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Rapid Assessment of Ebola-Related Implications for RMNCH Service Delivery and Utilization in Guinea

Presentation by Alimou Barry, Janine Barden-O’Fallon, Jack Hazerjian, and Paul Brodish.

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Rapid Assessment of Ebola-Related Implications for RMNCH Service Delivery and Utilization in Guinea

  1. 1. Alimou Barry, Janine Barden-O’Fallon, Jack Hazerjian, Paul Brodish MEASURE Evaluation 24 June 2015 A Rapid Assessment of Ebola-Related Implications for RMNCH Service Delivery and Utilization in Guinea
  2. 2. WEEKLY INCIDENCE of CONFIRMED CASES of EBOLA in GUINEA Rapid assessment data collection period http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015 0 20 40 60 80 100 120 140 160 180 Confirmed Ebola Cases per Week From Start of 2015 Confirmed Ebola Cases per Week through End of 2014 171
  3. 3. CASES of EBOLA in GUINEA Cumulative Number of Confirmed Cases by Age Group‡ (per 100,000 population) 0-14 years 15-44 years 45+ years Through 10 June, 2015 505 (11) 1846 (40) 838 (54) Population figures are based on estimates from the United Nations Department of Economic and Social Affairs ‡Excludes cases for which data on age are not available. From: http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015 Disproportionally affected adults and individuals in certain regions of the country
  4. 4. DEATHS from EBOLA in GUINEA Cumulative Number of Confirmed Deaths in Total Population (case fatality rate) among Health Care Workers (case fatality rate) Through 10 June, 2015 2018 (62.3%) 94 (50.3%) Population figures are based on estimates from the United Nations Department of Economic and Social Affairs From: http://apps.who.int/ebola/current-situation/ebola-situation-report-10-june-2015
  5. 5. INDIRECT EFFECTS of EBOLA  Reports of clinic closures, patients being turned away from services, and patients avoiding health facilities out of fear o In Sierra Leone, median inpatient admissions dropped 70% between May and October 2014 • Reports of suspension of services, such as vaccinations To what extent are routine RMNCH services in Guinea affected by Ebola?
  6. 6. OBJECTIVE ASSESS DELIVERY AND UTILIZATION OF ROUTINE RMNCH SERVICES IN SELECTED FACILITIES ACROSS GUINEA
  7. 7. METHODS  Compile and analyze facility data on key routine RMNCH services from October 2013 (pre-Ebola) through December 2014  Conduct interviews with: o directors of health districts o directors of health facilities o providers of RMNCH services o traditional practitioners  Use convenience sample of government and private clinics in locations throughout Guinea with variable Ebola incidence Koulewondy Health Center, Conakry
  8. 8. MAP of CONAKRY and 12 PRÉFECTURES SELECTED for the STUDY
  9. 9. SELECTED STUDY SITES CLASSIFIED‡ AS « ACTIVE », « CHANGING STATUS», or « INACTIVE >> ACTIVE (throughout) CHANGING STATUS INACTIVE (throughout) GUÈCKÈDOU CONAKRY CITY DISTRICTS: DIXINN MATAM RATOMA BOFA COYAH DABOLA DALABA FARANAH FRIA KISSIDOUGOU N’ZÈRÈKORÈ SIGUIRI MAMOU MANDIANA 13 FACILITIES 26 FACILITIES 6 FACILITIES ‡ Based on retrospective review of Ebola case incidence for the period March-December 2014
  10. 10. KEY RMNCH INDICATORS REPRODUCTIVE HEALTH o New and continuing accepters of modern contraceptive methods o Months with incidence of stockouts of contraceptive pills, injectables, and/or condoms Health education mural at Guèckèdou Prefectoral Hospital
  11. 11. MATERNAL HEALTH o Pregnant women tested for HIV o Pregnant women seen at first and third prenatal visits o Cases of pregnancy complications o Facility-based births o Maternal deaths o Outpatient services Horoya Health Center, N’Zèrèkorè KEY RMNCH INDICATORS
  12. 12. CHILD HEALTH o Children vaccinated with Penta 1 and Penta 3 o Children under 5 years of age with acute respiratory illness, moderate malnutrition, and diarrhea o Child outpatient services o Months with incidence of stockouts of oral rehydration salts and Cotrimoxazole o Children under 5 years of age hospitalized due to acute respiratory illness Pediatric Ward of Guèckèdou Prefectoral Hospital KEY RMNCH INDICATORS
  13. 13. DATA COLLECTION INSTRUMENTS
