Stock-outs of essential health products in Mozambique - longitudinal analyses from 2011 to 2013

Factors associated with medical consumable availability in level 1 facilities in Malawi: a secondary analysis of a facility census

BACKGROUND

Medical consumable stock-outs negatively affect health outcomes not only by impeding or delaying the effective delivery of services but also by discouraging patients from seeking care. Consequently, supply chain strengthening is being adopted as a key component of national health strategies. However, evidence on the factors associated with increased consumable availability is limited.

METHODS

In this study, we used the 2018-19 Harmonised Health Facility Assessment data from Malawi to identify the factors associated with the availability of consumables in level 1 facilities, ie, rural hospitals or health centres with a small number of beds and a sparsely equipped operating room for minor procedures. We estimate a multilevel logistic regression model with a binary outcome variable representing consumable availability (of 130 consumables across 940 facilities) and explanatory variables chosen based on current evidence. Further subgroup analyses are carried out to assess the presence of effect modification by level of care, facility ownership, and a categorisation of consumables by public health or disease programme, Malawi's Essential Medicine List classification, whether the consumable is a drug or not, and level of average national availability.

FINDINGS

Our results suggest that the following characteristics had a positive association with consumable availability-level 1b facilities or community hospitals had 64% (odds ratio [OR] 1·64, 95% CI 1·37-1·97) higher odds of consumable availability than level 1a facilities or health centres, Christian Health Association of Malawi and private-for-profit ownership had 63% (1·63, 1·40-1·89) and 49% (1·49, 1·24-1·80) higher odds respectively than government-owned facilities, the availability of a computer had 46% (1·46, 1·32-1·62) higher odds than in its absence, pharmacists managing drug orders had 85% (1·85, 1·40-2·44) higher odds than a drug store clerk, proximity to the corresponding regional administrative office (facilities greater than 75 km away had 21% lower odds [0·79, 0·63-0·98] than facilities within 10 km of the district health office), and having three drug order fulfilments in the 3 months before the survey had 14% (1·14, 1·02-1·27) higher odds than one fulfilment in 3 months. Further, consumables categorised as vital in Malawi's Essential Medicine List performed considerably better with 235% (OR 3·35, 95% CI 1·60-7·05) higher odds than other essential or non-essential consumables and drugs performed worse with 79% (0·21, 0·08-0·51) lower odds than other medical consumables in terms of availability across facilities.

INTERPRETATION

Our results provide evidence on the areas of intervention with potential to improve consumable availability. Further exploration of the health and resource consequences of the strategies discussed will be useful in guiding investments into supply chain strengthening.

FUNDING

UK Research and Innovation as part of the Global Challenges Research Fund (Thanzi La Onse; reference MR/P028004/1), the Wellcome Trust (Thanzi La Mawa; reference 223120/Z/21/Z), the UK Medical Research Council, the UK Department for International Development, and the EU (reference MR/R015600/1).

Availability of essential, generic medicines before and during COVID-19 at selected public pharmaceutical supply agencies in Ethiopia: a comparative cross-sectional study

OBJECTIVES

Lockdowns and border closures impacted medicine availability during the COVID-19 pandemic. This study aimed to assess the availability of essential, generic medicines for chronic diseases at public pharmaceutical supply agencies in Ethiopia.

DESIGN

Comparative cross-sectional study.

SETTING

The availability of essential, generic medicines for chronic diseases was assessed at two public pharmaceutical supply agency hubs.

PARTICIPANTS

The current study included public supply agency hub managers, warehouse managers and forecasting officers at the study setting.

OUTCOMES

The assessment encompassed the availability of chronic medicines on the day of data collection, as well as records spanning 8 months before the outbreak and 1 year during the pandemic. A total of 22 medicines were selected based on their inclusion in the national essential drug list for public health facilities, including 17 medicines for cardiovascular disease and 5 for diabetes mellitus.

RESULTS

The results of the study indicate that the mean availability of the selected basket medicines was 43.3% (95% CI: 37.1 to 49.5) during COVID-19, which was significantly lower than the availability of 67.4% (95% CI: 62.2 to 72.6) before the outbreak (p<0.001). Prior to COVID-19, the overall average line-item fill rate for the selected products was 78%, but it dropped to 49% during the pandemic. Furthermore, the mean number of days out of stock per month was 11.7 (95% CI: 9.9 to 13.5) before the outbreak of COVID-19, which significantly increased to 15.7 (95% CI: 13.2 to 18.2) during the pandemic, indicating a statistically significant difference (p<0.001). Although the prices for some drugs remained relatively stable, there were significant price hikes for some products. For example, the unit price of insulin increased by more than 130%.

CONCLUSION

The COVID-19 pandemic worsened the availability of essential chronic medicines, including higher rates of stockouts and unit price hikes for some products in the study setting. The study's findings imply that the COVID-19 pandemic has aggravated already-existing medicine availability issues. Efforts should be made to develop contingency plans and establish mechanisms to monitor medicine availability and pricing during such crises.

Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda

BACKGROUND

Essential health services can be disrupted due to several naturally occurring public health emergencies such as drought, flood, earthquake and outbreak of infectious diseases. However, little evidence exists on the status of essential health services delivery under the effect of drought and food insecurity. North-east Uganda is severely affected by prolonged drought that significantly affected the livelihood of the residents. Therefore, we aimed to determine the current status of essential health services and quality improvement (QI) actions in health facilities in north-east Uganda.

METHODS

We used a descriptive cross-sectional study design to assess the availability of essential health service and quality improvement activities in drought and food insecurity affected districts of north-east Uganda. We included a total of 150 health facilities from 15 districts with proportionated multistage sampling method. We interviewed health facilities' managers and services focal persons using structured questionnaire and observation checklist. We used a descriptive statistic to analyze the data with SPSS version 22.

RESULTS

A few health facilities (8.7%) had mental health specialist. There was also lack of capacity building training on essential health services. Considerable proportion of health facilities had no non-communicable diseases (38.3%), mental health (47.0%), and basic emergency obstetric care (40.3%) services. Stock out of essential medicines were observed in 20% of health facilities. There was lack of supportive supervision, and poor documentation of QI activities.

CONCLUSION

Essential health service and QI were suboptimal in drought and food insecure emergency affected districts. Human resource deployment (especially mental health specialist), provision of capacity building training, improving non-communicable diseases, mental health and basic emergency obstetric care services are required to improve availability of essential health services. Supporting supply chain management to minimize stock out of medicines, and promoting QI activities are also vital to assure quality of health service in drought and food insecurity affected districts in north-Eastern Uganda.

The knock-on effects of COVID-19 pandemic on the supply and availability of generic medicines in Ethiopia: mixed methods study

BACKGROUND

COVID-19 pandemic posed a major impact on the availability and affordability of essential medicines. This study aimed to assess the knock-on effects of the COVID-19 pandemic on the supply availability of non-communicable chronic disease (NCD) medicines and paracetamol products in Ethiopia.

METHODS

A mixed methods study was conducted to assess the supply and availability of twenty-four NCD drugs and four paracetamol products listed on the national essential medicines list for hospitals. Data were collected from twenty-six hospitals located in seven zones of Oromia region in the southwestern part of Ethiopia. We extracted data on drug availability, cost and stock out for these drugs between May 2019 and December 2020. The quantitative data were entered into Microsoft Excel and exported to statistical package software for social science (SPSS) version 22 (IBM Corporation, Armonk, NY, USA) software for analysis.

RESULTS

The overall mean availability of selected basket medicines was 63.4% (range 16.7% to 80.3%) during the pre-COVID-19 time. It was 46.3% (range 2.8% to 88.7) during the pandemic. There was a relative increase in the availability of two paracetamol products [paracetamol 500 mg tablet (67.5% versus 88.7%) and suppository (74.5% versus 88%)] during the pandemic. The average monthly orders fill rates for the selected products range from 43 to 85%. Pre-COVID-19, the average order fill rate was greater or equal to 70%. However, immediately after the COVID-19 case notification, the percentage of order(s) filled correctly in items and quantities began decreasing. Political instability, shortage of trained human resources, currency inflation, and limited drug financing were considered as the major challenges to medicine supply.

CONCLUSION

The overall stock out situation in the study area has worsened during COVID-19 compared to pre-COVID-19 time. None of the surveyed chronic disease basket medicines met the ideal availability benchmark of 80% in health facilities. However, availability of paracetamol 500 mg tablet surprisingly improved during the pandemic. A range of policy frameworks and options targeting inevitable outbreaks should exist to enable governments to ensure that medicines for chronic diseases are consistently available and affordable.

Access to Essential Medicines and Diagnostic Tests for Cardiovascular Diseases in Maputo City, Mozambique

Background

To tackle the increasing burden of non-communicable diseases (NCDs) and reduce premature cardiovascular (CV) mortality by a third by the year 2030, countries must achieve 80% availability of affordable essential medicines (EMs) and technologies in all health facilities.

Objectives

To evaluate access to EMs and diagnostics for CV diseases in Maputo City, Mozambique.

Methods

Using a modified version of World Health Organization (WHO)/Health Action International (HAI) methodology, we collected data on availability and price of 14 WHO Core EMs and 35 CV EMs in all 6 public-sector hospitals, 6 private-sector hospitals, and 30 private-retail pharmacies. Data on 19 tests and 17 devices were collected from hospitals. Medicine prices were compared with international reference prices (IRPs). Medicines were considered unaffordable if the lowest paid worker had to spend more than one day's wage to purchase a monthly supply.

Results

Mean availability of CV EMs was lower than that of WHO Core EMs in both public (hospitals: 20.7% vs. 52.6%) and private sectors (retail pharmacies: 21.5% vs. 59.8%; hospitals: 22.2% vs. 50.0%). Mean availability of CV diagnostic tests and devices was lower in public (55.6% and 58.3%, respectively) compared to private sector (89.5% and 91.7%, respectively). Across WHO Core and CV EMs, the median price of lowest priced generic (LPG) and most sold generic (MSG) versions were 4.43 and 3.20 times the IRP, respectively. Relative to the IRP, median price of CV medicines was higher than that of Core EMs (LPG: 4.51 vs. 2.93). The lowest paid worker would spend 14.0 to 17.8 days' wage monthly to undergo secondary prevention.

Conclusion

Access to CV EMs is limited in Maputo City owing to low availability and poor affordability. Public-sector hospitals are not well equipped with essential CV diagnostics. This data could inform evidence-based policies for improving access to CV care in Mozambique.

