Electronic medical record systems: A pathway to sustainable public health insurance schemes in sub-Saharan Africa

Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

BACKGROUND

Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP.

METHODS

We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums).

RESULTS

Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation.

CONCLUSIONS

Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.

Baseline study for improving diagnostic stewardship at secondary health care facilities in Nigeria

Background

Blood culture diagnostics are critical tools for sepsis management and antimicrobial resistance (AMR) surveillance. A baseline study was conducted to assess reported sepsis case finding, blood culture diagnostics, antimicrobial susceptibility testing (AST) and antimicrobial use at secondary health care facilities to inform the development of diagnostic stewardship improvement strategies in Nigeria.

Methods

A cross-sectional online survey was conducted among 25 public secondary health care facilities in Abuja, Federal Capital Territory (FCT) and Lagos State in Nigeria to evaluate the capacity for pathogen identification and AST. Data were then prospectively extracted on all patients with reported suspected sepsis from electronic medical records from selected departments at two facilities in the Federal Capital Territory from October 2020 to May 2021 to further assess practices concerning sepsis case-finding, clinical examination findings, samples requested, and laboratory test results. Data were descriptively analysed, and a multivariate logistic regression analysis was conducted to determine factors associated with blood culture requests.

Results

In the online survey, 32% (8/25) of facilities reported performing blood cultures. Only one had access to a clinical microbiologist, and 28% (7/25) and 4% (1/25) used standard bacterial organisms for quality control of media and quality control strains for AST, respectively. At the two facilities where data abstraction was performed, the incidence of suspected sepsis cases reported was 7.1% (2924/41066). A majority of these patients came from the paediatrics department and were outpatients, and the median age was two years. Most did not have vital signs and major foci of infection documented. Blood cultures were only requested for 2.7% (80/2924) of patients, of which twelve were positive for bacteria, mainly Staphylococcus aureus. No clinical breakpoints were used for AST. Inpatients (adjusted odds ratio [aOR]: 7.5, 95% CI: 4.6–12.3) and patients from the urban health care facility (aOR:16.9, 95% CI: 8.1–41.4) were significantly more likely to have a blood culture requested.

Conclusion

Low blood culture utilisation remains a key challenge in Nigeria. This has implications for patient care, AMR surveillance and antibiotic use. Diagnostic stewardship strategies should focus on improving access to clinical microbiology expertise, practical guidance on sepsis case finding and improving blood culture utilisation and diagnostics.

Polycyclic Aromatic Hydrocarbon Levels in Wistar Rats Exposed to Ambient Air of Port Harcourt, Nigeria: An Indicator for Tissue Toxicity

This study investigated the PAH levels in Wistar rats exposed to ambient air of the Port Harcourt metropolis. Twenty Wistar rats imported from a nonpolluted city (Enugu) were exposed to both indoor and outdoor air. Following the IACUC regulation, baseline data were obtained from 4 randomly selected rats, while the remaining 16 rats (8 each for indoor and outdoor) were left till day 90. Blood samples were obtained by cardiac puncture, and the PAH levels were determined using Gas Chromatography Flame-Ionization Detector (GC-FID). GraphPad Prism (version 8.0.2) Sidak's (for multiple data set) and unpaired t-tests (for two data sets) were used to evaluate the differences in group means. Seven of the PAHs found in indoor and outdoor rats were absent in baseline rats. The mean concentrations of PAH in indoor and outdoor animals were higher than those of baseline animals, except for Benzo(a)pyrene, which was found in baseline animals but absent in other animal groups. Additionally, Dibenz(a,h)anthracene, Indeno(1,2,3-c,d)pyrene, Pyrene, 2-methyl, and other carcinogenic PAHs were all significantly higher (p < 0.05) in outdoor groups. The vulnerable groups in Port Harcourt are at the greatest risk of such pollution. Therefore, urgent environmental and public health measures are necessary to mitigate the looming danger.

Low incidence of COVID-19 in the West African sub-region: mitigating healthcare delivery system or a matter of time?

Background

This study examines the growth trends in the COVID-19 pandemic and fatalities arising from its complications among tested patients in West Africa. Countries around the world have employed several measures in order to control the spread of the disease. In spite of the poor state of the healthcare delivery system in West Africa, the spread of the pandemic is relatively low compared to reported cases in other regions of the world. The study addresses this phenomenon by asking the question: is the low incidence of COVID-19 in the West African sub-region a mitigating healthcare delivery system or just a matter of time?

Methods

The study adopted a cross-sectional time series method. Data for Ghana, Nigeria, Burkina Faso, Ivory Coast, Senegal, Niger Republic, and global data were extracted from the World Health Organization COVID-19 databank. Data were extracted in intervals of 7 days from March 15 through April 19, 2020. Data regarding the incidence growth rate and fatalities arising from COVID-19 complications were generated from the total reported cases and fatalities over specified periods. Descriptive and inferential statistical analyses were carried out using Stata version 14.

Results

Results showed that the trends in growth patterns of COVID-19 for Senegal, Nigeria, Ghana, Republic of Niger, and West Africa generally followed the same fluctuating curves. The COVID-19 pandemic accounted for 92.3%, 97.8%, 90.3%, 65%, 90.4%, 93.6%, and 97% of complications that led to deaths of patients in Burkina Faso, Nigeria, Senegal, Ghana, Niger Republic, Ivory Coast, and West Africa, respectively. Also, the results established that there was a significant positive association between increased incidence of COVID-19 and percentage increase in fatalities arising from its complications in West Africa (ß = 0.032; t = 12.70; p < 0.001).

Conclusion

The threat presently posed by COVID-19 seems to be minimal in West Africa despite the poor state of the healthcare delivery system in the region. It is unlikely, however, that the region is well prepared for the pandemic in the event that it escalates out of control with time.

Collateral damage: the impact of the COVID-19 pandemic on the care of a patient with tuberculous neuroretinitis in Lagos, Nigeria

Tuberculous neuroretinis, a relatively rare manifestation of extra-pulmonary tuberculosis, is characterized by optic disc edema, peripapillary and macula swelling, with hard exudates forming a partial or complete 'macular star' While the disease may present a diagnostic challenge for Ophthalmologists, prognosis is usually good, with proper management. The Coronavirus Disease 2019 (COVID-19) pandemic has presented a healthcare delivery dilemma in many parts of the world, with poor accessibility to, and under-utilization of, important healthcare services by non-COVID-19-related cases. Herein is a report of a case of tuberculous neuroretinitis in Lagos, Nigeria, whose care was negatively impacted by the ongoing pandemic through the combined factors of the interruption of clinical services during the lockdown, patient avoidance of healthcare facilities and the absence of robust telehealth services. These all culminated in the delayed institution of therapy which may be responsible for the poor visual outcome of no-light-perception.