

In Mali, a critical shortage of health personnel is a key factor contributing to health disparities between those living in rural and urban areas. This project explored the role that telemedicine can play in improving recruitment and retention of health personnel and increasing access to quality care in rural areas.

The study demonstrated a positive impact on quality of care and services, increased consultations, and reduction in patient spending. Online simulation sessions were shown to be relevant and effective, enabling further learning and reducing errors

344 Number of specialists providing care in Mali’s urban centres.

0 Number of specialists providing care in Mali’s rural areas.

Source: WHO, GHWA & EU. 2009.

FEATURE STORY on page 22

Mali

in medical decision-making in remote areas. This project in-creased health worker motivation and increased patient confidence.

Interest from other countries led to new sites in Senegal, Burkina Faso, Guinea, and Bolivia, among others. The team is now working with Mali’s health authorities to scale up the project at the national level.

A pregnant woman undergoes an ultrasound by Dr. Florent Dacko at the Bankass district hospital in rural Mali (Photo credit: Mali telemedicine team)

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Investigating innovative approaches to task-shifting in mental health in Kenya

Kenya ~ CA$281,700 (2010-2013)

A study carried out by the Africa Mental Health Foundation (AMHF) to determine the availability and distribution of psychiatrists in Kenya found that most of the country’s psychiatrists were located in Nairobi and other urban centres. Given this reality, the authors argue, “If Kenya and other similar developing countries in Africa are to achieve realistic mental health service delivery in the foreseeable future, alternative non-specialist training in mental health is required.”

Taking an innovative approach to the problem, this team found that health workers, expert patients, faith healers and traditional healers can be trained to detect signs and symptoms of mental illness, and refer clients. The project’s activities increased referral, self referral, treatment, and follow-up of clients with mental disorders. This is contributing to a solution for providing effective mental health services at the community level, increasing access to mental health services. The team is continuing their work in the field and engaging with Kenyan decision-makers

Source: Ndetei et al. 2007.

7,344%Percentage increase in the number of psychiatrists required in Kenya for the country to match the psychiatrist-to-population ratio found in the United States in 2002.

Source: Ndetei et al. 2007.

FEATURE STORY on page 30

Kenya

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1:30,000Surgeon-to-population ratio in Uganda.

95% Percentage of Ugandan surgeons practicing in urban areas in 2011.

Source: WHO. 2011c.

Uganda

Developing a program to train physicians and health officers to provide emergency and essential surgical services in Uganda

Uganda ~ CA$344,500 (2009-2013)

“While infectious diseases remain the major killers in low- and middle-income countries,” note Weiser and colleagues, “traumatic injuries, complications of child-birth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries.” In Uganda, most surgical care is provided by physicians and health officers, rather than by trained surgical specialists, who are in short supply in the country.

This team developed a program to train physicians and health officers to provide emergency and essential surgical services. Trainings for 24 health units took place and specialist surgeons offered practical surgical mentorship to 48 medical and clini-cal officers. They can now confidently provide better quality surgical services.

The team is now engaging with policy makers to try to foster the development of a policy to regulate the conduct of efforts to empower non surgeon physicians and non physician clinicians to provide these surgical services in a country where the number of specialist surgeons is so limited. If successful, this will lead to increased access and improved quality of surgical services in Uganda.

Source: Weiser et al. 2008.

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Evaluating the effectiveness of strategies being implemented in rural Zambia to increase availability of health workers

Zambia ~ CA$333,800 (2010-2013)

The study’s purpose was two-fold: to evaluate the effectiveness of existing recruitment and retention schemes for health workers in rural Zambia, and to assess the alignment of the competencies of Zambia’s rural health workforce with the population’s needs.

Though 19 retention and recruitment schemes were identified, their impacts appear to have been minimal and insufficient to address the severe staff shortages in rural areas. While the competencies of the health workforces in Chibombo and Gwembe districts were mostly aligned with treating their leading health conditions – HIV/

Zambia

57 Countries including Zambia “experiencing a critical deficit in the health workforce” in 2010. Two thirds are in sub-Saharan Africa.*

AIDS and malaria, respectively – substantial gaps were found in laboratory testing and diagnostic imaging, physical exams and histories, and diagnosing.

