Nursing in Africa

In large parts of Africa, decades of war, conflict and instability have left its people with limited access to basic healthcare services. This is aggravated by the fact that the continent carries 25% of the global disease burden and the lowest number of global healthcare worker per capita.
The challenges that impact healthcare service delivery in Africa include (but are obviously not limited to) lacking infrastructure, poor management, lacking equipment, variable care standards and supply chain issues. In 2001, in an attempt to address some of these challenges, the countries belonging to the African Union (AU) committed to allocate 15% of their fiscal budget to healthcare (Abuja declaration 2001). Sadly only six countries succeeded in doing that. It is estimated that even if all of the AU countries allocated 15%, the size of their budgets are simply not enough to address and overcome some of the challenges that face healthcare systems in Africa.
The budget size and lack of allocation or investment in healthcare leads to another problem: dependency on donor funding. Unfortunately donor funding comes with vested interests and may inadvertently contribute to the vertical development of disease specific fields at the expense of horizontal or strengthening of the whole health system. A good example of this is HIV research that across the continent is disproportionately represented and funded.
Because the burden of disease and the demand for healthcare services that’s continuously rising, larger budgets and more healthcare workers are required. Alarmingly statistics demonstrates that in some African countries there has been a decline in the number of healthcare workers over the past twenty years. In addition, there is a known distribution of healthcare workers towards urban areas, leaving rural areas without adequate healthcare delivery structures and staffing.
In most of Africa, the first healthcare worker to provide care to a patient is a nurse (WHO2008). With nurses being the mostly widely spread and available health professionals on the continent, their role cannot be overestimated. Creating more enabling environments for nurses to be educated and work in better conditions should be prioritized. A few issues that seem to be universal to the ability of nurses to perform in Africa are highlighted below. These issues draw on my experience and my conversations with local nurses in the settings in which I’ve worked.
Quality and appropriateness of nurse training
Formal nursing education was brought to Africa by imperialism. This implies that the people who brought formal nursing education to Africa introduced it in a similar way to how it was done in the countries that they came from. Most of these models were (and still are) based on training nurses in-hospital and where one of the primary roles of the nurse is as team member with a medical doctor and others. This is very different from community based care that’s prevalent and required in rural Africa. In most of Africa, the nurse is often a solo practitioner that’s far from hospitals and other team members. The training of the nurses should prepare them for such roles and situations.
Clinical and educational gaps can be identified by furthering research, especially nursing science research in Africa. This then allows the design of curriculum’s that are contextually relevant to the needs of the continent. This is, however, complicated by other issues, namely:

Limited research on indigenous diseases in Africa
Most of the infectious diseases that are endemic to Africa such as schistosomiasis or trypanosomiasis are not well-researched. With limited evidence based guidance, there can be no best nursing practice for these endemic diseases.
The fields that are researched are according to donor specialization and interest. Sun and Larson (2015) did a review of all nursing research from Africa that was published over a decade and found that the most studied areas were associated with funding resources. They also found that prevalent conditions in Africa e.g. malnutrition, diarrhoea disease and other common causes of death were not studied and/or published. This demonstrated a clear gap between the healthcare needs and the fields researched.
Nursing research needs to focus and address the glaring healthcare issues in Africa. Often care in villages is rendered by persons with no training in healthcare, and addressing issues like the need for reliable community based care when developing curriculums or conducting research could impact the health systems tremendously.

IMG_5587IMG_2427
Training facilities
Training facilities across Africa lack enough classrooms, electricity, running tap water and technological advances. Internet has been reported as a scarce resource across various training settings in Africa. The access to electronic resources is limiting for both students and educators. Open-access resources have helped to make science more accessible globally, but there is still a high cost to obtaining research and information making it incredibly tough to stay abreast of new guidelines, especially for nurses in Africa.
Clinical guidance in hospitals is lacking and there are limited simulation models at training facilities. At some of the facilities where I’ve conducted training there have been no CPR manikin’s or other additional models for training. In most places we had to innovate and make our own manikins and other adjuncts.
For healthcare workers in rural areas, obtaining further education or refresher training means uprooting and even leaving a healthcare facility unattended for the duration of their training. This should be considered when we think about educating and upskilling nurses.
Knock-on impact of the doctor shortage in Africa
The lack of doctors, especially in rural areas has resulted in task shifting. Task shifting occurs when tasks that would normally be seen as the doctors’ domain, are shifted to nurses. It increases the nurses’ workload and the nurses are expected to perform tasks that they have not received training for.
The distribution of health facilities and different tiers of care means that the large drainage areas in the rural districts are often manned by nurses without any further medical support close by. This means that the nurses working in rural areas are isolated when dealing with cases that are not within their scope of practice, limited clinical guidelines and difficulty in obtaining help. Telemedicine and technology may offer some solutions provided that it can be reliable in areas with limited electricity, currently no internet etc.

