In partnership for health worldwide

GHRI IRSM

Africa Health Systems Initiative Support to African Research Partnerships

PROGRAM OVERVIEW

2

The Global Health Research Initiative

The Global Health Research Initiative (GHRI) is a partnership of Canadian government agencies with mandates spanning health, research and international development.

GHRI brings researchers and decision-makers together to tackle complex problems that have an impact on the health of people and communities around the world.

GHRI funds a wide range of global health research, capacity building and knowledge translation activities through several programs. Funded projects and programs of work involve Canadian researchers working with researchers and decision-makers in Asia, Africa, Eastern Europe, the Middle East, Latin America and the Caribbean.

About this booklet

This booklet presents projects being carried out as part of GHRI’s Africa Health Systems Initiative ~ Support to African Research Partnerships program. The program supports ten African-led research teams investigating ways to strengthen health systems in sub-Saharan Africa.

For more information about this program, contact:

Dr. Renée Larocque ~ Senior Program OfficerGlobal Health Research Initiativerlarocque@idrc.ca / +1 613 696 2540

In partnership for health worldwide

3

To learn more about the Global Health Research Initiative,

visit GHRI.CA

PROGRAM OVERVIEWAfrica Health Systems Initiative ~ Support

to African Research Partnerships

Table of Contents

Introduction 4

Project Profiles

Profiles of ten projects based in Burkina Faso, Kenya, 10 Malawi, Mali, Tanzania, Uganda and Zambia

Feature Stories

A role for telemedicine in Mali 22

Developing the PALM Plus diagnostic tool for Malawi 26

Making mental health services in Kenya accessible 30 through innovative task-shifting

Sources 34

4

Strengthening health systems

In Africa, particularly across the sub-Saharan region, people and their communities continue to face a heavy burden of preventable and treatable illnesses despite the existence of effective tools, technologies and practices for prevention and treatment. One of the principal reasons for this are weak health systems.

Encompassing “all organizations, people and actions whose primary intent is to promote, restore or maintain health,” health systems are vital to human well-being. Health systems in sub-Saharan Africa face a number of major challenges, including critical human resource shortages and persistent inequities in access to health care.

In recent years, organizations involved in efforts to improve health in low- and middle-income countries have been moving away from disease-specific approaches to ones that view health problems and potential solutions in the context of health systems. According to the World Health Organization (WHO), “strengthening health systems and making them more equitable have been recognized as key strategies for fighting poverty and fostering development.”

The projects described in this booklet are all contributing to this important effort.

Source: WHO. 2005.

“A good health system improves people’s lives tangibly every day.”

Source: WHO. 2005.

5

On the importance of health systems research

In her introductory remarks to Systems Thinking for Health Systems Strengthening (2009), the flagship report of the Alliance for Health Policy and Systems Research, WHO Director-General Dr. Margaret Chan underscores the importance of efforts to under-stand health systems in all their real-world complexity.

The report highlights the fact that many health systems, in particular those in low- and middle-income countries, “simply lack the capacity to measure or understand their own weaknesses and constraints, which effectively leaves policy-makers without scientifically sound ideas of what they can and should actually strengthen.” The report stresses that in these circumstances, “even the very simplest interventions often fail to achieve their goals” and that this may have less to do with the quality of the intervention itself than with “the often unpredictable behaviour of the system around it.”

Making a strong case for health systems research, the report’s authors argue that “as investments in health are expanding in low- and middle-income countries, and as funders increasingly support broader initiatives for health systems strengthening, we need to know not only what works but what works for whom and under what circumstances.” According to Dr. Chan, this context-rich research, and the “systems thinking” that informs it, are vital to the success of efforts “to strengthen systems, increase coverage, and improve health” around the world.

Source: de Savigny & Adam. 2009.

“We must know the health system in order to strengthen it.”

Source: de Savigny & Adam. 2009.

6

The Africa Health Systems Initiative

The Canadian International Development Agency’s (CIDA) Africa Health Systems Initiative (AHSI) aims to improve health outcomes and make progress toward the United Nations Millennium Development Goals (MDGs), particularly those related to child health (Goal 4) and maternal health (Goal 5).

AHSI provides support to train, equip and deploy new and existing health workers in Africa to make health care more accessible to the most vulnerable, particularly mothers and children. The majority of AHSI funding supports bilateral, country-led efforts in sub-Saharan Africa.

AHSI complements CIDA’s regular health programming in three areas: strengthening frontline health workers, improving health information systems—with a focus on better accountability and monitoring—and strengthening equity in health service delivery.

AHSI supports research on health systems issues through the Global Health Research Initiative’s Africa Health Systems Initiative ~ Support to African Research Partnerships program.

Source: CIDA. 2010.

7

Africa Health Systems Initiative ~ Support to African Research Partnerships Program (2008-2013)

GHRI’s Africa Health Systems Initiative ~ Support to African Research Partnerships program supports ten African-led research teams investigating innovative ways to strengthen health systems in sub-Saharan Africa.

Drawing on a range of knowledge and experience, the teams funded by this Global Health Research Initiative program are focusing on two main areas. The first area of focus is the recruitment and retention of health workers and the delegation of some tasks to less specialized health workers, an approach known as ‘task-shifting’.* The second area of focus is the role of health information systems and management in efforts to make health care more accessible and focused on the population’s needs.

