Primary Health Care in rural Malawi - a qualitative assessment exploring the relevance of the community-directed interventions approach

Characterising the performance measurement and management system in the primary health care systems of Malawi

BACKGROUND

 Performance Measurement and Management (PMM) systems are levers that support key management functions in health care systems. Just like many low- and middle-income countries (LMICs), Malawi strives to improve performance via evidence-based decision making and a suitable performance culture.

AIM

 This study sought to describe PMM practices at all levels of primary health care (PHC) in Malawi.

SETTING

 This study targeted three levels of PHC, namely the district health centres (DHCs), the zones, and the ministry headquarters.

METHODS

 This was a qualitative exploratory research study where decision-makers at each level of PHC were engaged using key-informant interviews (KII) and focus group discussions (FGDs).

RESULTS

 We found that there is a weak link among levels of PHC in supporting PMM practices leading to poor dissemination of priorities and goals. There is also failure to appropriately institute good PMM practices, and the use of performance information was found to be limited among decision-makers.

CONCLUSION

 Though PMM is acknowledged to be key in supporting health service delivery systems, Malawi's PHC system has not fully embarked on making this a priority. Some challenges include unsupportive culture and inadequate capacity for PMM.Contribution: This study contributes to the understanding of the PMM processes in Malawi and further highlights the salient challenges in the use of information for performance management. While the presence of policies on PMM is acknowledged, implementation studies that deal with challenges are urgent and imperative.

Mass drug administration campaigns: comparing two approaches for schistosomiasis and soil-transmitted helminths prevention and control in selected Southern Malawi districts

BACKGROUND

Mass drug administration is one of the key interventions recommended by WHO to control certain NTDs. With most support from donors, health workers distribute antihelminthic drugs annually in Malawi. Mean community coverage of MDA from 2018 to 2020 was high at 87% for praziquantel and 82% for albendazole. However, once donor support diminishes sustaining these levels will be challenging. This study intended to compare the use of the community-directed intervention approach with the standard practice of using health workers in delivery of MDA campaigns.

METHODS

This was a controlled implementation study carried out in three districts, where four health centres and 16 villages in each district were selected and randomly assigned to intervention and control arms which implemented MDA campaigns using the CDI approach and the standard practice, respectively. Cross-sectional and mixed methods approach to data collection was used focusing on quantitative data for coverage and knowledge levels and qualitative data to assess perceptions of health providers and beneficiaries at baseline and follow-up assessments. Quantitative and qualitative data were analyzed using IBM SPSS software version 26 and NVivo 12 for Windows, respectively.

RESULTS

At follow-up, knowledge levels increased, majority of the respondents were more knowledgeable about what schistosomiasis was (41%-44%), its causes (41%-44%) and what STH were (48%-64%), while knowledge on intermediate host for schistosomiasis (19%-22%), its types (9%-13%) and what causes STH (15%-16%) were less known both in intervention and control arm communities. High coverage rates for praziquantel were registered in intervention (83%-89%) and control (86%-89%) communities, intervention (59%-79) and control (53%-86%) schools. Costs for implementation of the study indicated that the intervention arm used more resources than the control arm. Health workers and community members perceived the use of the CDI approach as a good initiative and more favorable over the standard practice.

CONCLUSIONS

The use of the CDI in delivery of MDA campaigns against schistosomiasis and STH appears feasible, retains high coverages and is acceptable in intervention communities. Despite the initial high costs incurred, embedding into community delivery platforms could be considered as a possible way forward addressing the sustainability concern when current donor support wanes.

TRIAL REGISTRATION

Pan-African Clinical Trials Registry PACTR202102477794401, date: 25/02/2021.

Community engagement initiatives in primary health care to achieve universal health coverage: A realist synthesis of scoping review

BACKGROUND

Community engagement (CE) is an essential component in a primary health care (PHC) and there have been growing calls for service providers to seek greater CE in the planning, design, delivery and evaluation of PHC services. This scoping review aimed to explore the underlying attributes, contexts and mechanisms in which community engagement initiatives contribute to improved PHC service delivery and the realisation of UHC.

METHODS

PubMed, PsycINFO, CINAHL, Cochrane Library, EMBASE and Google Scholar were searched from the inception of each database until May 2022 for studies that described the structure, process, and outcomes of CE interventions implemented in PHC settings. We included qualitative and quantitative studies, process evaluations and systematic or scoping reviews. Data were extracted using a predefined extraction sheet, and the quality of reporting of included studies was assessed using the Mixed Methods Appraisal Tool. The Donabedian's model for quality of healthcare was used to categorise attributes of CE into "structure", "process" and "outcome".

RESULTS

Themes related to the structural aspects of CE initiatives included the methodological approaches (i.e., format and composition), levels of CE (i.e., extent, time, and timing of engagement) and the support processes and strategies (i.e., skills and capacity) that are put in place to enable both communities and service providers to undertake successful CE. Process aspects of CE initiatives discussed in the literature included: i) the role of the community in defining priorities and setting objectives for CE, ii) types and dynamics of the broad range of engagement approaches and activities, and iii) presence of an on-going communication and two-way information sharing. Key CE components and contextual factors that affected the impact of CE initiatives included the wider socio-economic context, power dynamics and representation of communities and their voices, and cultural and organisational issues.

CONCLUSIONS

Our review highlighted the potential role of CE initiatives in improving decision making process and improving overall health outcomes, and identified several organisational, cultural, political, and contextual factors that affect the success of CE initiatives in PHC settings. Awareness of and responding to the contextual factors will increase the chances of successful CE initiatives.