  14. 14. Questionnaire for Directors of Health Services at Health District o (Ex: facility closings; staffing issues; Ebola training; reporting continuity) Questionnaire for Directors of Health Facilities o (Ex: Ebola triage and referral; Ebola risk management; medical stockouts; medical and personal concerns related to Ebola; recommendations) Questionnaire for Providers of RMNCH Services o (Ex: service suspension; Ebola training; Ebola risk management; medical complications; Ebola-related concerns; recommendations) Questionnaire for Traditional Practitioners o (Ex: changes in service delivery and procedures; Ebola risk management) DATA COLLECTION INSTRUMENTS
  15. 15. ETHICAL CONSIDERATIONS  Informed consent received from all interviewees  No identifying information collected from respondents  No personally sensitive questions asked about health status  Exemption received from University of North Carolina’s Ethics Committee and Guinea’s Ministry of Health
  16. 16. LOGISTICS and COORDINATION  Collaborated with StatView International for data collection and data entry  Coordinated with Ministry of Health Office of Strategic Development and Family Health Department  Communicated with directors of health services at each study site, before and during field work, with request to have a designated official work along field study team
  17. 17. DATA QUALITY CONSIDERATIONS  Six data collection teams, each with a physician as lead  Three quality monitoring teams to ensure that protocols and practices were being observed and that forms were completed correctly  Data inscription into Epi 7 checked against the field study forms
  18. 18. TIME LINE 2015 DATES 12 January 19 – 24 January 25 – 27 January 28 January – 8 February 9 – 17 February 18 February 19 February – 28 April 29 April 30 April – 13 May 30 May 24 June • ACTIVITIES • Approval of protocols and instruments • Training of field workers and data clerks • Coordination meetings w/ Ministry of Health and Public Hygiene • UNC Ethics Committee approval • Data collection • Data entry and quality checks • Debriefing with USAID/Guinea on preliminary findings • Data cleaning, data analysis and preparation of report • Submission of draft report to USAID/Guinea • Review and finalization of report • Submission of final report in English and French translation • Presentation to USAID/Guinea
  19. 19. FACILITY DATA
  20. 20. OUTPATIENT SERVICES Macire Health Center, Dixinn Commune, Conakry
  21. 21. COMPARISON‡ of MEDIAN NUMBER of OUTPATIENT SERVCES in OCT-DEC 2013 and 2014 from 45 FACILITIES Oct-Dec 2013 Oct-Dec 2014 % Change ** p<.01 Outpatients (adults and children) Hospitals 1355 930 – 31** Health Centers 1223 1147 – 6** Pediatric Outpatient Ward, Donka National Hospital, Conakry Gonia Market Health Center, N’Zèrèkorè ‡ Wilcoxon signed rank test with median values of services provided in each of the 2 quarters
  22. 22. FINDINGS by EBOLA ZONE OUTPATIENT SERVICES 0 500 1000 1500 2000 2500 1 2 3 4 5 Time (quarters) changing active inactive Median number of outpatient visits at hospitals HOSPITALS • Median number of adult and child outpatients:  significantly declined across all Ebola status zones  increased in early 2014 in Ebola active zone before steady decline thereafter  relatively flat in inactive and changing Ebola status zones before large declines late in 2014
  23. 23. FINDINGS by EBOLA ZONE OUTPATIENT SERVICES Median number of outpatient visits at health centers 0 1000 2000 3000 1 2 3 4 5 Time (quarters) changing active inactive HEALTH CENTERS • Median number of adult and child outpatients:  small decline across all Ebola status zones  increased Apr-Jun 2014 in Ebola active zone before steady decline thereafter  gradual increases in inactive and changing Ebola status zones before small declines in Oct-Dec 2014
  24. 24. REPRODUCTIVE HEALTH Ratoma Communal Health Center, Ratoma Commune, Conakry
  25. 25. COMPARISON‡ of MEDIAN NUMBER of SERVCES and STOCKOUTS of MODERN CONTRACEPTIVES OCT-DEC 2013 and 2014 from 45 FACILITIES Oct-Dec 2013 Oct-Dec 2014 % Change New Acceptors: Modern Contraception Hospitals 19 12 – 37 Health Centers 25 34 + 36 Continuing Acceptors: Modern Contraception Hospitals 60 50 – 17 Health Centers 26 28 + 8 Number of Facilities Reporting Stockout Stockouts of Key Contraceptives over 15-Month Period over 9-Month Period of Ebola Injectables 10 3 Oral Contraceptive Pills 7 2 Condoms 11 2 ‡ Wilcoxon signed rank test with median values of services provided in each of the 2 quarters
  26. 26. MATERNAL HEALTH Hafia Health Center, Dixinn Commune, Conakry