The ten teams supported by this program are working to connect research, policy and action to improve health decision-making and programming in the sub-Saharan region. They are paying particular attention to the needs of disadvantaged segments of the population. The teams are based in Burkina Faso, Kenya, Malawi, Mali, Tanzania, Uganda and Zambia. They are led jointly by an African researcher and an African decision-maker and include several Canadian researchers.

* According to the World Health Organization, task-shifting is “the name given to a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers.” (WHO, 2008)

4%A 2011 survey found that only 4% of health policy and systems researchcarried out in low- and middle-income countries over the last decade was led by researchers fromthose countries.

Source: Adam et al. 2011.

8

~ PROJECT PROFILES ~

9

Burkina Faso

Kenya

Malawi

Mali

Tanzania

Zambia

Uganda

Project teams based in:

10

Assessing the impact of regionalization of health care worker recruitment in Burkina Faso on national and regional distribution of health care human resources Burkina Faso ~ CA$352,600 (2009-2012)

Burkina Faso’s health system is burdened by critical human resource shortages and an inequitable distribution of existing health care personnel. Shortages are especially acute in rural and remote areas of the country, where recruiting and retaining health care providers is particularly challenging.

This team is assessing the impact of government efforts to regionalize health personnel recruitment on the distribution of health care providers throughout Burkina Faso. The team is also investigating how job satisfaction among health personnel is influenced by different recruitment approaches.

TEAM LEADERS ~ Blaise Sondo (researcher), Institut de recherche en sciences de la santé, Ouaga-dougou (Burkina Faso); Adama Traoré (decision-maker), Ministère de la santé, Ouagadougou (Burkina Faso). CO-INVESTIGATORS ~ Pierre Fournier and Valéry Ridde, Université de Montréal, Montreal (Canada); Seni Kouanda and Baya Banza, Institut supérieur des sciences de la population, Ouagadougou (Burkina Faso); Sié Roger Hien, Assemblée Nationale, Ouagadougou (Burkina Faso); Abel Bicaba, Société d’études et de la recherche en santé publique, Ouagadougou (Burkina Faso); Benjamin Sanon and Romaric Somé, Ministère de la santé, Ouagadougou (Burkina Faso); Gilles Dussault, Institute of Hygiene and Tropical Medicine, Lisbon (Portugal).

7.3Number of nursing and midwifery personnel per 10,000 people in Burkina Faso in 2008.

100.5 Number of nursing and midwifery personnel per 10,000 people in Canada in 2008.

Source: WHO. 2011a.

Burkina Faso

11

Investigating innovative approaches to task-shifting in mental health in Kenya

Kenya ~ CA$281,700 (2010-2012)

A study carried out by the Africa Mental Health Foundation (AMHF) to determine the availability and distribution of psychiatrists in Kenya found that most of the country’s psychiatrists were located in Nairobi and other urban centres. Given this reality, the authors argue, “If Kenya and other similar developing countries in Africa are to achieve realistic mental health service delivery in the foreseeable future, alternative non-specialist training in mental health is required.”

Taking an innovative approach to the problem, this team is investigating whether health care workers, faith healers and traditional healers can be trained to provide effective mental health services at the community level. The goal is to increase access to mental health services for Kenyans, given the limited availability and distribution of specialized mental health personnel in the country.

TEAM LEADERS ~ Victoria Mutiso (researcher), Africa Mental Health Foundation, Nairobi (Kenya); Chris Rakuom (decision-maker), Ministry of Health, Nairobi (Kenya). CO-INVESTIGATORS ~ David Ndetei, Lincoln Khasakhala, Anne Mbwayo, Patricia Wekulo and Penny Holding, Africa Mental Health Foundation, Nairobi (Kenya).

Source: Ndetei et al. 2007.

7,344%Percentage increase in the number of psychiatrists required in Kenya for the country to match the psychiatrist-to-population ratio found in the United States in 2002.

Source: Ndetei et al. 2007.

See the FEATURE STORY about this project on page 30

Kenya

12

Investigating the potential of mobile phones to prevent mother-to-child transmission of HIV in Kenya

Kenya ~ CA$341,100 (2010-2013)

Mobile phones are spreading rapidly in Africa, with useful applications finding their way into the day-to-day operations of a number of sectors from banking to health services. In Kenya, 92% of men and 86% of women are regular mobile phone users.*

A study published in 2010 reported that text messages significantly improved adherence to HIV antiretroviral therapy.† Now this team, which includes several researchers from the 2010 study, is investigating whether text messages can help prevent mother-to-child transmission of HIV.‡ Text messages are being used to remind women to take prescribed medications, and improve care for both mothers and infants after birth.

TEAM LEADERS ~ Joshua Kimani (researcher), University of Nairobi, Nairobi (Kenya); Peter Cherutich (decision-maker), Ministry of Health, Nairobi (Kenya). CO-INVESTIGATORS ~ Richard Lester, University of Manitoba, Winnipeg (Canada) and University of Nairobi, Nairobi (Kenya); Charles Wanyonyi, Pumwani Maternity Hospital, Nairobi (Kenya); Lisa Avery, Shamir Mukhi and Larry Gelmon, University of Manitoba, Winnipeg (Canada); Benson Estambale, University of Nairobi Institute of Tropical & Infec-tious Diseases, Nairobi (Kenya); Samson Barasa and Antony Kariri, University of Nairobi, Nairobi (Kenya).

