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Gumisiriza H, Olet EA, Mukasa P, Lejju JB, Omara T. Ethnomedicinal plants used for malaria treatment in Rukungiri District, Western Uganda. Trop Med Health 2023; 51:49. [PMID: 37644587 PMCID: PMC10466780 DOI: 10.1186/s41182-023-00541-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 08/25/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Malaria remains a major global health challenge and a serious cause of morbidity and mortality in sub-Saharan Africa. In Uganda, limited access to medical facilities has perpetuated the reliance of indigenous communities on herbal medicine for the prevention and management of malaria. This study was undertaken to document ethnobotanical knowledge on medicinal plants prescribed for managing malaria in Rukungiri District, a meso-endemic malaria region of Western Uganda. METHODS An ethnobotanical survey was carried out between May 2022 and December 2022 in Bwambara Sub-County, Rukungiri District, Western Uganda using semi-structured questionnaire. A total of 125 respondents (81 females and 44 males) were randomly selected and seven (7) key informants were engaged in open interviews. In all cases, awareness of herbalists on malaria, treatment-seeking behaviour and herbal treatment practices were obtained. The ethnobotanical data were analyzed using descriptive statistics, informant consensus factor and preference ranking. RESULTS The study identified 48 medicinal plants belonging to 47 genera and 23 families used in the treatment of malaria and its symptoms in the study area. The most frequently cited species were Vernonia amygdalina, Aloe vera and Azadirachta indica. Leaves (74%) was the most used plant organ, mostly for preparation of decoctions (41.8%) and infusions (23.6%) which are administered orally (89.6%) or used for bathing (10.4%). CONCLUSIONS Indigenous knowledge of medicinal plants used as prophylaxis and for treatment of malaria still exist among the local communities of Bwambara Sub-County. However, there is a need to investigate the antimalarial efficacy, phytochemical composition and safety of species (such as Digitaria abyssinica and Berkheya barbata) with high percentage use values to validate their use.
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Affiliation(s)
- Hannington Gumisiriza
- Department of Chemistry, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Eunice Apio Olet
- Department of Biology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Paul Mukasa
- Department of Chemistry, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Julius B Lejju
- Department of Biology, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Timothy Omara
- Department of Chemistry and Biochemistry, School of Sciences and Aerospace Studies, Moi University, P.O. Box 3900, Eldoret, Kenya
- Center of Excellence II in Phytochemicals, Textile and Renewable Energy (ACE II PTRE), Moi University, P.O. Box 3900, Eldoret, Kenya
- Department of Chemistry, Institute of Chemistry of Renewable Resources, University of Natural Resources and Life Sciences, Vienna (BOKU), Konrad-Lorenz-Straße 24, 3430, Tulln, Austria
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Shu Z, Liu Y, Li M, Li J. The effects of health system reform on medical services utilization and expenditures in China in 2004-2015. Int Health 2021; 13:640-647. [PMID: 34263307 PMCID: PMC8643455 DOI: 10.1093/inthealth/ihab041] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/15/2021] [Accepted: 07/01/2021] [Indexed: 11/12/2022] Open
Abstract
Background In 2009, China began to implement new health system reform aimed at reducing the financial burden of patients. This study aimed to compare changes in the utilization of medical services and expenditures in different groups from 2004 to 2015. Methods Pooled cross-sectional data from 2004 to 2015 from the China Health and Nutrition Survey Database were used to conduct a segmental linear regression to estimate changes in the medical expenditures of different groups before and after implementation of the reform. Results During the reform process, the utilization rate of outpatient healthcare, primary health services and hospital health services showed a trend of increasing first and then decreasing slightly. The frequency of residents using inpatient services increased after the reform. The average medical expenditures increased significantly, especially for uninsured and primary health services users. Conclusions China's new round of health reform increased the coverage rate of basic medical insurance. Medical insurance has controlled the growth of the average medical expenditures; nevertheless, the average medical expenditures per patient has shown a continuous upward trend. Consequently, both basic medical insurance funds and residents face greater economic burdens and financial risks. Effective methods of controlling the growth of medical expenditures are therefore required.
