This Week's News 5 August 2011

Kenya: Clinics Struggle to Keep Patients Not Yet Eligible for ARVs

IRIN PlusNews

02/08/2011

Nairobi — Jairus Musau tested HIV-positive two years ago, but when he was told he would not immediately be given antiretrovirals, his parents insisted he visit a traditional healer in his eastern Kenya hometown of Kitui.

"The doctor told me I would not be given ARVs since I still did not qualify for them," the 25-year-old told News. "When I shared this with my parents, they told me I would live with somebody who would pray for me."
When Musau first sought treatment, his CD4 count - a measure of immune strength - was 389. The UN World Health Organization currently recommends that HIV-positive people initiate treatment at a CD4 count of 350 and below; while Kenya has indicated that it will switch to these guidelines, most people still access treatment at the national guidelines-stipulated threshold of 200 and below.
When he started feeling very ill, Musau left the traditional healer's home and went to Mbagathi District Hospital in the capital, Nairobi, where his CD4 count was found to be well below 200 and he was immediately given treatment.
"Now I can see I am improving soon after I started taking my drugs. If I had sunk my head in prayers, I would be dead today," he said. "Many people die like that, not because they want to, but because when you are told you are HIV positive but you must wait and start taking ARVs later, you believe even swallowing a rock can save you."
More than 400,000 HIV-positive Kenyans are currently on ARVs, but another 600,000 need the drugs and have no access to them; an estimated 1.5 million Kenyans are infected with HIV.
The national guidelines state that all patients diagnosed with HIV be put on cotrimoxazole, an antibiotic used as a prophylactic against opportunistic infections. A 2011 study conducted at Nairobi's Coptic Hospital found that provision of cotrimoxazole improved the retention rates of Kenyan HIV programmes from 63 percent to 84 percent; 16 percent continued to be lost to care.
Challenges

According to Georgina Masivi, a senior Comprehensive Care Centre Nurse at the country's largest referral facility, Kenyatta National Hospital, retaining HIV-positive patients not yet eligible for treatment remains a challenge.

"[Some] will come while they are still being treated for opportunistic infections and once they start to feel better, they just disappear, forgetting it is ARVs that they need for their long-term survival," she said.
According to Andrew Suleh, medical superintendent at Mbagathi District Hospital, the many processes involved in attaining ARV treatment can act as a deterrent. "There are procedures that health workers need to follow like taking CD4 counts of a patient, waiting for the results, counselling for adherence and making sure that a patient is psychologically prepared to be initiated on treatment," he said. "Some patients are lost along the way because of the frustration of having to wait and they run to seek treatment through some other means.
"Children are even more susceptible to loss to care because somebody, either a parent or a caregiver, doesn't care to take them back for treatment or fails to go back and collect their test results," he added.
A recent review of studies on retention of patients between testing and treatment found that more than two-thirds of people who tested positive for HIV but were not yet on treatment were lost.
Health workers in Kenya say some of the major reasons include: the stigma involved in visiting a health facility where they are known, long distances from health centres and the long wait for test results.
Ibrahim Mohamed, head of the National AIDS and Sexually transmitted infections Control Programme, noted that the government was trying to improve record keeping at health centres in an effort to keep track of patients.
"It would be too ambitious to say you can eradicate cases of patients getting lost before they can be initiated on treatment, but we emphasize proper health records and patient information management by healthcare workers to ease follow up," he said. "Maybe what we need to do now is share this information with all ART sites so that if one patient is lost at a particular centre, he or she can be traced should they seek treatment at another."
According to Suleh, boosting community health worker numbers and introducing technologies that give much faster CD4 and TB diagnoses would improve programmes' ability to retain patients on care. Most recently, the developers of an "mChip" successfully tested in Rwanda, say it can diagnose infectious diseases such as HIV and syphilis at patients' bedsides and potentially streamline blood testing worldwide.
"Now we are talking about point-of-care CD4 count and advanced technologies that can give results of TB diagnosis in just hours," he said. "If we invest in these and have more community workers to track down patients, then such cases of loss of patients can be reduced."

