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Background: Despite the large-scale rollout of malaria rapid diagnostic tests (RDTs) in Tanzania, many healthcare providers (HCPs) continue using blood film microscopy (BFM) and clinical examination to diagnose malaria, which can increase the risk of mal-diagnosis and over-prescribing of anti-malarials. Patients disregarding negative test results and self-treating exacerbate the problem. This study explored the knowledge, attitudes and practices of HCPs and healthcare-seekers regarding RDTs in comparison to BFM testing. Methods: A situational analysis was, therefore, conducted in Kondoa District, Dodoma Region, Tanzania. A multi-methodological approach was adopted including (i) a health facility inventory and screening of logbooks from May 2013 to April 2014 with 77,126 patient entries from 33 health facilities; (ii) a survey of 40 HCPs offering malaria services; and iii) a survey of 309 randomly selected household members from the facilities' catchment area. Surveys took place in April and May 2014. Results: Health facility records revealed that out of 77,126 patient entries, 22% (n = 17,235) obtained a malaria diagnosis. Of those, 45% were made with BFM, 33% with RDT and 22% with clinical diagnosis. A higher rate of positive diagnoses was observed with BFM compared with RDT (71% vs 14%). In the HCP survey, 48% preferred using BFM for malaria testing, while 52% preferred RDT. Faced with a negative RDT result for a patient presenting with symptoms typical for malaria, 25% of HCPs stated they would confirm the result with a microscopy test, 70% would advise or perform a clinical diagnosis and 18% would prescribe anti-malarials. Interviews with household members revealed a preference for microscopy testing (58%) over RDT (23%), if presented with malaria symptoms. For participants familiar with both tests, a second opinion was desired in 45% after a negative microscopy result and in 90% after an RDT. Conclusions: Non-adherence to negative diagnostics by HCPs and patients continues to be a concern. Frequent training and supportive supervision for HCPs diagnosing and treating malaria and non-malaria febrile illnesses is essential to offer quality services that can instil confidence in HCPs and patients alike. The introduction of new diagnostic devices should be paired with context-specific behaviour change interventions targeting healthcare-seekers and healthcare providers. [ABSTRACT FROM AUTHOR]

Introduction: The last two decades have seen a shift in former Soviet countries from highly specialized to more family medicine-focused systems. Medical education has slowly adjusted to these reforms, although the region is still at risk to have a chronic shortage of family doctors. This paper presents the evaluation of a new post-graduate family medicine program in Tajikistan, focused on competency-based training. The findings are relevant for policy makers, international organizations and practitioners participating in similar medical education reform programs. Methods: We employed a quasi-experimental control group design and compared intervention residents, control group residents with traditional training, and 1st year residents with no training in two outcomes, clinical knowledge and competencies. We employed two objective measures, a written multiple-choice question test (MCQT) and an Objective Structured Clinical Examination (OSCE), respectively. We report reliability and validity of the measures along with ANOVA, planned contrasts and effect size estimates to examine differences across groups. Results: We found statistically significant differences in both clinical knowledge and competencies between intervention and control groups. We also detected a large intervention effect size. Participants in the intervention outperformed control group participants in the two measures. Our analysis suggests that intervention and control group participants are comparable in terms of initial knowledge and competencies, strengthening the argument that the intervention caused the improvement in the program outcomes. Discussion: Receiving tailored training and structured opportunities to practice knowledge and competencies in clinical settings have a positive effect on the education of family medicine doctors in Tajikistan. Our results support curriculum reform and investment in medical education in the form of longer and supervised on-the-job preparation designed to be more in line with international standards. We discuss suggestions for future studies and potential requirements to inform replicability in other countries. Conclusion: Family medicine is well recognized as central to health systems throughout the world, but high quality residency training lags behind in some countries. Our study showed that investing in family medicine residency programs and structured training is effective in increasing critical clinical competencies. We encourage promoting comprehensive post graduate family medicine doctor training so that the goals of a family medicine centered health system are attainable. [ABSTRACT FROM AUTHOR]