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Affiliation(s)
- Zhan Shu
- School of Public Administration, Central China Normal University, Wuhan, Hubei, 430079, China
| | - Yingli Liu
- School of Public Administration, Central China Normal University, Wuhan, Hubei, 430079, China
| | - Minlin Li
- School of Public Administration, Central China Normal University, Wuhan, Hubei, 430079, China
| | - Jian Li
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100020, China
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Gumisiriza H, Sesaazi CD, Olet EA, Kembabazi O, Birungi G. Medicinal plants used to treat "African" diseases by the local communities of Bwambara sub-county in Rukungiri District, Western Uganda. JOURNAL OF ETHNOPHARMACOLOGY 2021; 268:113578. [PMID: 33189840 DOI: 10.1016/j.jep.2020.113578] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE In Africa, traditional medicine encompasses a diverse range of practices, including herbalism and spiritualism, where some diseases are believed to be "African" since they can only be traditionally treated. Indigenous knowledge on the management of "African" diseases using medicinal plants is still handed down orally from generation to generation by tribal societies of tropical Africa, and with the rapid westernization of these societies there is a pressing need to record local knowledge before it is lost forever. AIM This study documented medicinal plant species associated with the management of "African" diseases by the local communities of Bwambara sub-county in Rukungiri district, Western Uganda. METHODS A cross-sectional study was conducted using semi-structured questionnaires and interviews. The data collected included names of plant species, plant parts used, diseases treated, methods of preparation, and mode of administration of the herbal remedies. A total of 196 informants participated in the study. Data were analyzed and presented using descriptive statistics and the Informant consensus factor. RESULTS We documented 67 medicinal plant species distributed over 27 families and 62 genera. The most commonly reported species belong to Asteraceae family. The most frequently used medicinal species were Chenopodium opulifolium (27), Sesbania sesban (26), Thevetia peruviana (25), Leonotis nepetifolia (23), Momordica foetida (23), Euphorbia hirta (21) and Cassia mimosoides (20). Leaves were the most commonly used plants parts and decoctions were the main method of preparation. Water was the main medium used for the preparation of the remedies which were administered orally while petroleum jelly was the main medium for those which were used as ointments. The medicinal plant species reported are used to treat 39 conditions which were clustered into 10 International Classification of Primary Care (ICPC) disease categories. There is a high degree of consensus among the informants on which medicinal plant species they use for different diseases especially disorders in the following categories: neurological (FIC = 0.90), general and unspecified (FIC = 0.87), digestive (FIC = 0.86) and female genital (FIC = 0.82). CONCLUSION Local communities of Bwambara sub-county in Rukungiri district, Western Uganda use a rich diversity of medicinal plant species in the management of various "African" diseases. Therefore, collaboration between users of medicinal plants and scientists is paramount, to help in the discovery of new drugs based on indigenous knowledge.
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Affiliation(s)
- Hannington Gumisiriza
- Department of Chemistry, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda.
| | - Crispin Duncan Sesaazi
- Department of Pharmaceutical Sciences, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Eunice Apio Olet
- Department of Biology, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Owen Kembabazi
- Department of Marketing and International Business, Makerere University Business School, P.O Box 1337, Kampala, Uganda
| | - Grace Birungi
- Department of Chemistry, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
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Oliphant NP, Manda S, Daniels K, Odendaal WA, Besada D, Kinney M, White Johansson E, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Cochrane Database Syst Rev 2021; 2:CD012882. [PMID: 33565123 PMCID: PMC8094443 DOI: 10.1002/14651858.cd012882.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.