  27. 27. COMPARISON‡ of MEDIAN NUMBER of SERVICES in OCT-DEC 2013 and 2014 from 45 FACILITIES Oct-Dec 2013 Oct-Dec 2014 % Change * p<.05 Pregnant Women Tested for HIV Hospitals 112 55 – 51* Health Centers 255 246 – 4 Pregnancy Complications Hospitals 10 8 – 20 Pregnant Women Seen for ANC 1 Health Centers 337 295 – 12 Pregnant Women Seen for ANC 3 Health Centers 245 205 – 16 Facility-Based Births Hospitals 303 281 – 7 Health Centers 100 69 – 31 ‡ Wilcoxon signed rank test with median values of services provided in each of the 2 quarters
  28. 28. FINDINGS by EBOLA ZONE MATERNAL HEALTH SERVICES 0 100 200 300 1 2 3 4 5 Time (quarters) changing active inactive Median number of pregnant women tested for HIV in hospitals • Only HIV testing of pregnant women at hospitals showed a statistically significant decline • Drop in HIV testing at hospitals in Ebola active zone heavily accounts for overall decline
  29. 29. CHILD HEALTH Children Playing in Football Stadium, N’Zèrèkorè
  30. 30. COMPARISON‡ of MEDIAN NUMBER of SERVICES in OCT-DEC 2013 and 2014 from 45 FACILITIES Oct-Dec 2013 Oct-Dec 2014 % Change * p<.05 ** p<.01 PENTA 1 Vaccinations Given Hospitals 504 316 – 37 Health Centers 259 212 – 18** PENTA 3 Vaccinations Given Hospitals 353 320 – 9 Health Centers 244 167 – 32** Watery/Bloody Diarrhea, Child < 5 Yrs of Age Hospitals 34 14 – 59** Health Centers 16 12 – 25** Acute Respiratory Illness (ARI), Child < 5 Yrs Hospitals 98 41 – 58** Health Centers 108 83 – 23** Hospitalization due to ARI, Child < 5 Yrs Hospitals 18 16 – 11 ‡ Wilcoxon signed rank test with median values of services provided in each of the 2 quarters
  31. 31. Median number of Penta 1 vaccinations given at health centers FINDINGS by EBOLA ZONE CHILD HEALTH SERVICES – PENTA VACCINATIONS 0 100 200 300 400 500 1 2 3 4 5 Time (quarters) changing active inactive Median number of Penta 3 vaccinations given at health centers 0 100 200 300 400 1 2 3 4 5 Time (quarters) changing active inactive • Throughout all Ebola status zones, significant declines in vaccinations given at health centers -- but not at hospitals • Yet declines not constant:  Declining Pentavalent 1 vaccinations show some increases during last quarter of 2014  Pentavalent 3 vaccinations started falling as Ebola cases grew in detection, especially in Ebola active zone
  32. 32. Median number of cases of diarrhea in children under five years of age in hospitals FINDINGS by EBOLA ZONE CHILD HEALTH SERVICES –DIARRHEA Median number of cases of diarrhea in children under five years of age in health centers 0 50 100 150 1 2 3 4 5 Time (quarters) changing active inactive 0 50 100 150 1 2 3 4 5 Time (quarters) changing active inactive • Cases of diarrhea in children < 5 years significantly decreased across all Ebola status zones • Declines were not constant throughout 2014
  33. 33. Median number of cases of ARI in children under five years of age treated at hospitals FINDINGS by EBOLA ZONE CHILD HEALTH SERVICES – TREATMENT of ARI 0 100 200 300 400 1 2 3 4 5 Time (quarters) changing active inactive HOSPITALS • Median number of children < 5 with ARI:  significantly decreased across all Ebola status zones  declines not constant in Ebola changing status zones  slight increase in final quarter of 2014 in Ebola active zone
  34. 34. Median number of cases of ARI in children under five years of age treated at health centers 0 100 200 300 400 1 2 3 4 5 Time (quarters) changing active inactive HEALTH CENTERS • Median number of children <5 with ARI:  trended upwards in early 2014 in Ebola active and inactive zones before declining  steepest declines are in final quarter of 2014 for Ebola inactive and changing status zones FINDINGS by EBOLA ZONE CHILD HEALTH SERVICES – TREATMENT of ARI
  35. 35. Number of Facilities Reporting Stockout‡ Stockouts of Key Child Medications over 15-Month Period over 9-Month Period of Ebola Oral Rehydration Salts 22 8 Cotrimoxazole (Antibiotic) 18 9 STOCKOUTS of 2 KEY MEDICATIONS in 45 FACILITIES ‡Due to the small number of facilities reporting stockouts of key child medications and contraceptives, this information was reported by total number recorded for the 15‐month period, and the number recorded only after the start of the Ebola outbreak (April through December 2014)
  36. 36. INTERVIEW DATA MANAGERS / DIRECTORS of HEALTH FACILITIES Health Center of Horoya, N’Zèrèkorè