Participants, policymakers, researchers, and non-governmental organizations discussed the implications for Zambia with a view toward expanding on the study analyses. Targeted, on-site in-service training for staff may be the best approach to address the competency-service gap in the short term. In the longer term, in-creased collaboration between the Ministry of Health and other sectors, such as finance and education, is required to improve the health human resources situation in rural Zambia.

*Source: WHO. 2010. Gail Tomblin Murphy, Fastone Goma, Adrian MacKenzie and Mutale Chimutete at Gwembe District Hospital (Photo credit: Derrick Hamavhwa)

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~ FEATURE STORIES ~

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Making mental health services in Kenya accessible through

innovative task-shifting

p. 30

Kenya

Developing the PALM Plus diagnostic tool for Malawi

p. 26

Malawi

A role for telemedicine in Mali

p. 22

Mali

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A Role for Telemedicine in Mali

While pursuing studies at Bamako University’s Medical School in Mali, Cheick Oumar Bagayoko and his fellow medical students often worried about the prospect of being sent into Mali’s sparsely populated interior after graduation. It was widely known that once a doctor was sent to work in a rural area, a lack of access to continuing education and a more general experience of isolation meant that they inevitably began to lose the knowledge they had gained in medical school.

Dr. Bagayoko’s concerns as a medical student point to a wider problem for Mali’s health system, one that has a fundamental impact on its ability to provide services and care to people living in rural and remote areas of the country.

A serious shortage in health human resources is a key factor contributing to health inequalities between rural and urban areas in Mali. Rural residents, in general, have less access to health services and limited to no access to more complex diagnostic equipment. As a case in point, cardiologists are rarely found outside Bamako, Mali’s capital. Efforts to increase recruitment and retention of health personnel in rural areas face several challenges, including isolation and a lack of incentives, while patients take on a heavy financial burden and travel to urban areas for care and treatment.

As internet access began to increase in Bamako, Dr. Bagayoko became interested in the possibility of using the internet as a relatively inexpensive way to improve access to health care in Mali.

“I am convinced that these tools will enable physicians to remain on site in rural areas.”

Dr. Cheick Oumar BagayokoProject Principal Investigator

Source: Interview with Dr. Bagayoko, GHRI. 2010.

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When Dr. Bagayoko chose telemedicine as the focus for his doctoral thesis, he knew it was a risky choice. Telemedicine projects were rarely seen in low- and middle-income countries, and in a country with slow and sporadic coverage, the choice to focus on telemedicine seemed impractical. Despite this, one faculty member, Professor Abdel Kader Traoré, encouraged Dr. Bagayoko to pursue the idea and agreed to become his thesis advisor.

From the Swiss Alps to remote Mali

Dr. Bagayoko looked outside Mali to find someone with experience in developing telemedicine. He contacted Dr. Antoine Geissbuhler, a professor at the University of Geneva, to ask him to be on his thesis committee. Dr. Geissbuhler agreed, based on a shared interest in medical imaging, e-health and new medical applications for rapidly advancing information and communication technologies.

While in Switzerland, Dr. Bagayoko came across mobile technology used for ski rescues in the Alps. The portable technology allowed first responders to carry out diagnostic tests on the ski hill, far from the hospital. Dr. Bagayoko saw that the technology might be used to perform diagnostic tests on patients in rural Mali, in particular electrocardiograms (ECGs) and ultrasounds. The idea was to have a specialist based in the capital assist rural doctors in diagnosing patients.

The project evolved into a web-based network where physicians seeking training on a particular subject were able to access an online course on the subject provided by a specialist. Physicians practicing in remote communities now had access to training opportunities, and colleagues, connected virtually, to assist with complex cases. It was not simply a question of accessing technical information; there is also an

Dr. Kassim Diabaté, based at the Dioila District Hospital in rual Mali, conducts an abdominal ultrasound during a training session in Bamako.

Photo credit: Mali Telemedicine Team

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Dr. Mamadou Salia Diarra gives an online lecture on neurosurgery on the RAFT network.

Photo credit: RAFT. 2011.

important human factor. By participating in the network, doctors posted in rural and remote communities are able to interact with colleagues, located hundreds of kilometres away. This contact went a long way to alleviate the sense of isolation that marks the professional life of a rural doctor in Mali.

The success and growth of this network began to draw the attention of neighbouring countries interested in participating. With assistance from the Geneva University Hospitals and the Fonds de solidarité internationale de Genève, Drs. Bagayoko and Geissbuhler created the Réseau en Afrique francophone pour la télémédecine (RAFT) in 2001. The network has since expanded to include 28 countries. With the support of the World Health Organization, the network now also provides dozens of English lan-guage courses online.

