The interface between the national tuberculosis control programme and district hospitals in Cameroon: missed opportunities for strengthening the local health system –a multiple case study

BMC Public Health

Bart Criel³  Jean Meli²  Anne Buve³  Jean Macq¹  Basile Keugoung⁴ 

[1]Institut de Recherche Santé et Société, Université Catholique de Louvain, Brussels, Belgium

[2]Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon

[3]Public Health Department, Institute of Tropical Medicine, Nationalstraat 155, Antwerp, Belgium

[4]Ministry of Public Health, Cameroon

[5] Research, Education, and Health Development Group (GARES-Falaise), Dschang, Cameroun

关键词: Tuberculosis;    Sub-Saharan Africa;    Programme;    District hospital;    Cameroon;    Case study;   

Others  :  1162415
DOI  :  10.1186/1471-2458-13-265

 received in 2012-09-05, accepted in 2013-03-12,  发布年份 2013

【 摘 要 】

Background

Tuberculosis remains a major public health problem in sub-Saharan Africa. District hospitals (DHs) play a central role in district-based health systems, and their relation with vertical programmes is very important. Studies on the impact of vertical programmes on DHs are rare. This study aims to fill this gap. Its purpose is to analyse the interaction between the National Tuberculosis Control Programme (NTCP) and DHs in Cameroon, especially its effects on the human resources, routine health information system (HIS) and technical capacity at the hospital level.

Methods

We used a multiple case study methodology. From the Adamaoua Region, we selected two DHs, one public and one faith-based. We collected qualitative and quantitative data through document reviews, semi-structured interviews with district and regional staff, and observations in the two DHs.

Results

The NTCP trained and supervised staff, designed and provided tuberculosis data collection and reporting tools, and provided anti-tuberculosis drugs, reagents and microscopes to DHs. However, these interventions were limited to the hospital units designated as Tuberculosis Diagnostic and Treatment Centres and to staff dedicated to tuberculosis control activities. The NTCP installed a parallel HIS that bypassed the District Health Services. The DH that performs well in terms of general hospital care and that is well managed was successful in tuberculosis control. Based on the available resources, the two hospitals adapt the organisation of tuberculosis control to their settings. The management teams in charge of the District Health Services are not involved in tuberculosis control. In our study, we identified several opportunities to strengthen the local health system that have been missed by the NTCP and the health system managers.

Conclusion

Well-managed DHs perform better in terms of tuberculosis control than DHs that are not well managed. The analysis of the effects of the NTCP on the human resources, HIS and technical capacity of DHs indicates that the NTCP supports, rather than strengthens, the local health system. Moreover, there is potential for this support to be enhanced. Positive synergies between the NTCP and district health systems can be achieved if opportunities to strengthen the district health system are seized. The question remains, however, of why managers do not take advantage of the opportunities to strengthen the health system.