What improves access to primary healthcare services in rural communities? A systematic review

BACKGROUND

To compile key strategies from the international experiences to improve access to primary healthcare (PHC) services in rural communities. Different innovative approaches have been practiced in different parts of the world to improve access to essential healthcare services in rural communities. Systematically collecting and combining best experiences all over the world is important to suggest effective strategies to improve access to healthcare in developing countries. Accordingly, this systematic review of literature was undertaken to identify key approaches from international experiences to enhance access to PHC services in rural communities.

METHODS

All published and unpublished qualitative and/or mixed method studies conducted to improvement access to PHC services were searched from MEDLINE, Scopus, Web of Science, WHO Global Health Library, and Google Scholar. Articles published other than English language, citations with no abstracts and/or full texts, and duplicate studies were excluded. We included all articles available in different electronic databases regardless of their publication years. We assessed the methodological quality of the included studies using mixed methods appraisal tool (MMAT) version 2018 to minimize the risk of bias. Data were extracted using JBI mixed methods data extraction form. Data were qualitatively analyzed using emergent thematic analysis approach to identify key concepts and coded them into related non-mutually exclusive themes.

RESULTS

Our analysis of 110 full-text articles resulted in ten key strategies to improve access to PHC services. Community health programs or community-directed interventions, school-based healthcare services, student-led healthcare services, outreach services or mobile clinics, family health program, empanelment, community health funding schemes, telemedicine, working with traditional healers, working with non-profit private sectors and non-governmental organizations including faith-based organizations are the key strategies identified from international experiences.

CONCLUSION

This review identified key strategies from international experiences to improve access to PHC services in rural communities. These strategies can play roles in achieving universal health coverage and reducing disparities in health outcomes among rural communities and enabling them to get healthcare when and where they want.

An assessment of implementation and effectiveness of mass drug administration for prevention and control of schistosomiasis and soil-transmitted helminths in selected southern Malawi districts

Background

Mass drug administration (MDA) is one of the key interventions recommended by WHO for prevention and control of neglected tropical diseases (NTD). In Malawi, MDA is widely carried out annually since 2009 for prevention and control of schistosomiasis and soil-transmitted helminths (STH). No study has been carried out to assess effectiveness of the MDA approach and to document perceptions of health providers and beneficiaries regarding use of MDA. This study was done to understand how well MDA is being implemented and to identify opportunities for improvement in MDA delivery in Malawi.

Methods

Designed as a cross-sectional and multi-methods research, the study was carried out in three southern Malawi districts of Chiradzulu, Mangochi and Zomba. In each district, four health centres and 16 villages were randomly selected to participate. A mixed-methods approach to data collection focusing on quantitative data for coverage and knowledge, attitudes and practices assessments; and qualitative data for assessing perceptions of health providers and beneficiaries regarding MDA was used. Quantitative data were processed and analyzed using IBM SPSS software version 26 while qualitative data were analysed using NVivo 12 for Windows.

Results

Knowledge levels about schistosomiasis and STH in the districts varied according to disease aspects asked about. Majority are more knowledgeable about what schistosomiasis is (78%) and whether STH are treatable with drugs (97%); with least knowledgeable about the organism that transmits schistosomiasis (18%), types of schistosomiasis (11%) and what causes STH (20%). In 2018 and 2019 the districts registered high coverage rates for praziquantel and albendazole using community-based MDA (73–100%) and using school-based MDA (75–91%). Both the health authorities and community members perceived the MDA approach as good because it brings treatment closer to people.

Conclusion

With the high MDA coverage obtained in communities and schools, the effectiveness of MDA in the target districts is satisfactory. There are, however, several challenges including disproportionate knowledge levels, which are hampering progress towards attainment of the 2030 global NTD goals. There is a need for promotion of community participation and partnerships as well as implementation of other recommended interventions for sustainable prevention and control of schistosomiasis and STH.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07925-3.

Feasibility of upfront mobile money transfers for transportation reimbursement to promote retention among patients receiving lymphoma treatment in Malawi

BACKGROUND

Cancer outcomes in sub-Saharan Africa (SSA) remain suboptimal, in part due to poor patient retention. Many patients travel long distances to receive care, and transportation costs are often prohibitively expensive. These are well-known and established causes of delayed treatment and care abandonment in Malawi and across SSA.

METHODS

We sent visit reminder texts and offered upfront money to cover transportation costs through a mobile money transfer (MMT) platform to lymphoma patients enrolled in a prospective cohort in Malawi. The primary aim was to test the feasibility of upfront MMTs.

RESULTS

We sent 1034 visit reminder texts to 189 participating patients. Of these texts, 614 (59%) were successfully delivered, with 536 (52%) responses. 320/536 (60%) MMTs were sent to interested patients and 312/320 (98%) came to their appointment on time. Of 189 total patients, 120 (63%) were reached via text and 84 (44%) received MMTs a median of three times (IQR 2-5). Median age of reachable patients was 41 (IQR 30-50), 75 (63%) were male, 62 (52%) were HIV+ and 79 (66%) resided outside of Lilongwe.

CONCLUSION

MMTs were a feasible way to cover upfront transportation costs for patients reachable via text, however many of our patients were unreachable. Future studies exploring barriers to care, particularly among unreachable patients, may help improve the efficacy of MMT initiatives and guide retention strategies throughout SSA.

Prevalence, causes and impact of musculoskeletal impairment in Malawi: A national cluster randomized survey

BACKGROUND

There is a lack of accurate information on the prevalence and causes of musculoskeletal impairment (MSI) in low income countries. The WHO prevalence estimate does not help plan services for specific national income levels or countries. The aim of this study was to find the prevalence, impact, causes and factors associated with musculoskeletal impairment in Malawi. We wished to undertake a national cluster randomized survey of musculoskeletal impairment in Malawi, one of the UN Least Developed Countries (LDC), that involved a reliable sampling methodology with a case definition and diagnostic criteria that could clearly be related to the classification system used in the WHO International Classification of Functioning, Disability and Health (ICF).