Accessibility of essential anticancer medicines for children in the Sichuan Province of China

Background

Compared with high-income countries, the survival rate of childhood cancer is lower in low- and middle-income countries. Access to essential anticancer medicines is an indispensable component of pediatric cancer treatment, which is still a big challenge in low- and middle-income countries.

Objective

To assess the accessibility of essential anticancer medicines for children in public hospitals in the Sichuan Province of China.

Methods

Based on the data of the Sichuan Province Drug Use Monitoring Platform in 2020, a retrospective study was conducted to investigate the original brands and generics of 34 anticancer and three supportive essential medicines for children (a total of 97 specific strengths) in Sichuan Province. The availability, price, and affordability of surveyed medicines were evaluated in all 152 tertiary public hospitals (120 general hospitals, 31 children's hospitals, and one cancer hospital) that could diagnose and treat cancer for children.

Results

The average availability of generics and original brands was 18.5% and 2.6%, respectively. In regions with different gross domestic product (GDP) per capita levels, the average availability was similar, but the city with lower GDP per capita levels had fewer tertiary public hospitals. The prices of most original brands were higher than the lowest-priced generics, and the median price ratios of 31 lowest-priced generics and 16 original brands were 0.744 (P25~P75, 0.446~2.791) and 2.908 (1.719~6.465). After paying medical insurance for medicines, the affordability of essential anticancer medicines was improved. The monthly medicine cost did not exceed 10% of the monthly household income for 78.9% (30/38) of the lowest-priced generics and 50.0% (8/16) of the original brands.

Conclusion

The availability of lowest-priced generics was higher than original brands in public hospitals, but the availability of both was low, which was similar to previous studies in low- and middle-income countries. About half of the lowest-priced generics and 87.5% of the original brands cost more than 1.5 times the International Reference Price. Although the National Basic Medical Insurance greatly improved the affordability of essential anticancer medicines for children, higher subsidies for essential medicines for cancer treatment to limit catastrophic health expenditures are still recommended.

Availability and stock-out duration of essential medicines in Shegaw Motta general hospital and Motta Health Centre, North West Ethiopia

Essential medicines are those that meet the population’s most pressing healthcare needs. As a result, they should always be available in sufficient quantities and the proper dosage forms within health facilities. The study aimed to determine the availability and stock-out duration of essential medicines in Shegaw Motta General Hospital and Motta Health Centre. Descriptive study was conducted at Shegaw Motta General Hospital and Motta Health Centre. The data were collected from June-20 to July-20, 2021 G.C. Fifteen essential medicines from both health facilities’ tracer drug lists were reviewed. The frequency and percentage of availability and stick-out duration were calculated, and the results were briefly described in the text and displayed in tables. The average availability of essential medicines on the day of the survey was 80% and 93.3% in Shegaw Motta general hospital and Motta health center, respectively. Besides, 60% and 20% of the essential medicines were stocked out at least once in the last six months (before the data collection period) in the hospital and health center, respectively. The average stock-out duration in the last six months period (before the data collection period) was 38.8 days (ranges from 10 days to 157 days) in the hospital and 11.2 days in the health center. Ferrous salt + folic acid 150mg + 0.5mg and Medroxy Progesterone injection were the medicines with the longest stock-out duration in Shegaw Motta general hospital and Motta health center, respectively.The average availability of essential medicines was fairly high both in the hospital and health center. In comparison to the hospital, the health center had better availability and a shorter stock-out duration. Over the last six months, a significant percentage of essential medicines were stocked out at the hospital.

Primary Health Care Management Effectiveness as a Driver of Family Planning Service Readiness: A Cross-Sectional Analysis in Central Mozambique

INTRODUCTION

The effectiveness of facility-level management is an important determinant of primary health care (PHC) reach and quality; however, the nature of the relationship between facility-level management and health system effectiveness lacks sufficient empirical grounding. We describe the association between management effectiveness and facility readiness to provide family planning services in central Mozambique.

METHODS

We linked data from the Ministry of Health's 2018 Service Availability and Readiness Assessment and a second 2018 health facility survey that included the World Bank's Service Delivery Indicators management module. Our analysis focused on 68 public sector PHC facilities in Manica, Sofala, Tete, and Zambézia provinces in which the 2 surveys overlapped. We used logistic quantile regression to model associations between management strength and family planning service readiness.

RESULTS

Of the 68 facility managers, 47 (69.1%) were first-time managers and (18) 26.5% had received formal management training. Managers indicated that 63.6% of their time was spent on management responsibilities, 63.2% of their employees had received a performance review in the year preceding the survey, and 12.5% of employee incentives were linked to performance evaluations. Adjusting for facility type and distance to the provincial capital, facility management effectiveness, and urban location were significantly associated with higher levels of readiness for family planning service delivery.

CONCLUSIONS

We found that a higher degree of management effectiveness is independently associated with an increased likelihood of improved family planning service readiness. Furthermore, we describe barriers to effective PHC service management, including managers lacking formal training and spending a significant amount of time on nonmanagerial duties. Strengthening management capacity and reinforcing management practices at the PHC level are needed to improve health system readiness and outputs, which is essential for achieving global Sustainable Development Goals and universal health coverage targets.

Stock-outs of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs): a systematic literature review of the extent, reasons, and consequences

BACKGROUND

This paper explores the extent of community-level stock-out of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs) and identifies the reasons for and consequences of essential medicine stock-outs.

METHODS

A systematic review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Five electronic databases were searched with a prespecified strategy and the grey literature examined, January 2006-March 2021. Papers containing information on (1) the percentage of CHWs stocked out or (2) reasons for stock-outs along the supply chain and consequences of stock-out were included and appraised for risk of bias. Outcomes were quantitative data on the extent of stock-out, summarized using descriptive statistics, and qualitative data regarding reasons for and consequences of stock-outs, analyzed using thematic content analysis and narrative synthesis.

RESULTS

Two reviewers screened 1083 records; 78 evaluations were included. Over the last 15 years, CHWs experienced stock-outs of essential medicines nearly one third of the time and at a significantly (p < 0.01) higher rate than the health centers to which they are affiliated (28.93% [CI 95%: 28.79-29.07] vs 9.17% [CI 95%: 8.64-9.70], respectively). A comparison of the period 2006-2015 and 2016-2021 showed a significant (p < 0.01) increase in CHW stock-out level from 26.36% [CI 95%: 26.22-26.50] to 48.65% [CI 95%: 48.02-49.28] while that of health centers increased from 7.79% [95% CI 7.16-8.42] to 14.28% [95% CI 11.22-17.34]. Distribution barriers were the most cited reasons for stock-outs. Ultimately, patients were the most affected: stock-outs resulted in out-of-pocket expenses to buy unavailable medicines, poor adherence to medicine regimes, dissatisfaction, and low service utilization.

CONCLUSIONS

Community-level stock-out of essential medicines constitutes a serious threat to achieving universal health coverage and equitable improvement of health outcomes. This paper suggests stock-outs are getting worse, and that there are particular barriers at the last mile. There is an urgent need to address the health and non-health system constraints that prevent the essential medicines procured for LMICs by international and national stakeholders from reaching the people who need them the most.

Matrix analyses of pharmaceutical products for the years 2017 to 2019 among public health facilities in Hadiya zone, Ethiopia: a cross-sectional descriptive study

Background

To date, global healthcare spending becomes a primary concern, and pharmaceutical costs are the main drivers. The issue is more pressing in developing countries like Ethiopia. However, there is a scantiness of comprehensive data on inventory control practices in health facilities. This study, therefore, aimed to assess the criticality, financial value, and consumption patterns of pharmaceuticals using inventory matrix analyses and explore the related challenges.

Methods

A cross-sectional study supplemented with qualitative assessments was carried out from December 2020 to January 2021 in public health facilities. Three hospitals and 14 health centers were proportionally selected using a simple random sampling technique. Self-administered questionnaires and review of logistics documents and databases like Dagu-Facility were used to obtain the quantitative data. The data were analyzed using excel spreadsheets and SPSS version 23. We gathered the qualitative data through face-to-face in-depth interviews.

Results

The facilities spent 66,312,277.0 Ethiopian birrs to procure 518 pharmaceuticals between 2017 and 2019. Of the total products, 68 (13.1%) belonged to class A and 353 (68.1%) belonged to class C. Among 427 items identified by VEN analysis, 202 (47.3%) were vitals, and 201 (47.1%) were essential products making the highest proportions. Cross-tabulations of ABC and VEN showed that 230 (53.9%) items formed category I, representing 84.3% of total expenditures. Sterile surgical gloves #7.5, amoxicillin capsules, examination gloves, and 40% dextrose injection were among the top-ten high-value closing inventories, accounting for 21% of class X items. The fast-moving items were the most prevalent in all years, accounting for more than 45%, and shared the maximum expenditure, up to 90%. Scarcity of infrastructure and skilled human resources, shortage of pharmaceuticals and problems with suppliers, and management issues were the major challenges in the health facilities.

Conclusion

Most of the items identified by ABC-VEN and FSN-XYZ were Category one, i.e., mainly vital costly products and a few fast-moving items with high closing inventory values, respectively, suggesting close supervision. However, several issues became impediments. Hence, facilities should alleviate the bottlenecks and monitor the stock status to prevent theft and stock out.

The impact of public health sector stockouts on private sector prices and access to healthcare: Evidence from the anti-malarial drug market

In developing countries, public sector health facilities frequently run out of essential medicines ("stockouts"). I test whether anti-malarial drug stockouts affect prices, quality, and overall access to anti-malarial drugs in private sector outlets in Uganda. I combine data from four sources: 1) standardized patient drug purchases; 2) vendor surveys; 3) real customer surveys; 4) public sector supply delivery dates. Using a difference-in-differences approach, I find that stockouts increase private-sector antimalarial drug prices by $0.68, or 35 percent. I find few changes in quality. Real customer characteristics change, suggesting that stockouts lead less educated and poorer customers to drop out of the market. Analysis using the 2016 Demographic and Health Survey additionally shows stockouts reduce treatment at public sector facilities and reduce the likelihood that children receive medicine. My results suggest that stockouts increase prices in the private sector and lead to less equitable health outcomes.