Sources: *AudienceScapes 2010; † Lester et al. 2010; ‡ Prevention of mother-to-child transmission of HIV (PMTCT) “provides drugs, counselling and psychological support to help mothers safeguard their infants against the virus.” (UNICEF, 2011)

47%Estimated percentageof pregnant women living with HIV in sub-Saharan Africa not receiving treatment to prevent transmission of HIV to their child.

Source: WHO. 2011b.

370,000Estimated number of children infected with HIV through mother-to-child transmission in 2009.

Source: UNAIDS. 2010.

Kenya

13

1:30,000Surgeon-to-population ratio in Uganda.

95% Percentage of Ugandan surgeons practicing in urban areas in 2011.

Source: WHO. 2011c.

Uganda

Developing a program to train physicians and health officers to provide emergency and essential surgical services in Uganda

Uganda ~ CA$344,500 (2009-2012)

“While infectious diseases remain the major killers in low- and middle-income countries,” note Weiser and colleagues, “traumatic injuries, complications of child-birth, and other conditions that need surgery are important contributors to the overall burden of disease in these countries.” In Uganda, most surgical care is provided by physicians and health officers, rather than by trained surgical specialists, who are in short supply in the country.

This team is developing a program that will train physicians and health officers to provide emergency and essential surgical services. If successful, the program will lead to a process of certification that will help improve the quality of surgical services in Uganda.

TEAM LEADERS ~ Samuel Luboga (researcher), Makerere University, Kampala (Uganda); Francis Runumi Mwesigye (decision-maker), Commissioner of Health Services Planning, Ministry of Health, Kampala (Uganda). CO-INVESTIGATORS ~ Timothy Musila, Ministry of Health, Kampala (Uganda); Butch de Castro, University of Washington, Seattle (United States). All other co-investigators are based at Makerere University, Kampala (Uganda): Moses Galukande and Samuel Kaggwa, Department of Surgery; Patrick Sekimpi, Orthopedics; Achilles Katamba, Health Services Research; Kakaire Othman, Obstetricsand Gynecology; Ian Munabi, Anatomy. COLLABORATORS AND CONSULTANTS ~ Edward Mills, University of Ottawa, Ottawa (Canada); Geoff Blair, University of British Columbia, Vancouver (Canada); Amy Hagopian and Scott Barnhart, University of Washington, Seattle (United States).

Source: Weiser et al. 2008.

14

Strengthening human resources for health through simplified clinical tools and educational outreach

Malawi ~ CA$233,300 (2009-2012)

While an estimated 6.6 million people in low- and middle-income countries are receiving antiretroviral therapy (ART) for HIV, the majority are still without treatment.* Providing treatment close to where people live is crucial to expanding ART coverage, but weak health systems remain a significant barrier.

This team is implementing a pilot project in Malawi’s Zomba District. The goal is to strengthen health care worker capacity to support efforts to scale-up TB and HIV/AIDS services and integrate them within primary care. The project uses a simplified intervention tool called PALM Plus† adapted from South Africa, where it is known as PALSA-PLUS. This tool provides symptom-based, user-friendly guidelines for disease management of TB, malaria, asthma, HIV/AIDS and other sexually transmittedinfections. The guidelines are consistent with Malawi’s national treatment protocols.

TEAM LEADERS ~ Bertha Simwaka (researcher), REACH Trust Malawi, Lilongwe (Malawi); Damson Kathyola (decision-maker), Malawi Ministry of Health, Lilongwe (Malawi). CO-INVESTIGATORS ~ Michael Schull and Alexandra Martiniuk, Sunnybrook Health Sciences Centre, Toronto (Canada); Eric Bateman and Lara Fairall, University of Cape Town Lung Institute, Cape Town (South Africa); Hastings Banda, REACH Trust Malawi, Lilongwe (Malawi); Martha Mondiwa, Nurses and Midwives Council of Malawi, Lilongwe (Malawi); Sumeet Sodhi, Dignitas International, Toronto (Canada); Merrick Zwarenstein, Centre for Health Services Sciences, University of Toronto, Toronto (Canada); Ibrahim Idana, Ministry of Health, Lilongwe (Malawi); Martias Joshua, Zomba Central Hospital, Zomba(Malawi).

* WHO. 2011d; † PALM Plus: ‘Practical Approach to Lung Health and HIV/AIDS in Malawi’.

Malawi

219%Percentage increase in appropriate referrals for severely ill patients in South Africa using the PALSA-PLUS tool.

Source: Fairall et al. 2005.

See the FEATURE STORY about this project on page 26

15

Assessing the productivity and quality of eye care services to assist health human resource decision-making in Eastern Africa

Kenya, Tanzania and Malawi ~ CA$316,100 (2009-2012)

A joint effort of the World Health Organization and the International Agency for the Prevention of Blindness, Vision 2020 seeks to eliminate avoidable blindness* globally by the year 2020. One promising strategy to achieve this goal is task-shifting, whereby health care workers are trained to perform cataract surgery and other primary eye care services typically provided by physicians.

The project team is investigating the impact of task-shifting on the productivity and retention of eye care personnel. In addition, the team will evaluate the quality of eye care services in Eastern Africa following the implementation of task-shifting.