Regulatory issues
In many African countries, graduates are not subject to registration with a statutory body. There may be professional associations, but there is no compulsory registration process and professional licensing. In countries with no regulatory body, there is no representation to lobby for nursing rights or amendments to Acts of Parliament, salaries for nurses or to promote career progression.
Often healthcare worker salaries (including doctors) are not paid on time, if at all. This leads to some healthcare workers having secondary streams of income or funding their own incomes out of privately charging patients’ higher fees.
Gender inequality
In most African societies, gender equality has not yet been achieved. Women receive less education than men, they have less rights and their voice are not heard in the same way. Nursing remains a predominantly female profession and this limits the ability of nurses to assert themselves and it impacts on the ability of the profession to influence national policy.
There is a trend where even though the nurse workforce is mainly female at service delivery level, at top management and policy level it’s represented by men. In the DRC it was established that only 1% of the nurses are male, yet more than 90% of the top levels and education facilities positions are filled by men.
The social determinants allowing people to access healthcare includes basic primary education and gender equity amongst other factors. Sadly neither one of these has been achieved for nurses in Africa and it hampers the progress of nursing education and research across the continent.
Career progression
This tie in with the above, and the fact that because of the role of women in society, nurses being mostly female and the difficulties faced by nurses to render care, career progression may be stunted. Because healthcare workers in rural areas need to travel to further education and because nurses are predominantly women, it is hard for them to leave home and obligations at home to further their career.
Lack of mentorship and language barriers
There is a lack of mentorship to help nurses further themselves as researchers and educators. Organizations such as the AFEM Nurses Group developed a mentorship program with international mentorship support to African nurses. Another program is the Nursing Education Partnership Initiative (NEPI) that was formed in 2011 by PEPFAR to improve nursing and midwifery education in Africa. We need more programs like this.
Mentorship, inclusion into global healthcare networks, research and education are complicated by language barriers. Often nurses working in rural areas do not read or speak English; the language which much of the training material and research is presented in.
Conflict
It has been postulated that there’s a statistically significant relationship between accessibility to care and civil conflict (Rhode 2015). Unrest and conflict creates havoc on the ability to deliver healthcare, train providers, obtain supplies and in violent prone areas access may be restricted as patients are afraid of travelling. During periods of increased violence, the healthcare facilities are looted and healthcare workers intimidated. In violent prone areas, malnutrition is aggravated, harvests are regularly pillaged and access to fields is restricted due to security conditions.
Conclusion
There are various challenges to improving the fragile healthcare systems in Africa. Nurses form the backbone of healthcare service delivery in Africa. The difficulties faced by nurses across the continent are only one challenge; improving dilapidated health facilities and improving on the poor distribution of essential medicines and supplies are other challenges.
In order to improve healthcare systems, nurses needs to be more involved in policy-making, developing healthcare plans and research.

Please note: Africa is not a country and in some of the African countries, the health system is well-established and working. In other’s it’s not going that well. I’m aware that this blog makes blanket statements, however it refers to my experiences and conversations in the country’s that I have travelled to.

References
Munjana OK, Kibuka S, Dovlo D. (2005) The nursing workforce in Sub-Saharan Africa. Issue paper no 7. International Council of Nurses.
Sun C. Larson E. (2015) Clinical nursing and midwifery research in African countries: a scoping review. International Journal of Nursing Studies. 2015 May;52(5):1011-6. doi:10.1016/j.ijnurstu.2015.01.012.
http://www.our-africa.org/women
http://www.who.int/healthsystems/publications/abuja_declaration/en/
Rohde JT. (2015). The relationship between Access to Healthcare and Civil conflict. College of William and Mary. Honors Theses. Paper 99
Abuja Declaration 2001
Klopper HK, Uys LR. 2012. State of Nursing and Nursing Education in Africa: a country by country review. Sigma Theta Tau international
The nursing Education Partnership Initiative in the Democratic Republic of Congo. (2012). Assessment of nursing and midwifery education and training capacity at seven training institutes in the DRC. Synthesis report. Prepared by CapacityPlus, Intrahealth International

