Paper long abstract:

Background: In 2017, there were an estimated 10.4 million new tuberculosis (TB) cases worldwide and 1.4 million TB deaths. Tuberculosis is a public health problem in Cameroon, especially in Douala, the economic capital and the first TB epidemiology's region, which counts for 11% of total population, but register almost 20% of the TB prevalence in Cameroon. In Cameroon, tuberculosis cases are diagnosed and treated within a nationwide network of 248 diagnostic and treatment centres (DTC).The DTC are suppose geographically distributed according to World health organization (WHO) recommendations, planning to bring DTC (offer) closer to patients (demand). The objective of this study was to analyse the spatial distribution of TB cases, in relation with the DTC and to identify the socio-economic factors linking the "demand" to the "offer".

Methods: The studied population includes confirmed TB patients, permanently resident (≥ 3 months) in Douala, between May, 1st 2011 and April, 30th 2012. During one year, a cohort of 2132 adults patients consecutively diagnosed with TB in any one of the twenty one (21) DTCs, who consented to participate to the study were interviewed; their residence and DTC were mapped using Geographic information system, by going to their home (In Douala, as others African cities, houses and streets are not addressed). The membership of each patient to a DTC (closest to his residence) was established. The "observed" number of patients attending the DTCs during the study period was compared to the "expected" number, using a bivariate analysis. Multivariate analysis using logistic regression and the analysis of variance were used to determine factors associated to the "demand" and "offer" of DTCs respectively.

Results: It emerges that, even if TB patients are concentrated around the DTCs, the majority of them (65%) goes far from their designated DTC, to seek for treatment. The decentralization policy advocated by the national tuberculosis program (NTP) is not always followed by the patients. Thus, the "expected" and the "observed" number of patients in DTCs were not correlated. Patients seeking treatment closer to their residence were mainly women and patients from large size household. Attendance of DTC was associated with their category and the quality of service.

Conclusion: Generally, the health system emphasizes its policy in bringing health facilities (HF) closer to population. In large cities, where several HF "compete", this criterion should be extended to the category of HF and the socio-economic characteristics of the target population.

Paper short abstract:

This paper focuses on the transdisciplinary Africa-based research network Afrique One that works on zoonoses and one Health. Based on interviews with its principal investigators, the paper investigates the politics of knowledge production and knowledge transfer in One Health between 1980 and 2020.

Paper long abstract:

This paper looks at the production and transfer of knowledge in the field of One Health in Africa. It focuses on the Africa-based research network Afrique One that works on zoonoses (TB, Brucella and rabies). Based on interviews about the research pathways of its principal investigators who seek to construct their careers as researchers, this study investigates the politics of knowledge production and knowledge transfer in the field of One Health between 1980 and 2020.

It reflects on how the present body of knowledge on zoonoses has been shaped in research programmes that themselves are bound to different opportunities and constraints. This study asks how themes came into vogue, what topics got financed by whom, how research results were disseminated and eventually picked up by policy makers to improve health outcomes in Africa and elsewhere. Thus, it contributes to the question of how the world of research, as a social field of knowledge production and transfer, has shaped and continues to shape knowledge about zoonoses and One Health, as well as the possibilities to access and apply that knowledge in research-end user communities.

Paper long abstract:

Ethiopia’s Community Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure, mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced access to health care and led to reductions in out-of-pocket expenditure. Whether the scheme has also delivered on its other objectives is not known. This paper uses a double-difference approach applied to two rounds of health facility survey data and three rounds of household survey data to examine scheme effects on health facility revenues and on different dimensions of quality of care. We find that CBHI affiliated facilities experience a 111 percent increase in the annual volume of out-patient visits and annual revenues increased by about 47 percent. The increased revenues are used to deal with drug shortages. These increases seem to have translated into increases in patient satisfaction. The satisfaction of patients who sought outpatient health care from CBHI-contracted health centers is 11 percentage points higher as compared to those who received the service from non-contracted health centers. Furthermore, despite the increase in patient volume there is no discernible increase in waiting time to see medical professionals. These results combined with the relatively high levels of CBHI enrolment, suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block, that is, the poor quality of care, which has plagued similar voluntary health insurance schemes in Sub-Saharan Africa.

Co-authors: Anagaw Mebratie, Robert Sparrow

Paper long abstract:

The Ethiopian government has implemented nationwide strategies to improve access to basic health services and enhance health outcomes. The Health Extension Program (HEP) launched in 2003, expanded basic health infrastructure and local human resources. In 2011, the government introduced the Health Development Army (HDA). HDA is a women-centered community movement inspired by military structures and discipline. Its special objective is to improve maternal health outcomes. This paper uses a synthetic control approach to assess the effects of HEP and HDA on maternal mortality ratios (MMR). The MMR data are from the Global Burden of Diseases (GBD) database. A pool of 42 Sub-Saharan African countries, covering the period 1990 to 2016, is used to construct a synthetic comparator which displays a mortality trajectory similar to Ethiopia prior to the interventions. On average, since 2004, maternal mortality in the control countries exhibits a moderate downward trend. In Ethiopia, the downward trend is considerably steeper as compared to its synthetic control. By 2016, maternal mortality in Ethiopia was lower by 171 (p-value 0.048) maternal deaths per 100,000 live births as compared to its synthetic control. Between 2003 and 2016, Ethiopia's maternal mortality ratio declined from 728 to 357. These estimates suggest that a substantial proportion of this decline may be attributed to HEP/HDA. The Ethiopian experience of enhancing nation-wide access to and use of maternal health services in a short time-span is remarkable. Whether such a model may be transplanted is an open question.

Co-authors: Matthias Rieger, Anagaw Mebratie