TEAM LEADERS ~ Edson Eliah and Paul Courtright (researchers), Kilimanjaro Centre for Community Ophthalmology, Moshi (Tanzania); Michael Gichangi (decision-maker), Ministry of Health, Nairobi (Kenya). CO-INVESTIGATORS ~ Susan Lewallen, Kilimanjaro Centre for Community Ophthalmology, Moshi (Tanzania); Ken Bassett, University of British Columbia, Vancouver (Canada); Edward Kirumbi, Ministry of Health, Dar es Salaam (Tanzania); Amir Bedri, International Agency for the Prevention of Blindness, Addis Ababa (Ethiopia); Khumbo Kalua, Queen Elizabeth Central Hospital, Blantyre (Malawi); Marvice Okwen, Kilimanjaro Christian Medical College, Tumaini University, Moshi (Tanzania); Manisha Tharaney, Tulane University, New Orleans (United States).

* Avoidable blindness is defined as “blindness that can be either treated or prevented by known, cost-effective means.” (Vision 2020, 2011)

285 millionNumber of people world-wide who are visually impaired. Of these, 90%live in developing countries.

80%Percentage of global visual impairment that can be prevented, treated or cured.

Source: Vision 2020. 2011.

Tanzania Kenya Malawi

16

Understanding how information and communication technologies can increase access to health professionals in francophone Africa

Mali ~ CA$327,800 (2009-2012)

This team is exploring the potential of information and communication technologies (ICTs) in helping to alleviate problems created by health personnel shortages in Mali.

In Mali, a critical shortage of health personnel is a key factor contributing to health disparities between those living in rural and urban areas. To help address the problem, this project is exploring the potential role that telemedicine can play in improving recruitment and retention of health personnel and increasing access to quality care in rural areas. Key activities include testing the effectiveness of telemedicine services for rural doctors providing patient care and for continuing medical education in Mali.

TEAM LEADERS ~ Cheick Oumar Bagayoko (researcher), Centre d’expertise et de recherche en télémé-decine et E-santé, Bamako (Mali), Abdel Kader Traoré (decision-maker), Centre national d’appui à la lutte contre la maladie, Bamako (Mali). CO-INVESTIGATORS ~ Antoine Geissbuhler, University of Geneva and Geneva University Hospitals, Geneva (Switzerland); Anatole Tounkara and Anne Abdrahamane, Faculté de médicine et de pharmacie, Université de Bamako, Bamako (Mali); Younoussa Touré, Institut des sciences humaines du Mali, Bamako (Mali); Seydou Tidiane Traoré, Mahamoudane Niang and Dikaridia Traoré, Centre d’expertise et de recherche en télémédecine et E-santé, Bamako (Mali); Mamadou Touré, Centre hospitalier universitaire du point G, Bamako (Mali); Bocary Diarra, Hôpital mère-enfant Le Luxembourg, Bamako (Mali); Marie-Pierre Gagnon, Université Laval, Quebec (Canada).

344 Number of specialistsproviding care in Mali’s urban centres.

0 Number of specialists providing care in Mali’s rural areas.

Source: WHO, GHWA & EU. 2009.

See the FEATURE STORY about this project on page 22

Mali

17

Linking a community-based health information system and an institutional health information system to make decision-making more effective

Kenya ~ CA$320,570 (2009-2012)

This project is testing an approach that links health information collected at the community level to health facility information systems. The team is piloting the approach in three different types of communities in Kenya: rural villages, peri-urban settlements and among nomadic herders.

The approach is built on local health registers prepared and updated every six months by community health workers. These community-based registers are linked to the institutional health information system by including service users’ village or place of origin. This integrated system will enable service providers to relate and compare health data on topics such as service coverage and mortality, and will better support decision-making, planning, and resource allocation.

It is hoped that this approach will benefit both service providers and communities and will help to ensure equity in access to care.

TEAM LEADERS ~ Dan Kaseje (researcher), Great Lakes University of Kisumu, Kisumu (Kenya); John Odondi (decision-maker), Ministry of Public Health and Sanitation, Nairobi (Kenya). CO-INVESTIGATORS ~ Nancy Edwards, University of Ottawa, Ottawa (Canada); Violet Naanyu and Mabel Nangami, Moi University, Eldoret (Kenya); Violet Kimani, University of Nairobi, Nairobi (Kenya); George Otieno, Kenyatta University, Nairobi (Kenya).

“Community health workers (CHWs) can accurately and reliably collect household data which can be used for health decisions and actions, especially in resource poor settings”.

Source: Otieno et al. 2012.

Kenya

18

Investigating the impact and reproducibility of Healthy Child Uganda, a program that mobilizes village health volunteers to provide vital child health services in southwest Uganda

Uganda ~ CA$336,200 (2009-2012)

Children in sub-Saharan Africa continue to die from diarrhoea, acute respiratory illness and malaria despite the existence of inexpensive and highly effective treat-ments. Part of the reason for this is a shortage of trained rural health care providers.

Healthy Child Uganda has trained over 1,000 rural health volunteers in more than 275 villages across Uganda as part of a village health volunteer program. With this grant, Healthy Child Uganda is expanding the training program to enable village health volunteers to provide treatment to children in their home villages. The approach is called iCCM, or ‘integrated community case management’.

In tandem with implementation, the team is carrying out an evaluation to determine whether this approach increases the proportion of children receiving appropriate treatment for diarrhoea, acute respiratory illness and malaria. The lessons learned will help other sub-Saharan African countries as they plan for increased iCCM.