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Emergency care in Africa: There is no free lunch…

Let hunger be ranked first because if you are hungry you cannot work! No, health is number one, because if you are ill you cannot work! – Discussion group ranking; Musanya Village, Zambia1

The basic economic premise states that our wants are unlimited but our resources to obtain our wants are limited. On an individual level this implies that we are constantly prioritising desires in order to afford the most important ones (I’m using the word desire as an umbrella term for needs and wants). Sometimes we prioritize in a conscious way through budgeting, negotiating with our partners, saving for large expenditures or investing. At other times it’s automatic and we are largely unaware of the process. These ‘automatic’ decisions are based on beliefs and values, rooted in our culture, community and environment.

Every so often the desires are mutually exclusive and choosing one option means giving up on another, thus we make trade-offs or sacrifices. Our willingness to make a trade-off depends on the perceived benefit of the chosen option. The trade-off is not always financial, convenience or time might be valued more than cost. If the benefit is unknown or uncertain, the trade-off is viewed as risky and not worth the effort or cost.

Economics 101

  • Humans have unlimited needs and limited resources
  • We can’t have everything that we need or want
  • What you are willing to give up depends on what you get out of it (the benefit)
  • The decision is not always easy

fsdfs

The relation between income, benefit and trade-off can be seen in the triangle. Income represents the ability to raise financial resources to pay for care and it includes savings, obtaining a loan, etc. Benefit refers to treatment outcome and adequacy of emergency care. The trade-off is the sacrifice made to afford the benefit.

For people living in Africa the benefit is murky and the cost high. Ambulance services are rudimentary limiting the ability to obtain care at the site of injury, transport to definitive care or care during transit. Upon arrival at the health facility, Africans are burdened with out-of-pocket payments prior to stabilisation, resuscitation or basic care. In addition, due to low government investment, healthcare facilities create alternative funding methods to afford supplies, staff etc. These methods generally involve requesting (demanding) supplementary payments, known as informal payments, bribes or gifts. Paying these allows the patient to skip the queue, get a bed and receive care. Other cost considerations are the ‘hidden’ or indirect costs including the travelling costs, transportation, carer accommodation, waiting time and lost income opportunities.

Sadly, these expenditures are incurred to obtain care in facilities where infrastructure is lacking. Running tap water, electricity, basic equipment or medication are not a given. Also healthcare providers are often not well-equipped with basic emergency care skills.

Trade-offs are made in order to afford the care and may include

  • Reducing the household’s food consumption and budget
  • Selling a girl child into underage marriage
  • Selling assets such as livestock or dwelling
  • Removing children from school
  • Child labour
  • Selling foodstuffs like maize
  • Taking out loans at a high interest rates
  • If there’s more than one patient, prioritising care for one member at the expense of another

Basically, accessing emergency care requires massive trade-offs for a very uncertain benefit. An alternative is to not access care and hope for the best. This becomes a reasonable option when one considers that each year approximately 25 million Africans are pushed into poverty due to healthcare expenditure. Catastrophic health expenditure is calculated in various ways; however most methods exclude informal, indirect costs and the depletive sacrifices. The entire household suffers the repercussions of financial ruin.

tradeoff-for-blog

Emergency care benefits only the patient. The household makes the sacrifice so that one person can potentially benefit. It’s further complicated due to the urgency, emergency care requires time-critical interventions and delaying care can be devastating. The decisions taken shortly after a traumatic incident are probably not well-thought through, rational or informed. Predicting the required sacrifices is confounded due to different types of cost, changing costing structures and a whole lot of unknowns. It’s a tough call.

When we are involved in developing and strengthening systems in other communities than our own, we need to be aware that as outsiders we don’t understand the daily reality of those we serve. We can’t assume the local needs, wants, trade-offs and norms. Our observations are clouded by our own bias. This can be overcome by establishing ways to enable community participation that allows the implementation of sustainable and locally owned interventions.

