Management of possible serious bacterial infection in young infants where referral is not possible in the context of existing health system structure in Ibadan, South-west Nigeria

Introduction Neonatal infections contribute substantially to infant mortality in Nigeria and globally. Management requires hospitalization, which is not accessible to many in low resource settings. World Health Organization developed a guideline to manage possible serious bacterial infection (PSBI) in young infants up to two months of age when a referral is not feasible. We evaluated the feasibility of implementing this guideline to achieve high coverage of treatment. Methods This implementation research was conducted in out-patient settings of eight primary health care centres (PHC) in Lagelu Local Government Area (LGA) of Ibadan, Oyo State, Nigeria. We conducted policy dialogue with the Federal and State officials to adopt the WHO guideline within the existing programme setting and held orientation and sensitization meetings with communities. We established a Technical Support Unit (TSU), built the capacity of health care providers, supervised and mentored them, monitored the quality of services and collected data for management and outcomes of sick young infants with PSBI signs. The Primary Health Care Directorate of the state ministry and the local government led the implementation and provided technical support. The enablers and barriers to implementation were documented. Results From 1 April 2016 to 31 July 2017 we identified 5278 live births and of these, 1214 had a sign of PSBI. Assuming 30% of births were missed due to temporary migration to maternal homes for delivery care and approximately 45% cases came from outside the catchment area due to free availability of medicines, the treatment coverage was 97.3% (668 cases/6861 expected births) with an expected 10% PSBI prevalence within the first 2 months of life. Of 1214 infants with PSBI, 392 (32%) infants 7–59 days had only fast breathing (pneumonia), 338 (27.8%) infants 0–6 days had only fast breathing (severe pneumonia), 462 (38%) presented with signs of clinical severe infection (CSI) and 22 (1.8%) with signs of critical illness. All but two, 7–59 days old infants with pneumonia were treated with oral amoxicillin without a referral; 80% (312/390) adhered to full treatment; 97.7% (381/390) were cured, and no deaths were reported. Referral to the hospital was not accepted by 87.7% (721/822) families of infants presenting with signs of PSBI needing hospitalization (critical illness 5/22; clinical severe infection; 399/462 and severe pneumonia 317/338). They were treated on an outpatient basis with two days of injectable gentamicin and seven days of oral amoxicillin. Among these 81% (584/721) completed treatment; 97% (700/721) were cured, and three deaths were reported (two with critical illness and one with clinical severe infection). We identified health system gaps including lack of staff motivation and work strikes, medicines stockouts, sub-optimal home visits that affected implementation. Conclusions When a referral is not feasible, outpatient treatment for young infants with signs of PSBI is possible within existing programme structures in Nigeria with high coverage and low case fatality. To scale up this intervention successfully, government commitment is needed to strengthen the health system, motivate and train health workers, provide necessary commodities, establish technical support for implementation and strengthen linkages with communities. Registration Trial is registered on Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001373369.

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Innovative approach for potential scale-up to jump-start simplified management of sick young infants with possible serious bacterial infection when a referral is not feasible: Findings from implementation research

PLoS ONE ◽

10.1371/journal.pone.0244192 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0244192

Author(s):

Abadi Leul ◽

Tadele Hailu ◽

Loko Abraham ◽

Alemayehu Bayray ◽

Wondwossen Terefe ◽

...

Keyword(s):