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Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
- School of Public Health, University of the Western Cape, Belleville, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Hatfield, South Africa
- Department of Statistics, University of Pretoria, Hatfield, South Africa
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Mary Kinney
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Emily White Johansson
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Belleville, South Africa
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Ashton RA, Prosnitz D, Andrada A, Herrera S, Yé Y. Evaluating malaria programmes in moderate- and low-transmission settings: practical ways to generate robust evidence. Malar J 2020; 19:75. [PMID: 32070357 PMCID: PMC7027277 DOI: 10.1186/s12936-020-03158-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 02/09/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many countries have made substantial progress in scaling-up and sustaining malaria intervention coverage, leading to more focalized and heterogeneous transmission in many settings. Evaluation provides valuable information for programmes to understand if interventions have been implemented as planned and with quality, if the programme had the intended impact on malaria burden, and to guide programmatic decision-making. Low-, moderate-, and heterogeneous-transmission settings present unique evaluation challenges because of dynamic and targeted intervention strategies. This paper provides illustration of evaluation approaches and methodologies for these transmission settings, and suggests how to answer evaluation questions specific to the local context. METHODS The Roll Back Malaria Monitoring and Evaluation Reference Group formed a task force in October 2017 to lead development of this framework. The task force includes representatives from National Malaria Programmes, funding agencies, and malaria research and implementing partners. The framework builds on existing guidance for process and outcome evaluations and impact evaluations specifically in high transmission settings. RESULTS The theory of change describes how evaluation questions asked by national malaria programmes in different contexts influence evaluation design. The transmission setting, existing stratification, and data quality and availability are also key considerations. The framework is intended for adaption by countries to their local context, and use for evaluation at sub-national level. Confirmed malaria incidence is recommended as the primary impact indicator due to its sensitivity to detect changes in low-transmission settings. It is expected that process evaluations provide sufficient evidence for programme monitoring and improvement, while impact evaluations are needed following adoption of new mixes of interventions, operational strategies, tools or policies, particularly in contexts of changing malaria epidemiology. Impact evaluations in low-, moderate-, or heterogeneous-transmission settings will likely use plausibility designs, and methods highlighted by the framework include interrupted time series, district-level dose-response analyses, and constructed control methods. Triangulating multiple data sources and analyses is important to strengthen the plausibility argument. CONCLUSIONS This framework provides a structure to assist national malaria programmes and partners to design evaluations in low-, moderate- or heterogeneous-transmission settings. Emphasizing a continuous cycle along the causal pathway linking process evaluation to impact evaluation and then programmatic decision-making, the framework provides practical guidance in evaluation design, analysis, and interpretation to ensure that the evaluation meets national malaria programme priority questions and guides decision-making at national and sub-national levels.
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Affiliation(s)
- Ruth A Ashton
- MEASURE Evaluation, Center for Applied Malaria Research and Evaluation, Tulane School of Public Health and Tropical Medicine, Tulane University, 1440 Canal Street, Suite 2300, New Orleans, LA, USA.
