Mobilizing health district management teams through digital tools: Lessons from the District.Team initiative in Benin and Guinea using an action research methodology.

BACKGROUND: Improving capacities of health systems to quickly respond to emerging health issues, requires a health information system (HIS) that facilitates evidence-informed decision-making at the operational level. In many sub-Saharan African countries, HIS are mostly designed to feed decision-making purposes at the central level with limited feedback and capabilities to take action from data at the operational level. This article presents the case of an eHealth innovation designed to capacitate health district management teams (HDMTs) through participatory evidence production and peer-to-peer exchange. METHODS: We used an action research design to develop the eHealth initiative called "District.Team," a web-based and facilitated platform targeting HDMTs that was tested in Benin and Guinea from January 2016 to September 2017. On District.Team, rounds of knowledge sharing processes were organized into cycles of five steps. Quantitative and qualitative data were collected to assess the participation of HDMTs and identify enablers and barriers of using District.Team. RESULTS: Participation of HDMTs in District.Team varied between cycles and steps. In Benin, 79% to 94% of HDMTs filled in the online questionnaire per cycle compared to 61% to 100% in Guinea per cycle. In Benin, 26% to 41% of HDMTs shared a commentary on the results published on the platform while 21% to 47% participated in the online discussion forum. In Guinea, only 3% to 8% of HDMTs shared a commentary on the results published on the platform while 8% to 74% participated in the online discussion forum. Five groups of factors affected the participation: characteristics of the digital tools, the quality of the facilitation, profile of participants, shared content and data, and finally support from health authorities. CONCLUSION: District.Team has shown that knowledge management platforms and processes valuing horizontal knowledge sharing among peers at the decentralized level of health systems are feasible in limited resource settings.

Factors associated with the performance of routine health information system in Yaoundé-Cameroon: a cross-sectional survey.

BACKGROUND: Routine Health Information Systems (RHIS) of low-income countries function below the globally expected standard, characterised by the production and use of poor-quality data, or the non-use of good quality data for informed decision making. This has negatively influenced the health service delivery and uptake. This study focuses on identifying the factors associated with the performance of RHIS of the health facilities (HF) in Yaoundé, so as to guide targeted RHIS strengthening. METHODS: A HF-based cross-sectional study in the 6 health districts (HDs) of Yaoundé was conducted. HFs were chosen using stratified sampling with probability proportional to size per HD. Data were collected, entered into Microsoft Excel 2013 and analysed with IBM- SPSS version 25. Consistency of the questionnaire was measured using Cronbach's alpha coefficient. Pearson's chi-square (and Fisher exact where relevant) tests were used to establish relationships between qualitative variables. Associations were further quantified using unadjusted Odd ratio (OR) for univariable analysis and adjusted odds ratio (aOR) for multivariable analysis with 95% confidence interval (CI). A p-value of less than 0.05 was considered statistically significant. RESULTS: Of 111 selected HFs; 16 (14.4%) were public and 95 (85.6%) private. Respondents aged 24-60 years with an average of 38.3 ± 9.3 years; 58 (52.3%) males and 53(47.7%) females. Cronbach's alpha was 0.96 (95%CI: 0.95-0.98, p < 0.001), proving that the questionnaire was reliable in measuring RHIS performances. At univariable level, the following factors were positively associated with good performances: supportive supervision (OR = 3.03 (1.1, 8.3); p = 0.02), receiving feedback from hierarchy (OR = 3.6 (0.99, 13.2); p = 0.05), having received training on health information (OR = 5.0 (1.6, 16.0); p = 0.003), and presence of a performance evaluation plan (OR = 3.3 (1.4, 8.2), p = 0.007). At multivariable level, the only significantly associated factor was having received training on health information (aOR = 3.3 (1.01, 11.1), p = 0.04). CONCLUSION: Training of health staff in the RHIS favors RHIS good performance. Hence, emphasis should be laid on training and empowering staff, frequent and regular RHIS supervision, and frequent and regular feedback, for an efficient RHIS strengthening in Yaoundé.

Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools.

BACKGROUND: Reducing maternal mortality still remains a major challenge in low-income countries. This study aims to explore how digital communication tools can be used to evaluate the maternal deaths surveillance and response (MDSR) system at the health district level in Guinea. METHODS: A descriptive cross-sectional study was conducted, using an innovative digital approach called District.Team, from April to September 2017. This study targeted all 38 district medical officers in Guinea. In addition to district medical officers, the participation of health actors from regional and central levels were also expected in the online discussion forum. Data collected through the questionnaire were mixed and those from the online discussion forum were entirely qualitative. RESULTS: In total, 23 (61%) district medical officers (DMOs) participated in the study. Out of health districts (87%) which had updated guidelines and standards for the MDSR, 4 (20%) did not apply the content. In two health districts (8.7%), not all health facilities had maternal deaths notification forms. Three districts (13%) did not have maternal death review committees. In 2016, only half (50.2%) of reported maternal deaths were reviewed. The main recommendation formulated was related to quality of care. Other needs were also highlighted including continuous training of health care providers on emergency obstetric and neonatal care. Less than half (45%) of the review committee's recommendations were implemented. Six health districts (26.1%) did not have a response plan to reported maternal deaths and no district annual report on the MDSR was published in 2016. The weaknesses identified were, among others, insufficiency of human resources and lack of financial resources. Fifty-eight messages related to MDSR weaknesses and improvement solutions were posted in the online discussion forum by 28 participants (23 DMOs and 5 health actors from regional and central levels). CONCLUSION: Digital tools can be used to assess the functioning of a system like maternal deaths surveillance and response. Moreover, the findings of the evaluation conducted will help stakeholders (starting from the health districts themselves) to design strategies and interventions for an effective MDSR.