Background: A new two-year Post University Specialty Training (PUST) programme in family medicine was introduced to improve the quality of postgraduate speciality medical education in Tajikistan. Postgraduate education of family doctors (FDs) needs to be urgently scaled up, as 38% of FD positions in Tajikistan remained unfilled in 2018. Moreover, the international financial support for the PUST programme is ending. This investment case assesses the minimum funding needed for the continuation and scale-up of PUST and establishes the rationale for the investment in the light of a recent evaluation. Methods: The costs of the programme were calculated for 2018 and a scale-up forecast made for the period 2019–2023. The impact of the scale-up on the shortage of FDs was assessed. An evaluation using a Multiple Choice Questionnaire and Objective Structured Clinical Examination (OSCE) assessed and compared theoretical knowledge, clinical skills and competencies of PUST trained and conventionally trained FDs. Results: The annual costs of the programme were US$ 228,000 in 2018. The total investment needed for scaling up PUST from 31 new FDs in 2018 to 100 FD graduates each year by 2023 was US$ 802,000.However, when the retirement of FDs and population growth are considered, the scale-up will result only in maintaining the current level of FDs working and not solve the country’s FD shortage. The PUST FDs demonstrated significantly better clinical skills than the conventionally trained interns, scoring 60 and 45% of OSCE points, respectively. Theoretical knowledge showed a similar trend; PUST FDs answered 44% and interns 38% of the questions correctly. Conclusions: The two-year PUST programme has clearly demonstrated it produces better skilled family doctors than the conventional one-year internship, albeit some enduring quality concerns do still prevail. The discontinuation of international support for PUST would be a major setback and risks potentially losing the benefits of the programme for family medicine and also other specialities. To guarantee the supply of adequately trained FDs and address the FD shortage, the PUST should be continued and scaled up. Therefore, it is essential that international support is extended and a gradual transition to sustainable national financing gets underway. [ABSTRACT FROM AUTHOR]

The worldwide implementation of free antiretroviral therapy (ART) raised great hopes among policy makers and health organisations about the positive changes it would bring about in attitudes and behaviours towards HIV and AIDS, as well as for infected people's lives. A change in illness perception was anticipated, leading to the hypothesis of a possible change in disclosure rates, patterns and the choice of significant others to inform. In the era of free treatment availability in the United Republic of Tanzania, we examined reasons for disclosure and non-disclosure among HIV-seropositive women enrolled on ART and their choice of significant others to inform. In so doing, we contribute to the necessary yet neglected debate about the social impact of ART on the lives of infected women. The study, for which an ethnographic cross-sectional pilot approach was chosen, was conducted at the Care and Treatment Center (CTC) at Bombo Regional Hospital (BRH) in Tanga city, Tanzania. Data presented here derive from participant observation, questionnaires and semi-structured interviews conducted with 59 HIV-seropositive women on ART. Interestingly, and despite treatment availability, the choice of significant others to inform, as well as reasons for disclosure and non-disclosure, mirror findings from previous studies conducted before the introduction of free ART. The main reason for non-disclosure was fear of discrimination. The hope for social, economic or health support was the main motivation for disclosure, followed by the need for a ‘clinic companion’ in order to receive ART, as requested by hospital staff. Nevertheless, healthcare staff were not unanimous in thinking that disclosure is always beneficial, thus the recommended extent of disclosure varied. ART and concomitant factors were raised as an entirely new and significant reason for disclosure by interviewees. Finally, findings confirm that despite ART, disclosure remains a highly stressful event for women. [ABSTRACT FROM PUBLISHER]