7

Shortage of doctors is beyond critical

Mail and Guardian, SA

05/08/2011
A looming problem will, in the next few years, affect the health of every man, woman and child in South Africa: the dire shortage of doctors in every medical discipline. Put bluntly, the statistics are enough to induce an anxiety attack.
According to the Health Professions Council of South Africa, more than 37 300 doctors are registered in the country and almost 12 300 of them are qualified as specialists. But what is not known is how many of these doctors still practise here.
There are also no figures to indicate how many of these practitioners are working abroad, either permanently or temporarily. Estimates vary, but an educated guess by the council is that just more than half of the registered doctors are practising in South Africa.
Needless to say, with the country's population now well over the 50-million mark, this is a healthcare disaster waiting to happen. In the United States there are 901 nurses and 247 doctors per 100 000 people. South Africa has 393 nurses and 74 doctors per 100 000 people. This translates to 0.57 doctors per 1 000 patients, which is a dire situation, even compared with Brazil's 1.8 and Mexico's 1.9 doctors per 1 000 people.
Statistics pertaining to our public health sector make even more grim reading. Only about 30% of all our doctors work in the public sector. The rest earn their living caring for 16% of our population who are fortunate enough to be able to afford private medical insurance or pay for private healthcare when needed.
A survey reported that 23 407 South African-born doctors were practising in Australia, Canada, New Zealand and the US, whereas a mere 11 332 doctors were employed in the South African public sector. Bearing the brunt of this shortage are rural areas, where 46% of the South African population resides.
Healthcare professionals are reluctant to relocate to these areas. Although a few of the posts in our rural state hospitals are filled by -doctors from the United Kingdom, the US and Europe, they are too few and their postings are only temporary.
Alarmingly, vacancies in the public health sector remain high because of difficulties in recruitment and the freezing of posts owing to budget cuts. Almost 35% of medical practitioner positions and 40.3% of professional nurse positions were vacant in 2008. Expect these figures to be far higher today.
In fact, statistics revealed in Parliament recently indicated that South Africa needed an additional 46 000 nurses and 12 500 doctors to treat state patients. Filling these posts is a challenge our eight medical universities have little or no chance of overcoming. To maintain the number of doctors we have now, we should train at least 2 400 new ones a year, but our universities produce no more than 1 200 doctors annually -- and it is estimated that half of them will emigrate.
What is worse, there is more than 12 times the number of applicants seeking to train as doctors as there are positions available at tertiary institutions. This is a long-term problem that has no short-term solutions.
Even though the government is investing more than R8-billion to construct a ninth medical school in Polokwane, Limpopo, it will hardly be sufficient to plug the gaping holes that our public health system is going to experience for a number of years to come. Beyond our borders the problems are even more acute.
The World Health Organisation estimates that Africa has 25% of the world's disease burden but only 1.3% of its healthcare professionals. Compounding this problem is the annual emigration of about 20 000 African doctors and nurses who leave the continent for greener pastures in the developed world where better working conditions and higher wages are assured because of the ageing population.
So what is the prognosis for South Africa? Not good. Our healthcare system is in terminal decline.

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Asia & Pacific

1

BANGLADESH: Treatment gap for mental health problems

UN IRIN

01/08/2011

DHAKA, 1 August 2011 (IRIN) - Facilities and resources needed to treat the nearly 14.5 million adults with mental disorders in Bangladesh, as well as nearly 20 percent of children aged 12-17, are inadequate, health workers say.

