ABSTRACT
Introduction Neuromyelitis optica spectrum disorders (NMOSD) would disproportionately affect blacks within mixed populations. However, they are rarely reported in black African. The objective of this work was to report the experience of Togo, a West African country in terms of NMOSD. Methods This is a series of six cases diagnosed between 2015 and 2020 in the only three neurology departments in Togo. The diagnosis of NMOSD was made according to the criteria of the International Panel for NMO Diagnosis (2015) and the patients had a minimum clinical follow-up of 6 months after the diagnosis. The search for anti-aquaporin 4 (AQP4) antibodies was performed by immunofluorescence on transfected cells. Results The mean age was 25.33 years and the sex ratio female/male was 5/1. The average time between the first attack and the diagnosis was 122.83 days. Clinically, there was isolated medullary involvement (2/6), simultaneous opticomedullary involvement (3/6), and area postrema syndrome (1/6). Five patients were anti-AQP4 positive. All six patients had extensive longitudinal myelitis. At 6 months of follow-up, there was one case of death and one case of blindness. Conclusion The rarity of NMOSD cases in Togo could be linked to an underestimation. To better characterize the NMOSDs of the black African population, multicenter and multidisciplinary studies are necessary.
ABSTRACT
The financial crisis that affected the healthcare systems of most developing countries in the 1980s, the ensuing need to control hospital costs, the partial disengagement of States, and the resort to policies based on cost recovery -- all these led to the restructuring of hospital systems in Africa, in accordance with the Bamako initiative, adopted by the WHO regional committee in September 1987. This restructuring required populations to pay much of the cost of their health care. In practice, however, the major obstacle to this policy of cost recovery remains poverty. Twenty years after the adoption of this initiative, we sought to evaluate the cost of hospitalisation for cerebral stroke in Togo, where there is no national health insurance programme, and to propose strategies to improve its management. This prospective study was conducted in the neurology department of the University Hospital of Lomé over a period of 12 months, from 1 January to 31 December 2005 and included 412 consecutive patients with a confirmed diagnosis according to WHO criteria and cerebral computed tomography (CT) results. This department has 30 beds in rooms categorized according to their cost to the patients: EUR 27.30 for a superior single room, EUR 18.20 for the first category standard room, EUR 13.7 euros for the second, and EUR 8.20 for the third. Patients or their family could choose their room category. Of the 412 patients included in our study, 248 (60.2%) had an ischaemic stroke (IS) and 164 (39.8%) a haemorrhagic stroke (HS). The average length of stay was 17.4 +/- 10.4 days (range: 3 to 41 days), 10.17 days (range: 3 to 24) for IS and 26.7 (range: 13 to 41) for HS. In all, 124 (30%) patients produced insurance certificates, and 288 (70%) paid directly; among the latter 152 (36.9%) patients paid their own expenses, while relatives paid for 65 (63.10%). Housewives accounted for 136 (33%) patients, 96 (23%) retired and 180 (20.4%) civil servants. No one chose the superior quality private room; 256 (62%) patients used category 3 rooms, 68 (27.2%) of them housewives and 44 (17.2%) retired. The total cost averaged EUR 679.6 +/- 297.90, almost 19 times higher than the minimum monthly salary of civil servants in Togo (EUR 36.30). The total for IS was EUR 428.80 +/- 188.9 and for HS, EUR 935.6 +/- 36.50. The average person in Togo spends EUR 3.99 per person per year on health, while a stroke patient hospitalized in Lome spends an average of 170 times more in only 17.4 days. Accordingly, most of the Togolese cannot access specialized neurology care for a stroke. Drug expenses accounted for the highest portion of the cost, in part because patients are obliged to buy retail pharmaceutical products that could have been provided to them at the hospital. Use of generic drugs could reduce this cost. Length of stay and tests could be reduced by setting time limits for procedures and setting up rehabilitation facilities.
ABSTRACT
Epilepsy, the most common serious neurological condition, is one of the most widespread non-transmissible diseases in the world. In developing countries, about 90% of those with epilepsy do not receive appropriate treatment; this treatment gap, very high compared with other chronic diseases, helps to explain the marginalisation and poor living conditions of these people. Reducing this treatment gap and the burden that epilepsy represents is a difficult task and the obstacles are numerous. The cultural attitudes, the absence of priority for this disease, the weak health infrastructure and the insufficient supply of anti-epileptics are just some of the factors that prevent adequate treatment. The extent of this problem led WHO and the International League against Epilepsy to launch an international campaign in June 1997 to bring epilepsy "out from the shadows". We sought to evaluate a strategy of community-based care for epilepsy in the six pilot districts. This strategy consisted in reducing the treatment gap in six local primary care units (PCUs) and then spreading the programme to surrounding PCUs, the entire district and then the entire region. This prospective evaluation study, which took place from May 2008 to July 2009, applied many strategies. WHO/AFRO made available funding of USD 3500 a year. A training meeting was held for PCU staff and community health agents, and numerous meetings from May 2007 through March 2008 aimed to increase awareness and motivation. The National Program for Mental Health (NPMH) ensured the availability of a permanent supply of anti-epileptics. Monitoring with supervision of activities and evaluation were conducted during and at the end of the process by the members of the Lomé Hospital neurology team and the management team of every district. Community-based management of 816 people with epilepsy over a period of 15 months was assessed internally. The planned strategies were conducted. The sex ratio (M/W) was 1.10. Treatment adhesion ranged from 96% to 99%. Mortality was 9%. The treatment gap in the PCUs, which varied from 98% to 94% in May 2008 fell by July 2009, ranging from only 40% to 25%. The "good practice" of accepting and treating patients with epilepsy in these areas where traditional culture excludes them from the community demanded the local acceptance of responsibility -- both medical and psychosocial. The reduction in epilepsy attacks and the integration of 2 or 3 patients in a community sufficed to bring other people with epilepsy out from the shadows. These successes show that in developing countries, it is possible to improve the health of different populations when these projects are integrated into primary health care. Positive results, and specifically a treatment gap below 50%, were obtained in all six PCUs. These results, acquired after months of activity, contributed to decrease the stigmatisation of epilepsy. Maintaining this reduction in the treatment gap requires continuation of the struggle against epilepsy and permanent improvement of primary health care. The often unplanned moves of staff and the reluctance of district and regional health managers to allocate resources to the project to perpetuate the programme constitute major difficulties. It appears urgent to adopt an active policy for providing care of patients with epilepsy in Africa in order to increase their lifespan.