Estimation of health impact from digitalizing last-mile Logistics Management Information Systems (LMIS) in Ethiopia, Tanzania, and Mozambique: A Lives Saved Tool (LiST) model analysis

Background

Digital health has become a widely recognized approach to addressing a range of health needs, including advancing universal health coverage and achieving the Sustainable Development Goals. At present there is limited evidence on the impact of digital interventions on health outcomes. A growing body of peer-reviewed evidence on digitalizing last-mile electronic logistics management information systems (LMIS) presents an opportunity to estimate health impact.

Methods

The impact of LMIS on reductions in stockouts was estimated from primary data and peer-reviewed literature, with three scenarios of impact: 5% stockout reduction (conservative), 10% stockout reduction (base), and 15% stockout reduction (optimistic). Stockout reduction data was inverted to stock availability and improved coverage for vaccines and essential medicines using a 1:1 conversion factor. The Lives Saved Tool (LiST) model was used to estimate health impact from lives saved in newborns and children in Mozambique, Tanzania, and Ethiopia between 2022 and 2026 across the three scenarios.

Results

Improving coverage of vaccines with a digital LMIS intervention in the base scenario (conservative, optimistic) could prevent 4,924 (2,578–6,094), 3,998 (1,621–4,915), and 17,648 (12,656–22,776) deaths in Mozambique, Tanzania, and Ethiopia, respectively over the forecast timeframe. In addition, scaling up coverage of non-vaccine medications could prevent 17,044 (8,561–25,392), 21,772 (10,976–32,401), and 34,981 (17,543–52,194) deaths in Mozambique, Tanzania, and Ethiopia, respectively. In the base model scenario, the maximum percent reduction in deaths across all geographies was 1.6% for vaccines and 4.1% for non-vaccine medications.

Interpretation

This study projects that digitalization of last-mile LMIS would reduce child mortality by improving coverage of lifesaving health commodities. This analysis helps to build the evidence base around the benefits of deploying digital solutions to address health challenges. Findings should be interpreted carefully as stockout reduction estimates are derived from a small number of studies.

Adherence to Iron and Folic Acid Supplementation and Its Associated Factors among Pregnant Women Attending Antenatal Care at Bwindi Community Hospital, Western Uganda

Methods

This was a cross-sectional study that used an interviewer-administered questionnaire and reviewed medical records. Binary and multivariable logistic regression analyses were used to identify factors associated with iron and folic acid supplementation. Adjusted odds ratio (AOR) with 95% confidence interval (CI) and p value < 0.05 were used to assess for statistical significance.

Results

We enrolled 438 pregnant women aged 16 to 41years. Participants' mean age (±standard deviation (SD)) was 25.9 (±3.17) years. The self-reported adherence to iron and folic acid supplementation (consumed ≥4 tablets a week or 20 tablets in a month daily without missing the prescribed dosage) was 22.37% (N = 98). Among the adherent pregnant women, the reported reasons (and their respective proportionality) for adherence were getting advice and counseling from the healthcare worker about the good effects of iron and folic acid supplementation (N = 34, 34.69%) and knowledge about the health benefits of iron and folic acid supplementation such as preventing anemia (N = 16, 16.33%), among others. On the other hand, the reported reasons (and their respective proportionality) for iron and folic acid nonadherence were forgetfulness (N = 158, 46.47%), taking too many pills (N = 7, 2.06%), not knowing the usefulness of iron and folic acid supplementation (N = 29, 8.53%), fear of the side effects of the medication (N = 119, 35.00%), and not getting the supplement from the hospital (N = 27, 7.94%). Bivariable and multivariable logistic regression analyses indicated that pregnant women who were primigravida (adjusted odds ratio (AOR) = 4.5), who have parity of 2 or 3 (AOR = 3.4), who perceived importance of iron and folic acid supplementation to prevent anemia (AOR = 2.9), and who considered it important to take iron and folic acid supplementation (AOR = 2.9) showed a statistically significant association with adherence to iron and folic acid supplementation. Moreover, pregnant women who perceived the risk of not taking iron and folic acid supplementation (AOR = 5.2), those who received sufficient health education regarding the goals of iron and folic acid supplementation as well as the dangers of not taking the supplements (AOR = 4.4) and adequate counseling, and those who obtained an explanation of the effects of iron and folic acid (AOR = 4.8) showed a significant association with adherence to iron and folic acid supplementation.

Conclusion

This study found a low adherence of iron and folic acid supplementation and was associated with obstetric and client- and health system-related characteristics. To this end, there is a need for individualized strategies targeting such factors and intensifying health education, guidance, and counseling to optimize adherence to iron and folic acid supplementation.

Assuring health commodity security in resource-poor settings

Health planners charged with the task of building or at least maintaining the health of populations within low- and middle-income countries (LMICs) have to find ways of providing steady, predictable supplies of health commodities for unpredictable demands for healthcare and health. To address this issue, this paper emphasizes a focus on aggregate commodity security defined as the continuous interrupted supply of health commodities belonging to all therapeutic categories and not just a selected subset. Given this focus, the paper identifies logistics systems comprising of a set of logistics activities as the machinery for assuring aggregate commodity security. Steady reliable supplies of health commodities, whenever and wherever they are needed, however, means looking beyond logistics systems. Health planners must ask whether there is a healthy supplier base for the commodities needed. The paper notes that a secure supply of health commodities in any LMIC, will remain an illusion without functional logistics systems supported by a healthy supplier base.

Impact of social accountability monitoring on health facility performance: Evidence from Tanzania

Social accountability programs are increasingly used to improve the performance of public service providers in low-income settings. Despite their growing popularity, evidence on the effectiveness of social accountability programs remains mixed. In this manuscript, we assess the impact of a social accountability intervention on health facility management exploring quasiexperimental variation in program exposure in Tanzania. We find that the social accountability intervention resulted in a 1.8 SD reduction in drug stockouts relative to the control group, but did not improve facility infrastructure maintenance. The results of this study suggest that social accountability programs may be effective in areas of health service provision that are responsive to changes in provider behavior but may not work in settings where improvements in outcomes are conditional on larger health systems features.

Evaluating the availability of essential drugs for hypertension, diabetes and asthma in rural Rwanda, 2018

SETTING

Hypertension, diabetes mellitus and asthma are on the rise in developing countries, including Rwanda; there is thus a need to ensure uninterrupted drug availability.

OBJECTIVES

To assess 1) the frequency and duration of drug stock-outs; 2) lead time duration 3) monthly stock levels; and 4) drug quantities requested vs. quantity delivered for captopril, metformin and inhaled salbutamol between January and December 2018 Kirehe District, Rwanda.

DESIGN

This was a cross-sectional study using secondary programme data.

RESULTS

The median annual stock-outs for captopril, metformin and inhaled salbutamol were respectively 4 (IQR 3-4), 3 (IQR 2-3) and 4 (IQR 4-5) at rural health facilities (RHCs); no stock-outs occurred at the district hospital. For all three drugs, the median lead time was 7.5 days (IQR 5.5-11.5) at the hospital vs. 5 days (IQR 3-6) in RHCs. Stock status for captopril was below the 4-week minimum stock level for 2/12 months at the hospital vs. 7/12 months at the RHCs, while metformin and inhaled salbutamol were below the 4-week minimum stock levels for respectively 1/12 and 4/12 months at both hospital and RHCs. Total drug quantities delivered were less than the combined total quantities requested in respectively 8/12, 5/12 and 8/12 months for captopril, metformin and inhaled salbutamol.

CONCLUSION

There is a need to regularly and effectively monitor drug stock levels and ensure timely and sufficient stock replenishment to avert stock-outs.

HIV supply chains in low- and middle-income countries: overview and research opportunities

Purpose

Despite HIV being reported as one of the major global health issues, availability and accessibility of HIV services and supplies remain limited, especially in low- and middle-income countries. The effective and efficient operation of HIV supply chains is critical to tackle this problem. The purpose of this paper is to give an introduction to HIV supply chains in low- and middle-income countries and identify research opportunities for the operations research/operations management (OR/OM) community.

Design/methodology/approach

First, the authors review a combination of the scientific and grey literature, including both qualitative and quantitative papers, to give an overview of HIV supply chain operations in low- and middle-income countries and the challenges that are faced by organizing such supply chains. The authors then classify and discuss the relevant OR/OM literature based on seven classification criteria: decision level, methodology, type of HIV service modeled, challenges, performance measures, real-life applicability and countries covered. Because research on HIV supply chains in low- and middle-income countries is limited in the OR/OM field, this part also includes papers focusing on HIV supply chain modeling in high-income countries.

Findings

The authors conclude this study by identifying several tendencies and gaps and by proposing future research directions for OR/OM research.

Originality/value

To the best of the authors’ knowledge, this paper is the first literature review addressing this specific topic from an OR/OM perspective.

Assessment of local supply chains and stock management practices for trauma care resources in Ghana: a comparative small sample cross-sectional study

BACKGROUND

Injuries are a major public health problem globally. With sound planning and organization, essential trauma care can be reliably provided with relatively low-cost equipment and supplies. However, availability of these resources requires an effective and efficient supply chain and good stock management practices. Therefore, this study aimed to assess trauma care resource-related supply management structures and processes at health facilities in Ghana. By doing so, the findings may allow us to identify specific structures and processes that could be improved to facilitate higher quality and more timely care.

METHODS

Ten hospitals were purposively selected using results from a previously performed national trauma care capacity assessment of hospitals of all levels in Ghana. Five hospitals with low resource availability and 5 hospitals with high resource availability were assessed using the United States Agency for International Development (USAID) Logistics Indicators Assessment Tool and stock ledger review. Data were described and stock management practices were correlated with resource availability.

RESULTS

There were differences in stock management practices between low and high resource availability hospitals, including frequency of reporting and audit, number of stock-outs on day of assessment (median 9 vs 2 stock-outs, range 3-57 vs 0-9 stock-outs, respectively; p = 0.05), duration of stock-outs (median 171 vs 8 days, range 51-1268 vs 0-182 days, respectively; p = 0.02), and fewer of up-to-date stock cards (24 vs 31 up-to-date stock cards, respectively; p = 0.07). Stock-outs were common even among low-cost, essential resources (e.g., nasal cannulas and oxygen masks, endotracheal tubes, syringes, sutures, sterile gloves). Increased adherence to stock management guidelines and higher percentage of up-to-date stock cards were correlated with higher trauma resource availability scores. However, the variance in trauma resource availability scores was poorly explained by these individual factors or when analyzed in a multivariate regression model (r2 = 0.72; p value for each covariate between 0.17-0.34).