Critical Illness ◽

Bacterial Infection ◽

Implementation Research ◽

Severe Infection ◽

World Health ◽

Policy Dialogue ◽

Health Post ◽

Live Births ◽

Young Infants ◽

Oral Amoxicillin

Background Neonatal bacterial infections are a common cause of death, which can be managed well with inpatient treatment. Unfortunately, many families in low resource settings do not accept referral to a hospital. The World Health Organization (WHO) developed a guideline for management of young infants up to 2 months of age with possible serious bacterial infection (PSBI) when referral is not feasible. Government of Ethiopia with WHO evaluated the feasibility of implementing this guideline to increase coverage of treatment. Objective The objective of this study was to implement a simplified antibiotic regimen (2 days gentamicin injection and 7 days oral amoxicillin) for management of sick young infants with PSBI in a programme setting when referral was not feasible to identify at least 80% of PSBI cases, achieve an overall adequate treatment coverage of at least 80% and document the challenges and opportunities for implementation at the community level in two districts in Tigray, Ethiopia. Methods Using implementation research, we applied the PSBI guideline in a programme setting from January 2016 to August 2017 in Raya Alamata and Raya Azebo Woredas (districts) in Southern Tigray, Ethiopia with a population of 260884. Policy dialogue was held with decision-makers, programme implementers and stakeholders at federal, regional and district levels, and a Technical Support Unit (TSU) was established. Health Extension Workers (HEWs) working at the health posts and supervisors working at the health centres were trained in WHO guideline to manage sick young infants when referral was not feasible. Communities were sensitized towards appropriate home care. Results We identified 854 young infants with any sign of PSBI in the study population of 7857 live births. The expected live births during the study period were 9821. Assuming 10% of neonates will have any sign of PSBI within the first 2 months of life (n = 982), the coverage of appropriate treatment of PSBI cases in our study area was 87% (854/982). Of the 854 sick young infants, 333 (39%) were taken directly to a hospital and 521 (61%) were identified by HEW at health posts. Of the 521 young infants, 27 (5.2%) had signs of critical illness, 181 (34.7%) had signs of clinical severe infection, whereas 313 (60.1%) young infants 7–59 days of age had only fast breathing pneumonia. All young infants with critical illness accepted referral to a hospital, while 117/181 (64.6%) infants with clinical severe infection accepted referral. Families of 64 (35.3%) infants with clinical severe infection refused referral and were treated at the health post with injectable gentamicin for 2 days plus oral amoxicillin for 7 days. All 64 completed recommended gentamicin doses and 63/64 (98%) completed recommended amoxicillin doses. Of 313 young infants, 7–59 days with pneumonia who were treated by the HEWs without referral with oral amoxicillin for 7 days, 310 (99%) received all 14 doses. No deaths were reported among those treated on an outpatient basis at health posts. But 35/477 (7%) deaths occurred among young infants treated at hospital. Conclusions When referral is not feasible, young infants with PSBI can be managed appropriately at health posts by HEWs in the existing health system in Ethiopia with high coverage, low treatment failure and a low case fatality rate. Moreover, fast breathing pneumonia in infants 7–59 days of age can be successfully treated at the health post without referral. Relatively higher mortality in sick young infants at the referral level health facilities warrants further investigation.

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Implementation research on management of sick young infants with possible serious bacterial infection when referral is not possible in Jimma Zone, Ethiopia: Challenges and solutions

PLoS ONE ◽

10.1371/journal.pone.0255210 ◽

2021 ◽

Vol 16 (8) ◽

pp. e0255210

Author(s):

Melkamu Berhane ◽

Tsinuel Girma ◽

Workneh Tesfaye ◽

Nega Jibat ◽

Mulumebet Abera ◽

...

Keyword(s):

