Fragile States

Fragile States (including Afghanistan, Democratic Republic of Congo, Haiti, Liberia and South Sudan)

Makasi after two months of tuberculosis treatment. {Photo credit: A. Massimba/MSH.}Photo credit: A. Massimba/MSH.

With less than 1000 days until the Millennium Development Goals expire, the process for setting post-2015 goals continues to ramp up.  We take this opportunity to reflect on the current state of community health systems in low- and middle-income countries and consider how the post-2015 agenda could reshape them—perhaps dramatically.

Community health systems today

Integration moves ahead

Poor and rural communities in low- and middle-income countries are leaving behind the “one clinic, one service” approach. So-called vertical programs, which organized resources according to single health conditions, created a patchwork of health services at the community level. You could get HIV care from one provider, but would have to go down the hall, down the street, or often much farther to get maternal health care or malaria care.

Voice of America Interviews Dr. Stephen Macharia: On Tuberculosis in South Sudan (Audio).Voice of America Interviews Dr. Stephen Macharia: On Tuberculosis in South Sudan (Audio).

On the eve of World Tuberculosis Day, Voice of America interviewed Dr. Stephen Macharia, the TB CARE I country director for South Sudan.

During the interview (transcript, PDF), Dr. Macharia discussed the TB epidemic in South Sudan, TB CARE I project achievements, and the way forward for improving funding for TB services and multi-drug resistant TB (MDR-TB) control in fragile states, like South Sudan.

TB CARE I is a USAID-funded project, led by KNCV TB Foundation with partners, including Management Sciences for Health.

Voice of America, the official external broadcast institution of the United States federal government, produces nearly 1,500 hours of news and programs each week for an estimated global audience of 123 million people.

World Malaria Day 2013 {Photo credit: UNHCR/S. Hoibak.}Photo credit: UNHCR/S. Hoibak.

To me, malaria is a very personal disease.

I first came face to face with malaria during the war of my time: Vietnam. I was plucked out of residency after my first year, with only an internship under my belt, and sent as a Navy Medical Officer to war. Medical school and residency prepared me well for much of the trauma I encountered medically, but I was totally unprepared for the large-scale emotional trauma, and for the tropical diseases I had encountered only in books.

I was overwhelmed by the young children with malaria, some of whom literally died in my arms while treating them.  Yet, I also witnessed bona fide miracles: children at death’s door, comatose and unresponsive, who responded dramatically to treatments, and ultimately went home to their families.

To address malaria, I focused on promoting prevention (long-lasting insecticidal nets [LLINS] for families and intermittent preventive treatment [IPT] for pregnant women), early detection, and early treatment in the community—what is now called community case management.

That was 40 years ago.

Overcoming Barriers to Health Care for Women in Afghanistan.Overcoming Barriers to Health Care for Women in Afghanistan.

World Health Worker Week (" href="https://twitter.com/search?q=%23WHWW&src=hash" target="_blank">) is April 8-12, 2013. Let's show the world just how much . Watch and share the video, thank a health worker, and donate $10 in honor of a health worker. 

"We realized that educating the community was something we had to focus on," says Madina, a trained Afghan midwife, as she describes involving elders and religious leaders in helping to improve access to family planning and perinatal care for women in Khost province, including one woman who came to the health facility suffering complications from a home birth.

Health workers save lives. What will you do to thank a health worker?

 {Photo credit: Stephen Macharia/MSH.}Santo (right) and his father (left) share how Santo was finally diagnosed and treated for TB after being incorrectly treated for malaria for over two months.Photo credit: Stephen Macharia/MSH.

After South Sudan gained independence from Sudan in 2011, disagreements over oil-sharing between the two nations caused fighting and high economic inflation in certain regions. Desperate for security, over 110,000 Sudanese refugees escaped to South Sudan and now reside in camps in Maban County.

Bounj Hospital: Diagnosing and treating residents and refugees

These refugees, and the county’s 40,000 residents, are served by Bounj Hospital, the only TB diagnostic and treatment center in the district. This hospital is currently treating 75 patients for TB, 56 of whom are refugees.

The USAID-funded TB CARE I South Sudan project is helping to build the hospital staff’s capacity in TB treatment and infection control, despite the challenges the health workers face. Led by Management Sciences of Health in partnership with the National TB Program (NTP), the TB CARE I project team has trained over 200 health workers in TB diagnosis and treatment.

TB CARE I also teaches the health workers how to educate their patients about TB infection control and provides the trainees with regular supportive supervision and mentorship.

Mukabaha Ntakwigere (at right) at the General Reference Hospital in Nyangezi, DRC. {Photo credit: MSH staff.}Photo credit: MSH staff.

Tuberculosis (TB) is a leading cause of death in Democratic Republic of the Congo (DRC), partly due to a low case detection rate within the health system, compounded by little knowledge or awareness among patients of the disease’s symptoms. In the province of Sud Kivu, where people have relied on traditional healers for generations, those who were suffering from the persistent, painful coughing that is one symptom of TB were advised by traditional healers that they had been poisoned, and they were not referred to health centers.

In Sud Kivu province, in the health zone of Nyangezi, with a population of roughly 129,000 people, case detection was below 12%, which is the minimum "acceptable" threshold for TB detection.

Medical professionals in Nyangezi realized that they were never going to identify and treat those suffering from TB until they could educate the community about the symptoms and the treatment methods.

Dr. Jonathan Quick, President and CEO of MSH, tours with Dr. Christian Nzitimira, director of Kibagabaga Hospital in Rwanda. {Photo credit: Jon Jay/MSH.}Photo credit: Jon Jay/MSH.

In a postoperative ward of Kibagabaga Hospital, the district hospital serving Rwanda’s capital city of Kigali, Eric Bizimana sits up in bed. Bizimana, 25, had sought care after severe pain in his right leg forced him to stop work as a barber. He was diagnosed with a bone infection called osteomyelitis. Antibiotics alone couldn’t clear the infection. Without an operation to remove the diseased bone, Eric faced the possibility of losing his leg.

Eric was one of the 40 patients who enter Kibagabaga for surgery every day. In Rwanda’s tiered healthcare delivery system, patients are referred from local health centers up to the district hospital when their conditions require more complex care. Most babies are delivered at health centers, for example, but a woman suffering complications or who was expected to need a C-section would be referred to the district level.

Marie Madelaine Thomas receives antiretroviral therapy through an SDSH-supported clinic. Since August 2012, SDSH has provided ART to more than 3,665 individuals.

Private sector companies, like McDonald's and General Electric, have successfully been using internal universities or academies for decades. So how can programming for health service managers be better, more cost effective and more sustainable? Embed programming within special “Leadership Academies” based in ministries of health.

In Moen Kas, one of the villages where the project introduced community-led total sanitation, officials and villagers celebrate Open Defecation Free (ODF) certification. {Photo credit: Noorgha CLTS Supervisor/Afghanistan.}Photo credit: Noorgha CLTS Supervisor/Afghanistan.

A new report from the USAID-funded Afghan Sustainable Water Supply and Sanitation (SWSS) Project, led by Tetra Tech ARD, describes the methodology and results from the Sustainable Health Outcomes component, led by Management Sciences for Health (MSH). The SWSS project worked to improve the health and infrastructure of rural Afghans, with an emphasis on providing water supply and sanitation facilities and improving community hygiene behaviors (read stories).

SWSS was the first project in Afghanistan to implement community-led total sanitation (CLTS) on a broad scale. While challenges for ongoing hygiene and sanitation remain, the project’s success led the Afghan Ministry of Rural Rehabilitation and Development to include CLTS as part of its national water and sanitation policy and strategy.

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