METHODS

A sample size of 1,481 households was calculated using data from the latest national census and an expected prevalence based on similar surveys conducted in Rwanda and Cameroon. We randomly selected clusters across the whole country through probability proportional to size sampling with an urban/rural and demographic split that matched the distribution of the population. In the field, randomization of households in a cluster was based on a ground bottle spin. All household members present were screened, and all MSI cases identified were examined in more detail by medical students under supervision, using a standardized interview and examination protocol. Data collection was carried out from 1st July to 30th August 2016. Extrapolation was done based on study size compared to the population of Malawi. MSI severity was classified using the parameters for the percentage of function outlined in the WHO International Classification of Functioning (ICF). A loss of function of 5-24% was mild, 25-49% was moderate and 50-90% was severe. The Malawian version of the EQ-5D-3L questionnaire was used, and EQ-5D index scores were calculated using population values from Zimbabwe, as a population value set for Malawi is not currently available. Chi-square test was used to test categorical variables. Odds ratio (OR) was calculated with a linear regression model adjusted for age, gender, location and education.

RESULTS

A total of 8,801 individuals were enumerated in 1,481 households. Of the 8,548 participants that were screened and examined (response rate of 97.1%), 810 cases of MSI were diagnosed of which 18% (108) had mild, 54% (329) had moderate and 28% (167) had severe MSI as classified by ICF. There was an overall prevalence of MSI of 9.5% (CI 8.9-10.1). The prevalence of MSI increased with age, and was similar in men (9.3%) and women (9.6%). People without formal education were more likely to have MSI [13.3% (CI 11.8-14.8)] compared to those with formal education levels [8.9% (CI 8.1-9.7), p<0.001] for primary school and [5.9% (4.6-7.2), p<0.001] for secondary school. Overall, 33.2% of MSIs were due to congenital causes, 25.6% were neurological in origin, 19.2% due to acquired non-traumatic non-infective causes, 16.8% due to trauma and 5.2% due to infection. Extrapolation of these findings indicated that there are approximately one million cases of MSI in Malawi that need further treatment. MSI had a profound impact on quality of life. Analysis of disaggregated quality of life measures using EQ-5D showed clear correlation with the ICF class. A large proportion of patients with moderate and severe MSI were confined to bed, unable to wash or undress or unable to perform usual daily activities.

CONCLUSION

This study has uncovered a high prevalence of MSI in Malawi and its profound impact on a large proportion of the population. These findings suggest that MSI places a considerable strain on social and financial structures in this low-income country. The Quality of Life of those with severe MSI is considerably affected. The huge burden of musculoskeletal impairment in Malawi is mostly unattended, revealing an urgent need to scale up surgical and rehabilitation services in the country.

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

Strengthening primary health care at district-level in Malawi - determining the coverage, costs and benefits of community-directed interventions

Background

Community-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.

Methods

This was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.

Results

Implementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.

Conclusion

The CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.

Trial registration

The study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4341-5) contains supplementary material, which is available to authorized users.

Performance of primary care in different healthcare facilities: a cross-sectional study of patients' experiences in Southern Malawi

OBJECTIVE

In most African countries, primary care is delivered through a district health system. Many factors, including staffing levels, staff experience, availability of equipment and facility management, affect the quality of primary care between and within countries. The purpose of this study was to assess the quality of primary care in different types of public health facilities in Southern Malawi.

STUDY DESIGN

This was a cross-sectional quantitative study.

SETTING

The study was conducted in 12 public primary care facilities in Neno, Blantyre and Thyolo districts in July 2018.

PARTICIPANTS

Patients aged ≥18 years, excluding the severely ill, were selected to participate in the study.

PRIMARY OUTCOMES

We used the Malawian primary care assessment tool to conduct face-to-face interviews. Analysis of variance at 0.05 significance level was performed to compare primary care dimension means and total primary care scores. Linear regression models at 95% CI were used to assess associations between primary care dimension scores, patients' characteristics and healthcare setting.

RESULTS

The final number of respondents was 962 representing 96.1% response rate. Patients in Neno hospitals scored 3.77 points higher than those in Thyolo health centres, and 2.87 higher than those in Blantyre health centres in total primary care performance. Primary care performance in health centres and in hospital clinics was similar in Neno (20.9 vs 19.0, p=0.608) while in Thyolo, it was higher at the hospital than at the health centres (19.9 vs 15.2, p<0.001). Urban and rural facilities showed a similar pattern of performance.

CONCLUSION

These results showed considerable variation in experiences among primary care users in the public health facilities in Malawi. Factors such as funding, policy and clinic-level interventions influence patients' reports of primary care performance. These factors should be further examined in longitudinal and experimental settings.

The role of health animators in malaria control: a qualitative study of the health animator (HA) approach within the Majete malaria project (MMP) in Chikwawa District, Malawi

BACKGROUND

Malaria continues to place a high burden on communities due to challenges reaching intervention target levels in Chikwawa District, Malawi. The Hunger Project Malawi is using a health animator approach (HA) to address gaps in malaria control coverage. We explored the influence of community-based volunteers known as health animators (HAs) in malaria control. We assessed the impact of HAs on knowledge, attitudes, and practices towards malaria interventions.

METHODS

This paper draws on the qualitative data collected to explore the roles of communities, HAs and formal health workers attending and not attending malaria workshops for malaria control. Purposive sampling was used to select 78 respondents. We conducted 10 separate focus group discussions (FGDs)-(n = 6) with community members and (n = 4) key informants. Nine in-depth interviews (IDIs) were held with HAs and Health Surveillance Assistants (HSAs) in three focal areas near Majete Wildlife Reserve. Nvivo 11 was used for coding and analysis. We employed the framework analysis and social capital theory to determine how the intervention influenced health and social outcomes.