On another level, advocacy for the greater good of accessible care includes continued lobbying for universal access to healthcare. Emergency care, especially out-of-hospital systems can significantly reduce cost as a barrier to access care.

                        For me a good life is to be healthy1 – Old Man Ethiopia

This blog includes some aspects that I addressed at the BADem symposium regarding the trade-offs that people make in Africa to access healthcare.

  1. Dying for change, poor people’s experience of health and ill-health. World Bank Study 2000. www.worldbank.org/poverty/voices

 

 

 

Gugu Zulu: Another story about the barriers to access emergency care in Africa

In Africa, surviving serious illness or injury is like participating in Survivor.  In order to survive, people need to outwit, outlast and outplay the health system.

The death of the fit, apparently healthy 38-year old Gugu Zulu made news headlines. The events leading to his death are tragic. Zulu, a well-known South African personality died during the Trek4Mandela Kilimanjaro expedition that raises awareness for the #keepingagirlchildinschool movement.

Details on the descent that were supposed to improve Zulu’s condition and allow for further care are sketchy. The timeline in the media reports differ, some saying that it took 4 hours to cover 32 km on a bicycle stretcher, others say 8 hours.  Still, how terrifying the experience must’ve been for his wife that remained at his side throughout the journey.  Despite discrepancies in timelines and the exact cause of death still pending autopsy results, it appears that the lack of timely access to further emergency care was a contributing factor leading to his death.

Photo%20of%20the%20Week%20(15.10.26)%20Kilimanjaro%202011%20porter%20w%20stretcher

Example of the bicycle stretchers used in Kilimanjaro

 

Gugu Zulu required urgent emergency care, and he died because he couldn’t get to care. Sadly, the story repeats itself in various African settings on a daily basis where people frequently die because of health system failures. They die because there is no available transport to the health facilities, which are too far apart and ill-equipped.  They die because care is unaffordable and healthcare staff are not trained to deal with emergencies.  And they die because there are no out-of-hospital care systems (see earlier blogs on access to care and EFAR).

In Zulu’s case (and depending on the route taken) the closest appropriate facility was about 50km away from the National Park. The Kilimanjaro Christian Medical Clinic (KCMC) is a 600 bed facility and it has an emergency care department that doubles as outpatient clinic. It serves the healthcare needs of 15 million people. Time, geographical accessibility and method of transport appears to have been bigger issues contributing to his death than only the availability of an appropriate facility.

The effectiveness of emergency care is dependent on time. The following definition for emergency care was agreed upon at the African Federation for Emergency Medicine (AFEM) consensus conference in April this year: ‘emergency health conditions are those requiring rapid intervention to avert death or disability, and those for which treatment delays of hours or less make interventions less effective.’

Obtaining care for emergency health conditions are a challenge in Tanzania.  The country has a doctor to patient ratio of 2 per 100 000 people. Another constraint as highlighted in this case is the lack of formal out-of-hospital services. Formal systems would facilitate the delivery of care at site of injury/illness and continued care during transportation.

That said, Tanzania is one of the very few African countries that has emergency medicine residency and emergency nursing programmes. Local emergency care practitioners have been supported by international faculty to share expertise.  In 2011 the Emergency Medicine Association of Tanzania (EMAT) was formed.  This organisation works closely with the government to prioritise emergency care and to development emergency care.  EMAT and AFEM works closely together to advocate for the unrestricted access to emergency health care.

Ensuring unrestricted access to emergency care by developing sustainable systems requires awareness and funding.  Sadly, emergency care does not yet share a similar status to that of high-profile diseases like HIV, TB and Malaria.  People are aware of the high-profile diseases and thus they are well-funded and promoted.

The death of Gugu Zulu begs the important question, can global stakeholders in health care continue to ignore the importance of developing strong emergency care and out-of-hospital care systems?

As Olive Kobusingye says,

IMG_3364ok

In future, the stories told in Africa will depend on how well we advocate and continue building emergency healthcare systems.

P.S. I would like to share an idea that we’ve been talking about since the WHO Basic Emergency Course last year. The idea is to travel from clinic to clinic through some countries that has ties with AFEM by cycling and/or using the method of transport that the different communities would use to access care. The purpose is to raise the awareness of how hard it is to obtain emergency care.  I would welcome some ideas on how we could make such an undertaking work. 