“If you look at the total amount of expenditure for the mental health system, you understand that successive governments showed their negligence towards mental health,” Golam Rabbani, chief researcher on a recent survey by the National Institute of Mental Health, published in June 2011, and one of just 134 psychiatrists in the country, told IRIN.
The survey focused on the growing issue of mental health in children and found mental illness is more common among children in rural areas than in cities. As many as 17.5 percent of rural children have a mental illness, compared to 14.3 of city children, it said.
According to a World Health Organization (WHO) report, in 2005 the health department spent US$1.4 million (less than 0.5 percent of the healthcare budget) on mental health. No mental disorder is covered in social insurance schemes and no human rights review body exists to inspect mental health facilities, the report added.
Moreover, the Indian Lunacy Act of 1912, which allows discrimination against the mentally ill, remains in effect in Bangladesh.
Not much has changed since 2005, noted Mostafa Zaman, a WHO officer for non-communicable diseases in Bangladesh and co-author of the WHO report. It seems the number of people with mental disorders is on the rise, as is the number of people seeking professional help, he said.
The predominant affliction is depression and the main obstacle is stigma, explained Omar Rahman, a psychiatrist in Bangladesh and also an associate professor of epidemiology and demography at Harvard University.
“People do not consider mental health as a disease like other diseases. Moreover, people with mental disorders do not go to hospitals as they think it will hamper their social dignity,” Rahman said.
“The number of human resources is completely insufficient for the huge population in Bangladesh. The human resources have to be increased to reduce the treatment gap,” Rahman said. Currently there is less than one psychiatrist for every one million Bangladeshis.
In 2006 mental health policy, strategy and planning came under the surveillance and prevention of non-communicable diseases. At the time a draft version of the Mental Health Act was elaborated, but it has yet to be approved and enacted, Rabbani said.

2

Govt mulls raising retirement age of specialist docs

The Times of India

02/08/2011
Nishant SinhaNishant Sinha
PATNA: The Bihar government is considering raising the retirement age of specialist doctors serving in the state. This was stated by principal secretary, health, Amarjeet Sinha during a meeting with the Bihar Health Services Association a couple of days back.
The move is aimed at overcoming the shortage of doctors in the state. The state is facing shortage of doctors as against a requirement of 15,000 doctors under the National Rural Health Mission (NRHM), only 4,500 doctors are in position.
When it comes to specialist doctors, the situation is even more glaring. The state is short of 70 percent specialists. Only around 1,800 specialist doctors are in the state, including degree and diploma holders, against a requirement of 5,000 specialists.
Even the earlier initiative taken by the state government to plug the shortage of specialists had not met with the desired result as against 2,132 posts of specialists advertised only 372 could be appointed.
The NRHM, in its report, had recommended the raising of retirement age of doctors. Madhya Pradesh and Jharkhand governments have raised retirement age of doctors to 65 years. When the Association brought this to the notice of Sinha during the meeting, he said that he would apprise the government of Jharkhand government's notification to this effect.
Sinha on Monday said that the state government is considering raising the retirement age of specialist doctors though the Association is demanding the raising of the superannuation age of all government doctors to 65 years.
Health minister Ashwini Kumar Choubey, too, recently said that Bihar was facing shortage of doctors and their services could be utilized if their retirement age is raised.
The state government is set to appoint more than 4,000 doctors, including specialists and medical college teachers, both on regular as well as contract basis. Sinha had earlier said, "We are assessing the situation and once new appointments are made, the retirement age of doctors, too, could be raised, if required."

3

‘Country needs trained midwives and nurses’