CONCLUSIONS

Good supply chain and stock management practices are correlated with high trauma care resource availability. The findings from this study demonstrate several opportunities to improve stock management practices, particularly at low resource availability hospitals.

Constructing a malaria-related health service readiness index and assessing its association with child malaria mortality: an analysis of the Burkina Faso 2014 SARA data

Background

The Service Availability and Readiness Assessment surveys generate data on the readiness of health facility services. We constructed a readiness index related to malaria services and determined the association between health facility malaria readiness and malaria mortality in children under the age of 5 years in Burkina Faso.

Methods

Data on inpatients visits and malaria-related deaths in under 5-year-old children were extracted from the national Health Management Information System in Burkina Faso. Bayesian geostatistical models with variable selection were fitted to malaria mortality data. The most important facility readiness indicators related to general and malaria-specific services were determined. Multiple correspondence analysis (MCA) was employed to construct a composite facility readiness score based on multiple factorial axes. The analysis was carried out separately for 112 medical centres and 546 peripheral health centres.

Results

Malaria mortality rate in medical centres was 4.8 times higher than that of peripheral health centres (3.5% vs. 0.7%, p < 0.0001). Essential medicines was the domain with the lowest readiness (only 0.1% of medical centres and 0% of peripheral health centres had the whole set of tracer items of essential medicines). Basic equipment readiness was the highest. The composite readiness score explained 30 and 53% of the original set of items for medical centres and peripheral health centres, respectively. Mortality rate ratio (MRR) was by 59% (MRR = 0.41, 95% Bayesian credible interval: 0.19–0.91) lower in the high readiness group of peripheral health centres, compared to the low readiness group. Medical centres readiness was not related to malaria mortality. The geographical distribution of malaria mortality rate indicate that regions with health facilities with high readiness show lower mortality rates.

Conclusion

Performant health services in Burkina Faso are associated with lower malaria mortality rates. Health system readiness should be strengthened in the regions of Sahel, Sud-Ouest and Boucle du Mouhoun. Emphasis should be placed on improving the management of essential medicines and to reducing delays of emergency transportation between the different levels of the health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09994-7.

Stakeholder views of the practical and cultural barriers to epilepsy care in Uganda

OBJECTIVE

Epilepsy is one of the most prevalent, treatable neurological diseases globally. In sub-Saharan Africa, people with epilepsy (PWE) frequently seek treatment from traditional or pastoral healers, who are more accessible than biomedical care providers. This often contributes to the substantial time delay in obtaining adequate biomedical care for these patients. In Uganda, the few biomedical providers who can treat epilepsy cannot meet the great need for epilepsy care. Additionally, patients are often hesitant to seek biomedical care, often preferring the easily accessible and trusted sociocultural treatment options. This study sought to elucidate the barriers to biomedical care for PWE as well as identify potential solutions to overcome these barriers from various stakeholder perspectives.

METHODS

This study used qualitative research methods. Semistructured interviews and focus group discussions were conducted with four major stakeholder groups: PWE or family members of PWE, neurologists and psychiatrists, traditional healers, and pastoral healers. All interviews and focus group discussions that were in English were audio recorded and transcribed verbatim. Those that were not in English were translated live and audio recorded. A translator later translated the non-English portion of audio recording to ensure proper interpretation. Two independent coders coded the dataset and conducted an inter-rater reliability (IRR) assessment to ensure reliable coding of the data. Thematic analysis was then performed to discern themes from the data and compare nuances between each of the study design groups.

RESULTS

Participants discussed several different causes of epilepsy ranging from spiritual to biological causes, often incorporating elements of both. Commonly endorsed spiritual causes of epilepsy included witchcraft and ancestral spirits. Commonly endorsed biological causes included genetics, fever, malaria, and brain injury. For patients and families, beliefs about the cause of epilepsy often played a role in whom they chose to seek treatment from. Three major barriers to biomedical care were discussed: practical barriers, medical infrastructure barriers, and barriers related to stigma. Practical barriers related to issues such as transportation, cost of medical care, and distance to the nearest healthcare facility. Under medical infrastructure, drug stock-outs and lack of access to antiepileptic drugs (AEDs) were the most consistent problems stated among patients. Stigma was heavily discussed and brought up by nearly every participant. Additionally, three significant solutions to improving epilepsy care in Uganda were highlighted by participants: collaboration among treatment providers, community sensitization efforts to address stigma, and building medical infrastructure. Within building infrastructure, all participant types, except traditional healers, proposed the development of an epilepsy clinic designed to specifically treat epilepsy.

CONCLUSIONS

Based on these findings, there are four critical interventions that should be considered for improving epilepsy care in Uganda: the creation of dedicated epilepsy clinics, infrastructure strengthening to address medication stock-outs, community outreach programs for sensitization, and collaboration between biomedical providers and traditional healers. This article is part of the Special Issue "The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda".

Description of Maternal Morbidities Amongst 1000 Women During Pregnancy in Ambanja, Madagascar - Opportunities and Challenges of Using an mHealth System

Background

The estimated burden of maternal morbidities in lower-income countries, such as Madagascar, is high. However, there is still a lack of data on maternal morbidities, in part due to an absence of standardized assessment tools. This cross-sectional study aims to report maternal morbidities among 1015 women in the district of Ambanja, Madagascar, and to describe the advantages and limitations of a mHealth system.

Methods

Data were collected using the PANDA (pregnancy and newborn diagnosis assessment) system, an mHealth device that incorporates the WHO recommendations for antenatal care (ANC). Data, including personal and medical information, but also clinical data such as hypertension, anemia or HIV were collected from more than 1000 women attending ANC.

Results

A total of 1015 pregnant women were recruited from January 2015 to August 2018. The average age was 24.6 years old, and most women were married (82.3%). The majority lived in urban areas and were unemployed. Prevalence of hypertension and gestational diabetes was relatively low (4% vs 2.2%). Malaria infection was diagnosed in 2.2% and HIV was diagnosed in 1.2% of pregnant women. The most common morbidity was anemia (68.4%) and the only significant factor associated was being single compared to being married (OR 1.68, 95% CI 1.05–2.70, p-value 0.032).

Discussion

The prevalence of anemia in our study population was much higher than previously reported in Sub-Saharan Africa. This finding highlights the need for regular iron supplementation during pregnancy, especially in vulnerable (eg, single) women. The PANDA mHealth system provides unique opportunities due to its standardization of ANC and creation of a digital database accessible from a distance. However, one of the main challenges was that even a mHealth system such as the PANDA remains dependent on the local procurement chain. Therefore, future studies need to access opportunities of mHealth systems to support health service delivery.

Trial Registration

Registered on ISRCTN on 14th October 2015, number ISRCTN18270380. Retrospectively registered.

Availability, Costs and Stock-Outs of Essential NCD Drugs in Three Rural Rwandan Districts

Background:

To reduce the non-communicable diseases (NCDs) burden, the World Health Organization has set a target to reach 80% availability of the affordable essential medicines required to treat NCDs by 2025.

Objectives:

This study described the availability, costs, and stock-outs of essential NCD drugs in three rural Rwandan districts.

Methods:

We retrospectively assessed 54 NCD drugs listed for district hospitals or health centers in the Rwanda national essential medicines list. Data were collected from three district hospitals and 17 health centers that host NCD clinics. We extracted data on drug availability, quantity dispensed, costs, stock-outs, and the replenishing supplier for these drugs between January 1 and December 31, 2017.

Results:

Overall, 71% of essential medicines for health centers and 78% of essential medicines for district hospitals were available at facilities. Only 15% of health centers experienced a stock-out of beclomethasone, while 77% experienced at least one stock-out of amlodipine and metformin. The median length of stock-out ranged from nine to 72 days, and 78% of the stock-outs across all health centers were replenished by a Non-Governmental Organization (NGO) partner. Except for enoxaparin and metformin, all district hospitals experienced at least one stock-out of each drug. The median length of stock-out ranged from 3.5 to 228 days, and 82% of the stock-outs across all district hospitals were replenished by the Rwandan Ministry of Health (RMOH). The least expensive drug was digoxin ($0.02, Interquartile range (IQR): 0.01, 0.10), while the most expensive was beclomethasone ($9.35, IQR: 3.00, 13.20).

Conclusions:

This study shows the viability of drug-supported NCD care in rural settings of sub-Saharan Africa. Stock-outs are a challenge; our study emphasizes the importance of the MOH/NGO partnerships in this context. Medicine costs are also challenging, though, in these districts, drugs are more affordable through community-based health insurance, government, and NGO partner subsidies.

Availability, price, and affordability of WHO priority maternal and child health medicine in public health facilities of Dessie, north-East Ethiopia

Background

Access to health care is a fundamental human right, and the provision of affordable, high-quality, and appropriate medicines for maternal and child health is a vital component of a well-functioning health system. The study assessed the availability, price, and affordability of WHO priority maternal and child medicines in public health facilities, Dessie, North-East Ethiopia.

Methods

A retrospective cross-sectional study design was conducted in Dessie town from November 2018 to February 2019. A standard checklist adapted from the Logistics Indicator Assessment Tool and WHO/HAI was used to collecting data on the availability, affordability, and price of 45 priority life-saving medicines from eight public health centers and two public hospitals. Descriptive statistics (percent and median) were computed for availability and prices. Affordability was reported in terms of the daily wage of the lowest-paid unskilled government worker.

Results

Twenty-two medicines were not found at all in public health facilities. The overall availability of WHO priority maternal and child medicines was 34.02%. The mean number of stock-outs was 3.9, and the mean number was 128.9 days. The mean average point availability was 33.5%, and 7 medicines stock out on the days of assessment. From WHO priority maternal and child medicines, 4 (40%) of the products were unaffordable and 5 (55.5%) had higher prices than international prices. Ceftriaxone 1 g, ceftriaxone 500 mg, and hydralazine 20 mg injection required wages of 6.58, 8.01, and 5.02 to cover specific maternal health problems respectively. The median price ratio of priority lifesaving maternal and child medicines in public health facilities ranged from 0.65 to 3.19.

Conclusions

The average mean period and point mean availability was very low. The available products were encountered with a high number of stock-outs and unaffordable. The strict control of inventory is recommended to have a steady supply of these essential medicines and improve the quality of health services.

