Human resources for health governance and leadership strategies for improving health outcomes in low- and middle-income countries: a narrative review.

BACKGROUND: Many low- and middle-income countries (LMICs) are facing a crisis of human resources for health (HRH) attributed to poor governance and leadership that characterizes the health sector in this setting. It is unclear which specific strategies are effective in ameliorating the crisis. METHODS: Selected electronic databases were searched up until 30 May 2020. Two authors screened studies independently and extracted data from included studies. Quality assessment was done using the Mixed Methods Appraisal Tool. Thematic analysis of the outcomes was done. RESULTS: We included 18 studies of variable designs across Africa, Asia, South America and the Pacific islands. Most were case-based studies and were of moderate to high quality. Several governance strategies with a positive impact on the health workforce and health outcomes identified included decentralization, central coordination and facilitation process, posting and transfer policies as well as the setting up of human resource units. CONCLUSIONS: Governance and leadership strategies targeting the HRH crises in LMIC are variable, interdependent and complex. While some show benefits in improving health workforce outcomes, only a few have an impact on population health outcomes.

Interventions for improving attraction and retention of health workers in rural and underserved areas: a systematic review of systematic reviews.

BACKGROUND: Global health workforce shortages exist with disparities in the skill mix and distribution of health workers. Rural and underserved populations are often disadvantaged in terms of access to health care. METHODS: This systematic review summarized all systematic reviews that assessed interventions for improving attraction and retention of health workers in rural and underserved areas. We systematically searched selected electronic databases up to 31 March 2020. The authors independently screened the reviews, extracted data and assessed the certainty of evidence using GRADE. Review quality was assessed using the ROBIS tool. RESULTS: There was a paucity of evidence for the effectiveness of the various interventions. Regulatory measures were able to attract health workers to rural and underserved areas, particularly when obligations were attached to incentives. However, health workers were likely to relocate from these areas once their obligations were completed. Recruiting rural students and rural placements improved attraction and retention although most studies were without control groups, which made conclusions on effectiveness difficult. CONCLUSIONS: Cost-effective utilization of limited resources and the adoption and implementation of evidence-based health workforce policies and interventions that are tailored to meet national health system contexts and needs are essential.

Implementation of health workforce information systems: a review of eight sub-Saharan country experiences.

BACKGROUND: Globally, one of the major problems facing health systems is an acute deficit of health workforce. To ensure equitable distribution and deployment of health workers, up-to-date and timely information on the health workforce is vital. Health workforce registries (HWRs) have the potential to generate data for evidence-based human resource planning and policies. There is a lack of evaluative research on the capacity of HWRs to improve health systems. This review aims to assess the effectiveness of HWRs for improving health systems in low- and middle-income countries. METHODS: We searched selected electronic databases from inception to 14 April 2020. Two authors independently screened studies and extracted data from included studies. We presented results as a narrative synthesis. RESULTS: We included eight studies of moderate-high quality in this review. The results suggest that HWRs can improve the distribution and skill-mix of the health workforce, quality of health workforce data, availability and use of data for policy and planning, and user satisfaction. The evidence was derived from case studies, which limited our ability to infer a causal relationship. CONCLUSION: More rigorous research from controlled experimental studies is needed to consolidate the available evidence from observational studies.

Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria.

BACKGROUND: The emergency department (E.D) of any hospital is an important entry point of critically ill patients. The initial management of these patients is often challenging, and for valuable lives to be saved, the in fracture and manpower should be up to date. OBJECTIVE: To analyze the epidemiology of death in our Emergency Department within 72hours after admission, the death rate, and to establish any contributory factors. METHOD: Demographic data, time of arrival at the ED, physical finding, the Glasgow coma scale(GCS), the injury severity score(ISS), the diagnosis, investigations done, treatment offered, the time of death and the autopsy report, were entered into a Proforma. These data was analyzed using EPI-Info statistical programme version 3.4.3 of 2007. RESULTS: Four thousand and eleven (4,011) patients were seen in the E.D during the period. A total of three hundred and fifty five (355) mortalities were recorded. Their ages ranged from 4-87years, with an average of 34.5years. The male: female ratio was 2.1:1. The overall mortality in the hospital during the period was 859: the E.D mortality figure representing 41.3%. Fifteen patients were brought in dead. The 355 deaths fell into two categories: trauma and non-trauma. One hundred and forty-seven (41.4%) persons died from trauma; road traffic accidents (RTAs) accounting for 118 (80.3%). Two hundred and eight (58.6%) persons died from nontrauma related causes, with chronic cardiovascular disorders been the most frequent cause of death 52[25.0]. Majority of the mortalities were between 26-50 years age range. 86.2% of the mortalities presented late, greater than 6hours after the incidence. Within the 72 hours period, only 129(36.3%) were able to do the requested tests. Out of the 355 deaths, only 4[1.1%] were autopsied. An in-hospital 72hours death rate of 8.6 was recorded. CONCLUSION: Road traffic accidents and cardiovascular disorders are the common causes of emergency death in UCTH. A recorded death rate of 8.6% is high, suspected contributory factors include systemic deficiencies such as the lack of a trauma system, prehospital care; late presentation, the role of chemist operators, traditional healers, and delayed referral systems.

