Strengthening the Health System as a Strategy to Achieving a Universal Health Coverage in Underprivileged Communities in Africa: A Scoping Review

Universal health coverage (UHC) is defined as people having access to quality healthcare services (e.g., treatment, rehabilitation, and palliative care) they need, irrespective of their financial status. Access to quality healthcare services continues to be a challenge for many people in low- and middle-income countries (LMICs). The aim of this study was to conduct a scoping review to map out the health system strengthening strategies that can be used to attain universal health coverage in Africa. We conducted a scoping review and qualitatively synthesized existing evidence from studies carried out in Africa. We included studies that reported interventions to strengthen the health system, e.g., financial support, increasing work force, improving leadership capacity in health facilities, and developing and upgrading infrastructure of primary healthcare facilities. Outcome measures included health facility infrastructures, access to medicines, and sources of financial support. A total of 34 studies conducted met our inclusion criteria. Health financing and developing health infrastructure were the most reported interventions toward achieving UHC. Our results suggest that strengthening the health system, namely, through health financing, developing, and improving the health infrastructure, can play an important role in reaching UHC in the African context.

Estimated incidence and case fatality rate of traumatic brain injury among children (0–18 years) in Sub-Saharan Africa. A systematic review and meta-analysis

Introduction
Studies from Sub-Saharan Africa (SSA) countries have reported on the incidence and case fatality rate of children with Traumatic Brain Injury (TBI). However, there is lack of a general epidemiologic description of the phenomenon in this sub-region underpinning the need for an accurate and reliable estimate of incidence and outcome of children (0–18 years) with TBI. This study therefore, extensively reviewed data to reliably estimate incidence, case fatality rate of children with TBI and its mechanism of injury in SSA.

Methods
Electronic databases were systematically searched in English via Medline (PubMed), Google Scholar, and Africa Journal Online (AJOL). Two independent authors performed an initial screening of studies based on the details found in their titles and abstracts. Studies were assessed for quality/risk of bias using the modified Newcastle-Ottawa Scale (NOS). The pooled case fatality rate and incidence were estimated using DerSimonian and Laird random-effects model (REM). A sub-group and sensitivity analyses were performed. Publication bias was checked by the funnel plot and Egger’s test. Furthermore, trim and fill analysis was used to adjust for publication bias using Duval and Tweedie’s method.

Results
Thirteen (13) hospital-based articles involving a total of 40685 participants met the inclusion criteria. The pooled case fatality rate for all the included studies in SSA was 8.0%; [95% CI: 3.0%-13.0%], and the approximate case fatality rate was adjusted to 8.2%, [95% CI:3.4%-13.0%], after the trim-and-fill analysis was used to correct for publication bias. A sub-group analysis of sub-region revealed that case fatality rate was 8% [95% CI: 2.0%-13.0%] in East Africa, 1.0% [95% CI: 0.1% -3.0%] in Southern Africa and 18.0% [95% CI: 6.0%-29.0%] in west Africa. The pooled incidence proportion of TBI was 18% [95% CI: 2.0%-33.0%]. The current review showed that Road Traffic Accident (RTA) was the predominant cause of children’s TBI in SSA. It ranged from 19.1% in South Africa to 79.1% in Togo.

Conclusion
TBI affects 18% of children aged 0 to 18 years, with almost one-tenth dying in SSA. The most common causes of TBI among this population in SSA were RTA and falls. TBI incidence and case fatality rate of people aged 0–18 years could be significantly reduced if novel policies focusing on reducing RTA and falls are introduced and implemented in SSA.

A systematic review of randomized control trials of HPV self-collection studies among women in sub-Saharan Africa using the RE-AIM framework

Introduction
Self-collection of samples for HPV testing may increase women’s access to cervical cancer screening in low- and middle-income settings. However, implementation remains poor in many regions. The purpose of this systematic review was to examine implementation data from randomized controlled trials evaluating human papillomavirus (HPV) self-collection testing among women in sub-Saharan Africa using the RE-AIM (Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance) framework.

Methods
We searched four electronic databases (PubMed, CINAHL, Web of Science, and Global Health) for pragmatic randomized controlled trials that promote HPV self-collection among women in sub-Saharan Africa. Study selection and data extraction were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) checklist. Two researchers independently extracted information from each article using a RE-AIM data extraction tool. The reporting of RE-AIM dimensions was summarized and synthesized across included interventions.