TEAM LEADERS ~ Samuel Maling (researcher), Mbarara University of Science and Technology, Mbarara, (Uganda); Celestine Barigye (decision-maker), Bushenyi District Health Services, Bushenyi (Uganda). CO-INVESTIGATORS ~ Jerome Kabakyenga and Moses Ntaro, Mbarara University of Science and Technology, Mbarara (Uganda); Noni MacDonald, Dalhousie University, Halifax (Canada); Carolyn Pim, Jenn Brenner and Nalini Singhal, University of Calgary, Calgary (Canada); Amooti Kaguna and Eldard Mabumba, Mbarara District Health Services, Mbarara (Uganda); Kathryn Wotton, University of British Columbia, Vancouver (Canada); Jesca Nsungwa-Sabiiti, Ministry of Health, Kampala (Uganda).

86%Percentage of Healthy Child Uganda community health volunteers who have been volunteering with the program for more than 18 months, according to a 2011 study.

Source: Brenner et al. 2011.

Uganda

19

Evaluating the effectiveness of strategies currently being implemented in rural Zambia to increase availability of trained health care providers

Zambia ~ CA$333,800 (2010-2012)

In response to an ongoing health human resource crisis, governments in sub-Saharan Africa have implemented a number of strategies intended to increase recruitment and improve retention of health care providers. However, these strategies have not often been evaluated to determine their effectiveness, information that would help governments decide which are the best investments.

This team is evaluating existing recruitment and retention strategies in two pilot districts in rural Zambia. The goal is to determine the impact of these strategies on health care personnel satisfaction and on the health care system as a whole.

TEAM LEADERS ~ Fastone Goma (researcher), School of Medicine, University of Zambia, Lusaka (Zambia); Miriam Libetwa (decision-maker), Ministry of Health, Lusaka (Zambia). CO-INVESTIGATORS ~ Selestine Nzala, School of Medicine, University of Zambia, Lusaka (Zambia), Priscilla Chisha-Kalonde, Chibombo District Health Management Team, Chibombo (Zambia); Clara Mbwili-Muleya, Lusaka District Health Management Team, Lusaka (Zambia); Moses Lungu, Lusaka Equity Gauge, Lusaka (Zambia); Mercy Mbewe, National Institute for Public Administration, Lusaka (Zambia); Jennifer Nyoni, WHO Regional Office for Africa, Brazzaville (Congo); Mutale Chimutete, Gwembe District Health Management Team, Gwembe (Zambia); Mwinga Hamavhwa, Zambia Forum for Health Research—ZAMFOHR, Lusaka (Zambia); Gail Tomblin Murphy, Adrian MacKenzie and Janet Rigby, Dalhousie University, Halifax (Canada); Annette Ryan, IWK Health Centre and Dalhousie University, Halifax (Canada); Rob Alder, University of Western Ontario, London (Canada); Stephen Tomblin, Memorial Univeristy, St. John’s (Canada); Christine Heide-brecht, Canadian Coalition for Global Health Research, and St. Michael’s Hospital, Toronto (Canada).

Zambia

57 Countries, including Zambia, “experiencing a critical deficit in the health workforce” in 2010.

2/3Proportion of these countries located in sub-Saharan Africa.

Source: WHO. 2010.

20

~ FEATURE STORIES ~

21

Making mental health services in Kenya accessible through

innovative task-shifting

p. 30

Kenya

Developing the PALM Plus diagnostic tool for Malawi

p. 26

Malawi

A role for telemedicine in Mali

p. 22

Mali

22

A Role for Telemedicine in Mali

While pursuing studies at Bamako University’s Medical School in Mali, Cheick Oumar Bagayoko and his fellow medical students often worried about the prospect of being sent into Mali’s sparsely populated interior after graduation. It was widely known that once a doctor was sent to work in a rural area, a lack of access to continuing education and a more general experience of isolation meant that they inevitably began to lose the knowledge they had gained in medical school.

Dr. Bagayoko’s concerns as a medical student point to a wider problem for Mali’s health system, one that has a fundamental impact on its ability to provide services and care to people living in rural and remote areas of the country.

A serious shortage in health human resources is a key factor contributing to health inequalities between rural and urban areas in Mali. Rural residents, in general, have less access to health services and limited to no access to more complex diagnostic equipment. As a case in point, cardiologists are rarely found outside Bamako, Mali’s capital. Efforts to increase recruitment and retention of health personnel in rural areas face several challenges, including isolation and a lack of incentives, while patients take on a heavy financial burden and travel to urban areas for care and treatment.

As internet access began to increase in Bamako, Dr. Bagayoko became interested in the possibility of using the internet as a relatively inexpensive way to improve access to health care in Mali.

“I am convinced that these tools will enable physicians to remain on site in rural areas.”

Dr. Cheick Oumar BagayokoProject Principal Investigator

Source: Interview with Dr. Bagayoko, GHRI. 2010.

23

When Dr. Bagayoko chose telemedicine as the focus for his doctoral thesis, he knew it was a risky choice. Telemedicine projects were rarely seen in low- and middle-income countries, and in a country with slow and sporadic coverage, the choice to focus on telemedicine seemed impractical. Despite this, one faculty member, Professor Abdel Kader Traoré, encouraged Dr. Bagayoko to pursue the idea and agreed to become his thesis advisor.

From the Swiss Alps to remote Mali

Dr. Bagayoko looked outside Mali to find someone with experience in developing telemedicine. He contacted Dr. Antoine Geissbuhler, a professor at the University of Geneva, to ask him to be on his thesis committee. Dr. Geissbuhler agreed, based on a shared interest in medical imaging, e-health and new medical applications for rapidly advancing information and communication technologies.