Social determinants of alcohol use among drivers in Calabar.

OBJECTIVE: Hazardous use of alcohol is a public health problem which accounts for 4.0% of global disease burden. Although the prevalence of alcohol use among drivers of commercial vehicles in Nigeria has been documented, not much is known about its social determinants. This study was, therefore, aimed at assessing the social determinants of alcohol use among drivers of commercial vehicles in Calabar. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted among 360 male commercial drivers. A semistructured questionnaire, which included the World Health Organization Alcohol Use Disorders Identification Test, was administered at interview. Binary and multinomial logistic regression analyses were used to identify social determinants of any and hazardous alcohol use. RESULTS: Determinants of any alcohol use (binary logistic) were history of use by parents (adjusted odds ratios (AOR)=2.7; 95% CI=1.1-6.3), friends (AOR=3.2; 95% CI=1.3-7.8) and ready availability (AOR=4.1; 95% CI=1.9-8.8) while determinants of hazardous use (multinomial logistic) were history of use by parents (AOR=5.8; 95% CI=2.0-16.9), siblings (AOR=7.0; 95% CI=2.6-16.9), friends (AOR=6.6; 95% CI=1.8-24.4), hostile upbringing environment (AOR=3.8; 95% CI=1.3-11.1), use of other drugs (AOR=55.6, 95% CI=14.5-200), and respondents who had fathers with a maximum of primary or no formal education (AOR=4.6; 95% CI=1.8-11.8). CONCLUSION: Alcohol use was associated with family use, friends' use, and use of other drugs. Multiple health education interventions are needed to tackle these challenges.

Prevalence of Gallstone Disease in South-Eastern Nigeria

"Classically; gallstones are said to occur in a fat; fertile; flatulent female of fifty!1. in this prospective study; we found a prevalence rate of 3.3. the results did not correlate with the body mass index (BMI); weight (Wt) or complexion (Cpx). The mean BMI for those with stones was 24.43 with standard deviation (SD) of 1.97 as against mean BMI of 26.35 and SD of 4.98 for those without. The mean Wt. of those with gallstones was 65.43kg with SD of 9.55 while the mean Wt of those without was 68.01kg with SD of 15.43. regarding ""colour"". The Dark complexioned (Dc) were more common constituting 71.4of affected persons. The fair complexioned (Fc) constituted 28.6. Patients with tertiary education were the most frequently affected constituting 71.4and the same group constituted 51of those randomized. Patients with secondary school level of education constituted 33.14of those randomized and 28.43found with gallstones. In the studied sample; t6he female to male ratio in those affected was 6.1. the females also dominated the sample population to the tune of 84. In relation to occupation; the highest incidence was amongst civil servants who made up 43of those affected. Surprisingly; the unemployed came second making up 28.5and the professionals were 14.28of those affected. These results confirm a rising incidence of cholelithiasis in our population when compared with previous studies (0.007the sixties and 1.79in 2002. it also clearly demonstrates a different epidemiological profile from that classically described amongst the Caucasians."

Awareness and acceptability of strategies for preventing mother to child transmission of HIV among antenatal clients in Calabar, Nigeria.