Drs. Bagayoko and Kader continued their collaboration as co-principal investigators on this GHRI-funded project. The grant program required that each team be co-led by a researcher and a decision-maker. Professor Kader, who is director of the Centre national d’appui à la lutte contre la maladie in Bamako, was the decision-maker.

The team tested the effectiveness of distance medical training and telemedicine services, including transmission of medical images for cardiac and obstetric care and support to rural medical personnel in the diagnosis and treatment of patients. The goal was to determine whether this application of information and communication technologies would contribute to raise levels of recruitment and retention of health personnel and improve access to quality care in rural areas of Mali. Dr. Bagayoko, Professor Kader and their team are contributing to wider efforts to develop an organi-zational model for telemedicine services that is effective and responsive to the various local contexts in which they are implemented.

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A pregnant woman undergoes an ultrasound by Dr. Sow at the Kolokani district hospital in rural Mali (Photo credit: Mali Telemedicine Team)

“We realized that these tools may not only help to avoid unnecessary evacuations, but also to train health care professionals on site.”

Dr. Cheick Oumar BagayokoProject Principal Investigator

Source: Interview with Dr. Bagayoko, GHRI. 2010.

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Developing the Palm Plus diagnostic tool for Malawi

Like other countries in sub-Saharan Africa, Malawi’s health system suffers from an acute shortage of health care workers. While some efforts have focused on increasing the number of health workers, another strategy has sought to provide health care workers with the training and tools to use their time more effectively.

Due to the shortage of health care workers, existing staff are overburdened, which reduces access to quality health services. In this environment, inefficient time management is often a system-wide problem that staff have little capacity to address on their own. Tools that assist health care workers in working more effectively offer a practical solution that has the potential to reduce the burden on health care workers, thereby increasing the quality of patient services. This also has the potential to contribute to sustainable improvements in the health system.

In sub-Saharan Africa, existing pressures on health services are compounded by the HIV epidemic. Since the arrival of antiretrovirals for HIV/AIDS, the major concern has been getting treatment to those in need. Initially, the international community focused on efforts to reduce the cost of treatment, which was prohibitively expensive for the vast majority of people living with HIV/AIDS in Africa.

While the arrival of generic antiretrovirals significantly reduced the cost of treatment, the limiting factor was, and remains, the health system’s ability to provide timely and accessible treatment to people where they live. There have been advances in this area throughout the continent but it remains a problem due to a lack of infrastructure and staff, especially in rural areas.

The PALM Plus diagnostic tool

Photo credit: Dignitas International

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Clement Khondiwa leading a PALM Plus training session at the Police Hospital in Zomba District (Photo credit: Dignitas International)

“The evidence from South Africa shows that this kind of tool can improve clinical care and have a dramatic impact on staff satisfaction.”

Dr. Michael Schull Project co-investigator

Source: Interview with Dr. Michael

Schull, GHRI. 2010.

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From South Africa to Malawi

In the past several years, Malawi’s Ministry of Health has expanded HIV treatment to 16 rural centres in Zomba District in an effort to make treatment more accessible to rural residents. However, decentralizing services has the potential to strain an already overburdened rural health system. REACH Trust*, an independent Malawian research organization, and Dignitas International, a Canadian non-governmental organization, have been working with the Ministry to find ways to address the problem.

With ARV treatment, people are living with HIV/AIDS for longer periods of time. This means that there is an increased likelihood of resistance and co-infections—such as other sexually transmitted infections (STIs), tuberculosis or malaria—which can complicate treatment. In a district like Zomba, this translates into health facilities with more patients experiencing more complex health problems. Not only do health care personnel have less time to devote to individual patients, but they are faced with HIV cases that are increasingly difficult to treat and require more specific training. In this context, there is a growing need for a simplified decision-making tool to assist health care workers in making diagnostic and treatment decisions.

Developed for use in South Africa, the PALSA-PLUS diagnostic tool has been successful in improving care, treatment, referral and tuberculosis case detection. This Malawi-based team partnered with the developers of PALSA-PLUS to adapt the tool for use in Malawi. The partnership led to the creation of the PALM Plus, Simplified Tools and Training.