Further reading

Gugu Zulu

https://www.ecr.co.za/news-sport/news/small-medical-facility-needed-mount-kilimanjaro-letshego-zulu/

http://www.msn.com/en-za/news/localnews/gugu-zulus-wife-pleads-for-mini-medical-facility-to-be-erected-on-mount-kilimanjaro/ar-BBuZ6G2?li=AAaxc0E&ocid=spartandhp

https://www.researchgate.net/profile/David_Irwin3/publication/267102897_A_Retrospective_Study_of_Acute_Mountain_Sickness_on_Mt._Kilimanjaro_Using_Trekking_Company_Data/links/54da49c70cf233119bc29c23.pdf

http://www.iol.co.za/motoring/industry-news/gugu-zulus-death-is-a-blight-on-tanzania-2049525

http://www.iol.co.za/motoring/industry-news/kilimanjaro-tragedy-the-inside-story-2047032

Emergency care

http://www.afem.info/

http://www.emat.or.tz/

http://www.kcmc.ac.tz/index.php?q=casuality

http://www.epijournal.com/articles/167/hendry-sawe-young-leaders-bring-fresh-energy-to-african-emergency-medicine

Access to care: time to reconsider the concept?

Imagine the uncertainty and level of decision-making required to visit a healthcare facility for a cholesterol test, blood pressure check or the renewal of a script versus requiring care and transport at the scene of an accident where there’s multiple injured patients, some requiring urgent care.

The pressure to make decisions, the emotional intensity involved (fear, anxiety, anger, remorse) and the perceptions about the possible barriers to obtain emergency care seem more complex than those required when visiting a primary healthcare clinic. Injury, accidents, sudden illness and complications from non-communicable disease all fall under the umbrella of emergency care.  Because emergency care is a frequent entry point into the healthcare system, one would assume that the barriers to access emergency care have been well-described and explored.

I reviewed more than 50 of the most cited papers that describe access to care and only three mention emergency care. Another interesting observation is that most authors do not clarify what they mean when using the term ‘access to care’. Most articles do however refer to either the behaviour model of access to care or the 5A model.

Models in brief:

The behavioural model of access to care (Aday and Andersen, 1974) highlights the relationship between utilisation and access.  It suggests utilisation as a proxy to measure access.  The flaw of using utilisation as a proxy is that patients that died prior to reaching care are not captured in the measurement.  In emergency care those that could not access care and the reasons why they couldn’t or chose not to access care are incredibly important.

In the 5A model (Pechansky and Thomas, 1981) access to care is described as a best-fit between the characteristics of the health service, the provider and the patient.  (5A’s=Availability, accessibility, affordability, acceptability, accommodation).

In recent years, the approaches became more ‘holistic’ considering variables including culture, society and gender. Access to care has clearly become more than arriving at a healthcare facility.  But again, the ability to seek care during an emergency, at the site of injury/ out-of-hospital or during transit is not mentioned.

Most countries in Africa do not yet have emergency care systems or the infrastructure to support the development of emergency care. Functional and accessible emergency care systems would enable these countries to address the burden of disease, reduce the impact of road traffic accidents and under-5 mortality to name just a few.

In these countries, when a household member requires emergency care the household needs to make harsh decisions and weigh the risk of financial ruin against a family member’s life.  This can cause irrational decision-making or a delay to make the decision. How can this not be a consideration when describing access to care?

Why including emergency care in access to care discussions matter?

The terms emergency care and out-of-hospital care are relatively new and not included in discussions on access to care, especially not those building on the older, generic descriptions.  It makes it hard for policymakers and funders to actually understand what emergency care is, how it enables access to the rest of the healthcare system and why it matters.

If key stakeholders do not understand the terminology used, they are unlikely to prioritize it, promote it or fund it. Measurement and evaluation are important to stakeholders.  Emergency care does not lend itself to quick, affordable projects with measurable outcomes.  For instance to a politician or funder arriving in a village and vaccinating 500 children is measurable and can be promoted.  To develop emergency care takes time and is harder to define and measure and thus less likely to be funded. If we can clarify the concepts around access to emergency care better, we might be able to create measurable outcomes and thus obtain funding and prioritization.