BACKGROUND: Mother to child transmission is the major route through which children below the age of 15 years acquire HIV infection. The most effective way to reduce childhood HIV infection is to prevent the infection in mothers and for already infected mothers use appropriate strategies to prevent transmission to their children. This study was conducted to determine the level of awareness and acceptability of strategies for preventing mother to child transmission of HIV. METHOD: Exploratory multi-centric descriptive study involving 400 antenatal attendees in Federal, State and a Private health facility was used. Interviewer-administered questionnaire was the tool for data collection. RESULT: Majority of the respondents (94.7%) were aware of transmission of HIV from an infected mother to her child. Respondents were more aware of the use of antiretroviral drugs in pregnancy (63.2%) than they were of avoiding breastfeeding (58.5%) and Cesarean delivery (22.8%) as strategies for preventing mother to child transmission. They were also more likely to accept the use of antiretroviral drugs (78.2%) than they would avoid breastfeeding (69.0%) and accept Cesarean delivery (38.0%) for preventing mother to child transmission of HIV High educational status was significantly associated with a positive attitude to these strategies. CONCLUSION: There is need for more educational programs and social support to bridge the gap between the levels of awareness and acceptability of strategies for preventing mother to child transmission of HIV among the populace.

Awareness and Acceptability of Strategies for Preventing Mother to Child Transmission of HIV among Antenatal Clients in Calabar; Nigeria

Background: Mother to child transmission is the major route through which children below the age of 15 years acquire HIV infection. The most effective way to reduce childhood HIV infection is to prevent the infection in mothers and for already infected mothers use appropriate strategies to prevent transmission to their children. This study was conducted to determine the level of awareness and acceptability of strategies for preventing mother to child transmission of HIV. Method: Exploratory multi-centric descriptive study involving 400 antenatal attendees in Federal; State and a Private health facility was used. Interviewer-administered questionnaire was the tool for data collection. Result: Majority of the respondents (94.7) were aware of transmission of HIV from an infected mother to her child. Respondents were more aware of the use of antiretroviral drugs in pregnancy (63.2) than they were of avoiding breastfeeding (58.5) and Cesarean delivery (22.8) as strategies for preventing mother to child transmission. They were also more likely to accept the use of antiretroviral drugs (78.2) than they would avoid breastfeeding (69.0) and accept Cesarean delivery (38.0) for preventing mother to child transmission of HIV. High educational status was significantly associated with a positive attitude to these strategies. Conclusion: There is need for more educational programs and social support to bridge the gap between the levels of awareness and acceptability of strategies for preventing mother to child transmission of HIV among the populace

Patients' perception of obstetric practice in Calabar, Nigeria.

OBJECTIVE: To determine the influence of patients' perception of obstetric practice in Calabar on the low utilization of health facilities for delivery. METHODS: The University of Calabar Teaching Hospital, the general hospital and eight private clinics in Calabar were visited daily for a period of one month to interview postnatal mothers. This was to ascertain the mothers' perception of obstetric care in these facilities and their attitude towards some selected birth practices. RESULTS: All the interviewed mothers had some formal education, and 133 (92.4%) were aged 20 years and above. One hundred and forty (97.2%) of the mothers were satisfied with at least one aspect of care received. Areas of satisfaction mentioned by the mothers include attitude of health staff 114 (81.4%), clinical care received 85 (60.7%), sanitation of the facility 61 (43.6%), and basic amenities 47 (33.6%), poor sanitary condition of the health facility and lack of basic amenities were the major causes of dissatisfaction. Few mothers, 31 (22%) disagreed with dorsal position during second stage of labor. Most mothers, 92 (63.9%) would want pain relief in labor; 19 (13.2%) did not appreciate shaving of pubic hair and 50 (34.7%) felt episiotomy was not necessary for safe delivery. CONCLUSION: To improve the utilization of obstetric services in Calabar, basic amenities such as water and sanitation should be provided; and there should be restriction of routine birth practices that have no evidence of effectiveness.

Perception of ischaemic heart disease, knowledge of and attitude to reduction of its risk factors.