| | | | | | - Samantha Herrera
- MEASURE Evaluation, ICF, Rockville, MD, USA.,Save the Children, Washington, DC, USA
| | - Yazoumé Yé
- MEASURE Evaluation, ICF, Rockville, MD, USA
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Halliday KE, Witek-McManus SS, Opondo C, Mtali A, Allen E, Bauleni A, Ndau S, Phondiwa E, Ali D, Kachigunda V, Sande JH, Jawati M, Verney A, Chimuna T, Melody D, Moestue H, Roschnik N, Brooker SJ, Mathanga DP. Impact of school-based malaria case management on school attendance, health and education outcomes: a cluster randomised trial in southern Malawi. BMJ Glob Health 2020; 5:e001666. [PMID: 32133163 PMCID: PMC7042571 DOI: 10.1136/bmjgh-2019-001666] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/27/2019] [Accepted: 10/05/2019] [Indexed: 11/04/2022] Open
Abstract
Introduction Evidence indicates children who suffer from ill-health are less likely to attend or complete schooling. Malaria is an important cause of morbidity and mortality in school-age children. However, they are less likely to receive malaria treatment at health facilities and evidence for how to improve schoolchildren's access to care is limited. This study aimed to evaluate the impact of a programme of school-based malaria case management on schoolchildren's attendance, health and education. Methods A cluster randomised controlled trial was conducted in 58 primary schools in Zomba District, Malawi, 2011-2015. The intervention, implemented in 29 randomly selected schools, provided malaria rapid diagnostic tests and artemisinin-based combination therapy to diagnose and treat uncomplicated malaria as part of basic first aid kits known as 'Learner Treatment Kits' (LTK). The primary outcome was school attendance, assessed through teacher-recorded daily attendance registers and independent periodic attendance spot checks. Secondary outcomes included prevalence of Plasmodium spp infection, anaemia, educational performance, self-reported child well-being and health-seeking behaviour. A total of 9571 children from standards 1-7 were randomly selected for assessment of school attendance, with subsamples assessed for the secondary outcomes. Results Between November 2013 and March 2015, 97 trained teachers in 29 schools provided 32 685 unique consultations. Female schoolchildren were significantly more likely than male to seek a consultation (unadjusted OR=1.78 (95% CI 1.58 to 2.00). No significant intervention effect was observed on the proportion of child-days recorded as absent in teacher registers (n=9017 OR=0.90 (95% CI 0.77 to 1.05), p=0.173) or of children absent during random school visits-spot checks (n=5791 OR=1.09 (95% CI 0.87 to 1.36), p=0.474). There was no significant impact on child-reported well-being, prevalence of Plasmodium spp, anaemia or education scores. Conclusion Despite high community demand, the LTK programme did not reduce schoolchildren's absenteeism or improve health or education outcomes in this study setting. Trial registration number ClinicalTrials.gov NCT02213211.
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Affiliation(s)
- Katherine E Halliday
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Stefan S Witek-McManus
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Charles Opondo
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | | | - Elizabeth Allen
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine Faculty of Epidemiology and Population Health, London, UK
| | - Andrew Bauleni
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Saidi Ndau
- Zomba District Health Office, Ministry of Health, Zomba, Malawi
| | - Emmanuel Phondiwa
- District Education Office, Ministry of Education, Science and Technology, Zomba, Malawi
| | - Doreen Ali
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | - Virginia Kachigunda
- Department of School Health, Nutrition, HIV & AIDS, Ministry of Education, Science and Technology, Lilongwe, Malawi
| | - John H Sande
- National Malaria Control Programme, Ministry of Health, Lilongwe, Malawi
| | | | | | | | - David Melody
- Save the Children International, Lilongwe, Malawi
| | | | | | - Simon J Brooker
- Department of Disease Control, London School of Hygiene and Tropical Medicine Faculty of Infectious and Tropical Diseases, London, UK
| | - Don P Mathanga
- Malaria Alert Centre, College of Medicine, University of Malawi, Blantyre, Malawi
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Uwimana A, Penkunas MJ, Nisingizwe MP, Uyizeye D, Hakizimana D, Musanabaganwa C, Musabyimana JP, Ngwije A, Turate I, Mbituyumuremyi A, Murindahabi M, Condo J. Expanding home-based management of malaria to all age groups in Rwanda: analysis of acceptability and facility-level time-series data. Trans R Soc Trop Med Hyg 2019; 112:513-521. [PMID: 30184186 DOI: 10.1093/trstmh/try093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/01/2018] [Indexed: 11/14/2022] Open
Abstract
Background In response to a resurgence of malaria in Rwanda, home-based management (HBM) was expanded to enable community-health workers (CHWs) to provide malaria treatment to patients of all ages. We assessed the effect of the expanded HBM program on malaria case presentations at health facilities. Methods Services provided by CHWs and health facility presentations among individuals >5 y of age were considered. Presentations to CHWs were analyzed descriptively to assess acceptability and segmented regression modeling using facility-level data was employed to compare changes between the pre- and postintervention periods for intervention and control districts. Results Individuals >5 y of age readily accessed malaria diagnosis and treatment services from CHWs. Severe and uncomplicated malaria increased in the postintervention period for both the intervention and control districts. Presentations for uncomplicated malaria increased in the intervention and control districts to a similar degree. Severe cases increased to a greater degree in the intervention districts immediately after HBM was expanded compared with controls, but the monthly rate of increase was lower in the intervention districts. Conclusions Services were shifted to CHWs, as demonstrated by the number of individuals treated through the expanded program. The rate of severe malaria increased immediately after implementation within intervention districts relative to controls, potentially because of enhanced case-finding. The rate of increase in severe cases was lower in the intervention districts comparatively, likely due to expedited treatment.