Learning for Universal Health Coverage.

The journey to universal health coverage (UHC) is full of challenges, which to a great extent are specific to each country. 'Learning for UHC' is a central component of countries' health system strengthening agendas. Our group has been engaged for a decade in facilitating collective learning for UHC through a range of modalities at global, regional and national levels. We present some of our experience and draw lessons for countries and international actors interested in strengthening national systemic learning capacities for UHC. The main lesson is that with appropriate collective intelligence processes, digital tools and facilitation capacities, countries and international agencies can mobilise the many actors with knowledge relevant to the design, implementation and evaluation of UHC policies. However, really building learning health systems will take more time and commitment. Each country will have to invest substantively in developing its specific learning systemic capacities, with an active programme of work addressing supportive leadership, organisational culture and knowledge management processes.

[Current status of schistosomiasis in Santchou health area, (Santchou Health District, Cameroon western region)]. / Situation actuelle de la schistosomiase dans l'aire de santé de Santchou, (District de santé de Santchou, Région de l'Ouest-Cameroun).

INTRODUCTION: Schistosomiasis, the second endemic parasitic infection in the world, is a parasitosis caused by trematodes from the genus Schistosoma. Our study aims to assess the prevalence of different species of schistosomes (Schistosoma mansoni, haematobium and intercalatum) among schoolchildren and to identify risk factors, clinical signs of schistosomiasis, and schistosomiasis intermediate host snails in stagnant water. METHODS: We conducted a cross sectional study over a three months period. The study consisted of sociodemographic and clinical data recording, collection of stool samples and urine, molluscan research and treatment of positive students for other helminths. Laboratory tests were performed at the Medical Research Institute and the study of Medicinal Plants in Yaounde where stool samples and urine were examined using KATO KATZ and centrifugation technique respectively, and shellfish species were determined by a malacologist. RESULTS: A total of 400 students aged between 8-16 years, 223 (55.7%) girls and 177 (44.3%) boys attending 4 elementary school were enrolled in the study. The social survey revealed that 154 students out of 400 (or 38.5%) were in contact with the river water at least once a week, 58% from around noon. All students had at least one symptom of schistosomiasis although nonspecific and dominated by abdominal pain in 72% of cases (n = 288 of 400). Biologically, no schistosomiasis eggs were detected. Cercaria releasing rate was negative in the 100 watery species found. CONCLUSION: The Santchou health area is not an active outbreak of schistosomiasis, but remains a risk area because of rice cultivation and stagnant water. The intensification of health education campaigns among the general population would delay the onset of this infection in the locality.

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

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

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

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

Interface entre programmes verticaux et services de sante generaux. Comment optimiser cette relation dans les systemes de sante d'Afrique Subsaharienne?

En Afrique subsaharienne; l'interface entre les programmes verticaux et les services de sante generaux (SSG) est un domaine prioritaire de recherche. En effet; les approches horizontale et verticale d'offre de soins ont ete diversement utilisees pour delivrer des soins aux patients. Mais de nombreux besoins de sante des populations sont restes non couverts. Ceci a engendre des tensions sur le choix de l'approche la mieux adaptee et un debat d'ecole s'est installe au sein de la communaute de sante publique mondiale. Ce debat perdure depuis des decennies et a ete largement nourri par des positions ideologiques opposees. Aujourd'hui; en Afrique subsaharienne; la performance des systemes de sante reste globalement faible. Pourtant; les ressources allouees aux systemes de sante ont considerablement augmente a partir des annees 2000 suite a l'emergence des Initiatives Globales de Sante (IGS) qui se focalisent sur des problemes de sante specifiques. Ces IGS mobilisent des fonds et de l'expertise qui pourraient etre utilises pour renforcer les systemes de sante afin qu'ils deviennent plus performants et puissent mieux repondre aux attentes des populations. Les etudes sur la relation entre ces IGS et les systemes de sante ont surtout analyse leurs effets au niveau national ou leur impact sur des indicateurs specifiques de sante. Les effets des programmes sur les systemes locaux de sante et surtout sur les hopitaux de district (HD) ont ete peu etudies. Cette recherche vise a fournir davantage de donnees empiriques sur l'interface entre les programmes verticaux et les SSG en Afrique subsaharienne. Le document comporte cinq parties. La premiere partie concerne l'introduction; les hypotheses et les objecti

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

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

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

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

High Rates of Hepatitis B and C and HIV Infections among Blood Donors in Cameroon: A Proposed Blood Screening Algorithm for Blood Donors in Resource-Limited Settings.

Background. Infections with human immunodeficiency virus (HIV), hepatitis B (HBV), and hepatitis C virus (HCV) are currently major public health problems. Methods. A retrospective study was conducted from January to June 2008 at the Blood Bank of the Central Hospital, Yaoundé (Cameroon). The objective was to study the prevalence of HIV, HBV, and HCV and their coinfections among blood donors. Results. A total of 4650 donors were identified, and the sex ratio (male/female) was 14/1. The median age of donors was 28 years (range: 16 to 69 years). Among blood donors, HBV, HIV, and HCV infection prevalences were 12.14% (n = 565) , 4.44% (n = 206), and 1.44% (n = 67), respectively. Coinfection with HIV and HBV was observed among 0.77% donors, followed by hepatitis B and C co-infection (0.21%) and HIV and HCV coinfection (0.06%). Co-infection with HIV-HBV-HCV was encountered in 2 donors. The HIV, HBV, and HCV infections lead to a destruction of one out of six sets of blood collected. Conclusion. There is a need to review policies for blood collection from donors, by modifying the algorithm of blood donors testing. Pretesting potential donors using rapid tests could help to avoid collection and destruction of (infected) blood.

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

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