Results
We identified 2008 citations, and eight studies were included. These reported on five unique interventions. The five interventions were conducted in five countries: Cameroon, Ethiopia, Kenya, Nigeria, and Uganda. Intervention reach (80%) was the most commonly reported RE-AIM dimension, followed by adoption (56%), efficacy/effectiveness (52%), implementation (47%), and maintenance (0%). All the interventions described increased uptake of HPV testing among study participants (effectiveness). However, the majority of the studies focused on reporting internal validity indicators such as inclusion criteria (100%) and exclusion criteria (100%), and few reported on external validity indicators such as participation rate (40%), intervention cost (40%), staff selection (20%), and cost of maintenance (0%).

Conclusions
Our review highlights the under-reporting of external validity indicators such as participation rate, intervention, and maintenance costs in studies of self-collection for HPV testing among women in SSA. Future research should focus on including factors that highlight internal validity factors and external validity factors to develop a greater understanding of ways to increase not only reach but also implementation and long-term maintenance of these interventions. Such data may advance the translation of HPV interventions into practice and reduce health disparities in SSA. Findings highlight the need for innovative tools such as participatory learning approaches or open challenges to expand knowledge and assessment of external validity indicators to ultimately increase the uptake of HPV testing among women in SSA.

Supporting strategic health purchasing: a case study of annual health budgets from general tax revenue and social health insurance in Abia state, Nigeria

Background
Tracking general trends in strategic purchasing of health financing mechanisms will highlight where country demands may exist for technical support and where progress in being made that offer opportunities for regional learning. Health services in Abia State, Nigeria are funded from general tax-revenues (GTR), and a new state social health insurance scheme (SSHIS) is proposed to overcome the failings of the GTR and expand coverage of services. This study examined purchasing functions within the GTR and the proposed SSHIS to determine if the failings in GTR have been overcome, identify factors that shape health purchasing at sub-national levels, and provide lessons for other states in Nigeria pursuing a similar intervention.

Methods
Data was collected through document review and key informant interviews. Government documents were retrieved electronically from the websites of different organizations. Hard copies of paper-only files were retrieved from relevant government agencies and departments. Interviews were conducted with seven key personnel of the State Ministry of Health and State Health Insurance Agency. Thematic analysis of data was based on a strategic health purchasing progress tracking framework which delves into the governance arrangements and information architecture needed for purchasing to work well; and the core purchasing decisions of what to buy; who to buy from; and how to buy.

Results
There are differences in the purchasing arrangements of the two schemes. Purchaser-provider split does not exist for the GTR, unlike in the proposed SSHIS. There are no data systems for monitoring provider performance in the GTR-funded system, unlike in the SSHIS. Whereas GTR is based on a historical budgeting system, the SSHIS proposes to use a defined benefit package, which ensures value-for-money, as the basis for resource allocation. The GTR lacks private sector engagement, provider accreditation and contracting arrangements while the SSHIS will accredit and engage private providers through selective contracting. Likewise, provider payment is not linked to performance or adherence to established standards in the GTR, whereas provider payment will be linked to performance in the SSHIS.

Conclusions
The State Social Health Insurance has been designed to overcome many of the limitations of the budgetary allocation to health. This study provides insights into the enabling and constraining factors that can be used to develop interventions intended to strengthen the strategic health purchasing in the study area, and lessons for the other Nigeria states with similar characteristics and approaches.

Spectrum of paediatric surgical cases in a private mission teaching hospital in Nigeria