* Research on Equity and Community Health (REACH)

Malawi

PALSA-PLUS Practical Approach to Lung Health and HIV/AIDS in South Africa

PALM Plus Practical Approach to Lung Health and HIV/AIDS in Malawi

Zomba District

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Dr. Michael Schull providing training on PALM Plus to a nurse at the Pirimiti Community Hospital in Zomba District (Photo credit: Dignitas International)

“When you start talking about decentralization, you run up against a weak health system. The major weakness is not that the roof leaks, it’s the fact that there are just not enough staff. So the question is, how do you actually support the staff who are there?”

Dr. Michael Schull Project co-investigator

Source: Interview with Dr. Michael Schull, GHRI. 2010.

The team piloted the PALM Plus tool in health centres in the Zomba District. Using an approach known as a cluster-randomized trial, health centres were randomly assigned to two groups, one of which used the PALM Plus tool. The study compared the two groups to determine whether there were differences in staff retention and satisfaction, as well as patient outcomes in HIV/AIDS, TB, malaria and other primary care conditions.

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Making mental health services accessible through innovative task-shifting

For the general population living in the sub-Saharan region, psychiatric services are not accessible. Those suffering from mental health issues will often live their lives without a diagnosis or treatment.

Professor David Ndetei, a psychiatrist and professor at the University of Nairobi, has trained most of the psychiatrists currently working in Kenya. His efforts have helped to give Kenya the second highest psychiatrist-to-population ratio in the region after South Africa. Yet Prof. Ndetei realized that mental health services were not accessible to most Kenyans, particularly the most vulnerable.

In 2004, Prof. Ndetei founded the Africa Mental Health Foundation (AMHF) to address this gap in services. Since then, AMHF has been active in mentoring mental health researchers in order to develop their capacity to carry out high quality research on issues of relevance to the region. With the support of the foundation, a number of students mentored by Prof. Ndetei have completed doctoral programs and research fellowships and conducted their own studies in mental health. Dr. Victoria Mutiso is one exam-ple. Dr. Mutiso was a co-principal investigator on this GHRI grant.

Since training a sufficient number of psychiatrists was not feasible in the short term, the AMHF team began investigating innovative ways to make mental health services more accessible to the average Kenyan.

Victoria MutisoAMHFProject Principal Investigator

Photo credit: E. Lanktree. 2011.

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90%Percentage of people with mental disorders living in low-income countries who do not have access to mental health services at the primary-care level.

Source: Interview with Prof. David Ndetei, GHRI. 2009; AMHF. 2011.

AMHF and Ngwata Health Centre staff in Ngwata, Kenya (Photo credit: AMHF)

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1:500,000Estimated number of psychiatrists-to-population in Kenya.

Source: Interview with Prof. David Ndetei, GHRI. 2009; AMHF. 2011.

1:8,462Ratio of psychiatrists-to-population in Canada, slightly above the ratio recommended by the Canadian Psychiatric Association (1:8,400).

Source: Canadian Psychiatric Association. 2012; Statistics Canada. 2012.

In the absence of professionally trained mental health practitioners, Kenyans have sought out other options to alleviate the psychological or physical symptoms of mental illness. Whether faith healers, traditional healers, community based health workers or health facility personnel, AMHF saw these actors as potential points of access to reach people suffering from mental illness, since they are already known and accepted by the community.

With the support of this GHRI grant, AMHF staff investigated whether training these resource persons was an effective way to expand mental health service coverage to vulnerable populations across the country. The team trained members of these groups to perform basic psychiatric tasks, such as identifying symptoms, diagnosing conditions, and most importantly, referring patients to mental health services.

The team carried out the research in a rural area and in an informal urban settlement to determine whether this was an appropriate strategy for mental health service delivery in these contexts. The work involved both intervention and control groups at each site to allow the team to compare results.

This research could have an important impact on the health and quality of life of those suffering from mental illness in Kenya. With some psychiatric tasks shifted to community-based health workers, faith healers, traditional healers, nurses and clinical officers (who are present throughout the country), the service coverage has the potential to increase significantly. This research is of value not only to Kenya, but also to other low-income countries seeking to increase access to mental health services.

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Patients, caregivers and other community members attending an educational meeting at the Ngwata Health Centre in Ngwata, Kenya (Photo credit: AMHF)

Vision : “To be the mental health centre of excellence in Africa for research, training, knowledge translation, and advocacy.”