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Affiliation(s)
- Aline Uwimana
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Michael J Penkunas
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Marie Paul Nisingizwe
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Didier Uyizeye
- Maternal and Child Survival Program, United States Agency for International Development, Kigali, Rwanda
| | - Dieudonne Hakizimana
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | | | | | - Alida Ngwije
- Demand-Driven Evaluations for Decisions, Clinton Health Access Initiative, Kigali, Rwanda
| | - Innocent Turate
- Institute of HIV/AIDs Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Monique Murindahabi
- Malaria and Other Parasitic Diseases Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Jeanine Condo
- Office of the Director General, Rwanda Biomedical Center, Kigali, Rwanda
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Impact of universal medical insurance system on the accessibility of medical service supply and affordability of patients in China. PLoS One 2018. [PMID: 29513712 PMCID: PMC5841764 DOI: 10.1371/journal.pone.0193273] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background China’s universal medical insurance system (UMIS) is designed to promote social fairness through improving access to medical services and reducing out-of-pocket (OOP) costs for all Chinese. However, it is still not known whether UMIS has a significant impact on the accessibility of medical service supply and the affordability, as well as the seeking-care choice, of patients in China. Methods Segmented time-series regression analysis, as a powerful statistical method of interrupted time series design, was used to estimate the changes in the quantity and quality of medical service supply before and after the implementation of UMIS. The rates of catastrophic payments and seeking-care choices for UMIS beneficiaries were selected to measure the affordability and medical service flow of patients after the implementation of UMIS. Results China’s UMIS was established in 2008. After that, the trending increase of the expenditure of the UMIS was higher than that of increase in revenue compared to previous years. Up to 2014, the UMIS had covered 97.5% of the entire population in China. After introduction of the UMIS, there were significant increases in licensed physicians, nurses, and hospital beds per 1000 individuals. In addition, hospital outpatient visits and inpatient visits per year increased compared to the pre-UMIS period. The average fatality rate of inpatients in the overall hospital and general hospital and the average fatality rate due to acute myocardial infarction (AMI) in general hospitals was significantly decreased. In contrast, no significant and prospective changes were observed in rural physicians per 1000 individuals, inpatient visits and inpatient fatality rate in the community centers and township hospitals compared to the pre-UMIS period. After 2008, the rates of catastrophic payments for UMIS inpatients at different income levels were declining at three levels of hospitals. Whichever income level, the rate of catastrophic payments for inpatients of Urban Employee’s Basic Medical Insurance was the lowest. For the low-income patients, a single hospitalization at a tertiary hospital can lead to catastrophic payments. It is needless to say what the economic burden could be if patients required multiple hospitalizations within a year. UMIS beneficiaries showed the intention of growth to seek hospitalization services in tertiary hospitals. Conclusions Introduction of the UMIS contributed to an increase in available medical services and the use thereof, and a decrease in fatality rate. The affordability of UMIS beneficiaries for medical expenses was successfully ameliorated. The differences in patients’ affordability are mainly manifested in different medical insurance schemes and different seeking-care choices. The ability of the poor patients covered by UMIS to resist catastrophic medical payments is still relatively weak. Therefore, the current UMIS should reform the insurance payment model to promote the integration of medical services and the formation of a tiered treatment system. UMIS also should establish supplementary medical insurance packages for the poor.