  37. 37. % Public Facilities N = 43* % Private Facilities N = 19 Chi-Square Test Results Facility reduced hours due to Ebola crisis 5 32 p < 0.01 Facility suspended services due to Ebola concerns 7 26 p < 0.05 Manager / Director noticed increase in complications among patients who delayed accessing health services during Ebola crisis 28 0 p < 0.01 Director reported service providers at the facility have received training on Ebola infection control 93 68 p < 0.05 Director feels community members have concerns about the safety of services at the facility 84 58 p < 0.05 Facility has been able to maintain routine data collection and reporting as usual during Ebola crisis 98 74** p < 0.01 DIRECTORS of HEALTH FACILITIES (n = 62) SIGNIFICANT DIFFERENCES‡ BY PUBLIC AND PRIVATE FACILITY ‡Chi-square test for equivalency was used *While data was collected at a total of 45 public facilities, interviews with heads of such facilities could only be collected at 43 of them **Percent for routine data collection only; reporting of health services data by private health care facilities not studied
  38. 38. RMNCH Providers (n = 117) Views on Health Delivery Services and Use o 28% cited increase in complications o 86% cited changes in use of health services by those in the community o 96% reported to have changed their own practices in providing maternal and child health services o 97% reported regular wearing gloves when offering services o 70% received training in Ebola prevention Staff Bulletin Board, N’Zèrèkorè Hospital
  39. 39. o 63% cited concerns about Ebola held by those in their community o 36% cited negative reactions from family members and friends about Ebola o 80% reported concerns about their security when offering health services o 7% reported that health services at their health facility had been suspended or stopped due to Ebola Ebola Treatment Center, Donka National Hospital, Conakry RMNCH Providers (n = 117) Views on Health Delivery Services and Use
  40. 40. Significant Negative Findings o Overall decline in services, found more greatly at hospitals than at other facilities o Child health services most affected by Ebola  especially vaccinations that require multiple visits, diarrhea and ARI cases  possibly due to parental reluctance to visit a health facility o Significant decline reported by hospitals of HIV testing of pregnant women o Stockouts of some basic medicines have continued to be an ongoing concern o One‐third of health care providers received no training in Ebola infection control o A sizeable percentage of interviewees felt that their position as health care providers is stigmatized by those in their community Summary Conclusions
  41. 41. Significant Positive Findings o Despite Ebola, information system on routine health services continued to function o Ebola does not appear to have had a widespread negative impact on the availability of health services o Many improved infection control measures have been adopted, including routine hand washing by both health care workers and traditional healers Summary Conclusions
  42. 42. FIELD STUDY TEAMS
  43. 43. QUESTIONS? COMMENTS?
  44. 44. THANK YOU !
  45. 45. ACKNOWLEDGEMENTS We are deeply grateful to USAID/Guinea and the Ministry of Health and Public Hygiene for their support and commitment to this rapid assessment In particular, we would like to cite the valuable assistance provided by: Dr. Younoussa Ballo, Secretary General, Ministry of Health and Public Hygiene Dr. Sekou Condé, Deputy Coordinator of the Fight against Ebola Dr. Mamady Kourouma, the Director of Family Health and Nutrition Dr. Boubacar Sall, Acting Director, Office of Strategy and Development We also acknowledge the meaningful support and cooperation of the dedicated professionals we met in the field, most notably, all health staff at the Regional Health Directorate and District Health Offices and the dedicated staff at the hospitals, health centers, and clinics we visited in Conakry and the 12 prefectures Finally, we give our sincere thanks to StatView International for recruiting excellent data collectors and providing tremendous logistical support to the field work, without which this rapid assessment would not have been completed so promptly
  46. 46. MEASURE Evaluation is funded by the U.S. Agency for International Development (USAID) under terms of Cooperative Agreement AID-OAA-L-14-00004 and implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnership with Futures Group, ICF International, John Snow, Inc., Management Sciences for Health, and Tulane University. The views expressed in this presentation do not necessarily reflect the views of USAID or the United States government. www.measureevaluation.org

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