While in Switzerland, Dr. Bagayoko came across mobile technology used for ski rescues in the Alps. The portable technology allowed first responders to carry out diagnostic tests on the ski hill, far from the hospital. Dr. Bagayoko saw that the technology might be used to perform diagnostic tests on patients in rural Mali, in particular electrocardiograms (ECGs) and ultrasounds. The idea was to have a specialist based in the capital assist rural doctors in diagnosing patients.

The project evolved into a web-based network where physicians seeking training on a particular subject were able to access an online course on the subject provided by a specialist. Physicians practicing in remote communities now had access to training opportunities, and colleagues, connected virtually, to assist with complex cases. It was not simply a question of accessing technical information; there is also an

Dr. Kassim Diabaté, based at the Dioila District Hospital in rual Mali, conducts an abdominal ultrasound during a training session in Bamako.

Photo credit: Mali Telemedicine Team

24

Dr. Mamadou Salia Diarra gives an online lecture on neurosurgery on the RAFT network.

Photo credit: RAFT. 2011.

important human factor. By participating in the network, doctors posted in rural and remote communities are able to interact with colleagues, located hundreds of kilometres away. This contact went a long way to alleviate the sense of isolation that marks the professional life of a rural doctor in Mali.

The success and growth of this network began to draw the attention of neighbouring countries interested in participating. With assistance from the Geneva University Hospitals and the Fonds de solidarité internationale de Genève, Drs. Bagayoko and Geissbuhler created the Réseau en Afrique francophone pour la télémédecine (RAFT) in 2001. The network has since expanded to include 28 countries, including several in which English is used. With the support of the World Health Organization, the network now provides dozens of English language courses online.

Drs. Bagayoko and Kader are now continuing their collaboration as co-principal investigators on this GHRI-funded project. The grant program requires that each team be co-led by a researcher and a decision-maker. Professor Kader, who is director of the Centre national d’appui à la lutte contre la maladie in Bamako, is the decision-maker.

The team is testing the effectiveness of distance medical training and telemedicine services, including transmission of medical images for cardiac and obstetric care and support to rural medical personnel in the diagnosis and treatment of patients. The goal is to determine whether this application of information and communication technologies contributes to raise levels of recruitment and retention of health personnel and improves access to quality care in rural areas of Mali. Dr. Bagayoko, Professor Kader and their team are contributing to wider efforts to develop an organi-zational model for telemedicine services that is effective and responsive to the various local contexts in which they are implemented.

25

A pregnant woman undergoes an ultrasound by Dr. Sow at the Kolokani district hospital in rural Mali (Photo credit: Mali Telemedicine Team)

“We realized that these tools may not only help to avoid unnecessary evacuations, but also to train health care professionals on site.”

Dr. Cheick Oumar BagayokoProject Principal Investigator

Source: Interview with Dr. Bagayoko, GHRI. 2010.

26

Developing the Palm Plus diagnostic tool for Malawi

Like other countries in sub-Saharan Africa, Malawi’s health system suffers from an acute shortage of health care workers. While some efforts have focused on increasing the number of health workers, another strategy has sought to provide health care workers with the training and tools to use their time more effectively.

Due to the shortage of health care workers, existing staff are overburdened, which reduces access to quality health services. In this environment, inefficient time management is often a system-wide problem that staff have little capacity to address on their own. Tools that assist health care workers in working more effectively offer a practical solution that has the potential to reduce the burden on health care workers, thereby increasing the quality of patient services. This also has the potential tocontribute to sustainable improvements in the health system.

In sub-Saharan Africa, existing pressures on health services are compounded by the HIV epidemic. Since the arrival of antiretrovirals for HIV/AIDS, the major concern has been getting treatment to those in need. Initially, the international community focused on efforts to reduce the cost of treatment, which was prohibitively expensive for the vast majority of people living with HIV/AIDS in Africa.

While the arrival of generic antiretrovirals significantly reduced the cost of treatment, the limiting factor was, and remains, the health system’s ability to provide timely and accessible treatment to people where they live. There have been advances in this area throughout the continent but it remains a problem due to a lack of infrastructure and staff, especially in rural areas.

The PALM Plus diagnostic tool

Photo credit: Dignitas International

27

Clement Khondiwa leading a PALM Plus training session at the Police Hospital in Zomba District (Photo credit: Dignitas International)

“The evidence from South Africa shows that this kind of tool can improve clinical care and have a dramatic impact on staff satisfaction.”

Dr. Michael Schull Project co-investigator

Source: Interview with Dr. Michael

Schull, GHRI. 2010.

28

From South Africa to Malawi

In the past several years, Malawi’s Ministry of Health has expanded HIV treatment to 16 rural centres in Zomba District in an effort to make treatment more accessible to rural residents. However, decentralizing services has the potential to strain an already overburdened rural health system. REACH Trust*, an independent Malawian research organization, and Dignitas International, a Canadian non-governmental organization, have been working with the Ministry to find ways to address the problem.

With ARV treatment, people are living with HIV/AIDS for longer periods of time. This means that there is an increased likelihood of resistance and co-infections—such as other sexually transmitted infections (STIs), tuberculosis or malaria—which can complicate treatment. In a district like Zomba, this translates into health facilities with more patients experiencing more complex health problems. Not only do health care personnel have less time to devote to individual patients, but they are faced with HIV cases that are increasingly difficult to treat and require more specific training. In this context, there is a growing need for a simplified decision-making tool to assist health care workers in making diagnostic and treatment decisions.