Not including emergency care as a core aspect when defining access to care in general complicates the development and advocacy of emergency care.  Maybe it’s time to design a model similar to the 3D model used for maternal mortality to define the determinants of access to emergency care.

I would love to hear your thoughts:  how would you describe access to care and if you agree that emergency care deserve more mention (or am I just biased?).

Please note that due to space I’m not including all the article. I can send a spreadsheet if anyone would like to see it.  Some of the authors include Donabedian, Aday and Andersen, Frenk, Pechansky and Thomas, McCintyre et al., Ensor and Cooper, Dutton, Gulliford, Goddard and Smith, Hadid and Mohindra, Mooney, Culyer, van Doorslaer and Wagstaff, Peters, O’Donnel and others.

Making EFAR stick

There is no question about the need to develop better emergency care systems in low and middle income countries (LMIC).  However, the significant barriers to developing the systems may appear daunting and unattainable.  This is partially because any emergency care system need to start within the community or wherever incidents may occur, continue with care during transportation of the patient and allow early appropriate treatment at a healthcare facility.

Developing a system across the above continuum is complicated in LMIC’s.  It is expensive and requires the presence of enabling factors external to healthcare.  Examples of the enabling factors include sufficient technology and infrastructure such as telecommunications and roads.

As mentioned in a previous blog, an alternative and/or parallel strategy is to enhance the ability of the community to respond during an emergency.  This is feasible even in areas where healthcare facilities are scarce, roads non-existent and telecommunications lacking.

Developing community responder systems are based on a fundamental principle that developing a basic capacity to render emergency care can be simple, efficient and cost-effective. To ensure sustainability, the following should be considered:

  • Mismatching

The trained members need to either live or work within the community.  This might sound obvious, but often it is not.  Also, training economically active people may result in these people not being within the community most hours of the day.  Design should thus involve training the employed, pensioners, people who work within the community (they might even travel from outside the community to work there) and the unemployed.

  • Managing expectation

Training the unemployed and even the employed may lead to another problem: expectation.  People might participate with the expectation of getting a job or advancing their career and receiving job opportunities.  Expectations needs to be managed by being upfront about what the community responder program is about and what is required from trained community members.

Community members may experience a downer after the initial high of being equipped with life-saving skills, or they may be traumatised by exposure to critically ill and injured people.  Early attention to ways to keep members motivated, engaged and supported emotionally is required.

  • Integration of formal/informal system

If there is a formal ambulance system, the informal (community) and formal systems should be integrated. Community members may feel intimidated by formal emergency care practitioners, and the formal practitioners may not help the situation.  This seems to be a major difficulty when implementing community systems.

  • Equipment and innovation

The other barrier to sustaining community first aid responder programs is the availability of equipment and stock, including splints, bandages and gloves.  In LMIC’s even in healthcare facilities these are scarce items.  Yet if it was freely accessible, it may be impractical to carry stock around at all times.  This makes a case for training the community members ways to improvise and innovate.

A deterrent to continued participation is the cost of phones and airtime for telecommunications with formal emergency services and/or hospitals.

  • Other

Concerns from the community may include if and how good Samaritan legislation would protect them, the need for documentation and remaining current with training and skills.

one tier system

The two tier system.  Mould-Millan et al. 2014

Further discussion

Emergency care competes with an existing bias from foreign funders to fund vertical disease programs, with early and easy measurable outcomes.  For policy makers there is competing budgetary priorities and poor economic growth.

So when advocating for the development of emergency care systems, we need to motivate for cost-effective, easy to implement systems whilst simultaneously developing the more expensive formal systems. Formal systems would include tertiary training, specialization of medical practitioners etc.

Training community volunteers to provide early emergency care and stabilisation can save lives and prevent disability.  The training provided and subsequent informal system needs to be context-specific, defined by the community and their needs.  The greatest challenge after obtaining funding is integrating the participatory community system within formal more bureaucratic systems.

Read more

Jayamaran S, Mabweijano J, Lipnick M, et al. First things first: effectiveness and scalability of a basic prehospital trauma care program for lay first-responders in Kampala, Uganda.  PLoS One 2009; 4: e6955

Mould-Millman NK, et al. AFEM Consensus Conference, 2013.  AFEM out-of-hospital emergency care workgroup consensus paper: advancing out-of-hospital emergency care in Africa – advocacy and development.  African Journal of Emergency Medicine. 2014; 4:90-95

Sasser S, Varghese M, Kellerman A, Lormand JD. Prehospital trauma care systems. Geneva: World Health Organisation.