Availability of Tracer Drugs and Implementation of Their Logistic Management Information System in Public Health Facilities of Dessie, North-East Ethiopia

Background

Tracer drugs are the representative of essential medicines and satisfy the priority healthcare needs of the population. Managing tracer drugs through logistics management information systems is a strategy to enhance their smooth flow for continuous provision of quality health service. This study assessed the availability of tracer drugs and implementation of their logistic management information system in public health facilities of Dessie, North-East Ethiopia.

Methods

Cross-sectional study was conducted from September 15–30, 2017, in all public health facilities of Dessie. The data were collected by reviewing tracer drugs logistic formats and conducting physical inventory. Key informant interview was employed to all pharmacy heads and store managers. Data analysis was done using statistical package for social science version 20 and Microsoft Excel 2010.

Results

Twelve tracer drugs were managed by health facilities. The overall mean availability, mean duration, and average frequency of stock out of tracer drugs (last 6 months) were 74.7%, 48.8 days, and 1.43, respectively. In eight health facilities, logistic records were available, but all health facilities did not use stock cards. Also, 3 out of 9 used the health commodity management information system. On average, 77.8% of the tracer drugs had bin cards, of which, 86% were updated. The discrepancy between physical count and stock keeping records was ranged from 0% to 100%. The causes of stock out were inadequate supply, lack of recording forms, and their inconsistent use.

Conclusion and Recommendations

The availability of tracer drugs was less than the recommended percent, and inadequate supply, poor availability and use of recording forms were the reasons for stock out. Thus, health facility managers and pharmacy heads should work in harmony to ensure uninterrupted supply and implement a logistic management information system.

'We all have the same right to have health services': a case study of Namati's legal empowerment program in Mozambique

BACKGROUND

Legal empowerment and social accountability are two strategies that are increasingly used to address gaps in healthcare in low- and middle-income countries, including failure to provide services that should be available and poor clinical and interpersonal quality of care. This paper is an explanatory case study of a legal empowerment effort that employs community paralegals and trains Village Health Committees (VHCs) in Mozambique. The research objective was to explore how community paralegals solved cases, the impact paralegals had on health services, and how their work affected the relationship between the community and the health sector at the local level.

METHODS

The case study had two components: (1) a retrospective review of 24 cases of patient/community grievances about the health system, and (2) qualitative investigation of the program and program context. The case reviews were accomplished by conducting structured in-depth interviews (IDIs) with those directly involved in the case. The qualitative investigation entailed semi-structured Key Informant Interviews (KIIs) with district, provincial, and national health managers and Namati staff. In addition, focus group discussions (FGDs) were held with Health Advocates and VHC members.

RESULTS

Case resolution conferred a sense of empowerment to clients, brought immediate, concrete improvements in health service quality at the health facilities concerned, and seemingly instigated a virtuous circle of rights-claiming. The program also engendered incipient improvements in relations between clients and the health system. We identified three key mechanisms underlying case resolution, including: bolstered administrative capacity within the health sector, reduced transaction and political costs for health providers, and provider fear of administrative sanction.

CONCLUSIONS

This study contributes to the limited literature regarding the mechanisms of legal empowerment case resolution in health systems and the impact of hybrid legal empowerment and social accountability approaches. Future research might assess the sustainability of case resolution; how governance at central, provincial, and district level is affected by similar programs; and to what extent the mix of different cases addressed by legal empowerment influences the success of the program.

Patient Knowledge of Correct Dosage Regimen; The Need for Good Dispensing Practice

Background: The inappropriate use of medicine is a widespread problem, especially in developing countries. Proper dispensing practices as part of medication therapy increase benefits and minimize risks to the consumers. Objective: The purpose of this study was to assess patient knowledge of dosage regimen and the pharmacists dispensing practice. Method: A cross-sectional study design was conducted at Jimma Medical Center from March 1, 2018 to April 29, 2018. Data were collected prospectively using checklists and structured questionnaires. Results: Of the total prescribed drugs, 689 (74.25%) were actually dispensed, and 239 (34.7%) drugs were adequately labeled. The average dispensing and consultation times were 41.45 ± 12.1 and 49.13 ± 12 seconds, respectively. Of the total participants on exit interview, 267 (74.8%) correctly reported the dosage schedule of dispensed medicines. From the multivariate logistics regression analysis, language barrier (adjusted odds ratio [AOR] = 32.6, 95% confidence interval [CI] = 12.23-87.15), severity of health condition (AOR = 7.3, 95% CI = 2.70-19.56), and the number of drugs dispensed (AOR = 0.41, 95% CI = 0.18-0.87 [1 drug], AOR = 0.16, 95% CI = 0.61-0.42 [2 drugs]) have shown significant association with patient knowledge of dosage regimen. Conclusions: Majority of the patients did not receive the prescribed medicines from the outpatient pharmacy of Jimma Medical Center. Plus, only a few of the dispensed drugs contain all the necessary information. However, a large portion of the participants correctly reported the dosage schedule of their drugs.

Inequalities in the access to and quality of healthcare in Mozambique: evidence from the household budget survey

OBJECTIVES

To assess the inequalities in the access to and quality of care and its related direct payments.

DESIGN

Secondary analysis of the cross-sectional Mozambican Household Budget Survey (HBS).

SETTING

Nationally-representative sample of households in Mozambique.

PARTICIPANTS

11 480 households (58 118 individuals) interviewed during HBS 2014/15.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Equity, utilization of healthcare, access to quality care and direct payments.

RESULTS

About 12.2% of women and 10.1% of men of the survey report a perceive health need. About 72.1% of women and 72.9% men use healthcare. Population in a disadvantaged position living in rural areas have less probabilities of using healthcare for equal health compared to the individuals of a wealthier position and living in urban settings. With regard to quality care, 47.7% women and 46.8% men do not report quality problems. No differences for women's wealth. Men in a disadvantaged position report less chances of accessing quality care compared to men of advantaged position. Also, women and men living in rural areas have less probabilities of accessing quality care. Finally, the majority of people who access healthcare paid 1 Mt during their visit.

CONCLUSIONS

This study tackles a fundamental policy concern for health systems of Sub-Saharan Africa and points to areas that urge action to address the existent of socioeconomic and geographical inequalities in the access to and quality of care for women and men, including the strengthening of health facilities in rural and deprived areas to ensure that access to adequate care of acceptable quality is distributed according to need.

Beyond coverage: a qualitative study exploring the perceived impact of Gabon's health insurance plan on access to and quality of prenatal care

BACKGROUND

Access to affordable and adequate healthcare in a health system determines the universal health coverage achievement for all residents in a country. Achieving access to healthcare requires the availability of a financing system that ensures access to and provision of adequate care, regardless of the ability to pay. In sub-Saharan Africa, accessibility, use and coverage of prenatal visits are very low and poor, which reduces the quality of care. This paper explored the impact of a social health insurance scheme on the quality of antenatal care in Gabon.

METHODS

This qualitative study involved the analysis of data collected from semi-structured interviews and non-participant observations to assess the quality of antenatal care. The study elicited perceptions on the demand side (pregnant women) and the supply side (health professionals) in health facilities. Fifteen semi-structured interviews were conducted with pregnant women (aged between 15 and 49) and 5 with health professionals, who each had a seniority of at least 10 years, at different levels of care. Nine non-participant observations were also conducted. Coded transcripts were reviewed and analyzed using the Canadian Institute for Public Administration of Citizen-Centered Services model as an analytical guide.

RESULTS

On the demand side, women were generally satisfied with the prenatal services they receive in health facilities. However, complaints were made about the rudeness of some nurses, the high price of the delivery kit (50,000 XAF), and the fact that some essential medicines for maternity are not covered. On the supply side, participants agreed that compulsory health insurance is important in providing antenatal care access to those who need it the most. However, some problems remain. The participants outlined some logistical problems and a lack of medical equipment, including the stock of drugs, disinfectants, and the absence of clean water.

CONCLUSION

Understanding the perceptions of pregnant women and health professionals regarding the quality of antenatal care can help to inform refinements to methods through which the services can be better provided. In addition, the study findings are vital to increasing the use of care, as well as combating high maternal mortality rates. Compulsory health insurance has improved the accessibility and utilization of healthcare services and has contributed to improved quality of care.

Challenges and barriers to HIV service uptake and delivery along the HIV care cascade in Cameroon

Introduction

The year 2017 marked a transition period with the end of the implementation of Cameroon´s 2014-2017 HIV/AIDS National Strategic Plan (NSP) and the development of the 2018-2022 NSP. We assessed barriers and challenges to service delivery and uptake along the HIV care cascade in Cameroon to inform decision making within the framework of the new NSP, to achieve the UNAIDS 90-90-90 target.

Methods

We conducted a cross sectional descriptive study nationwide, enrolling HIV infected patients and staff. Data were collected on sociodemographic characteristics, HIV testing, antiretroviral therapy and viral load testing delivery and uptake and factors that limit their access.

Results

A total of 137 staff and 642 people living with HIV (PLHIV) were interviewed. Of 642 PLHIV with known status, 339 (53%) repeated their HIV test at least once, with range: 1-10 and median: 2 (IQR: 1-3). Having attained secondary level of education (OR: 2.07, 95% CI: 1.04-4.14; P=0.04) or more (OR: 2.91, 95% CI: 1.16-7.28; P=0.02) were significantly associated with repeat testing. Psychological (refusal of service uptake and existence of HIV), community-level (stigmatization and fear of confidentiality breach) and commodity stock-outs “HIV test kits (21%), antiretrovirals (ARVs) (71.4%), viral load testing reagents (100%)” are the major barriers to service delivery and uptake along the cascade.

Conclusion

We identified individual, community-level, socio-economic and health care system related barriers which constitute persistent bottlenecks in HIV service delivery and uptake and a high rate of repeat testing by PLHIV with known status. Addressing all these accordingly can help the country achieve the UNAIDS 90-90-90 target.