Developed for use in South Africa, the PALSA-PLUS diagnostic tool has been suc-cessful in improving care, treatment, referral and tuberculosis case detection. This Malawi-based team is partnering with the developers of PALSA-PLUS to adapt the tool for use in Malawi. The partnership led to the creation of the PALM Plus, Simplified Tools and Training.

* Research on Equity and Community Health (REACH)

Malawi

PALSA-PLUS Practical Approach to Lung Health and HIV/AIDS in South Africa

PALM Plus Practical Approach to Lung Health and HIV/AIDS in Malawi

Zomba District

29

Dr. Michael Schull providing training on PALM Plus to a nurse at the Pirimiti Community Hospital in Zomba District (Photo credit: Dignitas International)

“When you start talking about decentralization, you run up against a weak health system. The major weakness is not that the roof leaks, it’s the fact that there are just not enough staff. So the question is, how do you actually support the staff who are there?”

Dr. Michael Schull Project co-investigator

Source: Interview with Dr. Michael Schull, GHRI. 2010.

The team is now piloting the PALM Plus tool in health centres in the Zomba District. Using an approach known as a cluster-randomized trial, health centres were randomly assigned to two groups, one of which will use the PALM Plus tool. The study will compare the two groups to determine whether there are differences in staff retention and satisfaction, as well as patient outcomes in HIV/AIDS, TB, malaria and other primary care conditions.

30

Making mental health services accessible through innovative task-shifting

For the general population living in the sub-Saharan region, psychiatric services are not accessible. Those suffering from mental health issues will often live their lives without a diagnosis or treatment.

Professor David Ndetei, a psychiatrist and professor at the University of Nairobi, has trained most of the psychiatrists currently working in Kenya. His efforts have helped to give Kenya the second highest psychiatrist-to-population ratio in the region after South Africa. Yet Prof. Ndetei realized that mental health services were not accessible to most Kenyans, particularly the most vulnerable.

In 2004, Prof. Ndetei founded the Africa Mental Health Foundation (AMHF) to address this gap in services. Since then, AMHF has been active in mentoring mental health researchers in order to develop their capacity to carry out high quality research on issues of relevance to the region. With the support of the foundation, a number of students mentored by Prof. Ndetei have completed doctoral programs and research fellowships and conducted their own studies in mental health. Dr. Victoria Mutiso is one exam-ple. Dr. Mutiso is now a co-principal investigator on this GHRI grant.

Since training a sufficient number of psychiatrists was not feasible in the short term, the AMHF team began investigating innovative ways to make mental health services more accessible to the average Kenyan.

Victoria MutisoAMHFProject Principal Investigator

Photo credit: E. Lanktree. 2011.

31

90%Percentage of people with mental disorders living in low-income countries who do not have access to mental health services at the primary-care level.

Source: Interview with Prof. David Ndetei, GHRI. 2009; AMHF. 2011.

AMHF and Ngwata Health Centre staff in Ngwata, Kenya (Photo credit: AMHF)

32

1:500,000Estimated number of psychiatrists-to-population in Kenya.

Source: Interview with Prof. David Ndetei, GHRI. 2009; AMHF. 2011.

1:8,462Ratio of psychiatrists-to-population in Canada, slightly above the ratio recommended by the Canadian Psychiatric Association (1:8,400).

Source: Canadian Psychiatric Association. 2012; Statistics Canada. 2012.

In the absence of professionally trained mental health practitioners, Kenyans have sought out other options to alleviate the psychological or physical symptoms of mental illness. Whether faith healers, traditional healers, community based health workers or health facility personnel, AMHF saw these actors as potential points of access to reach people suffering from mental illness, since they are already known and accepted by the community.

With the support of this GHRI grant, AMHF staff are investigating whether training these resource persons is an effective way to expand mental health service coverage to vulnerable populations across the country. The team is training members of these groups to perform basic psychiatric tasks, such as identifying symptoms, diagnosing conditions, and most importantly, referring patients to mental health services.

The team is carrying out the research in a rural area and in an informal urban settlement to determine whether this is an appropriate strategy for mental health service delivery in these contexts. The work will involve both intervention and con-trol groups at each site to allow the team to compare results.

If successful, this research could have an important impact on the health and quality of life of those suffering from mental illness in Kenya. With some psychiatric tasks shifted to community-based health workers, faith healers, traditional healers, nurses and clinical officers (who are present throughout the country), the service coverage has the potential to increase significantly. This research will be of value not only to Kenya, but also to other low-income countries seeking to increase access to mental health services.

33

Patients, caregivers and other community members attending an educational meeting at the Ngwata Health Centre in Ngwata, Kenya (Photo credit: AMHF)

Vision : “To be the mental health centre of excellence in Africa for research, training, knowledge translation, and advocacy.”

Africa Mental Health Foundation

Source: AMHF. 2011.

34

Adam T, Ahmad S, Bigdeli M, Ghaffar A, Røttingen J-A. 2011. Trends in health policy and systems research over the past decade: still too little capacity in low-income countries. PLoS ONE 6(11): e27263. doi:10.1371/journal.pone.0027263.