Tiska MA, et al. A model of prehospital trauma training for lay persons devised in Africa. Emergency Medicine Journal. 2004; 21:237 – 9

http://www.who.int/bulletin/volumes/84/7/editorial20706html/en/

 

 

EFAR: a sustainable way to increase access to emergency care

Low and middle-income countries not only suffer the highest rates of every category of injury, they also have the highest rates of acute complications for communicable disease, maternal death and under-5 mortality (Jamison et al., 2012). Sadly these countries are the least likely to have established and effective emergency care systems.

When developing emergency care systems, lower-income countries often strive to duplicate systems from higher income countries. Implementing what has worked in high-income countries is a problematic strategy for various reasons: high-income countries have enabling infrastructure in place.  This is external from healthcare and includes roads, technology, telecommunications, and developed micro-financing/other insurance schemes.  Legislation and government policy also influences the success of the healthcare system.  Higher income countries government expenditure on healthcare is typically much higher than the expenditure in lower-income countries.

A strategy that might be more appropriate in lower-resource settings is to involve the community.  Engaging communities through the EFAR concept is a low-cost, context-appropriate strategy.  It allows for the community to bridge the gap whilst infrastructure and formal health systems are advanced.

So you might be wondering how teaching people first aid could be considered a national strategy.  There are two main differences between EFAR and first aid.  The first is that EFAR’s are integrated with the coordinated response system.  Secondly EFAR programs are designed to be context-specific and are adapted to the needs within the specific location.  This is a very different from ‘formal’ first aid courses that are designed to be generic.  EFAR training is aimed at teaching participants to manage conditions that they are likely to see within their context.  As example in Ghana out-of-hospital systems are not yet adequate, and long-distance truck drivers are likely to be on scene first.  Thus Ghanaian truck drivers were taught the basic principles when treating motor vehicle accident patients and basic scene management.

efar

THE EFAR CONCEPT

 

EFAR was also implemented in the gangster-ridden areas of Manenberg and Lavender Hill in Cape Town.  Cape Town has a well-established ambulance service, however there is some difficulties responding into gangster-ridden areas and informal areas with unmarked roads etc. There have been some difficulties with sustaining EFAR in these areas and it’s been suggested that integrating the informal system into a well-developed system is trickier than when the system is not yet matured.  For example in Zambia, EFAR has been rolled out to some of the country’s most rural areas.  This project has been ongoing since 2013 and a recent site visit (formal report pending) suggests that it is functioning well.

In Cambodia and Iraq healthcare workers were trained to be ‘paramedics’.  They then trained 2 800 community members. In the first two years of the project the community members managed approximately 800 patients and the mortality rate from trauma dropped from 28.7% to 9.4%.

EFAR as a strategy to enhance the capacity of emergency care systems are a feasible solution in low-resource settings.  In fact is appears to be more feasible than copying ‘international practice’ from well-developed systems. However EFAR is a bridging strategy whilst the formal emergency system is maturing, it is not a replacement strategy.  It is a cost-effective and easily implemented method to establishing out-of-hospital capacity.

References

Jamison, D. et al (editors) (2006) Disease control priorities in developing countries.  NCBI bookshelf http://www.ncbi.nlm.gov/books/NBK11728/

EFAR website: http://www.efarsystem.com/

Husum H, Gilbert M, Wisborg T.  Training pre-hospital trauma care in low-income countries: the ‘Village University’ experience.  Med Teach 2003: 25: 142-148

Sun JH, et al.  A strategy to implement and support pre-hospital emergency medical systems in developing resource-constrained areas of South Africa.  Injury (2012) http://dx.doi.org/10.1016/j.injury.2012.08.015

Wisborg T, Murad M, Edvardsen O, Husum H.  Prehospital trauma system in a low-income country system maturation and adaption during 8 years.  J Trauma 2008: 64 (5)1324-1348

And it is limited to low resource settings anymore.  Scotland are rolling out a system http://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-460

 

A brief summary: health systems of Uganda, Zambia, Tanzania and South Africa

To improve the delivery of emergency care; awareness of the health system and in-country factors that influence the delivery of healthcare services are needed. Recently I visited Uganda, Tanzania and Zambia. This blog aims to compare relevant existing health data between these countries and South Africa as my point of reference. Data is according to WHO country profiles and World Bank.