Monitoring Pharmacy and Test Kit Stocks in Rural Mozambique: U.S. President's Emergency Plan for AIDS Relief Surveillance to Help Prevent Ministry of Health Shortages

Support of human immunodeficiency virus (HIV) and tuberculosis (TB) testing and treatment supported by President's Emergency Plan for AIDS Relief (PEPFAR) in Africa requires immense quantities of tests and medications. We sought to use central pharmacy supply data of Mozambique's rural Zambézia Province (2017 population ≈5.11 million persons; ≈12.6% adult HIV prevalence in 2016) to examine shortages, stockouts, and trends in availability. Using stock surveillance for 60 weeks in 2014-2015, we assessed availability of 36 medications [4 classes: adult antiretroviral (ARV) medications, pediatric ARVs, anti-TB medications, and antibiotics] and diagnostic test kits (2 rapid tests for HIV; 1 each for malaria and syphilis). We contrasted these to 2018-2019 data. We modeled pharmacy data using ordinal logistic regression, characterizing weekly product availability in four categories: good, adequate, shortage, or complete stockout. We found 166 (7_.7%) stockouts and 150 (6.9%) shortages among 2,160 weekly records. Earlier calendar time was associated with reduced medication supplies (p < .001). Certain medication/test kit classes were associated with reduced supply (p < .001). We found an interaction between time and medication class on the odds of reduced supply (p < .001). Pediatric ARVs had a 17.4 (95% confidence interval: 8.8-34.4) times higher odds of reduced medication supply compared with adult ARVs at study midpoint. Trends comparing the first and last weeks showed adult ARVs having 67% and pediatric having 71% lower odds of reduced supplies. Only adult ARV shortages improved amid growing demand. Data from 2018 to 2019 suggest continuing inventory management challenges. Monitoring of drug (especially pediatric) and test kit shortages is vital to ensure quality improvement to guarantee adequate supplies to enable patients and care providers to achieve sustained viral suppression. A central Mozambican drug repository in the nation's second largest Province continues to experience drug and rapid test kit stockouts.

Vaccine stock management in primary health care facilities in OR Tambo District, Eastern Cape, South Africa

BACKGROUND

Poor stock management has been identified as one of the causes of vaccine stock-outs in health facilities. This study assessed the occurrence of vaccine stock-outs and vaccine stock management practices in primary health care facilities in OR Tambo district of the Eastern Cape province, South Africa.

METHODS

Descriptive cross-sectional study design was used in this study to assess both the stock management practices and the availability of vaccines in the facilities. The study was conducted in 64 primary health care facilities across all sub-districts in OR Tambo. Data were collected using a questionnaire administered by the researcher, record checks and through observation. The occurrence of stock-outs of six tracer vaccines on the day of the visit and in the preceding 24 months were assessed. The data were captured into REDCap tool and analysed using STATA version 14.

RESULTS

Most standard stock management procedures were not adhered to, as these procedures were mostly handled by health care workers who either required formal training or refresher training on vaccine management. Cold chain capacity was not adequate and some vaccines were exposed to freezing. Both stock cards and the stock visibility solution (SVS) device were used in all the facilities for vaccine stock management. Less than half of the facilities visited 27 (44%) filled their stock cards regularly. Delays in receiving supplies from the pharmaceutical depot were commonly reported by facilities, which contributed to stock-outs. A total of 49 (77%) health facilities had at least one stockout for at least one vaccine on the day of the visit. Furthermore, BCG and OPV were the most affected vaccines in 37 (58%) and 28 (44%) of facilities, respectively.

CONCLUSION

Interventions for improving vaccine availability should be considered, especially those targeting human resources and the entire stock management system.

Misoprostol for the prevention of post-partum haemorrhage in Mozambique: an analysis of the interface between human rights, maternal health and development

BACKGROUND

Mozambique has high maternal mortality which is compounded by limited human resources for health, weak access to health services, and poor development indicators. In 2011, the Mozambique Ministry of Health (MoH) approved the distribution of misoprostol for the prevention of post-partum haemorrhage (PPH) at home births where oxytocin is not available. Misoprostol can be administered by a traditional birth attendant or self-administered. The objective of this paper is to examine, through applying a human rights lens, the broader contextual, policy and institutional issues that have influenced and impacted the early implementation of misoprostol for the prevention of PPH. We explore the utility of rights-based framework to inform this particular program, with implications for sexual and reproductive health programs more broadly.

METHODS

A human rights, health and development framework was used to analyse the early expansion phase of the scale-up of Mozambique's misoprostol program in two provinces. A policy document review was undertaken to contextualize the human rights, health and development setting in Mozambique. Qualitative primary data from a program evaluation of misoprostol for the prevention of PPH was then analysed using a human rights lens; these results are presented alongside three examples where rights are constrained.

RESULTS

Structural and institutional challenges exacerbated gaps in the misoprostol program, and sexual and reproductive health more generally. While enshrined in the constitution and within health policy documents, human rights were not fully met and many individuals in the study were unaware of their rights. Lack of information about the purpose of misoprostol and how to access the medication contributed to power imbalances between the state, health care workers and beneficiaries. The accessibility of misoprostol was further limited due to dynamics of power and control.

CONCLUSIONS

Applying a rights-based approach to the Mozambican misoprostol program is helpful in contextualising and informing the practical changes needed to improve access to misoprostol as an essential medicine, and in turn, preventing PPH. This study adds to the evidence of the interconnection between human rights, health and development and the importance of integrating the concepts to ensure women's rights are prioritized within health service delivery.

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial

BACKGROUND

Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation.

METHODS

We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN.

DISCUSSION

SAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04088656 (registered 09/13/2019; https://clinicaltrials.gov/ct2/show/NCT04088656).

The economic burden of malaria on households and the health system in a high transmission district of Mozambique

Background

Malaria remains a leading cause of morbidity and mortality in Mozambique. Increased investments in malaria control have reduced the burden, but few studies have estimated the costs of malaria in the country. This paper estimates the economic costs associated with malaria care to households and to the health system in the high burden district of Mopeia in central Mozambique.

Methods

Malaria care-seeking and morbidity costs were routinely collected among 1373 households with at least one child enrolled in an active case detection (ACD) cohort in Mopeia, and through cross-sectional surveys with 824 families in 2017 and 805 families in 2018. Household costs included direct medical expenses, transportation and opportunity costs of the time lost due to illness. Structured questionnaires were used to estimate the health system costs associated with malaria care in all 13 district health facilities. Cost estimations followed an ingredient-based approach with a top-down allocation approach for health system expenses.

Results

Among participants in cross-sectional studies, households sought care for nine severe malaria cases requiring hospital admission and for 679 uncomplicated malaria cases. Median household costs associated with uncomplicated malaria among individuals of all ages were US$ 3.46 (IQR US$ 0.07–22.41) and US$ 81.08 (IQR US$ 39.34–88.38) per severe case. Median household costs were lower among children under five (ACD cohort): US$ 1.63 (IQR US$ 0.00–7.79) per uncomplicated case and US$ 64.90 (IQR US$ 49.76–80.96) per severe case. Opportunity costs were the main source of household costs. Median health system costs associated with malaria among patients of all ages were US$ 4.34 (IQR US$ 4.32–4.35) per uncomplicated case and US$ 26.56 (IQR US$ 18.03–44.09) per severe case. Considering household and health system costs, the overall cost of malaria care to society was US$ 7.80 per uncomplicated case and US$ 107.64 per severe case, representing an economic malaria burden of US$ 332,286.24 (IQR US$ 186,355.84–1,091,212.90) per year only in Mopeia.

Conclusions

Despite the provision of free malaria services, households in Mopeia incur significant direct and indirect costs associated with the disease. Furthermore, the high malaria cost on the Mozambican health system underscores the need to strengthen malaria prevention to reduce the high burden and improve productivity in the region.

Availability of WHO Essential Medicines for Cancer Treatment in Botswana

Purpose

Stock outs of cancer drugs are potentially fatal but have not been systematically studied in low- and middle-income countries. The aim of this study was to determine the availability and alignment of the Botswana National Essential Medicines List (NEML) for cancer drugs with the WHO’s Essential Medicines List (EML).

Methods

The availability and cost of cancer drugs were analyzed using data from a weekly stock catalog sent by Botswana’s Central Medical Store to all pharmacy departments in government hospitals. Comparative data were extracted from the WHO EML and the “International Drug Price Indicator Guide-2014” from the Management Sciences for Health. Interviews with key informants were used to collect data on the Botswana NEML and the drug supply chain in the public sector.

Results

The 2015 Botswana NEML for cancer had 80.5% alignment with the WHO EML. At least 40% of essential drugs were out of stock for a median duration of 30 days in 2015. Stock outs affected chemotherapy drugs included in first-line regimens for treating potentially curable diseases such as cervical, breast, and colorectal cancer and were not associated with buyer price of therapy. Analyses showed that the median price ratio for procured drugs was greater than 1 for 61% of the NEML drugs, which suggests inefficiency in procurement in the public sector.

Conclusions

Botswana has one of the highest alignments of NEML to the WHO EML in the sub-Saharan African region, which is consistent with investment in the health care system evident in other clinical spheres. Better quantification of chemotherapy requirements using data from the National Cancer Registry and resource-sensitive treatment guidelines can help reduce stock outs and facilitate more effective and efficient procurement processes.

Availability, Price and Affordability of Anticancer Medicines: Evidence from Two Cross-Sectional Surveys in the Jiangsu Province, China

Objectives: With the increasing incidence of cancer, poor access to affordable anticancer medicines has been a serious public health problem in China. To help address this issue, we assessed the availability, price and affordability of pharmacotherapy for cancer in public hospitals in the Jiangsu Province, China. Methods: In 2012 and 2016, anticancer medicine availability and price information in the capital and five other cities was collected. A total of six cancer care hospitals, 26 tertiary general hospitals and 28 secondary general hospitals were sampled, using an adaptation of the World Health Organization/Health Action International methodology. Data was collected for the anticancer medicines in stock at the time of the surveys. Prices were expressed as inflation-adjusted median unit prices (MUPs). Medicine was affordable if the overall cost of all the prescribed anticancer medicines was less than 20% of the household’s capacity to pay. We used generalized estimating equations to estimate the significance of differences in availability from 2012 to 2016 and the Wilcoxon rank test to estimate the significance of differences in MUPs. Multivariate logistic regression was computed to measure predictors of affordability. Results: From 2012 to 2016 there was a significant decrease in the mean availability of originator brands (OBs) (from 7.79% to 5.71%, p = 0.012) and lowest-priced generics (LPGs) (36.29% to 32.67%, p = 0.009). The mean availability of anticancer medicines in secondary general hospitals was significantly lower than the cancer care, as well as in tertiary general hospitals. The MUPs of OBs (difference: −21.29%, p < 0.01) and their LPGs (−22.63%, p < 0.01) decreased significantly from 2012 to 2016. The OBs (16.67%) of all the anticancer medicines were found to be less affordable than LPGs (34.62% for urban residents and 30.77% for rural residents); their affordability varied among the different income regions. From 2012 to 2016, the proportion of LPGs with low availability and low affordability dropped from 30.77% to 19.23% in urban areas and 34.62% to 26.92% in rural areas, respectively. Generic substitution and medicine covered by basic medical insurance are factors facilitating affordability. Conclusion: There were concerning decreases in the availability of anticancer medicines in 2016 from already low availability in 2012. Anticancer medicines were more affordable for the patients in high-income regions than the patients in low-income regions. Governments should consider using their bargaining power to reduce procurement prices and abolish taxes on anticancer medicines. Policy should focus on the special health insurance plan for low-income patients with cancer. The goal of drug policy should ensure that first-line generic drugs are available for cancer patients and preferentially prescribed.

