Chapter  7  - Primary Health Care   (Emer M, Abito B, Kokor M, Angela S. P. Locham J)

 

 

 

1.0    Catchment area

The health sub-district comprises 6 sub-counties of Bokora county i.e. Matany, Iriri, Lokopo, Lopei, Ngoleriet, and Lotome Sub-counties.

 

Table 1 Service population (catchment area population) for 1998/99

 

BOKORA HEALTH ZONE1998-99

Total service population                         76,396

Infants < 1 Yr.

4.7%

3,591

Children < 5 Yrs

18.0%

13,751

Women 15 to 49 Yrs

23.0%

17,571

Pregnant Women

5.2%

3,973

 

 

 

2.0 Personnel/Staffing

 

2.1 Matany Hospital Public Health Department

The Public health department (PHD) is strong of 5 established staff (1 double-trained registered nurse and registered midwife/TBA trainer, 1 primary opthalmic assistant, two vaccinators, and 1 assistant to the public health officer) and a public health officer who supervises the department. At the community level, are 28 field health Workers (FHWs) who are supervised by the PHD. The FHWs carry out PHC activities at community level. The activities include health education on common diseases (including School visits) immunisation, guinea worm eradication activities, TB case finding, contact tracing, and follow up of cases on maintenance. 

 

 

2.2 Peripheral health units and staffing levels.

Over 65% of personnel are non- professional/unqualified staff.

 

Table 2.  Personnel by qualification and units in Bokora health sub district (HSD)

 

 

 

 

HEALTH UNIT

(OWNERSHIP)

Clinical Officer

Registered Nurse

Enrolled Nurse

Health Assistant

TB/LP assistant

 

Nurse aides

TOTAL

% of professionals

IRIRI SUB-DISP

(Govt)

0

1

0

1

1

4

7

43%

KANGOLE

SUB-DISP

(Catholic Church)

0

1

1

0

0

5

7

29%

NGOLERIET SUB-DISP

(Govt)

0

1

0

1

1

3

6

50%

LOTOME

 SUB-DISP

(Govt)

0

1

0

1

1

4

7

43%

KOBULIN

SUB-DISP

(Govt)

0

0

0

0

0

4

4

0

APEITOLIM

AIDS POST

(Community)

0

0

0

0

0

1

1

0

TOTAL

0

 

4

1

3

3

21

32

34%

 

 

3.0 Activities/Achievements

 

The PHD conducts Support supervision to the 6 peripheral health units of bokora health Zone and offers a package of service to the community. Community activities offered are in line with the concept of PHC. Integration, community participation, and multidisciplinary approach are the basis of our activities.

 

Activity areas include the following:

 

3.1 Support supervision to peripheral health units (Govt. & Non Govt.) and supply of logistics.

A medical officer visits each of the 6 units once a month. Supervision is done with the aim of ensuring correct patient management and continuous quality assurance improvement. The activities supervised include clinical assessments and prescription habits to ensure rational drug use (EDMP), HMIS, UNEPI cold chain maintenance, and generally quality of services offered at the health units. Problems identified by the unit staffs or the supervisor are discussed at the end of the day work and possible solutions (which form the basis for subsequent supervision) suggested and agreed upon for implementation.

 

Table 3: Support supervision visits to health units in Bokora Health Sub-district

 

 

 

 

 

 

 

 

Health Units’ Supervision

1994

1995

1996

1997

1998*

1998/99**

Target

No. of visits to Government units

34

13

10

17

18

31

60

No. of visits to Diocesan units

12

17

22

4

4

8

12

Total visits to all the units

46

30

32

21

22

39

72

Total no.of the units

n.r.

n.r

n.r

n.r

6

6

6

Average visits per unit

 

 

 

 

3.67

6.5

12

 

 

 

 

 

 

 

 

NB.  Up to 1997, supervision visits included Kotido and  Moroto Diocesan units.

         For the year 1998, supervisory visits concentrated in Bokora county only.

     * 1998 = period from January to December 1998

 

 

 

 

     ** 1998/99 = period from July 1998 to June 1999

 

 

 

 

 

The target for supervision visits was not met due to the prolonged wave of insecurity that started since January 1999.

 

 

3.2 MCH/FP

A double trained registered nurse- midwife (URM/URN/TBA trainer), supervised by the Public Health Officer, is responsible for the “training and supervision” of TBAs and the delivery of ANC activities in the zone. All the sub-counties except Iriri have trained TBAs (total 145) and they are supervised once every month. Four ANC outreaches every month and daily static hospital ANC services are done in Bokora HSD. 

 


Figure 1: antenatal Care first attendance in Bokora health Zone From 1995.