Africa Mental Health Foundation

Source: AMHF. 2011.

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AudienceScapes. 2010. “Kenya: Mobile communications.” Accessed February 2, 2012 from http://audiencescapes.org/coun-try-profiles/kenya/media-and-communication-overview/mobile-communications/mobile-communications-

Brenner JL, Kabakyenga J, Kyomuhangi T, Wotton KA, Pim C, et al. 2011. Can volunteer community health workers decrease child morbidity and mortality in Southwestern Uganda? An impact evaluation. PLoS ONE 6(12):e27997. doi:10.1371/journal.pone.0027997.

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Canadian Psychiatric Association. 2012. “How many psychiatrists are there in Canada?” Accessed February 2, 2012 from: http://www.cpa-apc.org/browse/documents/19. Calculation based on 4,100 psychiatrists for a population of 34,694,560 Canadians (see Statistics Canada, 2012).

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Ndetei DM, Ongecha FA, Mutiso V, Kuria M, Khasakhala LI, et al. 2007. The challenges of human resources in mental health in Kenya. South African Psychiatry Review. 1033-36.

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Team members

“A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently.”

Source: WHO. 2012.

“Samuel Maling*, Mbarara University of Science and Technology (UG); Celestine Barigye†, Bushenyi Dis-trict Health Services (UG), Jerome Kabakyenga and Moses Ntaro, Mbarara University of Science and Tech-nology (UG); Noni MacDonald, Dalhousie University (CA); Carolyn Pim, Jenn Brenner and Nalini Singhal, University of Calgary (CA); Amooti Kaguna and Eldard Mabumba, Mbarara District Health Services (UG); Kathryn Wotton, University of British Columbia (CA); Jesca Nsungwa-Sabiiti, Ministry of Health (UG).

Dan Kaseje*, Great Lakes University of Kisumu (KE); John Odondi†, Ministry of Public Health and Sani-tation (KE), Nancy Edwards, University of Ottawa (CA); Violet Naanyu and Mabel Nangami, Moi Univer-sity (KE); Violet Kimani, University of Nairobi (KE); George Otieno, Kenyatta University (KE).

Edson Eliah* and Paul Courtright*, Kilimanjaro Centre for Community Ophthalmology (TZ); Michael Gichangi†, Ministry of Health (KE), Susan Lewallen, Kilimanjaro Centre for Community Ophthalmology (TZ); Ken Bassett, University of British Columbia (CA); Edward Kirumbi, Ministry of Health (TZ); Amir Bedri, International Agency for the Prevention of Blindness (ET); Khumbo Kalua, Queen Elizabeth Central Hospital (MW); Marvice Okwen, Kilimanjaro Christian Medical College, Tumaini University (TZ); Mani-sha Tharaney, Tulane University (US).

Bertha Simwaka*, REACH Trust Malawi (MW); Damson Kathyola†, Malawi Ministry of Health (MW), Michael Schull and Alexandra Martiniuk, Sunnybrook Health Sciences Centre (CA); Eric Bateman and Lara Fairall, University of Cape Town Lung Institute (ZA); Hastings Banda, REACH Trust Malawi (MW); Martha Mondiwa, Nurses and Midwives Council of Malawi (MW); Sumeet Sodhi, Dignitas International (CA); Merrick Zwarenstein, Centre for Health Services Sciences, University of Toronto (CA); Ibrahim Idana, Ministry of Health (MW); Martias Joshua, Zomba Central Hospital (MW).

Joshua Kimani*, University of Nairobi (KE); Peter Cherutich†, Ministry of Health (KE), Richard Lester, University of Manitoba (CA) and University of Nairobi (KE); Charles Wanyonyi, Pumwani Maternity Hospital (KE); Lisa Avery, Shamir Mukhi and Larry Gelmon, University of Manitoba (CA); Benson Est-ambale, University of Nairobi Institute of Tropical & Infectious Diseases (KE); Samson Barasa and Antony Kariri, University of Nairobi (KE).

Blaise Sondo*, Institut de recherche en sciences de la santé (BF); Adama Traoré†, Ministère de la santé (BF), Pierre Fournier and Valéry Ridde, Université de Montréal (CA); Seni Kouanda and Baya Banza, Insti-tut supérieur des sciences de la population (BF); Sié Roger Hien, Assemblée Nationale (BF); Abel Bicaba, Société d’études et de la recherche en santé publique (BF); Benjamin Sanon and Romaric Somé, Ministère de la santé (BF); Gilles Dussault, Institute of Hygiene and Tropical Medicine (PT).

