Non‐physician cataract surgeons in Sub‐Saharan Africa: situation analysis

Objectives Non‐physician cataract surgeons (NPCS) provide cataract surgical services in some Sub‐Saharan African (SSA) countries. However, their training, placement, legal framework and supervision have not been documented. We sought to do so to inform decision‐making regarding future training. Methods Standard questionnaires were sent to national eye coordinators and other ophthalmologic leaders in Africa to collect information. Face‐to‐face interviews were conducted at training programmes in Ethiopia, Tanzania and Kenya, and email interviews were conducted with directors at training programmes in the Gambia and Malawi. Results Responses were provided for 31/39 (79%) countries to which questionnaires were sent. These countries represent about 90% of the population of SSA. Overall, 17 countries have one or more NPCS; two‐thirds of the total 245 NPCS are found in only three countries. Thirty‐six percent of NPCS work alone, but a formal functioning supervision system was reported to be present in only one country. The training centres are similar and face similar challenges. Conclusions There is considerable variation across SSA in the use and acceptance of NPCS. The placement and support of NPCS after training generally does not follow expectations, and training centres have little role in this. Overall, there was no consensus on whether the cadre, as it is currently viewed, is necessary, desirable or will contribute to addressing cataract surgical needs in SSA.     

Early loss to follow‐up of recently diagnosed HIV‐infected adults from routine pre‐ART care in a rural district hospital in Kenya: a cohort study

Objective To determine the rate and predictors of early loss to follow‐up (LTFU) for recently diagnosed HIV‐infected, antiretroviral therapy (ART)‐ineligible adults in rural Kenya. Methods Prospective cohort study. Clients registering for HIV care between July 2008 and August 2009 were followed up for 6 months. Baseline data were used to assess predictors of pre‐ART LTFU (not returning for care within 2 months of a scheduled appointment), LTFU before the second visit and LTFU after the second visit. Logistic regression was used to determine factors associated with LTFU before the second visit, while Cox regression was used to assess predictors of time to LTFU and LTFU after the second visit. Results Of 530 eligible clients, 178 (33.6%) were LTFU from pre‐ART care (11.1/100 person‐months). Of these, 96 (53.9%) were LTFU before the second visit. Distance (>5 km vs. <1 km: adjusted hazard ratio 2.6 [1.9–3.7], P < 0.01) and marital status (married vs. single: 0.5 [0.3–0.6], P < 0.01) independently predicted pre‐ART LTFU. Distance and marital status were independently associated with LTFU before the second visit, while distance, education status and seasonality showed weak evidence of predicting LTFU after the second visit. HIV disease severity did not predict pre‐ART LTFU. Conclusions A third of recently diagnosed HIV‐infected, ART‐ineligible clients were LTFU within 6 months of registration. Predictors of LTFU among ART‐ineligible clients are different from those among clients on ART. These findings warrant consideration of an enhanced pre‐ART care package aimed at improving retention and timely ART initiation.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.