OBJECTIVES: To assess the perception of ischaemic heart disease (heart attack) as a cause of mortality and determine the current knowledge of its risk factors as well as the level of adoption of preventive strategies among Nigerians working in a tertiary institution. DESIGN: Cross-sectional study. SETTING: University of Calabar, Calabar, Nigeria. SUBJECTS: Five hundred randomly selected University workers both senior and junior staff. MAIN OUTCOME MEASURES: Assessment of the awareness of ischaemic heart disease as a cause of morbidity and mortality, knowledge of risk factors and degree of adoption of lifestyle modification strategies. RESULTS: Only 136 (27.7%) of respondents considered ischaemic heart disease (heart attack) as the leading cause of death in their environment while 201 (40.2%) thought it was hypertension. Smoking was readily identified by 70.6% as a risk factor, excessive alcohol use by 52.8% and 41.6% of respondents identified obesity. Sedentary life-style and oral contraceptive use were least identified with only 16.6% and 6.4% of respondents respectively identifying them. This knowledge was significantly influenced by the educational status and cadre of the subjects. The senior staff who were also better educated demonstrated more knowledge. Two point two percent of respondents were smokers and smoked ten sticks of cigarettes or less per day. All expressed willingness to stop. One hundred and fifty eight admitted taking alcohol, most taking less than ten units a week and of these, only 64 were willing to quit. Fifty three point four percent (29.2% of senior and 24.2% of junior undertook some exercise while only 45.6% checked their body weights regularly. Only 25% of all the respondents visited the hospital or clinic for routine medical check-up. No statistically significant difference was found between the senior/better educated and the junior/less educated members of staff in the adoption of these life style modification measures. Sixty four point four percent got medical information from doctors and other health workers. CONCLUSION: Level of awareness of ishaemic heart disease as a leading cause of death is poor even in an academic environment. Knowledge of risk factors is also poor and is influenced by the level of educational attainment. Life style modification strategies are still not widely accepted irrespective of educational status. A concerted public health response is advocated to improve the present level of knowledge and establish behavioural changes.

KAP of HIV prevention and screening among pregnant women attending specialist antenatal clinics in Calabar, Nigeria.

BACKGROUND: There is a growing concern globally to reverse the growing incidence of HIV especially in Sub-Saharan Africa. This study was conducted to determine the level of awareness, attitude and practice of antenatal HIV screening in Calabar. METHOD: Descriptive multi-centric study of 400 antenatal attendees in Calabar, carried out in October 2005 using pre-tested, semi-structured and interviewer-administered questionnaire for data collection. RESULT: Of the 96.7% women with knowledge of HIV infection, 41.2% were assessed to have excellent knowledge of the mode of transmission. Awareness of antenatal HIV screening was observed in 96.2% women; while 93.7% approved of antenatal HIV screening. Awareness and approval of antenatal HIV screening was significantly related to age and educational status. The proportion of women who had HIV test in current pregnancy was 70.2%. Pre-test counseling was done in 65.8% of women. Most women (78.2%) who had not been screened were willing to undergo HIV testing. Spousal disapproval (23.1%) was the main reason for unwillingness to undergo HIV testing. CONCLUSION: The study revealed high levels of awareness, approval and practice of antenatal HIV screening. However, pre test counseling was not consistently given in cases tested.

Quality of child health services in primary health care facilities in south-east Nigeria.

BACKGROUND: To assess the quality of child health services in primary health care (PHC) facilities in Calabar, south-east Nigeria. DESIGN: Cross-sectional, descriptive design. METHODS: Key informant interviews, structured observation, self-administered questionnaire and focus group discussion. SETTING: Calabar, south-east Nigeria. Participants All 10 PHC facilities in Calabar, 252 PHC workers serving in the facilities, and 76 mothers whose children received care in the facilities. OUTCOME MEASURES: Adequacy of structure (equipment and personnel); process (diagnosis, training and knowledge, use of national case-management algorithm, and supervision), and output (clients' satisfaction). MAIN RESULTS: PHC facilities were adequately equipped to the extent of providing immunization services and management of diarrhoea but not for other aspects of care expected of a PHC centre, including management of acute respiratory infections (ARI), a common problem in children in the region. Supply of essential drugs was inadequate in all centres and facilities for emergency care were lacking. Many of the health care workers (68.3%) had adequate training in immunization, and their knowledge scores on immunization issues (62%) was higher than in other aspect of PHC. Use of the national case management algorithm was low among PHC workers. Results of the focus group discussions with mothers showed that a few perceived quality of care to be poor. The main concerns were long waiting time, lack of essential drugs, and attitude of the health workers. CONCLUSIONS: Inadequacy in the quality of child health services in PHC facilities is a product of failures in a range of quality measures -- structural (lack of equipment and essential drugs), process failings (non-use of the national case management algorithm and lack of a protocol of systematic supervision of health workers). Efforts to improve the quality of child health services provided by PHC workers in the study setting and similar locales in less developed countries should focus not only on resource-intensive structural improvements, but also on cheap, cost-effective measures that address actual delivery of services (process), especially the proper use of national guidelines for case management, and meaningful supervision.