RESULTS

Using education, feedback sessions and advocacy in malaria workshop had mixed outcomes. There was a high awareness of community participation and comprehensive knowledge of the HA approach as key to malaria control. HAs were identified as playing a complementary role in malaria intervention. Community members' attitudes towards advocacy for better health services were poor. Attendance in malaria workshops was sporadic towards the final year of the intervention. Respondents mentioned positive attitudes and practices on net usage for prevention and prompt health-seeking behaviours.

CONCLUSION

The HA approach is a useful strategy for complementing malaria prevention strategies in rural communities and improving practices for health-seeking behaviour. Various factors influence HAs' motivation, retention, community engagement, and programme sustainability. However, little is known about how these factors interact to influence volunteers' motivation, community participation and sustainability over time. More research is needed to explore the acceptability of an HA approach and the impact on malaria control in other rural communities in Malawi.

TRANSPORTATION BARRIERS TO ACCESS HEALTH CARE FOR SURGICAL CONDITIONS IN MALAWI a cross sectional nationwide household survey

Background

It is estimated that nearly five billion people worldwide do not have access to safe surgery. This access gap disproportionately affects low-and middle-income countries (LMICs). One of the barriers to healthcare in LMICs is access to transport to a healthcare facility. Both availability and affordability of transport can be issues delaying access to health care. This study aimed to describe the main transportation factors affecting access and delay in reaching a facility for health care in Malawi.

Methods

This was a multi-stage, clustered, probability sampling with systematic sampling of households for transportation access to general health and surgical care. Malawi has an estimated population of nearly 18 million people, with a total of 48,233 registered settlements spread over 28 administrative districts. 55 settlements per district were randomly selected for data collection, and 2–4 households were selected, depending on the size. Two persons per household were interviewed.

The Surgeons Overseas Assessment of Surgical need (SOSAS) tool was used by trained personnel to collect data during the months of July and August 2016.

Analysis of data from 1479 households and 2958 interviewees was by univariate and multivariate methods.

Results

Analysis showed that 90.1% were rural inhabitants, and 40% were farmers. No formal employment was reported for 24.9% persons. Animal drawn carts prevailed as the most common mode of transport from home to the primary health facility - normally a health centre. Travel to secondary and tertiary level health facilities was mostly by public transport, 31.5 and 43.4% respectively. Median travel time from home to a health centre was 1 h, and 2.5 h to a central hospital. Thirty nine percent of male and 59% of female head of households reported lack financial resources to go to a hospital.

Conclusion

In Malawi, lack of suitable transport, finances and prolonged travel time to a health care centre, all pose barriers to timely access of health care. Improving the availability of transport between rural health centres and district hospitals, and between the district and central hospitals, could help overcome the transportation barriers to health care.

Capacity gaps in health facilities for case management of intestinal schistosomiasis and soil-transmitted helminthiasis in Burundi

Background

Schistosomiasis and soil-transmitted helminthiasis (STH) are endemic diseases in Burundi. STH control is integrated into health facilities (HF) across the country, but schistosomiasis control is not. The present study aimed to assess the capacity of HF for integrating intestinal schistosomiasis case management into their routine activities. In addition, the current capacity for HF-based STH case management was evaluated.

Methods

A random cluster survey was carried out in July 2014, in 65 HF located in Schistosoma mansoni and STH endemic areas. Data were collected by semi-quantitative questionnaires. Staff with different functions at the HF were interviewed (managers, care providers, heads of laboratory and pharmacy and data clerks). Data pertaining to knowledge of intestinal schistosomiasis and STH symptoms, human and material resources and availability and costs of diagnostic tests and treatment were collected.

Findings

Less than half of the 65 care providers mentioned one or more major symptoms of intestinal schistosomiasis (abdominal pain 43.1%, bloody diarrhoea 13.9% and bloody stool 7.7%). Few staff members (15.7%) received higher education, and less than 10% were trained in-job on intestinal schistosomiasis case management. Clinical guidelines and laboratory protocols for intestinal schistosomiasis diagnosis and treatment were available in one third of the HF. Diagnosis was performed by direct smear only. Praziquantel was not available in any of the HF. The results for STH were similar, except that major symptoms were more known and cited (abdominal pain 69.2% and diarrhoea 60%). Clinical guidelines were available in 61.5% of HF, and albendazole or mebendazole was available in all HF.

Conclusions

The current capacity of HF for intestinal schistosomiasis and STH detection and management is inadequate. Treatment was not available for schistosomiasis. These issues need to be addressed to create an enabling environment for successful integration of intestinal schistosomiasis and STH case management into HF routine activities in Burundi for better control of these diseases.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0447-y) contains supplementary material, which is available to authorized users.

Transforming Nursing Education to Strengthen Health System in Malawi: An Exploratory Study

Background:

Malawi made great strides to increase the number of nurses through the Emergency Human Resource for Health Program. However, quantity of health workforce alone is not adequate to strengthen the health system. Malawi still reports skill mix imbalance and geographical mal-distribution of the nursing workforce. Health systems must continuously adapt and evolve according to the health care needs and inform health professionals’ education to accelerate gains in health outcomes. The Lancet Commission reported that health professionals’ education has generally not lived up pace with health care demands.

Objectives:

The aim of this study was to describe the strategies being implemented in Malawi to improve nursing education. Specifically, the objectives of the study were to explore strategies being implemented, identify stakeholders and their targets in order to share practices with countries experiencing similar nursing education challenges.