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Hansen KS, Ndyomugyenyi R, Magnussen P, Lal S, Clarke SE. Cost-effectiveness analysis of malaria rapid diagnostic tests for appropriate treatment of malaria at the community level in Uganda. Health Policy Plan 2017; 32:676-689. [PMID: 28453718 PMCID: PMC5406761 DOI: 10.1093/heapol/czw171] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2016] [Indexed: 11/21/2022] Open
Abstract
In Sub-Saharan Africa, malaria remains a major cause of morbidity and mortality among children under 5, due to lack of access to prompt and appropriate diagnosis and treatment. Many countries have scaled-up community health workers (CHWs) as a strategy towards improving access. The present study was a cost-effectiveness analysis of the introduction of malaria rapid diagnostic tests (mRDTs) performed by CHWs in two areas of moderate-to-high and low malaria transmission in rural Uganda. CHWs were trained to perform mRDTs and treat children with artemisinin-based combination therapy (ACT) in the intervention arm while CHWs offered treatment based on presumptive diagnosis in the control arm. Data on the proportion of children with fever 'appropriately treated for malaria with ACT' were captured from a randomised trial. Health sector costs included: training of CHWs, community sensitisation, supervision, allowances for CHWs and provision of mRDTs and ACTs. The opportunity costs of time utilised by CHWs were estimated based on self-reporting. Household costs of subsequent treatment-seeking at public health centres and private health providers were captured in a sample of households. mRDTs performed by CHWs was associated with large improvements in appropriate treatment of malaria in both transmission settings. This resulted in low incremental costs for the health sector at US$3.0 per appropriately treated child in the moderate-to-high transmission area. Higher incremental costs at US$13.3 were found in the low transmission area due to lower utilisation of CHW services and higher programme costs. Incremental costs from a societal perspective were marginally higher. The use of mRDTs by CHWs improved the targeting of ACTs to children with malaria and was likely to be considered a cost-effective intervention compared to a presumptive diagnosis in the moderate-to-high transmission area. In contrast to this, in the low transmission area with low attendance, RDT use by CHWs was not a low cost intervention.
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Affiliation(s)
- Kristian S Hansen
- Department of Public Health, Section for Health Services Research, University of Copenhagen, Denmark
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK
| | | | - Pascal Magnussen
- Centre for Medical Parasitology and Microbiology & Institute of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Sham Lal
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK
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10
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Burchett HED, Leurent B, Baiden F, Baltzell K, Björkman A, Bruxvoort K, Clarke S, DiLiberto D, Elfving K, Goodman C, Hopkins H, Lal S, Liverani M, Magnussen P, Mårtensson A, Mbacham W, Mbonye A, Onwujekwe O, Roth Allen D, Shakely D, Staedke S, Vestergaard LS, Whitty CJM, Wiseman V, Chandler CIR. Improving prescribing practices with rapid diagnostic tests (RDTs): synthesis of 10 studies to explore reasons for variation in malaria RDT uptake and adherence. BMJ Open 2017; 7:e012973. [PMID: 28274962 PMCID: PMC5353269 DOI: 10.1136/bmjopen-2016-012973] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The overuse of antimalarial drugs is widespread. Effective methods to improve prescribing practice remain unclear. We evaluated the impact of 10 interventions that introduced rapid diagnostic tests for malaria (mRDTs) on the use of tests and adherence to results in different contexts. DESIGN A comparative case study approach, analysing variation in outcomes across different settings. SETTING Studies from the ACT Consortium evaluating mRDTs with a range of supporting interventions in 6 malaria endemic countries. Providers were governmental or non-governmental healthcare workers, private retail sector workers or community volunteers. Each study arm in a distinct setting was considered a case. PARTICIPANTS 28 cases from 10 studies were included, representing 148 461 patients seeking care for suspected malaria. INTERVENTIONS The interventions included different mRDT training packages, supervision, supplies and community sensitisation. OUTCOME MEASURES Analysis explored variation in: (1) uptake of mRDTs (% febrile patients tested); (2) provider adherence to positive mRDTs (% Plasmodium falciparum