Factors Influencing the Incidence of Pre-term Birth in Calabar, Nigeria.

Women who had pre-term birth in the University of Calabar Teaching Hospital, Calabar, over a two and a half year period were studied. The aim was to establish the factors influencing the incidence of pre-term birth in Calabar. Factors which significantly increase the incidence of pre-term delivery included: previous induced abortion [P < 0.0001], nulliparity [P < 0.001], out of wedlock birth [P < 0.05] and lack of antenatal care [P < 0.01]. Women with multiple pregnancy [P < 0.001] or previous pre-term delivery [P < 0.01], have a significantly high risk for pre-term birth. Antenatal complications [P < 0.0001] particularly anaemia [P < 0.001] or malaria [P < 0.05] in the index pregnancy constitute risk factors for pre-term delivery. However, educational status, social class and previous spontaneous abortion did not seem to significantly influence the incidence of pre-term birth in this study [P < 0.05]. Wider use of family planning, less restrictive abortion laws and training of doctors and nurses on the use of manual vacuum aspiration in the management of post-abortion complications may help reduce the incidence of pre-term birth in Calabar. Replacing pyrimethamine chemoprophylaxis for malaria in pregnancy by intermittent treatment of malaria with sulphadoxine-pyrimethamine and deworming our women during antenatal care may also help reduce the incidence of pre-term birth in our community.

Physical methods for treating fever in children.

BACKGROUND: Health workers recommend bathing, sponging and other physical methods to treat fever in children and to avoid febrile convulsions. We know little about the most effective methods, or how these methods compare with commonly used drugs. OBJECTIVES: To evaluate the benefits and harms of physical cooling methods used for managing fever in children. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group specialized trials register (February 2003), the Cochrane Central Register of Controlled Trials (Issue 1, 2003), MEDLINE (1966 to February 2003), EMBASE (1988 to November 2002), CINHAL (1982 to February 2003), LILACS (February 2003), Science Citation Index (1981 to February 2003), and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomized and quasi-randomized trials comparing physical methods with a drug placebo or no treatment in children with fever of presumed infectious origin. Studies where children in both groups were given an antipyretic drug were included. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial methodological quality. One reviewer extracted data and the other checked the data for accuracy. Results were expressed as Relative Risk (RR) with 95% confidence intervals (CI) for discrete variables, and weighted mean differences for continuous outcomes. MAIN RESULTS: Seven trials, involving 467 participants, met the inclusion criteria. One small trial (n = 30), comparing physical methods with drug placebo, did not demonstrate a difference in the proportion of children without fever by one hour after treatment in a comparison between physical methods alone and drug placebo. In 2 studies, where all children received an anti-pyretic drug, physical methods resulted in a higher proportion of children without fever at one hour (n=125, RR 11.8, CI 3.39 to 40.8). I; in a third study (n=130), which only reported mean change in temperature, no differences wereas detected. Mild adverse events (shivering and goose pimples) were more common in the physical methods group (3 trials, RR 5.09; CI 1.56 to 16.60). REVIEWER'S CONCLUSIONS: A few small studies demonstrate that tepid sponging helps to reduce fever in children.

Paracetamol for treating fever in children.

BACKGROUND: Paracetamol (acetaminophen) is widely used for treating fever in children. Like ibuprofen, aspirin, and physical methods (such as fanning), paracetamol aims to provide relief from symptoms and prevent febrile convulsions. Uncertainty exists about the benefits of using it to treat fever in children. OBJECTIVES: To assess the effects of paracetamol for treating fever in children in relation to fever clearance time, febrile convulsions, and resolution of associated symptoms. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group specialized trials register (November 2001), The Cochrane Controlled Trials Register (The Cochrane Library Issue 4, 2001), MEDLINE (1966 to November 2001), EMBASE (1988 to November 2001), LILACS (2001, 40a Edition CD-ROM), Science Citation Index (November 2001), and reference lists of articles. We also contacted researchers in the field. SELECTION CRITERIA: Randomized and quasi-randomized trials of children with fever from infections comparing: (1) paracetamol with placebo or no treatment; and (2) paracetamol with physical cooling methods (eg, sponging, bathing, or fanning). The primary outcomes were fever clearance time and febrile convulsion. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data on methods, types of participants, interventions, and outcomes. The meta-analysis was conducted using Relative Risk with 95% confidence intervals for discrete variables, and weighted mean differences for continuous outcomes. MAIN RESULTS: 12 trials (n = 1509 participants) met the inclusion criteria. Outcomes varied between trials. No data were available on the primary outcome. There is insufficient evidence to show whether paracetamol influenced the risk of febrile convulsions. In a meta-analysis of two trials (n = 120), the proportion of children without fever by the second hour after treatment did not differ significantly between those given paracetamol and those sponged (Relative Risk 1.84; confidence interval 0.94 to 3.61, random effects model). The statistical test showed significant heterogeneity between the groups receiving paracetamol or physical methods. No severe adverse events were reported. The number of children with mild adverse events did not differ significantly between paracetamol and placebo, or paracetamol and physical methods, but numbers were small. REVIEWER'S CONCLUSIONS: Trial evidence that paracetamol has a superior antipyretic effect than placebo is inconclusive. There is limited evidence that there is no difference between the antipyretic effect of paracetamol and physical methods. Data on adverse events in these trials were limited. Establishing standard outcomes will help comparisons between studies and meta-analysis.