Health Care ◽

Critical Illness ◽

Bacterial Infection ◽

Implementation Research ◽

Health Centre ◽

Outpatient Basis ◽

Health Post ◽

Young Infants ◽

Oral Amoxicillin ◽

Jimma Zone

Introduction Of 2.5 million newborn deaths each year, serious neonatal infections are a leading cause of neonatal death for which inpatient treatment is recommended. However, manysick newborns in sub-Saharan Africa and south Asia do not have access to inpatientcare. A World Health Organization (WHO) guideline recommends simplified antibiotic treatment atan outpatient level for young infants up to two months of age with possible serious bacterial infection (PSBI), when referral is not feasible.We implemented this guidelinein Ethiopia to increase coverage of treatment and to learn about potential facilitating factors and barriers for implementation. Methods We conducted implementation research in two districts (Tiro Afata and Gera) in Jimma Zone, Ethiopia, to learn about the feasibility of implementing the WHO PSBI guideline within a programme setting using the existing health care structure. We conducted orientation meetings and policy dialogue with key stakeholders and trained health extension workers and health centre staff to identify and manage sick young infants with PSBI signs at a primary health care unit. We established a Technical Support Unit (TSU) to facilitate programme learning, built health workers’ capacity and provided support for quality control, monitoring and data collection.We sensitized the community to appropriate care-seeking and supported the health care system in implementation. The research team collected data using structured case recording forms. Results From September 2016 to August 2017, 6185 live births and 601 sick young infants 0–59 days of age with signs of PSBI were identified. Assuming that 25% of births were missed (total births 7731) and 10% of births had an episode of PSBI in the first two months of life, the coverage of appropriate treatment for PSBI was 77.7% (601/773). Of 601 infants with PSBI, fast breathing only (pneumonia) was recorded in 432 (71.9%) infants 7–59 days of age; signs of clinical severe infection (CSI) in 155 (25.8%) and critical illnessin 14 (2.3%). Of the 432 pneumonia cases who received oral amoxicillin treatment without referral, 419 (97.0%) were successfully treated without any deaths. Of 169 sick young infants with either CSI or critical illness, only 110 were referred to a hospital; 83 did not accept referral advice and received outpatient injectable gentamicin plus oral amoxicillin treatment either at a health post or health centre. Additionally, 59 infants who should have been referred, but were not received injectable gentamicin plus oral amoxicillin outpatient treatment. Of infants with CSI, 129 (82.2%) were successfully treated as outpatients, while two died (1.3%). Of 14 infants with critical illness, the caregivers of five accepted referral to a hospital, and nine were treated with simplified antibiotics on an outpatient basis. Two of 14 (14.3%) infants with critical illness died within 14 days of initial presentation. Conclusion In settings where referral to a hospital is not feasible, young infants with PSBI can be treated on an outpatient basis at either a health post or health centre, which can contribute to saving many lives. Scaling-up will require health system strengthening including community mobilization. Registration Trial is registered on Australian New Zealand Clinical Trials registry (ANZCTR) ACTRN12617001373369.

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Clinical signs of possible serious infection and associated mortality among young infants presenting at first-level health facilities

PLoS ONE ◽

10.1371/journal.pone.0253110 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0253110

Author(s):

Yasir Bin Nisar ◽

Antoinette Tshefu ◽

Adrien Lokangaka Longombe ◽

Fabian Esamai ◽

Irene Marete ◽

...

Keyword(s):