Introduction: Establishing the nature of conditions requiring surgery among children in a particular location may be crucial for policy formulation and implementation as regards paediatric surgery. Objective: This study aimed to describe the pattern and outcome of paediatric surgical cases operated upon in a newly established paediatric surgical unit in Nigeria. Subjects and Methods: This was a cross-sectional study of all subjects that were operated upon by the paediatric surgery unit over a 28-month period. Data obtained included age, sex, diagnosis, timing of surgery, post-treatment complications and outcome. Diagnoses were categorised based on the International Classification of Diseases 11th revision for morbidity and mortality statistics. Data analysis was done using Stata version 12. Results: A total of 377 procedures were performed on 336 patients with a male-to-female ratio of 2.1:1. The median age at surgery was 36 months. Disorders of the digestive system (184, 48.8%) and developmental anomalies (119, 31.6%) accounted for majority of the cases, with inguinal hernias and hydrocoeles accounting for 17.0% of all cases. Thirty-six per cent of the procedures were emergent ones, and the overall complication rate was 23.6% (89/377). The unplanned re-operation rate was 7.4% (25/336) and mortality rate was 5.1% (17/336). Typhoid ileal perforation was responsible for 4 (23.5%) of the deaths. Conclusion: Congenital anomalies and surgical infections represent a major surgical burden among children in our sub-region of Nigeria. There is, therefore, the need for focused research on these conditions and the integration of children surgery into public health programmes for children in sub-Saharan Africa.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

Background
Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

Aims
To describe the current landscape of digital health interventions in oncology in Africa.

Methods
We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

Results
The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship.

Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

Conclusion
Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of lif

Cancer pain control in a Nigerian oncology clinic: treating the disease and not the patient

Introduction: inadequate pain control negatively impacts the quality of life of patients with cancer while potentially affecting the outcome. Proper pain evaluation and management are therefore considered an important treatment goal. This study assessed the prevalence of pain, the prescribing patterns, and the efficacy of pain control measures in cancer patients at the Radiation Oncology Unit of the Lagos University Teaching Hospital, Lagos.
Methods: this was a longitudinal study design recruiting adults attending outpatient clinics. Participants were assessed at initial contact and again following six weeks using the Universal Pain Assessment Tool developed by the UCLA Department of Anaesthesiology.
Results: among the patients reviewed, 34.0% (118 of 347) were at the clinic, referred for initial assessment following primary diagnosis. All respondents had solid tumours; the most common was breast cancer. The prevalence of pain at initial assessment was 85.9% (298 of 347), with over half of respondents, 74.5% (222 of 347) characterising their pain as moderate to severe. Over a quarter, 28.9% (100 of 347) of patients were not asked about their pain by attending physicians, and none of the patients had a pain assessment tool used during evaluation. In 14.4% (43 of 298) of patients, no intervention was received despite the presence of pain. At six weeks review, 31.5% (94 of 298) of patients had obtained no pain relief despite instituted measures.
Conclusion: under-treatment of cancer pain remains a significant weak link in cancer care in (Low-to-middle-income country) LMICs like Nigeria, with a significant contributor being physician under-evaluation and under-treatment of pain. To ensure pain eradication, the treatment process must begin with a thorough evaluation of the patient’s pain, an explicit pain control goal and regular reevaluation

Assessment of proton-pump inhibitor use at a tertiary teaching hospital in Nigeria

Background:
Proton-pump inhibitor (PPI) is a widely used medication class globally. Because of its good safety profile, there is a huge likelihood of inappropriate use.

Objectives:
To determine the prevalence of PPI use and indications, describe its pattern of usage, and identify factors associated with inappropriate prescriptions at a federal tertiary teaching hospital in Maiduguri, Nigeria.

Methods:
PPI prescriptions were retrospectively assessed in the General Outpatients’ Department (GOPD) and Gastroenterology Unit (GITU) of a teaching hospital. Relevant data for the study were extracted from the patients’ medical records. Chi-square or Fisher’s exact tests where appropriate were used to identify factors associated with inappropriate PPI prescriptions. A p < 0.05 was considered to be significant.

Results:
PPIs were prescribed to 73.3% (220/300) of patients, while inappropriate prescriptions were noted in 91.4% (201/220) of these patients. Epigastric pain (49.5%) was the most common PPI indication, while omeprazole was the highest prescribed (53.4%). Nearly all inpatients (98.2%), those with epigastric pain (95.7%), and patients who were prescribed intravenous PPIs had more inappropriate PPI prescriptions compared to others.

Conclusion:
This study revealed a high prevalence of PPI use and inappropriate prescriptions at the study hospital. As a result, these findings highlight the importance PPI-based stewardship program at the study hospital.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

Objective
Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

Methods
Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women’s experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

Results
There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

Conclusion
There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities

Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.

Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria.

Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.

Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.

Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as w