Methods:

This was a cross sectional descriptive study with a concurrent mixed method design. One hundred and sixty participants including nurse practitioners and educators responded to a questionnaire. Fifteen nurse practitioners and eight nurse educators were also engaged in one to one interview.

Results:

Respondents showed varied opinion on how nursing education is being implemented. Six themes as regards strategies being implemented to improve nursing education emerged namely- capacity building, competency based curriculum, regulation, clinical learning environment, transformative teaching and infrastructure/ resources.

Conclusion:

Findings of this study show that the strategies being implemented to improve nursing education are relevant to closing the gap between health care needs and nursing education.

A middle-range model for improving quality of nursing education in Malawi

Background

Despite a global consensus that nurses and midwives constitute the majority and are a backbone of any country’s health workforce system, productive capacity of training institutions remains low and still needs more guidance. This study aimed at developing a middle-range model to guide efforts in nursing education improvements.

Objective

To explore challenges facing nursing education in Malawi and to describe efforts that are being put in place to improve nursing education and the process of development of a model to improve nursing education in Malawi.

Method

The study used a qualitative descriptive design. A panel discussion with eight nursing education and practice experts was conducted guided by core concepts derived from an analysis of research report from a national nursing education conference. Two focus group discussions during two quarterly review meetings engaged nurse educators, practitioners and clinical preceptors to fill gaps from data obtained from a panel discussion. A qualitative abductive analysis approach was used for the development of the model.

Results

Transforming and scaling up of nursing education emerged as the main concept of the model with nursing education context, academic practice partnership, regulation, competent graduate and nursing workforce as sub concepts. Key main strategies in the model included curriculum reforms, regulation, transformative learning, provision of infrastructure and resources and capacity building.

Conclusion

The model can be used to prioritise nursing education intervention aimed at improving quality of nursing education in Malawi and other similar settings.

Community prevalence of chronic respiratory symptoms in rural Malawi: Implications for policy

Background

No community prevalence studies have been done on chronic respiratory symptoms of cough, wheezing and shortness of breath in adult rural populations in Malawi. Case detection rates of tuberculosis (TB) and chronic airways disease are low in resource-poor primary health care facilities.

Objective

To understand the prevalence of chronic respiratory symptoms and recorded diagnoses of TB in rural Malawian adults in order to improve case detection and management of these diseases.

Methods

A population proportional, cross-sectional study was conducted to determine the proportion of the population with chronic respiratory symptoms that had a diagnosis of tuberculosis or chronic airways disease in two rural communities in Malawi. Households were randomly selected using Google Earth Pro software. Smart phones loaded with Open Data Kit Essential software were used for data collection. Interviews were conducted with 15795 people aged 15 years and above to enquire about symptoms of chronic cough, wheeze and shortness of breath.

Results

Overall 3554 (22.5%) participants reported at least one of these respiratory symptoms. Cough was reported by 2933, of whom 1623 (55.3%) reported cough only and 1310 (44.7%) combined with wheeze and/or shortness of breath. Only 4.6% (164/3554) of participants with chronic respiratory symptoms had one or more of the following diagnoses in their health passports (patient held medical records): TB, asthma, bronchitis and chronic obstructive pulmonary disease)

Conclusions

The high prevalence of chronic respiratory symptoms coupled with limited recorded diagnoses in patient-held medical records in these rural communities suggests a high chronic respiratory disease burden and unmet health need.

Feasibility and acceptability of training community health workers in ear and hearing care in Malawi: a cluster randomised controlled trial

OBJECTIVE

To assess the feasibility and acceptability of training community health workers (CHWs) in ear and hearing care, and their ability to identify patients with ear and hearing disorders.

DESIGN

Cluster randomised controlled trial (RCT).

SETTING

Health centres in Thyolo district, Malawi.

PARTICIPANTS

Ten health centres participated, 5 intervention (29 CHWs) and 5 control (28 CHWs).

INTERVENTION

Intervention CHWs received 3 days of training in primary ear and hearing care, while among control CHWs, training was delayed for 6 months. Both groups were given a pretest that assessed knowledge about ear and hearing care, only the intervention group was given the posttest on the third day of training. The intervention group was given 1 month to identify patients with ear and hearing disorders in their communities, and these people were screened for hearing disorders by ear, nose and throat clinical specialists.

OUTCOME MEASURES

Primary outcome measure was improvement in knowledge of ear and hearing care among CHWs after the training. Secondary outcome measures were number of patients with ear or hearing disorders identified by CHWs and number recorded at health centres during routine activities, and the perceived feasibility and acceptability of the intervention.

RESULTS

The average overall correct answers increased from 55% to 68% (95% CI 65 to 71) in the intervention group (p<0.001). A total of 1739 patients with potential ear and hearing disorders were identified by CHWs and 860 patients attended the screening camps, of whom 400 had hearing loss (73 patients determined through bilateral fail on otoacoustic emissions, 327 patients through audiometry). Where cause could be determined, the most common cause of ear and hearing disorders was chronic suppurative otitis media followed by impacted wax. The intervention was perceived as feasible and acceptable to implement.

CONCLUSIONS

Training was effective in improving the knowledge of CHW in ear and hearing care in Malawi and allowing them to identify patients with ear and hearing disorders. This intervention could be scaled up to other CHWs in low-income and middle-income countries.

TRIAL REGISTRATION NUMBER

Pan African Clinical Trial Registry (201705002285194); Results.

Our chairman is very efficient: community participation in the delivery of primary health care in Ibadan, Southwest Nigeria

Introduction

Community participation is rapidly being viewed as a requirement for the successful acceptance of health services; it integrates a complicated process which involves customs, beliefs, culture and power relations, not only structures and policies. Yet, there is a wide knowledge gap and changes favouring community participation in primary health care is still minimal. This study aims to assess the process indicators and other factors influencing community participation in the delivery of primary health care.