 

 


NB: “98/99” is the period from July 98 to June 99

 

As demonstrated in figure 1 above, the declining trend in ANC coverage observed from 1995 to 1997 has reversed. The coverage improved by 30% from 1997 to 1998 probably due to the intensive community mobilisation, increased number of out reach services, training and supervision of TBAs carried out in 1998.The 5% drop in the year 98/99 could be explained by the rampant waves of insecurity which affected mobilisation hence low turn-up.

 

Table 4: Activities carried out by trained TBAs in Bokora Health sub-district

 

 

1998

1998/99

Antenatal care

23%

14%

Deliveries

14%

11.4%

Referral to Hospital

1.2%

0.7%

Average number of contacts per pregnancy

2

2.7

 

NB: indicators are expressed as new cases/target population x 100%, and Total attendance/new attendance for average number of contacts.

 

 The TBAs successfully conducted 453 (11.4%) normal deliveries, referred 29 (0.7%) high-risk pregnant mothers to the Hospital, and carried out ANC to 566 (14%) first attendance and 941 re-attendance in 1998/99. The indicators compare unfavourably to those in 1998 with possible reasons as stated earlier.    

Despite the above efforts, the proportion of pregnant mothers delivered under supervision of trained personnel (Hospital and TBAs) is as low as 22.6% (routine data collection, HMIS from Bokora HSD). This implies that the majority (78%) of deliveries in Bokora may not be clean and safe.  A community survey is necessary to find out the factors influencing the utilisation of ANC  and maternity services in Bokora health Zone.

 

3.3 UNEPI/(NIDs)

Bokora county has 6 static units (corresponding to the number of health units supervised by the Public health department) and 25 outreach posts distributed all over the county. Each sub-county has on average 4 outreach posts manned by the field health workers and health unit staffs attached to MATANY HOSPITAL and peripheral health units respectively. 

 

 

Table 5. Immunisation coverage by antigen for the six killer diseases in Bokora health Sub-district

 

Antigen

Coverage

1998

Actual coverage

1998-99

Target for 1998-99

BCG

100%

100%

100%

POLIO 3

95%

102%

85%

DPT3

95%

102%

85%

MEASLES

77%

92%

85%

TT2+ P

27%

25%

80%

TT2+ NP

11%

10%

20%

 

 

Coverage for the BCG, DPT3, Measles, and Polio3 are above targets while for TT2+ pregnant and TT2+ non-pregnant are below targets (not different from past experience). Measles immunisation coverage improved by 15% from last year. The improvement was due to the intensive house to house community mobilisation for children to be immunised, soon after the measles outbreak in April 1999. While for TT2+ P, most mothers reported having completed the 5 doses already when interviewed. There is yet no sufficient data to quantify and validate this. Another evidence is the barely reported incidence of neonatal tetanus in Bokora HSD.    

 

3.4 TBLCP

Although TB case finding is predominantly passive, our FHWs actively seek, identify, and refer all cases with chronic cough to the hospital for free TB screening. To achieve high case holding rate, the FHWs follow up TB patients discharged from the 2 months intensive treatment to ensure treatment compliance and to supply more drugs to patients on maintenance phase.

The expected no. of sputum positive cases (Case finding) for the period 01/07/97 to 30/06/98 was estimated using the formula ( 55 x Annual rate of infection. x Population/100000) = 147  M+

Actual sputum positive cases found were 38 patients from Bokora health Zone thus a Case finding rate = 26% (29.4% in 1997, 42.6% in 1996). Is the control programme having an impact ? or, we are not able to identify all the cases. There is need to re-examine our policy on case finding and to strengthen supervision of the FHWs and unit staffs.

 

Table 6 TB control. Case finding & case holding indicators for sputum positive cases in Bokora health Zone

 

Indicators

1994

1995

1996

1997

1997/98

1998/99
No. M+ cases identified

43

34

58

40

38

(147 target)

55

(142 target)

Case finding rate*

36%

25%

43%

29%

26%

39%

Sputum conversion rate

100%

91%

91%

93%

89.5%

(85% target)

100%

(85% target)

Case holding rate *

80%

69%

69%

 

60.5%

(100% target)

 

Cure rate *

-

-

-

-

58%

(85% target)

 

Transferred out rate *

-

4.8%

1.7%

-

5.3%

 

Defaulting rate *

16%

9.5%

18.9%

-

23.7%

(<10% target)

 

Death rate *

22%

17%

10%

-

10.5%

 

Failure rate*

 

 

 

 

2.6%

(<4% target)

 

NB. * The rates are computed on the cohort sputum positive.

 

The declining case holding rate is mainly due to high defaulting (9 out of 38 sputum positive patients) and increasing transfer out rates. Five out of 9 defaulters were traced within one month by the FHWs and maintenance treatment continued. The remaining 4 could not be traced because two of them left for other districts and two could not be found at the addresses that they gave when still in the ward. Case finding improved by 13% in the year 1998/99 possibly due to the active case search and referral by the FHWs in Bokora health sub-district.