【 授权许可】

   
2013 Keugoung et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]Ooms G, Stuckler D, Basu S, McKee M: Financing the millennium development goals for health and beyond: sustaining the ‘Big Push’. Global Health 2010, 6:17. BioMed Central Full Text
• [2]Stuckler D, Basu S, McKee M: Drivers of inequality in millennium development goal progress: a statistical analysis. PLoS Med 2010, 7:e1000241.
• [3]Unger JP, Van DP, Sen K, De Paepe P: International health policy and stagnating maternal mortality: is there a causal link? Reprod Health Matters 2009, 17(33):91-104.
• [4]WHO: Global tuberculosis control. Geneva: WHO; 2011. [WHO report 2011]
• [5]WHO: World health statistics 2012. Geneva: WHO; 2012.
• [6]Kawonga M, Blaauw D, Fonn S: Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa. Health Res Policy Syst 2012, 10:2. BioMed Central Full Text
• [7]Atun R, Lazarus JV, Van Damme W, Coker R: Interactions between critical health system functions and HIV/AIDS, tuberculosis and malaria programmes. Health Policy Plan 2010, 25(Suppl 1):i1-i3.
• [8]Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G: The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan 2009, 24(4):239-252.
• [9]Cavalli A, Bamba SI, Traore MN, Boelaert M, Coulibaly Y, Polman K, Pirard M, Van Dormael M: Interactions between global health initiatives and country health systems: the case of a neglected tropical diseases control program in Mali. PLoS Negl Trop Dis 2010, 4:e798.
• [10]Rasschaert F, Pirard M, Philips MP, Atun R, Wouters E, Assefa Y, Criel B, Schouten EJ, Van Damme W: Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi. J Int AIDS Soc 2011, 14(Suppl 1):S3. BioMed Central Full Text
• [11]Assefa Y, Kiflie A, Tesfaye D, Mariam DH, Kloos H, Edwin W, Laga M, Van Damme W: Outcomes of antiretroviral treatment program in Ethiopia: retention of patients in care is a major challenge and varies across health facilities. BMC Health Serv Res 2011, 11:81. BioMed Central Full Text
• [12]Harries AD, Nyirenda TE, Banerjee A, Boeree MJ, Salaniponi FM: Treatment outcome of patients with smear-negative and smear-positive pulmonary tuberculosis in the national tuberculosis control programme, Malawi. Trans R Soc Trop Med Hyg 1999, 93(4):443-446.
• [13]Yumo HA, Mbanya D, Kuaban C, Neuhann F: Outcome assessment of a global fund grant for tuberculosis control at the district level in rural Cameroon. Int J Tuberc Lung Dis 2011, 15(3):352-357.
• [14]Einterz EM: Health district development and the need to dig deeper. Lancet 2011, 377(9771):1122-1123.
• [15]Raviglione M, Pio M: Evolution of WHO policies for tuberculosis control, 1948–2001. Lancet 2002, 359(9308):775-780.
• [16]Raviglione M, Zumla A, Marais B, Horton R, Motsoaledi A: A sustainable agenda for tuberculosis control and research. Lancet 2012, 379(9821):1077-1078.
• [17]Yin RK: Case study methods. Revised draft 2004. Cosmos Corporation; 2004. http://www.cosmoscorp.com/Docs/AERAdraft.pdf webcite
• [18]Bowling A: Research methods in health: investigating health and health services. 2nd edition. Buckingham: Open University Press; 2002.
• [19]Yin RK: Enhancing the quality of case studies in health services research. Health Serv Res 1999, 34(5 Pt 2):1209-1224.
• [20]Yin RK: Case study research: design and methods. 4th edition. London: Sage; 2009.
• [21]Okalla R, Le Vigouroux A: Cameroun: de la réorientation des soins de santé primaires au plan national de développement sanitaire. Bull APAD 2001, 21:181.
• [22]Keugoung B, Nolna D, Buvé A, Macq J, Meli J, Criel B: 30 ans de lutte antituberculeuse au Cameroun: une interaction dynamique entre systèmes d’offre de soins de santé « vertical » et « horizontal ». Rev Epidemiol Sante Publique 2013, 61(2):129-138.
• [23]Ministry of Public Health: The health sector strategy 2001–2015. Yaounde: Ministry of Public Health; 2009.