Dawn, Pakistan

30/07/2011

KARACHI: Highlighting the role of midwives in the improvement of maternal health, senior health professionals on Friday urged the government to ensure a significant increase in the number of health workers equipped with midwifery skills in the country.
Speaking at a press conference, they said that trained midwives could not only make pregnancies normal and safer, but also timely identify complications, if there were any, that needed medical specialists’ intervention, particularly in rural areas.
The press conference, which was led by Dr Shershah Syed, was held in connection with the launch of a teleplay on maternal health produced by Tehrik-i-Niswan in collaboration with the Pakistan National Forum on Women’s Health (PNFWH) and the United Nations Population Fund (UNFPA).
The executive producer of the play, Sheema Kermani of Tehrik-i-Niswan, said that the play “Maen Jioungi Sar Utha Kay” depicting the story of a fistula patient had been shot at different hospitals and health institutions.
She said that artists in the teleplay observed sufferings of women with obstetric complications and their handling by their families and medical care staff and would be seen interacting with real gynaecologists and midwives in a real environment and health infrastructure.
She said that the teleplay was linked with the overall status of women in the country and presented trained midwives as a role model in averting maternal disabilities, including obstetric fistula.
“We have planned to have a review launch of the teleplay on July 30 at the Arts Council of Pakistan to get input from medical experts and social scientists so that we can amend the content and presentation of the play further, following which efforts will be made to get the play telecast on the state TV and private television channels and have a good number of CDs prepared for its distribution,” she said.
Dr Faria Ahsan, UNFPA programme officer on reproductive health, said that the UNFPA was associated with the teleplay project since its inception and would also extend necessary support to it as it believed that maternal health issues needed to be addressed on priority basis, particularly in the developing countries.
Dr Shershah, who is also the president of the PNFWH, expressed dissatisfaction over the existing status maternal health and situation of midwifery training in the country.
He said that despite millions and billions of rupees investment in the maternal healthcare sector, situation had not improved significantly, adding that women were still dying in childbirth and suffering pregnancy associated complications, including genital fistula.
He said that there was a dire need to check the working of the Pakistan Medical and Dental Council and the Pakistan Nursing Council.
“Pakistan needs an increasing force of nurses, midwives and paramedics to face the challenges of primary and secondary health care. However, the people at the helm are just busy in producing thousands of glorified MBBS quacks majority of whom are ladies not pursuing the medical profession for any practical and public welfare purposes.”
He said that in Sindh about 3,300 doctors were being produced on yearly basis, while the number of male nurses was 570, female nurses 553, midwives 533 and just 185 lady health workers each year.
“A country like us, in fact, needs to see manifold increase in the midwifery force,” he said.
Dr Aziz Khan Tank of the College of Family Medicine said that the health system in the country was nearing to a total collapse.
“We badly need to increase the numbers of midwives, paramedics and nursing staffs to help ease the load from general physicians,” he said.
Dr Mirza Ali Azhar, secretary of the PMA central, said that the PMDC and other responsible institutions were failing to address health issues.
“We need not only to increase the number of appropriately trained midwives, but also to make the nursing and midwives profession respectable in the country on emergency basis, particularly in order to avert their departure and employment in middle-east and other countries.
Imtiaz Kamal, president of the Midwives Association of Pakistan, said that midwives because of their capabilities were considered as real helping hand in the early 10-15 years after the creation of Pakistan.
“We now need to have midwives with specific skills trained by qualified teachers and subject specialists,” she added.
Dr Nighat Shah, secretary of the Society of Obstetrics and Gynaecology of Pakistan, said that midwives had a vital role in ensuring a normal delivery.
They worked dedicatedly and were in a unique position to offer something of great value to a woman and her family and children, Dr Nighat added.
According to an estimate, every year over 500,000 women die because of complications during pregnancy and in childbirth worldwide.
At least seven million of women who survive childbirth suffer serious health problems and further 50 million women suffer adverse health consequences after childbirth.