Critical Illness ◽

Body Temperature ◽

Mortality Risk ◽

Inpatient Treatment ◽

Case Fatality ◽

Severe Pneumonia ◽

Severe Infection ◽

Case Fatality Ratio ◽

Young Infants ◽

Serious Infection

Background The World Health Organization recommends inpatient hospital treatment of young infants up to two months old with any sign of possible serious infection. However, each sign may have a different risk of death. The current study aims to calculate the case fatality ratio for infants with individual or combined signs of possible serious infection, stratified by inpatient or outpatient treatment. Methods We analysed data from the African Neonatal Sepsis Trial conducted in five sites in the Democratic Republic of the Congo, Kenya and Nigeria. Trained study nurses classified sick infants as pneumonia (fast breathing in 7–59 days old), severe pneumonia (fast breathing in 0–6 days old), clinical severe infection [severe chest indrawing, high (> = 38°C) or low body temperature (<35.5°C), stopped feeding well, or movement only when stimulated] or critical illness (convulsions, not able to feed at all, or no movement at all), and referred them to a hospital for inpatient treatment. Infants whose caregivers refused referral received outpatient treatment. The case fatality ratio by day 15 was calculated for individual and combined clinical signs and stratified by place of treatment. An infant with signs of clinical severe infection or severe pneumonia was recategorised as having low- (case fatality ratio ≤2%) or moderate- (case fatality ratio >2%) mortality risk. Results Of 7129 young infants with a possible serious infection, fast breathing (in 7–59 days old) was the most prevalent sign (26%), followed by high body temperature (20%) and severe chest indrawing (19%). Infants with pneumonia had the lowest case fatality ratio (0.2%), followed by severe pneumonia (2.0%), clinical severe infection (2.3%) and critical illness (16.9%). Infants with clinical severe infection had a wide range of case fatality ratios for individual signs (from 0.8% to 11.0%). Infants with pneumonia had similar case fatality ratio for outpatient and inpatient treatment (0.2% vs. 0.3%, p = 0.74). Infants with clinical severe infection or severe pneumonia had a lower case fatality ratio among those who received outpatient treatment compared to inpatient treatment (1.9% vs. 6.5%, p<0.0001). We recategorised infants into low-mortality risk signs (case fatality ratio ≤2%) of clinical severe infection (high body temperature, or severe chest indrawing) or severe pneumonia and moderate-mortality risk signs (case fatality ratio >2%) (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection). We found that both categories had four times lower case fatality ratio when treated as outpatient than inpatient treatment, i.e., 1.0% vs. 4.0% (p<0.0001) and 5.3% vs. 22.4% (p<0.0001), respectively. In contrast, infants with signs of critical illness had nearly two times higher case fatality ratio when treated as outpatient versus inpatient treatment (21.7% vs. 12.1%, p = 0.097). Conclusions The mortality risk differs with clinical signs. Young infants with a possible serious infection can be grouped into those with low-mortality risk signs (high body temperature, or severe chest indrawing or severe pneumonia); moderate-mortality risk signs (stopped feeding well, movement only when stimulated, low body temperature or multiple signs of clinical severe infection), or high-mortality risk signs (signs of critical illness). New treatment strategies that consider differential mortality risks for the place of treatment and duration of inpatient treatment could be developed and evaluated based on these findings. Clinical trial registration This trial was registered with the Australian New Zealand Clinical Trials Registry under ID ACTRN 12610000286044.

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Management of pharmaceutical services in the Brazilian primary health care

Revista de Saúde Pública ◽

10.11606/s1518-8787.2017051007063 ◽

2017 ◽

Vol 51 (suppl.2) ◽

Cited By ~ 3

Author(s):

Letícia Farias Gerlack ◽

Margô Gomes de Oliveira Karnikowski ◽

Camila Alves Areda ◽

Dayani Galato ◽

Aline Gomes de Oliveira ◽

...

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health System ◽

Pharmaceutical Services ◽

Limiting Factors ◽

Health Board ◽

Complex Samples ◽

Financial Autonomy ◽

Unified Health System ◽

Primary Health

OBJECTIVE: To identify limiting factors in the management of pharmaceutical services in the primary health care provided by the Brazilian Unified Health System (SUS). METHODS: This study was based on the data from the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos no Brasil (PNAUM – National Survey on Access, Use and Promotion of Rational Use of Medicines), and it was conducted by interviews with professionals responsible for pharmaceutical services in Brazilian cities, in 2015. To identify the management limiting factors, we considered the organizational, operational, and sustainability indicators of the management. For the analyses, we included the weights and structure of analysis plan for complex samples. The results were expressed by frequencies and measures of central tendency with 95% confidence interval, considering the Brazilian geographic regions. RESULTS: We identified the following limiting factors: lack of pharmaceutical services in the Municipal Health Secretariat organization chart (24%) and in the health plan (18%); lack of participation of managers in the Health Board and the absence of reference to this topic in the agenda of meetings (58.4%); lack of financial autonomy (61.5%) and lack of knowledge on the available values (81.7%); lack of adoption of operational procedures (about 50%) for selection, scheduling, and acquisition; and the fact that most professionals evaluate the organization of pharmaceutical services as good and great (58.8%), despite the worrisome indicators. CONCLUSIONS: Pharmaceutical services management is currently supported by a legal and political framework that should guide and contribute to improve the pharmaceutical services in the Brazilian Unified Health System primary health care. However, there is a mismatch between the goals established by these guidelines and what is actually happening