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p. 11

p. 12

p. 13

p. 14

p. 15

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“A good health system delivers quality services to all people, when and where they need them.”

Source: WHO. 2005.

“

Fastone Goma*, School of Medicine, University of Zambia (ZM); Miriam Libetwa†, Ministry of Health (ZM), Selestine Nzala, School of Medicine, University of Zambia (ZM), Priscilla Chisha-Kalonde, Chi-bombo District Health Management Team (ZM); Clara Mbwili-Muleya, Lusaka District Health Manage-ment Team (ZM); Moses Lungu, Lusaka Equity Gauge (ZM); Mercy Mbewe, National Institute for Public Administration (ZM); Jennifer Nyoni, WHO Regional Office for Africa (CG); Mutale Chimutete, Gwembe District Health Management Team (ZM); Mwinga Hamavhwa, Zambia Forum for Health Research—ZAMFOHR (ZM); Gail Tomblin Murphy, Adrian MacKenzie and Janet Rigby, Dalhousie University (CA); Annette Ryan, IWK Health Centre and Dalhousie University (CA); Rob Alder, University of Western On-tario (CA); Stephen Tomblin, Memorial Univeristy (CA); Christine Heidebrecht, Canadian Coalition for Global Health Research, and St. Michael’s Hospital (CA).

Samuel Luboga*, Makerere University (UG); Francis Runumi Mwesigye†, Commissioner of Health Services Planning, Ministry of Health (UG), Timothy Musila, Ministry of Health (UG); Butch de Castro, University of Washington (US). All other co-investigators are based at Makerere University (UG): Moses Galukande and Samuel Kaggwa, Department of Surgery; Patrick Sekimpi, Orthopedics; Achilles Katamba, Health Services Research; Kakaire Othman, Obstetrics and Gynecology; Ian Munabi, Anatomy, Edward Mills, University of Ottawa (CA); Geoff Blair, University of British Columbia (CA); Amy Hagopian and Scott Barnhart, University of Washington (US).

Cheick Oumar Bagayoko*, Centre d’expertise et de recherche en télémédecine et E-santé (ML), Abdel Kader Traoré†, Centre national d’appui à la lutte contre la maladie (ML), Antoine Geissbuhler, University of Geneva and Geneva University Hospitals (CH); Anatole Tounkara and Anne Abdrahamane, Faculté de médicine et de pharmacie, Université de Bamako (ML); Younoussa Touré, Institut des sciences humaines du Mali (ML); Seydou Tidiane Traoré, Mahamoudane Niang and Dikaridia Traoré, Centre d’expertise et de recherche en télémédecine et E-santé (ML); Mamadou Touré, Centre hospitalier universitaire du point G (ML); Bocary Diarra, Hôpital mère-enfant Le Luxembourg (ML); Marie-Pierre Gagnon, Université Laval (CA).

Victoria Mutiso*, Africa Mental Health Foundation (KE); Chris Rakuom†, Ministry of Health (KE), Da-vid Ndetei, Lincoln Khasakhala, Anne Mbwayo, Patricia Wekulo and Penny Holding, Africa Mental Health Foundation (KE).

* principal researcher; † decision-maker

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p. 17

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Acknowledgements

This work was carried out with support from the Global Health Research Initiative (GHRI), a research funding partnership composed of the Canadian Institutes of Health Research, Foreign Affairs, Trade and Development Canada, and the International Development Research Centre.

This work was carried out with the aid of a grant from the International Development Research Centre (IDRC), Ottawa, Canada, and with the financial support of the Government of Canada provided through Foreign Affairs, Trade and Development Canada (DFATD).

Thank you to program grantees for providing content for this booklet.

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Research & writing: Esmé Lanktree and Gyde ShepherdGlobal Health Research Initiative

Editing: Esmé LanktreeDesign: Gyde Shepherd

For more information about this program, contact:

Marc Cohen ~ Program OfficerGlobal Health Research Initiative mcohen@idrc.ca / +1 613 696 2166

Esmé Lanktree ~ Program Management Officer Global Health Research Initiativeelanktree@idrc.ca / +1 613 696 2616

“We must know the health system in order

to strengthen it.”