Ready to deliver maternal and newborn care? Health providers' perceptions of their work context in rural Mozambique

Background: Deficiencies in the provision of evidence-based obstetric care are common in low-income countries, including Mozambique. Constraints relate to lack of human and financial resources and weak health systems, however limited resources alone do not explain the variance. Understanding the healthcare context ahead of implementing new interventions can inform the choice of strategies to achieve a successful implementation. The Context Assessment for Community Health (COACH) tool was developed to assess modifiable aspects of the healthcare context that theoretically influence the implementation of evidence.

Objectives: To investigate the comprehensibility and the internal reliability of COACH and its use to describe the healthcare context as perceived by health providers involved in maternal care in Mozambique.

Methods: A response process evaluation was completed with six purposively selected health providers to uncover difficulties in understanding the tool. Internal reliability was tested using Cronbach’s α. Subsequently, a cross-sectional survey using COACH, which contains 49 items assessing eight dimensions, was administered to 175 health providers in 38 health facilities within six districts in Mozambique.

Results: The content of COACH was clear and most items were understood. All dimensions were near to or exceeded the commonly accepted standard for satisfactory internal reliability (0.70). Analysis of the survey data indicated that items on all dimensions were rated highly, revealing positive perception of context. Significant differences between districts were found for the Work culture, Leadership, and Informal payment dimensions. Responses to many items had low variance and were left-skewed.

Conclusions: COACH was comprehensible and demonstrated good reliability, although biases may have influenced participants’ responses. The study suggests that COACH has the potential to evaluate the healthcare context to identify shortcomings and enable the tailoring of strategies ahead of implementation. Supplementing the tool with qualitative approaches will provide an in-depth understanding of the healthcare context.

HIV Rapid Diagnostic Test Inventories in Zambézia Province, Mozambique: A Tale of 2 Test Kits

Background: The first pillar of the UNAIDS 90-90-90 goal seeks to accurately identify persons living with HIV (PLHIV), a process that is predicated on facilities having the necessary HIV tests available to perform the task. In many rural settings, the identification of PLHIV is accomplished through a two-step process involving the sequential use of 2 separate rapid diagnostic tests (RDTs). Inadequate inventory of either test has ramifications for the success of HIV-related programs. The purpose of this study was to evaluate the inventory levels of HIV RDT kits at specific healthcare facilities in Zambézia province, Mozambique.

Methods: Using facility-level pharmacy stock surveillance data from October 2015 through September 2016, we assessed the inventory levels of HIV RDTs at 75 health facilities in 8 districts within Zambézia province, Mozambique. Using programmatically established categories (good, sufficient, threatened, or stockout), defined in conjunction with the provincial health authorities, descriptive statistics were performed to determine inventory control of HIV RDTs at the district and health facility levels. Monthly proportions of adequate (good + sufficient) inventory were calculated for each district to identify inventory trends over the evaluation period. To assess whether the proportion of inadequate stocks differed between RDT, a mixed-effects logistic regression was conducted, with inadequate inventory status as the outcome of interest.

Results: When viewed as a whole, the inventory of each test kit was reported as being at adequate levels more than 89% of the time across the 75 facilities. However, disaggregated analysis revealed significant variability in the inventory levels of HIV RDTs at the district level. Specifically, the districts of Inhassunge, Namacurra, and Pebane reported inadequate inventory levels (threatened + stockout), of one or both test kits, for more than 10% of the study period. In addition, a disparity between inventory levels of each test kit was identified, with the odds of reporting inadequate inventory levels of the confirmatory test (Uni-Gold™) being approximately 1.8-fold greater than the initial test (Determine™) (odds ratio: 1.82, 95% CI: 1.40-2.38).

Conclusion: As Test and Treat programs evolve, a significant emphasis should be placed on the "test" component of the strategy, beginning with assurances that health facilities have the adequate inventory of RDT necessary to meet the needs of their community. As national policy-makers rely predominantly on data from the upstream arm of the supply chain, it is unlikely the disparity between inventory levels of HIV RDTs identified at individual districts and specific health facilities would have been recognized. Moving forward, our findings point to a need for (1) renewed efforts reinforcing appropriate downstream forecasting of essential medicines and diagnostic tests in general and for Uni-Gold™ test kits specifically, and (2) simple metrics that may be routinely collected at all health facilities and which may then easily and quickly flow upstream so that policy-makers may optimally allocate resources.

Scaling-up the Systems Analysis and Improvement Approach for prevention of mother-to-child HIV transmission in Mozambique (SAIA-SCALE): a stepped-wedge cluster randomized trial

BACKGROUND

The introduction of option B+-rapid initiation of lifelong antiretroviral therapy regardless of disease status for HIV-infected pregnant and breastfeeding women-can dramatically reduce HIV transmission during pregnancy, birth, and breastfeeding. Despite significant investments to scale-up Option B+, results have been mixed, with high rates of loss to follow-up, sub-optimal viral suppression, continued pediatric HIV transmission, and HIV-associated maternal morbidity. The Systems Analysis and Improvement Approach (SAIA) cluster randomized trial demonstrated that a package of systems engineering tools improved flow through the prevention of mother-to-child HIV transmission (PMTCT) cascade. This five-step, facility-level intervention is designed to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). This protocol describes a novel model for SAIA delivery (SAIA-SCALE) led by district nurse supervisors (rather than research nurses), and evaluation procedures, to serve as a foundation for national scale-up.

METHODS

The SAIA-SCALE stepped wedge trial includes three implementation waves, each 12 months in duration. Districts are the unit of assignment, with four districts randomly assigned per wave, covering all 12 districts in Manica province, Mozambique. In each district, the three highest volume health facilities will receive the SAIA-SCALE intervention (totaling 36 intervention facilities). The RE-AIM framework will guide SAIA-SCALE's evaluation. Reach describes the proportion of clinics and population in Manica province reached, and sub-groups not reached. Effectiveness assesses impact on PMTCT process measures and patient-level outcomes. Adoption describes the proportion of districts/clinics adopting SAIA-SCALE, and determinants of adoption using the Organizational Readiness for Implementing Change (ORIC) tool. Implementation will identify SAIA-SCALE core elements and determinants of successful implementation using the Consolidated Framework for Implementation Research (CFIR). Maintenance describes the proportion of districts sustaining the intervention. We will also estimate the budget and program impact from the payer perspective for national scale-up.

DISCUSSION

SAIA packages user-friendly systems engineering tools to guide decision-making by frontline health workers, and to identify low-cost, contextually appropriate PMTCT improvement strategies. By integrating SAIA delivery into routine management structures, this pragmatic trial is designed to test a model for national intervention scale-up.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03425136 (registered 02/06/2018).

Scaling Up Misoprostol to Prevent Postpartum Hemorrhage at Home Births in Mozambique: A Case Study Applying the ExpandNet/WHO Framework

Facilitating factors for this community-level scale up in 35 districts included strong government support, local champions, and a national policy on preventing postpartum hemorrhage (PPH). Challenges included a lack of a systematic scale-up strategy, limited communication of the PPH policy, a shift from a universal distribution policy to application of eligibility criteria, difficulties engaging remote traditional birth attendants, and implementation of a parallel M&E system.

Background:

Mozambique has a high maternal mortality ratio, and postpartum hemorrhage (PPH) is a leading cause of maternal deaths. In 2015, the Mozambican Ministry of Health (MOH) commenced a program to distribute misoprostol at the community level in selected districts as a strategy to reduce PPH. This case study uses the ExpandNet/World Health Organization (WHO) scale-up framework to examine the planning, management, and outcomes of the early expansion phase of the scale-up of misoprostol for the prevention of PPH in 2 provinces in Mozambique.

Methods:

Qualitative semistructured interviews were conducted between February and October 2017 in 5 participating districts in 2 provinces. Participants included program stakeholders, health staff, community health workers (CHWs), and traditional birth attendants (TBAs). Interviews were analyzed using the ExpandNet/WHO framework alongside national policy and planning documents and notes from a 2017 national Ministry of Health maternal, newborn, and child health workshop. Outcomes were estimated using misoprostol coverage and access in 2017 for both provinces.

Results:

The study revealed a number of barriers and facilitators to scale-up. Facilitators included a supportive political and legal environment; a clear, credible, and relevant innovation; early expansion into some Ministry of Health systems and a strong network of CHWs and TBAs. Barriers included a reduction in reach due to a shift from universal distribution to application of eligibility criteria; fear of misdirecting misoprostol for abortion or labor induction; limited communication and understanding of the national PPH prevention strategy; inadequate monitoring and evaluation; challenges with logistics systems; and the inability to engage remote TBAs. Lower coverage was found in Inhambane province than Nampula province, possibly due to NGO support and political champions.

Conclusion:

This study identified the need for a formal review of the misoprostol program to identify adaptations and to develop a systematic scale-up strategy to guide national scale-up.

Logistics management information system performance for program drugs in public health facilities of East Wollega Zone, Oromia regional state, Ethiopia

Background

Proper logistics management information system in the supply chain improves health outcomes by maintaining accurate and timely information. The purpose of this study was to determine program drugs logistics management information system performance in public health facilities of East Wollega Zone, Oromia Regional State.

Methods

A facility-based descriptive cross-sectional study design complemented with a qualitative method was conducted from April 01 to May 30, 2017. The quantitative data were gathered through reviewing logistics tools, a physical count of the selected program drugs, and interview of the pharmacy staffs. The evaluation of data quality was done on 134 RRFs and 805 bin-cards. A statistical package for social science version 20 was used to analyze the quantitative data. A chi-square test was performed to determine the association between dependent and independent variables. For the qualitative method, 11 face to face in-depth interviews were carried out, and the data were analyzed using thematic analysis technique.