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Access to medicines by patients of the primary health care in the Brazilian Unified Health System

Revista de Saúde Pública ◽

10.11606/s1518-8787.2017051007139 ◽

2017 ◽

Vol 51 ◽

pp. 20s ◽

Cited By ~ 3

Author(s):

Juliana Álvares ◽

Augusto Afonso Guerra Junior ◽

Vânia Eloisa de Araújo ◽

Alessandra Maciel Almeida ◽

Carolina Zampirolli Dias ◽

...

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health System ◽

Developed Countries ◽

Access To Medicines ◽

Essential Medicines ◽

Unified Health System ◽

Primary Health ◽

Significant Difference ◽

Good For

OBJECTIVE: To evaluate the access to medicines in primary health care of the Brazilian Unified Health System (SUS), from the patients’ perspective. METHODS: This is a cross-sectional study that used data from the Pesquisa Nacional sobre Acesso, Utilização e Promoção do Uso Racional de Medicamentos – Services, 2015 (PNAUM – National Survey on Access, Use and Promotion of Rational Use of Medicines), conducted by interviews with 8,591 patients in cities of the five regions of Brazil. Evaluation of access to medicines used concepts proposed by Penshansky and Thomas (1981), according to the dimensions: availability, accessibility, accommodation, acceptability, and affordability. Each dimension was evaluated by its own indicators. RESULTS: For the “availability” dimension, 59.8% of patients reported having full access to medicines, without significant difference between regions. For “accessibility,” 60% of patients declared that the basic health unit (UBS) was not far from their house, 83% said it was very easy/easy to get to the UBS, and most patients reported that they go walking (64.5%). For “accommodation,” UBS was evaluated as very good/good for the items “comfort” (74.2%) and “cleanliness” (90.9%), and 70.8% of patients reported that they do not wait to receive their medicines, although the average waiting time was 32.9 minutes. For “acceptability,” 93.1% of patients reported to be served with respect and courtesy by the staff of the dispensing units and 90.5% declared that the units’ service was very good/good. For “affordability,” 13% of patients reported not being able to buy something important to cover expenses with health problems, and 41.8% of participants pointed out the expense with medicines. CONCLUSIONS: Results show 70%–90% compliance, which is compatible with developed countries. However, access to medicines remains a challenge, because it is still heavily compromised by the low availability of essential medicines in public health units, showing that it does not occur universally, equally, and decisively to the population

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Evaluation of Access on the perspective of adult users of Primary Health Care in Fortaleza, Brazil

European Journal of Public Health ◽

10.1093/eurpub/ckaa166.1334 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

L Borges Costa ◽

C Salles Gazeta Vieira Fernandes ◽

T Custódio Mota ◽

E Torquato Santos ◽

M Moura de Almeida ◽

...