4

`Basic health units lack basic facilities`

Dawn, Pakistan

30/07/2011
KARACHI, July 29: Most government-run basic health units (BHUs) and dispensaries in the rural areas of Sindh are without basic facilities and necessary equipment.
The health units lack furniture, drinking water, sanitation and medicines.
This was pointed out during a seminar titled “Provincial dialogue: role of district health monitoring committees for the betterment of health services in Sindh” organised by the Strengthening Participatory Organisations (SPO) here on Friday.
Health officers and representatives of community organisations of Matiari, Tando Mohammed Khan and Badin participated in the seminar.
The SPO informed the audience about the findings of a survey they conducted in these three areas of the province with the help of local community organisations and district governments.
The survey shows that besides unavailability of staff and equipment in several BHUs, it has been observed that there are no facilities of drinking water, sanitation and waiting rooms, especially for women visiting the facilities.
In the absence of these facilities the people, especially women visiting the units, undergo a great deal of suffering, the survey shows.
Those who spoke on the occasion included renowned child health specialist and chief of the Health and Nutrition Development Society (HANDS) Dr Abdul Ghaffar Billoo, health department special secretary Dr Suresh Kumar, executive district officer of community development department of Matiari district Qurban Ali Memon, Dr Zaid Jamali of Tando Mohammed Khan, regional head of the SPO of Karachi Elahi Bakhsh, Karachi SPO programme officer Rahima Panhwar and Sangrasi Programme Officer of the SPO of Hyderabad region Abdul Wahid.
In his keynote speech, Dr Billoo appreciated the SPO for its survey of the three districts and findings.
He said that 80 per cent health facilities were available, but there were gaps in the delivery of services.
The survey showed that there was a lack of coordination between the government and community people, he said.
“Why are we not finding its solutions? Primary healthcare is a human right which the community people do not get,” he said.
There were no lady health workers (LHWs) in Pakistans 45 per cent areas to help women, he added.
“It is our responsibility to provide health facilities in all areas. If the government does not have these plans, private partnerships should extend initiatives.”
He emphasised the need for strengthening of monitoring, supervision and evaluation system in the health sector.
In future the SPO should follow the health indicators while compiling findings in surveys in other districts, he added.
He said when the HANDS started 25 health centres, the government functionaries realised how the centres were functioning.
“We advised the government that we should have authority of hiring and firing so that we can improve government health facilities,” he said.
Dr Suresh Kumar said that the district health monitoring committees which collected these findings should be expanded to other districts to highlight problems and issues so that they could be addressed through a proper channel.
Elahi Bakhsh said during the focus group discussions district officers pointed out that the health units` staff usually remained absent and their performance was unsatisfactory.
Qurban Ali Memon appreciated the role of the SPO for its findings which would be shared with government functionaries at provincial level to improve the healthcare system.
The recommendations of the meeting included that a regular dialogue should be initiated to review these issues and proper action should be taken to resolve the same at the earliest.
It was stressed that coordination between all the stakeholders, including district governments, community and the civil society, should be strengthened.
Earlier, Rahima Panhwar in her welcome address said that the SPO focused on the Local Government Ordinance, 2001 which ensured community participation in all activities.
She said the SPO tried to collect information of communities to learn about their health and education problems and work with local communities, legislators and other stakeholders.

5

Healthcare at crossroads: One facility, too many patients
The Express Tribune, Pakistan
03/08/2011
By Manzoor Ali
PESHAWAR: The only Burn and Plastic Surgery Unit catering to the people of Khyber-Pakhtunkhwa (K-P), the tribal areas and Afghanistan is facing a categorical shortage of doctors, beds and other facilities, officials have revealed.
The burn centre at the Khyber Teaching Hospital (KTH) is the only facility of its kind in the entire province to treat burn-related injuries and plastic surgery. Unfortunately, patients in this unit, who need significant privacy, are at the mercy of the visitors as the only entrance to the unit passes through an only-male ward.
Burn unit Registrar Dr Syed Asif Shah told The Express Tribune that the facility currently possesses only 12 beds and two qualified doctors to treat burn cases of the entire province including the tribal areas.
Dr Shah revealed that operations on the burn patients were performed only once a week, while the rest of the week, the operation theatres remained idle.
“This facility also lacks an Intensive Care Unit (ICU) and those patients requiring an ICU are referred to other cities like Wah,” he said.
Dr Shah said that annually the facility received 400 to 600 patients and half of them required operations while the other half needed intensive care.
Burn patients, in general, take at least two weeks to recover, while in serious cases the treatments could span over a period of two to three years – requirements the facility is often unable to cater to.
The registrar of the burn unit said that legally there should be two doctors for a single bed and keeping this standard in mind, the facility needed 24 doctors and same number of paramedics for better treatment of patients.
Due to it being the only facility in the province and tribal areas, entry to its ward is also difficult. According to Dr Shah, patients have had to wait up to six months for treatment which had resulted in high mortality and deformity rates.
Dr Shah said that the ongoing insurgency in the region had also caused an increase in the number of cases as many of the bomb blast victims either received burn injuries or needed plastic surgery.
“Cost of treatment is also expensive and it costs Rs3,000 to Rs10,000 per patient per day.”
Dr Shah said that he had asked the authorities to appoint more doctors, support staff, beds and two operation theatres to cope up with the increasing load of patients but a response was not forthcoming.
He said that work for a 100-bed Burn and Trauma Centre was still in progress and it would take at least three years to complete, while the extension work of the KTH facility was still under process.