 


Figure 2. Age distribution of sputum positive tuberculosis in Bokora County in the years 1997/98 and 1998/99

 


Open lung TB is more prevalent in the age group 20-29 years in Bokora County. This age group is sexually active hence prone to HIV/AIDS with the associated Tuberculosis. The same age group often socialises through sharing of local brew (kutu-kuto) where every body drinks from the same spot on the pot including those with prolonged cough. Interventions like active case search will be intensified for the age group 20-29 years and health education on prevention and control of TB targeted for all age groups. 

 

3.5 PRIMARY EYE CARE

The PHD has a primary opthalmic assistant who conducts health education on primary prevention of eye problems and carries out treatment of simple eye problems on a daily basis. Complicated eye cases are referred or booked for the eye specialist attention (visited Matany at the end of September 1998 and carried out eye operations). Out reach services integrated with others are offered to the 6 sub-counties on scheduled visits. Eight to ten out-reaches are made per month

No. of uncomplicated eye problems treated in 1998/99 were = 855 (in 1997 were 821)

No. of complicated eye problems referred to Mulago Hospital were = 3

No. of cases booked for the eye specialist and were operated in Matany Hospital were = 89 (in 1997 were 105)

 

3.6 GWEP

Bokora is the most highly endemic county for guinea worm disease in Moroto district. With the establishment of active surveillance, Bokora has achieved the highest (83%) case containment ever (meaning cases identified, treated, prevented from contaminating water, and verified by Sub-county/District supervisor within 24 hrs of worm emerging from the blister) and this will be maintained throughout this year to interrupt the transmission cycle

 

Table 7: Guineaworm surveillance and containment in Bokora 1998-99

 

Total cases

Total cases

Containment.

 

Reported

Contained

Rate

1998

203

133

65.5%

1998/99

53

44

83%

 

3.7 SURVEILLANCE (Measles, Cholera, AFP, NNT and malaria)

There were two fresh Cholera outbreaks in Ngoleriet (15 cases) and Lopei (5 cases) Sub-counties respectively. Community sensitisation was conducted and Matany Hospital supported the treatment centres.

In the month of April 1999, our routine surveillance timely detected measles outbreak in 3 sub-counties and a community investigation result suggested that a declining measles immunisation coverage from 98% in 1994 to 80% in 1998 was the most likely cause of the outbreak.

Malaria epidemiological surveillance did not detect any abnormal trend to suggest an epidemic

Two cases of AFP were identified and notified. Stool specimens were sent to Virus institute Entebbe using reverse cold chain but only one result was received which was negative for the wild poliovirus.

 

3.8    HEALTH EDUCATION

Health education, a public health intervention cutting across all areas, is conducted at individual, family, community, and health unit levels. Hospital staffs, students, and FHWs carry out the activity using various methods and tools to facilitate learning through voluntary adaptation of knowledge, attitude, behaviour, and practices for disease prevention, control, and health promotion.

 

  Table 8. Health education sessions by Field health workers (FHWs)

 

1995

1996

1997

1998/99

In the field

2253

3126

3445

2415

In the Hospital

n.r.

n.r.

119

52

 

4.0  Workshops

Four workshops were conducted in Bokora health sub district (HSD) in 1998/99.

The first, workshop on Malaria control and prevention, integrated with Tuberculosis control, was conducted in November 1998 at KHRDCH. Participants were 21 FHWs under Matany Hospital and 8 Government health workers from the 6 health units in Bokora health Sub-district.

The second workshop, on PRA, was carried out in December 1998 at KHRDCH. Participants were 10 FHWs under Matany Hospital.

A third workshop on Reproductive Health issues integrated with EPI was conducted in March 1999 Participant were field health workers attached to Matany Hospital and Government health workers in the peripheral health units in Bokora County.

Four series of TBAs’ refresher training workshops were conducted in the months of May and June 1999.

Participants were 100 trained TBAs from 5 Sub-counties of Bokora HSD.

 

5.0  Problems/Constraints

·         Insecurity due to road ambushes and cattle rustling

·         Prolonged drought associated with migration to neighbouring districts

·         New settlements

·         The basic staffing requirement of the community health department is not yet met.

 

6.0  Recommendations/possible solutions/action taken

·         Three outreach immunisation posts and one extra ANC outreach were established.

·         To recruit more staffs

 

7.0  Plan for next year 1999-2000

·         Continue with support supervision and supply of logistics to peripheral health units

·         Continue with delivering an integrated MCH/FP/TBA, UNEPI, TBLCP, GWEP, EDMP, and primary eye care activities.

·         Continue with epidemiological surveillance for notifiable diseases of cholera, AFP, Measles, NNT, and other diseases of epidemic potential like Malaria.

·         Co-ordination of Malaria control and prevention activities in the two districts of Kotido and Moroto.

·         Community survey on Utilisation of ANC and maternity services, and Immunisation coverage

 

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