Country Data Uganda Zambia Tanzania South Africa
1 World Bank income class Low Lower-middle Low Upper- middle
2 Population (thousands) 37579 14539 49253 52776
3 % of population under age of 15years 48% 47% 45% 30%
4 % of population living in urban areas 15% 40% 30% 64%
5 Total expenditure on health as % of GDP 9.8% 5% 7.3% 8.9%
6 Government expenditure as % of total expenditure on health 44% 58.3% 36.3% 14%
7 Out of Pocket expenditure as % of health (OOP) 69.1% 66.7% 52.1% 13.8%
8 Private prepaid plans as % of private expenditure on health 0.3% 3.5% 1.5% 61.1%

Interpretation

Number 2 -4

Population is relative to the size of the country and when expressed as population per sq.km of land; Uganda is the most populated country of the four; 188 ppsqkm, followed by Tanzania (59ppsqkm), South Africa (45ppsqkm) and then Zambia (21ppsqkm).

Zambia has the lowest population density and 60% of the population live in rural areas. Due to the distances between referral facilities and external factors including infrastructure, transport facilities etc.  Zambia probably face the most challenges to improve access to emergency care

In Uganda, only 15% of the population lives in urban areas. Due to the high population in rural areas, access and availability of care are also challenging.

Number 5- 8

An important question to consider when talking about health systems is: who is spending how much and for what.  The answer to this determines whether people can access care. In Africa (and other developing countries) the expenditure measurements is typically divided into three categories:

  • The government’s direct expenditure to health care services
  • Private expenditure on health care, divided into out-of-pocket expenditure and medical insurance
  • External sources including foreign aid and non-profit organisations contributions

Government’s Expenditure on health

Total expenditure on health as % of GDP demonstrates the level of resources channelled to health in relation to the wealth of the country.  GDP (Gross Domestic Product) are defined as the total market value of all goods and services produced within a country per year.

The government expenditure on health shows the relative weight of government resources in the total expenditure of health.  It provides an indication of the need and priority of healthcare in government policy and budget.  The amount of resources that are assigned to the health sector as %GDP also provides clues about the relative size of the health sector.

In Zambia there is a large difference between healthcare as %GDP and government expenditure. This is interesting and it appears slightly disproportionate in comparison to the other countries.  I’m not sure of the reason, one possible explanation is that Zambia might be training more healthcare professionals (government expenditure includes training of healthcare professionals).  However, this is unconfirmed.

In 2001, all heads of state of the African Union pledged to commit 15% of their national (domestic) budgets to healthcare.  This was to not only to improve healthcare but also to show the African government’s commitment to improving healthcare.  It is observed that none of the four countries adheres to the pledge.

Low government health spending is associated with high out of pocket (OOP) expenditure resulting in catastrophic health expenditure and increased mortality and morbidity.  Furthermore, when government restricts the expenditure on healthcare, they may reduce training budgets thus creating additional barriers to access care.

Private expenditure on health

OOP expenditure is described by WHO as a measure providing insight into the relative weight of direct payments in total health expenditure. If the OOP expenditure is high, a single visit to a health facility may result in catastrophic health expenditure. In Uganda and Zambia the OOP expenditure is very high. It is concerning and OOP expenditure as a government policy is doomed to fail in lower income countries.

Number 7 demonstrates the importance of not only considering single measures.  At first glance it appears as if OOP in South Africa is low.  However health insurance (private prepaid plans) are not included in this measurement; it is shown in number 8.

Private prepaid plans includes expenditures of pooled resources with no government control. It shows the relative weight of voluntary health insurance payments in total health expenditure. This includes voluntary health insurance, medical aids and direct payments for health by non-profit organisations. South Africa has a very high rate of private prepaid plans (81%) in comparison to Uganda’s 0.3%.  OOP expenditure and private prepaid plans are characterised by limited regulations; exposing the population to exploitation and catastrophic expenditure.

External sources to fund healthcare is not discussed here.

Summary

In this blog I’ve only touched on the health systems, and some of the potential vicious cycles. It would be interesting to explore each of these cycles. Watch this space!

Please feel free to comment!