positive prescribed/given Artemisinin Combination Treatment); (3) provider adherence to negative mRDTs (% P. falciparum negative not prescribed/given antimalarial). RESULTS Outcomes varied widely across cases: 12-100% mRDT uptake; 44-98% adherence to positive mRDTs; 27-100% adherence to negative mRDTs. Providers appeared more motivated to perform well when mRDTs and intervention characteristics fitted with their own priorities. Goodness of fit of mRDTs with existing consultation and diagnostic practices appeared crucial to maximising the impact of mRDTs on care, as did prior familiarity with malaria testing; adequate human resources and supplies; possible alternative treatments for mRDT-negative patients; a more directive intervention approach and local preferences for ACTs. CONCLUSIONS Basic training and resources are essential but insufficient to maximise the potential of mRDTs in many contexts. Programme design should respond to assessments of provider priorities, expectations and capacities. As mRDTs become established, the intensity of supporting interventions required seems likely to reduce.
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Affiliation(s)
- Helen E D Burchett
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Baptiste Leurent
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Baiden
- Epidemiology Unit, Ensign College of Public Health, Kpong, Ghana
| | - Kimberly Baltzell
- Department of Family Health Care Nursing, and Global Health Science, University of California, Berkeley, California, USA
| | - Anders Björkman
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Siân Clarke
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Deborah DiLiberto
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristina Elfving
- Department of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Heidi Hopkins
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Sham Lal
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Marco Liverani
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Centre for Medical Parasitology, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Mårtensson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wilfred Mbacham
- Laboratory for Public Health Research Biotechnologies, The Biotechnology Center, University of Yaoundé, Yaoundé, Cameroon
| | - Anthony Mbonye
- School of Public Health- Makerere University and Commissioner Health Services, Ministry of Health, Uganda
| | - Obinna Onwujekwe
- Department of Pharmacology and Therapeutics, University of Nigeria Enugu-Campus, Nigeria
| | | | - Delér Shakely
- Department of Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
- Department of Medicine, Kungälv Hospital, Sweden
| | - Sarah Staedke
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Lasse S Vestergaard
- Centre for Medical Parasitology, University of Copenhagen and Copenhagen University Hospital Rigshospitalet, Denmark
- Department of Infectious Disease Epidemiology, Statens Serum Institut, Denmark
| | - Christopher J M Whitty
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Community Medicine, Australia
| | - Clare I R Chandler
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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Lal S, Ndyomugenyi R, Paintain L, Alexander ND, Hansen KS, Magnussen P, Chandramohan D, Clarke SE. Community health workers adherence to referral guidelines: evidence from studies introducing RDTs in two malaria transmission settings in Uganda. Malar J 2016; 15:568. [PMID: 27881136 PMCID: PMC5121932 DOI: 10.1186/s12936-016-1609-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many malaria-endemic countries have implemented national community health worker (CHW) programmes to serve remote populations that have poor access to malaria diagnosis and treatment. Despite mounting evidence of CHWs' ability to adhere to malaria rapid diagnostic tests (RDTs) and treatment guidelines, there is limited evidence whether CHWs adhere to the referral guidelines and refer severely ill children for further management. In southwest Uganda, this study examined whether CHWs referred children according to training guidelines and described factors associated with adherence to the referral guideline. METHODS A secondary analysis was undertaken of data collected during two cluster-randomized trials conducted between January 2010 and July 2011, one in a moderate-to-high malaria transmission setting and the other in a low malaria transmission setting. All CHWs were trained to prescribe artemisinin-based combination therapy (ACT) and recognize symptoms in children that required immediate referral to the nearest health centre. Intervention arm CHWs had additional training on how to