Methods

This descriptive cross-sectional study using qualitative methods was conducted in Ibadan South East Local Government Area of Oyo State, Nigeria between July and September, 2015. The interview and Focus Group Discussion guides centred around five participation indicators of needs assessment, leadership, resource mobilization, organization and management was used to collect data. A total of 12 in-depth interviews and four FGDs were conducted among male and female respondents consisting PHC service providers and community members purposively selected from four wards of the LGA. Spidergrams were constructed to visualize the levels of community participation from respondents' opinions.

Results

About 51.1% of the 45 respondents (with mean age 45.5 ± 8.09 years) were males. The respondents view community participation in the delivery of PHC in the LGA as being wide (open). Majority of the service users believe and agree that the level of community participation in their wards is about average while the service providers believed that participation was very high. However, respondents identified female representation, collaboration with pre-existing community structures, top-down and bottom-up approach to service delivery as factors affecting community participation in PHC delivery.

Conclusion

This study provides a baseline data on community participation in the delivery of primary health care. Community participation is still an important principle in the delivery of primary health care and it guarantees the positive changes desired in the uptake and sustainability of primary health care programmes.

The global burden of diagnostic errors in primary care

Diagnosis is one of the most important tasks performed by primary care physicians. The World Health Organization (WHO) recently prioritized patient safety areas in primary care, and included diagnostic errors as a high-priority problem. In addition, a recent report from the Institute of Medicine in the USA, 'Improving Diagnosis in Health Care', concluded that most people will likely experience a diagnostic error in their lifetime. In this narrative review, we discuss the global significance, burden and contributory factors related to diagnostic errors in primary care. We synthesize available literature to discuss the types of presenting symptoms and conditions most commonly affected. We then summarize interventions based on available data and suggest next steps to reduce the global burden of diagnostic errors. Research suggests that we are unlikely to find a 'magic bullet' and confirms the need for a multifaceted approach to understand and address the many systems and cognitive issues involved in diagnostic error. Because errors involve many common conditions and are prevalent across all countries, the WHO's leadership at a global level will be instrumental to address the problem. Based on our review, we recommend that the WHO consider bringing together primary care leaders, practicing frontline clinicians, safety experts, policymakers, the health IT community, medical education and accreditation organizations, researchers from multiple disciplines, patient advocates, and funding bodies among others, to address the many common challenges and opportunities to reduce diagnostic error. This could lead to prioritization of practice changes needed to improve primary care as well as setting research priorities for intervention development to reduce diagnostic error.

Use of Lot quality assurance sampling surveys to evaluate community health worker performance in rural Zambia: a case of Luangwa district

BACKGROUND

The Better Health Outcomes through Mentoring and Assessment (BHOMA) project is a cluster randomized controlled trial aimed at reducing age-standardized mortality rates in three rural districts through involvement of Community Health Workers (CHWs), Traditional Birth Attendants (TBAs), and Neighborhood Health Committees (NHCs). CHWs conduct quarterly surveys on all households using a questionnaire that captures key health events occurring within their catchment population. In order to validate contact with households, we utilize the Lot Quality Assurance Sampling (LQAS) methodology. In this study, we report experiences of applying the LQAS approach to monitor performance of CHWs in Luangwa District.

METHODS

Between April 2011 and December 2013, seven health facilities in Luangwa district were enrolled into the BHOMA project. The health facility catchment areas were divided into 33 geographic zones. Quality assurance was performed each quarter by randomly selecting zones representing about 90% of enrolled catchment areas from which 19 households per zone where also randomly identified. The surveys were conducted by CHW supervisors who had been trained on using the LQAS questionnaire. Information collected included household identity number (ID), whether the CHW visited the household, duration of the most recent visit, and what health information was discussed during the CHW visit. The threshold for success was set at 75% household outreach by CHWs in each zone.

RESULTS

There are 4,616 total households in the 33 zones. This yielded a target of 32,212 household visits by community health workers during the 7 survey rounds. Based on the set cutoff point for passing the surveys (at least 75% households confirmed as visited), only one team of CHWs at Luangwa high school failed to reach the target during round 1 of the surveys; all the teams otherwise registered successful visits in all the surveys.

CONCLUSIONS

We have employed the LQAS methodology for assurance that quarterly surveys were successfully done. This methodology proved helpful in identifying poorly performing CHWs and could be useful for evaluating CHW performance in other areas.

TRIAL REGISTRATION

Identifier: NCT01942278 . Date of Registration: September 2013.

The Role of Nurses and Community Health Workers in Confronting Neglected Tropical Diseases in Sub-Saharan Africa: A Systematic Review

INTRODUCTION

Neglected tropical diseases produce an enormous burden on many of the poorest and most disenfranchised populations in sub-Saharan Africa. Similar to other developing areas throughout the world, this region's dearth of skilled health providers renders Western-style primary care efforts to address such diseases unrealistic. Consequently, many countries rely on their corps of nurses and community health workers to engage with underserved and hard-to-reach populations in order provide interventions against these maladies. This article attempts to cull together recent literature on the impact that nurses and community health workers have had on neglected tropical diseases.

METHODS

A review of the literature was conducted to assess the role nurses and community health workers play in the primary, secondary, and tertiary prevention of neglected tropical diseases in sub-Saharan Africa. Articles published between January 2005 and December 2015 were reviewed in order to capture the full scope of nurses' and community health workers' responsibilities for neglected tropical disease control within their respective countries' health systems.

RESULTS

A total of 59 articles were identified that fit all inclusion criteria.