Africa Mental Health Foundation. 2011. Accessed February 2, 2012 from: http://www.africamentalhealthfoundation.org/

AudienceScapes. 2010. “Kenya: Mobile communications.” Accessed February 2, 2012 from http://audiencescapes.org/coun-try-profiles/kenya/media-and-communication-overview/mobile-communications/mobile-communications-

Brenner JL, Kabakyenga J, Kyomuhangi T, Wotton KA, Pim C, et al. 2011. Can volunteer community health workers decrease child morbidity and mortality in Southwestern Uganda? An impact evaluation. PLoS ONE 6(12):e27997. doi:10.1371/journal.pone.0027997.

Canadian International Development Agency. Africa Health Systems Initiative. 2010. Accessed February 2, 2012 from: http://www.acdi-cida.gc.ca/acdi-cida/acdi-cida.nsf/eng/JUD-824143542-PTE

Canadian Psychiatric Association. 2012. “How many psychiatrists are there in Canada?” Accessed February 2, 2012 from: http://www.cpa-apc.org/browse/documents/19. Calculation based on 4,100 psychiatrists for a population of 34,694,560 Canadians (see Statistics Canada, 2012).

de Savigny D & Adam T, Eds. 2009. Systems thinking for health systems strengthening. Alliance for Health Policy and Systems Research, World Health Organization.

Fairall L, Zwarenstein M, Bateman ED, Bachmann OM, Lombard C, et al. 2005. Educational outreach to nurses improves tuber-culosis case detection and primary care of respiratory illness: a pragmatic cluster randomized controlled trial. British Medical Journal. 331:750-754.

Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, et al. 2010. Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet. 376: 1838–45, doi:10.1016/S0140-6736(10)61997-6.

Ndetei DM, Ongecha FA, Mutiso V, Kuria M, Khasakhala LI, et al. 2007. The challenges of human resources in mental health in Kenya. South African Psychiatry Review. 1033-36.

Otieno CF, Kaseje D, Ochieng’ BM, Githae MN. 2012. Reliability of community health worker collected data for planning and policy in a peri-urban area of Kisumu, Kenya. Journal of Community Health. 37(1):48-53.

Statistics Canada. 2012. “Canada’s Population Clock.” Accessed January 31, 2012 from: http://www.statcan.gc.ca/ig-gi/pop-ca-eng.htm. Calculation based on 4,100 psychiatrists for a population of 34,694,560 Canadians (see Canadian Psychiatric Association, 2012).

Sources

35

UNAIDS. 2010. Global report: UNAIDS report on the global AIDS epidemic 2010. Accessed February 16, 2012 from: http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf

UNICEF. 2011. “Preventing Mother-to-Child Transmission (PMTCT) of HIV 2011.” Accessed February 2, 2012 from: http://www.unicef.org/aids/index_preventionyoung.html

Vision 2020. 2011. “Blindness and Visual Impairment: Global Facts.” Accessed February 2, 2012 from: http://www.vision2020.org/main.cfm?type=FACTS

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, et al. 2008. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 372: 139–144.

World Health Organization. 2005. “Health topics: Health systems. What is a health system?” Accessed February 2, 2012 from: http://www.who.int/features/qa/28/en/

World Health Organization. 2008. “First Global Conference on Task Shifting.” Accessed February 2, 2012 from: http://www.who.int/healthsystems/task_shifting/en/

World Health Organization. 2010. “Health Workforce.” Global Health Observatory. Accessed February 2, 2012 from: http://www.who.int/gho/health_workforce/en/

World Health Organization. 2011a. World Health Statistics. Accessed February 2, 2012 from: http://www.who.int/gho/publi-cations/world_health_statistics/en/index.html

World Health Organization. 2011b. Global health sector strategy on HIV/AIDS 2011-2015. Accessed February 2, 2012 from: http://whqlibdoc.who.int/publications/2011/9789241501651_eng.pdf

World Health Organization. 2011c. “Emergency and Essential Surgery: the backbone of primary health care.” Accessed February 2, 2012 from: http://www.who.int/eht/sb/en/

World Health Organization. 2011d. “HIV treatment reaching 6.6 million people, but majority still in need.” Accessed February 2, 2012 from: http://www.who.int/mediacentre/news/releases/2011/hivtreatement_20110603/en/index.html

World Health Organization. 2012. “About health systems.” Accessed February 2, 2012 from: http://www.who.int/healthsys-tems/about/en/

World Health Organization, Global Health Workforce Alliance and the European Union. 2009. Profil en ressources humaines pour la santé du Mali. Observatoire de ressources humaines pour la santé de l’Afrique. Accessed February 2, 2012 from: http://www.hrh-observatory.afro.who.int/images/Docu-ment_Centre/mali_hrh_country_profile.pdf

36

Notes

“A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently.”

Source: WHO. 2012.

“

37

“A good health system delivers quality services to all people, when and where they need them.”

Source: WHO. 2005.

“

38

Acknowledgements

This work was carried out with the aid of a grant from the International Development Research Centre (IDRC) and with the financial support of the Government of Canada provided through the Canadian International Development Agency (CIDA).

Thank you to program grantees for providing content for this booklet.

39

Research & writing: Esmé Lanktree and Gyde ShepherdGlobal Health Research Initiative

Editing: Gyde Shepherd and Esmé LanktreeDesign: Gyde Shepherd

For more information about this program, contact:

Dr. Renée Larocque ~ Senior Program Officer Global Health Research Initiativerlarocque@idrc.ca / +1 613 696 2540

Marc Cohen ~ Program OfficerGlobal Health Research Initiative mcohen@idrc.ca / +1 613 696 2166

In partnership for health worldwide

GHRI IRSM

“We must know the health system in order

to strengthen it.”