• [24]Owona Essomba R, Bryant M, Bodart C: The reorientation of primary health care in Cameroon: rationale, obstacles and constraints. Health Policy Plan 1993, 8(3):232-239.
• [25]Van Lerberghe W, Van Balen H, Kegels G: Typologie et performances des hôpitaux de premier recours en Afrique sub-saharienne. Ann Soc Belg Med Trop 1992, 72(Suppl 2):1-52.
• [26]Diallo K, Zurn P, Gupta N, Dal PM: Monitoring and evaluation of human resources for health: an international perspective. Hum Resour Health 2003, 1:3. BioMed Central Full Text
• [27]WHO: Scientific Peer Review Group on Health System Assessment Performance Final Report. Geneva: WHO; 2002.
• [28]Aqil A, Lippeveld T, Hozumi D: PRISM framework: a paradigm shift for designing, strengthening and evaluating routine health information systems. Health Policy Plan 2009, 24(3):217-228.
• [29]Hotchkiss DR, Aqil A, Lippeveld T, Mukooyo E: Evaluation of the performance of routine information system management (PRISM) framework: evidence from Uganda. BMC Health Serv Res 2010, 10:188. BioMed Central Full Text
• [30]Health Metrics Network: Components of a strong health information system, a guide to the HMN framework. Geneva: WHO; 2012.
• [31]WHO: Key components of a well-functioning health system. Geneva: WHO; 2002.
• [32]Guevart E, Binam F, Laah-Njoya S, Wirba JB, Tchofa JC, Penlap-Temdie E: Préparation du système de santé camerounais à la prise en charge des urgences. Evaluation du premier niveau de référence. JEUR 2005, 18:163.
• [33]Boulenger D, Criel B: The difficult relationship between faith-based health care organisations and the public sector in sub-Saharan Africa. The case of contracting experiences in Cameroon, Tanzania, Chad and Uganda. SHSOP 2012, 29:1-232.
• [34]Gauvrit E, Okalla R: La difficile mise en place des districts sanitaires urbains. Bull APAD 2001, 21:186.
• [35]Global Fund: The Global Fund strategy 2012–2016: investing for impact. 2012. http://www.theglobalfund.org/en/about/strategy/ webcite
• [36]PNLT: Guide technique à l’usage des personnels de santé. Yaounde: Programme National de Lutte contre la Tuberculose; 2006.
• [37]Chee G, Pielemeier N, Lion A, Connor C: Why differentiating between health system support and health system strengthening is needed. Int J Health Plann Mgmt 2013, 28(1):85-94.
• [38]Potter C, Brough R: Systemic capacity building: a hierarchy of needs. Health Policy Plan 2004, 19(5):336-345.
• [39]Travis P, Bennett S, Haines A, Pang T, Bhutta Z, Hyder AA, Pielemeier NR, Mills A, Evans T: Overcoming health-systems constraints to achieve the millennium development goals. Lancet 2004, 364(9437):900-906.
• [40]WHO: The work of WHO in the African Region. Annual report of the Regional Director to the sixty-firt session of the Regional committee for Africa. Brazzaville: WHO Afro; 2011.
• [41]Buve A, Kalibala S, McIntyre J: Stronger health systems for more effective HIV/AIDS prevention and care. Int J Health Plann Manage 2003, 18(Suppl 1):S41-S51.
• [42]WHO: Maximizing positives synergies between health systems and Global Health Initiatives. Geneva: WHO; 2008.
• [43]Samb B, Evans T, Dybul M, Atun R, Moatti JP, Nishtar S, Wright A, Celletti F, Hsu J, Kim JY, Brugha R, Russel A, Etienne C: An assessment of interactions between global health initiatives and country health systems. Lancet 2009, 373(9681):2137-2169.
• [44]Marchal B, Van DM, Pirard M, Cavalli A, Kegels G, Polman K: Neglected tropical disease (NTD) control in health systems: the interface between programmes and general health services. Acta Trop 2011, 120(Suppl 1):S177-S185.
• [45]Rowe AK, De Savigny D, Lanata CF, Victora CG: How can we achieve and maintain high-quality performance of health workers in low-resource settings? Lancet 2005, 366(9490):1026-1035.
• [46]Keugoung B, Macq J, Buve A, Meli J, Criel B: The interface between health systems and vertical programmes in Francophone Africa: the managers’ perceptions. Trop Med Int Health 2011, 16(4):478-485.
• [47]WHO: Global tuberculosis report 2012. Geneva: WHO; 2012.