CONCLUSIONS

Successful disease control requires deep and meaningful engagement with local communities. Expanding the role of nurses and community health workers will be required if sub-Saharan African countries are to meet neglected tropical disease treatment goals and eliminate the possibility future disease transmission. Horizontal or multidisease control programs can create complimentary interactions between their different control activities as well as reduce costs through improved program efficiencies-benefits that vertical programs are not able to attain.

The 'community' in community case management of childhood illnesses in Malawi

BACKGROUND

Malawi has achieved a remarkable feat in reducing its under-5 mortality in time to meet its MDG 4 target despite high levels of poverty, low female literacy rates, recurrent economic crises, a severe shortage of human resources for health, and poor health infrastructure. The country's community-based delivery platform (largely headed by Health Surveillance Assistants, or HSAs) has been well established since the 1960s, although their tasks and responsibilities have evolved from surveillance to health promotion and prevention, and more recently to include curative services. However, the role of and the form that community involvement takes in community-based service delivery in Malawi is unclear.

DESIGN

A qualitative rapid appraisal approach was utilised to explore the role of community involvement in the HSA programme in Malawi to better understand how the various community providers intersect to support the delivery of integrated community case management by HSAs. Twelve focus group discussions and 10 individual interviews were conducted with HSAs, HSA supervisors, mothers, members of village health committees (VHCs), senior Ministry of Health officials, district health teams, and implementing partners.

RESULTS

Our findings reveal that HSAs are often deployed to areas outside of their village of residence as communities are not involved in selecting their own HSAs in Malawi. Despite this lack of involvement in selection, the high acceptance of the HSAs by community members and community accountability structures such as VHCs provide the programme with legitimacy and credibility.

CONCLUSIONS

This study provides insight into how community involvement plays out in the context of a government-managed professionalised community service delivery platform. It points to the need for further research to look at the impact of removing the role of HSA selection and deployment from the community and placing it at the central level.

The Potential for Community-Directed Interventions: Reaching Underserved Populations in Africa

Community-directed interventions (CDIs) have the potential for fulfilling the promise of primary health care by reaching underserved populations in various settings. CDI has been successfully tested by expanding access to additional health services like malaria case management through local effort in communities where ivermectin distribution is ongoing. The question remains whether the CDI approach has potential in communities that do not have a foundation of community-directed treatment with ivermectin. The UNICEF/UNDP/World Bank/WHO Special Program of Research and Training in Tropical Diseases commissioned three sets of formative studies to explore the potential for introducing CDI among nomads, urban poor, and rural areas with no community-directed treatment with ivermectin. This article reviews their findings. Community and health system respondents identified a set of mainly communicable diseases that could be adapted to CDI as well as participatory mechanisms like community-based organizations and leaders that could form a foundation for local organizing and participation. It is hoped that the results of these formative studies will spur further research on CDI among peoples with poor health-care access.

The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'

BACKGROUND

A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example.

METHODS

We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi.

RESULTS

Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks.

CONCLUSION

The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.

Health systems challenges in cervical cancer prevention program in Malawi

Background

Cervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa. In Malawi, very few women have undergone screening and the incidence of cervical cancer is on the increase as is the case in most developing countries. We aimed at exploring and documenting health system gaps responsible for the poor performance of the cervical cancer prevention program in Malawi.

Design

The study was carried out in 14 randomly selected districts of the 29 districts of Malawi. All cervical cancer service providers in these districts were invited to participate. Two semi-structured questionnaires were used, one for the district cervical cancer coordinators and the other for the service providers. The themes of both questionnaires were based on World Health Organization (WHO) health system frameworks. A checklist was also developed to audit medical supplies and equipment in the cervical cancer screening facilities. The two questionnaires together with the medical supplies and equipment checklist were piloted in Chikwawa district before being used as data collection tools in the study. Quantitative data were analyzed using STATA and qualitative in NVIVO.

Results

Forty-one service providers from 21 health facilities and 9 district coordinators participated in the study. Our findings show numerous health system challenges mainly in areas of health workforce and essential medical products and technologies. Seven out of the 21 health facilities provided both screening and treatment. Results showed challenges in the management of the cervical cancer program at district level; inadequate service providers who are poorly supervised; lack of basic equipment and stock-outs of basic medical supplies in some health facilities; and inadequate funding of the program. In most of the health facilities, services providers were not aware of the policy which govern their work and that they did not have standards and guidelines for cervical cancer screening and treatment.

Conclusion

Numerous health system challenges are prevailing in the cervical cancer prevention program in Malawi. These challenges need to be addressed if the health system is to improve on the coverage of cervical cancer screening and treatment.

Integration of community home based care programmes within national primary health care revitalisation strategies in Ethiopia, Malawi, South-Africa and Zambia: a comparative assessment

BACKGROUND

In 2008, the WHO facilitated the primary health care (PHC) revitalisation agenda. The purpose was to strengthen African health systems in order to address communicable and non-communicable diseases. Our aim was to assess the position of civil society-led community home based care programmes (CHBC), which serve the needs of patients with HIV, within this agenda. We examined how their roles and place in health systems evolved, and the prospects for these programmes in national policies and strategies to revitalise PHC, as new health care demands arise.

METHODS

The study was conducted in Ethiopia, Malawi, South Africa and Zambia and used an historical, comparative research design. We used purposive sampling in the selection of countries and case studies of CHBC programmes. Qualitative methods included semi-structured interviews, focus group discussions, service observation and community mapping exercises. Quantitative methods included questionnaire surveys.