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health Services ◽

Health System ◽

Assessment Tool ◽

Health Coverage ◽

Access To Health Services ◽

Primary Health ◽

Care Assessment ◽

The City

Abstract The Alma-Ata Conference promoted Primary Health Care (PHC) worldwide as a form of universal and continuous access to quality and effective health services. In Brazil, PHC, through the Family Health Strategy (FHS), aims to be the gateway to the health system and its structuring axis. For this, it is necessary to promote access, an essential condition for the quality of health care services, following the attributes systematized by Barbara Starfield. The aim of this study was to evaluate the presence of the attribute “First Contact Access” on the perspective of adult users of public PHC services in the city of Fortaleza, Ceará, Brazil. A transversal study was carried out, in 19 PHC Units, from June to December 2019, using the Primary Care Assessment Tool (PCATool) Brazil version for adult users. Kruskal-Wallis test was used for statistical analysis. 233 users participated, mostly women (69.5%), aged 30 to 59 years old (55.3%), mixed-race (69.5%), with complete high school (38.2%), without private health coverage (89.3%), homeowners (68.7%) and belonging to families of up to 4 members (87.9%). The “Accessibility” component had the lowest score, 2.83, and the “Utilization” had the highest score, 8.06. Older age was associated with higher “Accessibility” scores (p = 0,018), while lower values of “Utilization” were associated with higher education (p = 0,004). The main problems observed were: low access for acute demand consultations, lack of access at nighttime and weekends, little access through non-personal ways, bureaucratic barriers and a long time for scheduling appointments. We conclude that, although there was an improvement in PHC coverage in the city over the years, mainly due to FHS, there is still a lot to improve to ensure timely access to health services. Key messages Users consider PHC as the usual source of care, demonstrated by the high score of 'Utilization', however, they are unable to use it when necessary, demonstrated by the low score of 'Accessibility'. Expanding forms of access is essential to contribute to the strengthening of PHC in Fortaleza, Brazil, facilitating the entry to its national Universal Health System.

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8.2. Prospects for the use of a comprehensive assessment of the resource potential of medical organizations

Audit and Financial Analysis ◽

10.38097/afa.2020.98.43.028 ◽

2020 ◽

Author(s):

С.С. Бударин ◽

Ю.В. Эльбек

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health System ◽

Comprehensive Assessment ◽

State Health ◽

Resource Potential ◽

Primary Health ◽

Potential Use

Статья посвящена рассмотрению методики комплексной оценки ресурсного потенциала медицинских организаций, оказывающих населению первичную медико-санитарную помощь. Предложена система показателей оценки эффективности использования ресурсного потенциала по трем направлениям – экономичность, продуктивность, результативность, – сформированная с использованием элементов методологии аудита эффективности. На основании данных медицинских организаций государственной системы здравоохранения г. Москвы, выбранных для исследования, рассчитана комплексная оценка их ресурсного потенциала. The article is devoted to the method of complex assessment of the resource potential of medical organizations that provide primary health care to the population. A system of indicators for evaluating the effectiveness of resource potential use in three areas: Efficiency, Productivity, and Effectiveness, formed using elements of the efficiency audit methodology. A comprehensive assessment of their resource potential is calculated, based on the data of medical organizations of the Moscow state health system selected for the study.

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Resolution And Continuity Of Primary Health Care: Reference And Counter-Reference In The Sus (Unified Health System)

Health Systems and Policy Research ◽

10.21767/2254-9137.100065 ◽

2017 ◽

Vol 04 (01) ◽

Author(s):

Maria Beatriz Rodrigues Criscuolo ◽

Duane Ferreira Melo ◽

Selma Maria da Fonseca Viegas

Keyword(s):

Health Care ◽

Primary Health Care ◽

Health System ◽

Unified Health System ◽

Primary Health

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What are the roles of community health workers? Looking back at the philosophies of primary health care

Global Health Promotion ◽

10.1177/1757975918811087 ◽

2019 ◽

Vol 27 (2) ◽

pp. 117-120

Author(s):

Marietou Niang

Keyword(s):

Health Care ◽

Primary Health Care ◽

Community Development ◽

Health System ◽

Community Health ◽

Community Health Workers ◽

Health Workers ◽

Primary Health ◽

Looking Back

This commentary discusses the different roles of community health workers (CHWs), their challenges and limitations in a historical perspective of primary health care (PHC). We first try to show that the comprehensive philosophy of PHC promulgated in Alma-Ata proposed the role of CHWs as actors who work in community development. On the other hand, in the 1980s, with the emergence of the selective philosophy of PHC, CHWs’ role was more affiliated with the health system. We conclude our pitch about the balance that can exist between these different roles by suggesting that CHWs can work in continuity with the health system, but they should not be considered as affordable labor. Also, they must be supported in their activities to develop their communities, allowing them to participate effectively in programs and policies that concern them and their community.

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