Factors associated with missed opportunities to immunise with tetanus toxoid at a tertiary health institution in Nigeria.

OBJECTIVE: To determine the magnitude of and the reasons for missed opportunities to immunise with tetanus toxoid at a tertiary health institution in Nigeria. The information obtained would be used in developing an intervention strategy for eliminating missed opportunities in the future. DESIGN: Missed opportunity was assessed by using the Revised WHO/EPI protocol (WHO/EPI/MLM/91.7). Exit interviews were carried out on pregnant women visiting the antenatal (prenatal) clinic to register the present pregnancy. SETTING: A tertiary health institution in Nigeria. SUBJECTS: Pregnant women who attended the antenatal clinic for the purpose of registering the present pregnancy during the last two booking days in February, 1997 and the first booking day in March, 1997. MAIN OUTCOME MEASURES: Missed opportunities and contributory factors. RESULTS: The prevalence of missed opportunity was 66%. The factors responsible for missed opportunity were poor history taking, lack of knowledge of the current schedule of immunisation, dependence on physician referral for immunisation and inefficient immunisation record keeping system. CONCLUSION: The findings establish the need for providing physicians in antenatal settings with an update on current immunisation policy and practice and for improved documentation of immunisation histories.

PIP: This report presents the magnitude of the problem and the reason for missed opportunities for tetanus toxoid (TT) immunization at the University of Calabar Teaching Hospital (UCTH) in Nigeria. The information obtained will be used in developing a strategy for eliminating missed opportunities in the future. The subjects were all pregnant women who attended the antenatal clinic for the purpose of registering pregnancy during the last two booking days in February 1997 and the first booking day in March 1997. Information were collected from 54 pregnant women by means of exit interview conducted by trained by data collectors. Information obtained includes: dose(s) of TT received and when; record of offer of TT; and acceptance or decline of TT offered. Results of the exit interview showed a 66% prevalence rate of missed opportunity. Factors contributing to this high prevalence of missed opportunity were poor history taking, lack of knowledge of current schedule of immunization, dependence on physician referral for immunization, and an inefficient immunization record keeping system. The findings point out the need to provide physicians in antenatal settings with an update on current immunization policy and practice and for improved documentation of immunization histories.

Hyperventilation in febrile Nigerian children without pneumonia: an evaluation of the influence of anaemia.

A total of 225 pre-school Nigerians were studied to evaluate the effect of anaemia on the respiratory rate of febrile children, and the influence of this on the reliability of the WHO criteria for the clinical diagnosis of pneumonia in the primary health care setting. Malaria was the commonest cause of febrile illness (63.1 pc). The prevalence of severe anaemia was 28.0 pc. The mean respiratory rate of anaemic children (53.9 +/- 12.8/min) was significantly higher than that of the non-anaemic (48.4 +/- 12.7/min; p = 0.011). Mean body temperature was not significantly different in both groups. Haematocrit was negatively correlated with respiratory rate. The positive correlation observed between temperature and respiratory rate was enhanced by decreasing haematocrit. More of the severely anaemic children (68.6 pc) exceeded the WHO respiratory rate threshold for diagnosis of pneumonia than the moderately anaemic (55.4 pc) or non-anaemic (36.1 pc). The specificity of the WHO criteria for clinical diagnosis of pneumonia decreased with decreasing haematocrit.