RESULTS

The capacity of PHC services increased rapidly in the mid-to-late 2000s via CHBC programme facilitation of community mobilisation and participation in primary care services and the exceptional investments for HIV/AIDS. CHBC programmes diversified their services in response to the changing health and social care needs of patients on lifelong anti-retroviral therapy and there is a general trend to extend service delivery beyond HIV-infected patients. We observed similarities in the way the governments of South Africa, Malawi and Zambia are integrating CHBC programmes into PHC by making PHC facilities the focal point for management and state-paid community health workers responsible for the supervision of community-based activities. Contextual differences were found between Ethiopia, South Africa, Malawi and Zambia, whereby the policy direction of the latter two countries is to have in place structures and mechanisms that actively connect health and social welfare interventions from governmental and non-governmental actors.

CONCLUSIONS

Countries may differ in the means to integrate and co-ordinate government and civil society agencies but the net result is expanded PHC capacity. In a context of changing health care demands, CHBC programmes are a vital mechanism for the delivery of primary health and social welfare services.

Gaps in universal health coverage in Malawi: a qualitative study in rural communities

BACKGROUND

In sub-Saharan Africa, universal health coverage (UHC) reforms have often adopted a technocratic top-down approach, with little attention being paid to the rural communities' perspective in identifying context specific gaps to inform the design of such reforms. This approach might shape reforms that are not sufficiently responsive to local needs. Our study explored how rural communities experience and define gaps in universal health coverage in Malawi, a country which endorses free access to an Essential Health Package (EHP) as a means towards universal health coverage.

METHODS

We conducted a qualitative cross-sectional study in six rural communities in Malawi. Data was collected from 12 Focus Group Discussions with community residents and triangulated with 8 key informant interviews with health care providers. All respondents were selected through stratified purposive sampling. The material was tape-recorded, fully transcribed, and coded by three independent researchers.

RESULTS

The results showed that the EHP has created a universal sense of entitlements to free health care at the point of use. However, respondents reported uneven distribution of health facilities and poor implementation of public-private service level agreements, which have led to geographical inequities in population coverage and financial protection. Most respondents reported affordability of medical costs at private facilities and transport costs as the main barriers to universal financial protection. From the perspective of rural Malawians, gaps in financial protection are mainly triggered by supply-side access-related barriers in the public health sector such as: shortages of medicines, emergency services, shortage of health personnel and facilities, poor health workers' attitudes, distance and transportation difficulties, and perceived poor quality of health services.

CONCLUSIONS

Moving towards UHC in Malawi, therefore, implies the introduction of appropriate interventions to fill the financial protection gaps in the private sector and the access-related gaps in the public sector and/or an effective public-private partnership that completely integrates both sectors. Current universal health coverage reforms need to address context specific gaps and be carefully crafted to avoid creating a sense of universal entitlements in principle, which may not be effectively received by beneficiaries due to contextual and operational bottlenecks.

Baseline assessment of adult and adolescent primary care delivery in Rwanda: an opportunity for quality improvement

BACKGROUND

As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda.

METHODS

Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard.

RESULTS

Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively).

CONCLUSION

Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Accessibility of health care service in Thasongyang, Tak Province, Thailand

Accessibility to health care services in Thailand is generally good, but a few areas in the country are difficult to reach. The purpose of this study was to investigate the accessibility of health care services in rural and remote areas of Thailand. It was conducted in 16 remote villages within a catchment area with a primary health care post. The health care post staff interviewed 394 respondents (197 males and 197 females) using a structured questionnaire. Most respondents utilized primary health care posts (98.5%) and medical institutes. Most of the respondents were Karen, had low incomes, and were illiterate. However, they had health insurance. Most of them took more than 30 minutes to travel from home to their primary health care post (60.9%), and took more time in the rainy season than in the dry season. Moreover, it took more than 2 hours for them to travel to the nearest hospital from their residences (64.5% in the dry season and 84.5% in the rainy season). They also paid more for medical services, travelling and food on the way to the hospital. Not only primary health care posts, but also many other medical institutes provided health care services in the villages. In conclusion, based on the results of this study, primary health care posts in remote areas are necessary to ensure the residents' healthy lives. Therefore, improvement of the quality and accessibility of primary health care posts should be considered as the top priority.

Coping with uncertainty during healthcare-seeking in Lao PDR

BACKGROUND

Uncertainty is regarded as a central dimension in the experience of illness and in the processes of alleviating it. Few studies from resource-poor settings have investigated this and how it interacts with other factors. This study aims to shed light on how healthcare-seeking develops in the context of multiple medical alternatives and to understand what bearing uncertainty has on this process.

METHODS

The study was conducted in six purposively selected rural communities in Lao PDR. In each community, two focus group discussions were held: first with mothers and then with fathers of children younger than five years old. Eleven in-depth interviews with caregivers of severely sick children were conducted. Subsequently, traditional healers, drug vendors, community health workers, nurses and medical doctors were recruited for interviews or group discussions. The data were transcribed and key themes and similarities were identified. Additional readings were conducted to better understand the interactions of factors during which uncertainty was identified as one of several factors mentioned during interviews and focus group discussions.

RESULTS

Care-seekers expressed a strong preference for initially seeking local providers. Subsequently, multiple providers were consulted to increase the chances of recovery. This resulted in patients leaving the health facilities before recovery and in ending the recommended treatment regime prematurely. These healthcare-seeking decisions reflect the social significance of being a responsible caregiver and of showing respect for household norms. In general, healthcare-seeking was shrouded in uncertainty when it came to selecting the right provider, the likelihood of finding the real cause of the illness, spending savings on treatments and ultimately the likelihood of recovery.

CONCLUSIONS

Care-seekers' initial strong preference for local providers irrespective of the providers' legitimacy indicates the need for a robust primary healthcare system. Care-seekers' subsequent consultations must be understood in the light of their uncertainty regarding the skills of the available providers. The social connotations of seeking healthcare including the vulnerability of poor households in public health facilities were taken into account to only a limited extent by health workers. Health workers should have greater awareness of the social and cultural aspects of seeking care.