conduct an RDT; CHWs in the control arm used a presumptive diagnosis for malaria using clinical signs and symptoms. CHW treatment registers were reviewed to identify children eligible for referral according to training guidelines (temperature of ≥38.5 °C), to assess whether CHWs adhered to the guidelines and referred them. Factors associated with adherence were examined with logistic regression models. RESULTS CHWs failed to refer 58.8% of children eligible in the moderate-to-high transmission and 31.2% of children in the low transmission setting. CHWs using RDTs adhered to the referral guidelines more frequently than CHWs not using RDTs (moderate-to-high transmission: 50.1 vs 18.0%, p = 0.003; low transmission: 88.5 vs 44.1%, p < 0.001). In both settings, fewer than 20% of eligible children received pre-referral treatment with rectal artesunate. Children who were prescribed ACT were very unlikely to be referred in both settings (97.7 and 73.3% were not referred in the moderate-to-high and low transmission settings, respectively). In the moderate-to-high transmission setting, day and season of visit were also associated with the likelihood of adherence to the referral guidelines, but not in the low transmission setting. CONCLUSIONS CHW adherence to referral guidelines was poor in both transmission settings. However, training CHWs to use RDT improved correct referral of children with a high fever compared to a presumptive diagnosis using sign and symptoms. As many countries scale up CHW programmes, routine monitoring of reported data should be examined carefully to assess whether CHWs adhere to referral guidelines and take remedial actions where required.
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Affiliation(s)
- Sham Lal
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | | | - Lucy Paintain
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Neal D Alexander
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kristian S Hansen
- Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Pascal Magnussen
- Faculty of Health and Medical Sciences, Institute of International Health, Immunology and Microbiology & Institute of Veterinary Disease Biology, University of Copenhagen, Copenhagen, Denmark
| | - Daniel Chandramohan
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
| | - Siân E Clarke
- Department of Disease Control, Faculty of Infectious Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK
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12
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Larocca A, Moro Visconti R, Marconi M. Malaria diagnosis and mapping with m-Health and geographic information systems (GIS): evidence from Uganda. Malar J 2016; 15:520. [PMID: 27776516 PMCID: PMC5075756 DOI: 10.1186/s12936-016-1546-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 10/05/2016] [Indexed: 11/17/2022] Open
Abstract
Background Rural populations experience several barriers to accessing clinical facilities for malaria diagnosis. Increasing penetration of ICT and mobile-phones and subsequent m-Health applications can contribute overcoming such obstacles. Methods GIS is used to evaluate the feasibility of m-Health technologies as part of anti-malaria strategies. This study investigates where in Uganda: (1) malaria affects the largest number of people; (2) the application of m-Health protocol based on the mobile network has the highest potential impact. Results About 75% of the population affected by Plasmodium falciparum malaria have scarce access to healthcare facilities. The introduction of m-Health technologies should be based on the 2G protocol, as 3G mobile network coverage is still limited. The western border and the central-Southeast are the regions where m-Health could reach the largest percentage of the remote population. Six districts (Arua, Apac, Lira, Kamuli, Iganga, and Mubende) could have the largest benefit because they account for about 28% of the remote population affected by falciparum malaria with access to the 2G mobile network. Conclusions The application of m-Health technologies could improve access to medical services for distant populations. Affordable remote malaria diagnosis could help to decongest health facilities, reducing costs and contagion. The combination of m-Health and GIS could provide real-time and geo-localized data transmission, improving anti-malarial strategies in Uganda. Scalability to other countries and diseases looks promising.
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Affiliation(s)
| | | | - Michele Marconi
- Research and Consulting GIS, Natural Resources Management, Marine Ecology, Disaster Risk Reduction, Hue, Vietnam
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