Results

Twenty three selected public health facilities were included in the study of which 39% of them had an automated recording system. Concerning the data quality, 65% of RRFs and 79.1% of bin-cards were accurately filled, and 97.8% of the reports were found to be complete. Sixty-nine percent of the facilities had timely submitted their report to the higher level and the reporting rate of the facilities was determined to be 97%. A significant association was observed between RRF data accuracy and type of profession, X² (4, N = 134) =35.0, P = 0.040, trainings, X² (2, N = 134) =37.12, P = 0.001, e-LMIS, X² (2, N = 134) = 38.67, P = 0.03, educational status, X² (2,N = 134) = 90.38, P = 0.012, & supervision, X² (2, N = 134) = 94.03,P < 0.001. Shortage of skilled human resources and poor commitment of the staffs were identified to be the major bottlenecks of logistics management information system performances.

Conclusions

The facilities’ report submission rates were promising yet the quality of the reports need improvement. Poor data quality was more likely because of weak supportive supervision and the information system being managed by non-pharmacy professionals.

Quality of care in family planning services in rural Mozambique with a focus on long acting reversible contraceptives: a cross-sectional survey

BACKGROUND

In Mozambique, both the government and partners have undertaken efforts over the last decade to improve FP (family planning) services, especially through training health care providers and promoting the uptake of LARCs (Long Acting Reversible Contraceptives). Despite this, uptake of FP methods has not increased significantly. This study aims to examine women's knowledge on LARCs, including their main sources of information, and the quality of care of FP services in rural areas.

METHODS

We conducted a repeated cross-sectional study, interviewing 417 women leaving FP consultations in 15 health facilities in Maputo Province, Mozambique. The main quality outputs measured were: 1)discussed, preferred and received contraceptive methods, 2)information received on usage and side-effects, 3)client-provider interaction, 4)being informed about the need for a follow-up visit 5)health examinations conducted and travel time to the facility. In addition, knowledge on LARCs was measured among the clients as well as sources of information regarding FP methods. Taking into account the design effect of the study, Chi-square statistics were used to detect differences between groups and linear regression analyses to identify associations between sources of information and higher knowledge.

RESULTS

We found that IUDs (intrauterine devices) and implants were discussed in 23 and 33% of the consultations respectively, but only administered in a very few cases(< 1%). Half of the women were counselled on side-effects of contraceptives; this did not differ between first time clients and follow-up clients. Almost all women(98%) were satisfied with the received service and 83% of the women found the waiting time acceptable. Health examinations were performed on 18% of the women. Overall, women's knowledge about LARCs was poor and misconceptions are still common. Women who had received FP information through outreach activities had better knowledge than those counselled at a facility.

CONCLUSIONS

Our study highlights that only a minority of the women received information regarding LARCs during the consultation and that usage is almost non-existent. Counseling about all types of contraceptives during the consultation is sub-optimal, resulting in poorly informed clients. Multifaceted long-term interventions, focusing on both users and providers, are needed to improve uptake of contraceptives (including LARCs) in rural areas.

Pharmaceutical Services in Mozambique: foreign aid in public provision of medicines

This article examines the activities of national and international actors in Pharmaceutical Services (PS) in Mozambique from 2007 to 2012, focusing on the public provision of HIV/Aids, malaria and tuberculosis medicines. It describes how PS functions in the country, what actors are involved in this area and the relations among them, pursuing salient issues in the modus operandi of partners in cooperation. The methodology combines literature review, document survey and analysis and interviews. The theoretical and analytical framework was given by the policy analysis approach, focusing on the role of the State and its interrelations with other actors in foreign aid in PS, and also by the networks approach. It was concluded that the interactions among the actors involved is complex and characterised by operational fragmentation and overlapping of activities between entities, centralised medicine procurement in the hands of few agents, bypassing of national structures and disregard for the strengthening needed to bolster national health system autonomy. Despite some advances in the provision and availability of medicines for these diseases, external dependence is strong, which undermines the sustainability of PS in Mozambique.

Evaluating the quality of routinely reported data on malaria commodity stocks in Guinea, 2014-2016

BACKGROUND

Ensuring malaria commodity availability at health facilities is a cornerstone of malaria control. Since 2013, the Guinea National Malaria Control Programme has been routinely collecting data on stock levels of key malaria commodities through a monthly routine malaria information system (RMIS). In parallel, biannual end-user verification (EUV) surveys have also assessed malaria commodity availability at a subset of health facilities, potentially representing a duplication of efforts.

METHODS

Data on 12 malaria commodity stock levels verified during four EUV surveys conducted between 2014 and 2016 was compared to data for the corresponding months submitted by the same health facilities through the RMIS. The sensitivity and specificity of the RMIS in detecting stock-outs was calculated, as was the percent difference between average stock levels reported through the two systems.

RESULTS

Of the 171 health facilities visited during the four EUV surveys, 129 (75%) had data available in the RMIS. Of 351 commodity stock-outs observed during the EUV in the sampled reporting health facilities, 256 (73%) were also signaled through the corresponding RMIS reports. When the presence of malaria commodity stocks was confirmed during the EUV surveys, the RMIS also reported available stock 87% (677/775) of the time. For all commodities, the median percent difference in average stock levels between the EUV and RMIS was 4% (interquartile range - 7 to 27%).

CONCLUSION

The concordance between stock levels reported through the RMIS and those verified during the EUV visits provides certain evidence that RMIS data can inform quantification and procurement decisions. However, lower than acceptable rates of reporting and incomplete detection of stock-outs from facilities that do report suggest that further systems strengthening is needed to improve RMIS reporting completeness and data quality.

Characteristics of patients with thromboembolic disorders on warfarin therapy in resource limited settings

Background

Warfarin is a drug with narrow therapeutic index used in the management of thromboembolic disorders. Several factors affect its plasma concentrations with a resultant risk of toxicity. We examined the database of patients on warfarin therapy in order to establish the factors that affect the stability of INR and correlated them to clinical outcomes in resource limited settings.

Methods

We analysed retrospective data of patients admitted to adult medical wards at Moi Teaching and Referral Hospital (MTRH) in 2015. Inclusion criteria were patients with thromboembolic and related disorders and on warfarin treatment. Derived data included demographics, indications for warfarin use, co-prescribed drugs, co-morbidities, INR measurements, duration of hospital stay and clinical outcomes. Descriptive statistics were used to summarize the data. Pearson’s correlation coefficient was used to assess relationships between duration of hospitalization and number of INR tests. Regression splines were used to capture INR trends during the follow up period. Data was analysed using R v. 3.3.1.

Results

A total of 310 patients had thromboembolic disorders, out of which 63 met the study criteria.

The median age was 48 years, while the mean number of INR measurements was once every four days. Majority of patients did not achieve stable INR values, with only two having consecutive INR values within therapeutic goal. Patients who died had high INR levels. The median duration of hospital stay was 9 days (IQR: 7.0, 16.5). There was a significant correlation between length of stay in hospital and the number of times that INR were measured (Corr = 0.667, p < 0.001). The two most common indications for warfarin were DVT (64.4%) and atrial fibrillation (24.7%). All the patients had one or more comorbid conditions except for 11 with DVT alone, with cardiovascular diseases and infections being the most frequent, and on concomitant medications, majority of which are known to interact with warfarin.

Conclusions

It was difficult to achieve stable INR under the prevailing conditions despite the frequent tests.

The potential factors that may have contributed to the fluctuations include drug-drug interactions, frequency of INR tests, comorbidities and the short duration of hospital stay.

You pray to your God: A qualitative analysis of challenges in the provision of safe, timely, and affordable surgical care in Uganda

BACKGROUND

Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception.

METHODS

From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda. Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis.

RESULTS

The Ugandan public health care sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Hospital staff reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public to provide surgical care to those most in need.

CONCLUSION

Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda's surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity.

Acceptability and performance of a directly assisted oral HIV self-testing intervention in adolescents in rural Mozambique

INTRODUCTION

Whereas progress in HIV testing and treatment has been made globally, the UNAIDS goal of "90 90 90" is still out of sight in rural northern Mozambique. New strategies that promote testing in hard to reach groups will aid Mozambique's response to the HIV epidemic. HIV self-testing (HIVST) is recommended by the WHO as an additional approach to augment the HIV testing services available to adolescents. This study evaluates acceptability and performance of a directly assisted oral HIVST intervention for adolescents in rural Mozambique.

METHODS

Adolescents aged 16-20 years were included at schools and invited to attend the local hospital's youth friendly service for directly assisted oral HIVST. Baseline and post-test questionnaires were obtained. OraQuick Rapid HIV-1/2 Anti body test® was used. Results were read by the participant and by a nurse. Results were confirmed by finger prick HIV test (Determine® HIV 1/2 Alere and Unigold™ HIV Trinity Biotech) according to the Mozambican national standard.

RESULTS

Between September and November 2016, 496 adolescents were included, of which 299 performed an oral HIV self-test. 70% were first time testers. The positivity rate was 1.7%. The inter-rater agreement between adolescent and nurse was 99.6% (kappa 0.93); there were no false negative or false positive results of the oral HIV self-test. Five tests were invalid. 7.1% found the test difficult to use. Over 80% preferred directly assisted HIVST compared to the standard finger prick testing. While 20% thought it would be good to do HIVST at home, 76% preferred to do HIVST at the health centre, for reasons including increased security, privacy, and the presence of a counsellor.

CONCLUSIONS

Directly assisted oral HIVST is a feasible intervention for adolescents in rural Mozambique and showed encouraging results for first time HIV testers.

Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique

Background

Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided through Agentes Polivalentes Elementares (APEs). We assessed the contribution of the program to improved care–seeking and appropriate treatment of childhood febrile illness in Nampula Province.

Methods

We used a post–test quasi–experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care–seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first–level health facilities.

Results

A total of 773 children 6–59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8–93.4) of children 6–59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7–92.7) of all first–line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0–93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4–73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1–43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2–79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4–74.6) compared to children taken to health facilities (41.4%; 95% CI33.7–49.2 and 19.4%; 95% CI 8.4–30.5, respectively). Overall, 61.3% (95% CI 51.5–71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2–33.9) of those receiving care from health facilities.

Conclusion

iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.