Introducing quality management into primary health care services in Uganda

In 1994; a national quality assurance programme was established in Uganda to strengthen district-level management of primary health care services. Within 18 months both objective and subjective improvements in the quality of services had been observed. In the examples documented here; there was a major reduction in maternal mortality among pregnant women referred to Jinja District Hospital; a reduction in waiting times and increased patient satisfaction at Masaka District Hospital; and a marked reduction in reported cases of measles in Arua District. Beyond these quantitative improvements; increased morale of district health team members; improved satisfaction among patients; and greater involvement of local government in the decisions of district health committees have been observed. At the central level; the increased coordination of activities has led to new guidelines for financial management and the procurement of supplies. District quality of health headquarters have led to a greater uderstanding by central staff of the issues faced at the district level. The quality assurance programme has also fotered improved coordination among national disease-control programmes. Difficulties encountered at the central level have included delays in carrying out district support visits and the failure to provide appropriate support. At the district level; some health teams tackled problems over which they had little control or which were overly complex; others lacked the management capacity for problem solving

Evaluation of clinical signs to diagnose anaemia in Uganda and Bangladesh, in areas with and without malaria

The object of this study was to assess the ability of pallor and other clinical signs, including those in the Integrated Management of Childhood Illness (IMCI) guidelines developed by WHO and UNICEF, to identify severe anaemia and some anaemia in developing country settings with and without malaria. A total of 1226 and 668 children aged 2 months to 5 years were prospectively sampled from patients presenting at, respectively, a district hospital in rural Uganda and a children's hospital in Dhaka, Bangladesh. The study physicians obtained a standardized history and carried out a physical examination that included pallor, signs of respiratory distress, and the remaining IMCI referral signs. The haematocrit or haemoglobin level was determined in all children with conjunctival or palmar pallor, and in a sample of the rest. Children with a blood level measurement and assessment of pallor at both sites were included in the anaemia analysis. Using the haematocrit or haemoglobin level as the reference standard, the correctness of assessments using severe and some pallor and other clinical signs in classifying severe and some anaemia was determined. While the full IMCI process would have referred most of the children in Uganda and nearly all the children in Bangladesh with severe anaemia to hospital, few would have received a diagnosis of severe anaemia. Severe palmar and conjunctival pallor, individually and together, had 10-50% sensitivity and 99% specificity for severe anaemia; the addition of grunting increased the sensitivity to 37-80% while maintaining a reasonable positive predictive value. Palmar pallor did not work as well as conjunctival pallor in Bangladesh for the detection for severe or some anaemia. Combining "conjunctival or palmar pallor" detected 71-87% of moderate anaemia and half or more of mild anaemia. About half the children with no anaemia were incorrectly classified as having "moderate or mild" anaemia. Anaemia was more easily diagnosed in Uganda in children with malaria. Our results show that simple clinical signs can correctly classify the anaemia status of most children. Grunting may serve as a useful adjunct to pallor in the diagnosis of severe anaemia. Conjunctival pallor should be added to the IMCI anaemia box, or the guidelines need to be adapted in regions where palmar pallor may not readily be detected

Onchocerciasis in Malawi. 2. Subjective complaints and decreased weight in persons infected with Onchocerca volvulus in the Thyolo highlands

In the course of an onchocerciasis survey in southern Malawi; body weight was recorded for 10;335 persons aged 20 years and older; and the body mass index was calculated for 5572. A history of symptomatic complaints was elicited from 5653 persons 20 years of age and older. Persons with microfilariae in the skin snips weighed significantly less than persons with negative skin snips. Symptomatic complaints of musculoskeletal pains; itching; dizziness and poor vision were reported more commonly in the group with microfilariae. These findings suggest that onchocerciasis should no longer be considered a disease affecting the eye and skin only but an infection which produces systemic effects as well. Systemic effects of onchocerciasis may lessen productivity of an endemic region by a process distinct from the effects of visual impairment

Onchocerciasis in Malawi. 1. Prevalence; intensity and geographical distribution of Onchocerca volvulus infection in the Thyolo highlands

Skin snips from 23;373 persons living in the Thyolo (formerly Cholo) highlands focus of southern Malawi showed infection with Onchocerca volvulus to be unevenly distributed within the highland area. In the centre of the focus most adults were infected; though intensity of infection was light; not exceeding a geometric mean of 8 microfilariae per mg of skin. It was estimated that 327;000 persons live in areas where prevalence of infection exceeds 10 percent and; of these; 94;500 persons over the age of one year are infected with O. volvulus. There is a significant relationship between infection with O. volvulus and bilateral blindness in the Thyolo focus; although the number of persons blind from onchocerciasis is probably less than 300

HIV seropositivity and tuberculosis in a rural Malawi hospital

This study was undertaken to determine the extent to which human immunodeficiency virus (HIV) infection has increased hospital admissions for tuberculosis (TB) in a rural population of southern Malawi. The notes and chest X-rays of TB patients admitted to Malamulo hospital in 1983 and 1984; before the recognition of acquired immune deficiency syndrome (AIDS) in Malawi; were compared with those of patients admitted in 1987 and 1988. We found a 160 percent increase in TB admissions between the 2 periods. Extrapulmonary TB; especially pleural TB; was much commoner in 1987-1988 and occurred in a younger age group. HIV seroreactivity was measured in a third group of 152 tuberculosis patients admitted during 1988-1989. HIV seropositivity was found in 52 percent of all tuberculosis admissions and in 75 percent of those with extrapulmonary disease. There was no difference in clinical response to TB therapy between the HIV seropositive patients and those who were seronegative. Extrapulmonary TB should be considered in all HIV seropositive patients; especially in areas where the prevalence of TB is high. Health personnel involved in TB programmes where HIV and TB infections are prevalent should plan for a large increase in the TB case load secondary to the HIV pandemic

The immune system in malaria: part II; immunologic changes in malaria

When a host; infected with malaria; is challenged with several antigens; the immune system may be altered by different mechanisms for each antigen involved. The article looks at some of these responses

Progress toward onchocerciasis control in Malawi

"Discusses a project by the Liverpool School of Tropical Medicine and the Ministry of Health to study the breeding habits of the simulium fly; which is responsible for the spread of onchocerciasis or ""river blindness""; in order to formulate vector control strategies"

Malarial immunity: part III

A review of attempts to make a vaccine against malaria to counteract the growing resistance to chloroquine