As in many countries in Eastern Europe, the Romanian Health care system was characterised by hospital-based, specialised and centrally managed health care services up to the 1990s. Decentralisation, the introduction of compulsory health insurance and the development of family health services were major steps towards improving access to curative and preventive health services at community level. However, community nursing, which had previously provided outreach to the rural poor, was practically abandoned in the mid-1990s when the salaried general practitioners providing primary health care services for a catchment population were transformed into private practice family doctors with health insurance fund service contracts, providing care based on lists of insured patients. Hence, the community nurses/ health visitors that had been hired previously within the public primary health care setting found themselves unemployed. Community level health prevention and public health services, as well as services for pregnant women, mothers and children, were subsequently stopped. A few mother and child health programmes tried to redress this problem during the early 2000s and some good practices have been documented. The new vision for Romania, The Romanian Government National Strategy for Health 2014 - 2020 [1], addresses this service gap and foresees the development of sustainable integrated socio-medical services at community level. Since 1992, longstanding cooperation between Switzerland and Romania has connected the two countries. After a period of limited collaborative activities following Romania's accession to the European Union, Switzerland restarted programme activities within the framework of an EU agreement supporting new accession countries. The main goals of the current Swiss support programme are to reduce social and economic disparities between Romania and more advanced EU countries, and between regions within Romania. To this end, Switzerland and Romania signed a Thematic Fund Agreement in 2011, called the Reform Fund linked to Health Issues, effective until 2019. The Swiss Agency for Development (SDC) [2] has mandated a consortium of the Swiss Tropical and Public Health Institute (Swiss TPH) [3] and the CRED Foundation - The Romanian-Swiss Centre for Health Sector Development [4] to facilitate the implementation of this agreement through the Technical Fund for Health, with the goal of broadening access to health and social services. The Romanian Ministry of Health [5] is a major partner within the collaboration. The main objective of the Community Integrated Health and Social Services component is to strengthen collaboration between service providers at the local community level in order to improve targeting, access to and quality of services for those most in need. This includes strengthening the leadership role of local authorities, harmonising and coordinating available services, and identifying and prioritising interventions based on the needs of the beneficiaries. The component seeks to develop functional and effective models based on the specific context of Romanian communities and to disseminate them throughout the country. Sharing information and experiences with related interventions in Romania, Eastern Europe and Western Europe is a necessary first step in order to learn from best practices and to analyse options for the Romanian context. For the present conference, with its focus on community integrated health and social services, projects were selected based on publications, grey literature and expert contacts to represent conceptual and implementation experiences from Eastern Europe, Western Europe and Central Asia. International and national speakers were identified based on their experiences and innovative ideas in the context of community integrated care and social services. Submitted abstracts were peer reviewed and selected for presentation based on criteria such as the innovation of the approach, the quality of the abstract, its contribution to the overall diversity of contexts and approaches and the feasibility of adaptation to the Romanian context. The conference was held in Bucharest, Romania on February 21st, 2014 and combined experiences from Romania, Moldova, Tajikistan, and Kyrgyzstan as well as from Germany, France, Great Britain and Switzerland. The projects presented varied greatly in terms of character (pilot, regional or national approach), geographical context (rural/urban), orientation (volunteer-based/market-oriented) and their focus (social empowerment/cost-saving) and provided a rich source of learning and inspiration. The conference and a subsequent workshop day were the starting point of a training component for local authorities and served to widen the scope of ideas for future interventions. With a total of eight international and ten national contributions, and more than 100 participants attending the event -- the majority of which represented the local Romanian authorities as well as community health workers and nurses -- the conference was a great success. The presentations provided participants and stakeholders with valuable knowledge and lessons learnt, which will be very helpful for future planning and implementation processes. The evidence generated from this experience will help to disseminate future intervention models in Romania. We would like to acknowledge the support of the Swiss-Romanian Cooperation Programme to Reduce Economic and Social Disparities within the Enlarged European Union and its Thematic Health Fund, from which this conference was funded (by Switzerland). Furthermore we would like to express our gratitude to everyone involved in organising the conference and the various speakers and participants who contributed to its successful implementation. [ABSTRACT FROM AUTHOR]

Background: A new two-year Post University Specialty Training (PUST) programme in family medicine was introduced to improve the quality of postgraduate speciality medical education in Tajikistan. Postgraduate education of family doctors (FDs) needs to be urgently scaled up, as 38% of FD positions in Tajikistan remained unfilled in 2018. Moreover, the international financial support for the PUST programme is ending. This investment case assesses the minimum funding needed for the continuation and scale-up of PUST and establishes the rationale for the investment in the light of a recent evaluation.Methods: The costs of the programme were calculated for 2018 and a scale-up forecast made for the period 2019-2023. The impact of the scale-up on the shortage of FDs was assessed. An evaluation using a Multiple Choice Questionnaire and Objective Structured Clinical Examination (OSCE) assessed and compared theoretical knowledge, clinical skills and competencies of PUST trained and conventionally trained FDs.Results: The annual costs of the programme were US$ 228,000 in 2018. The total investment needed for scaling up PUST from 31 new FDs in 2018 to 100 FD graduates each year by 2023 was US$ 802,000.However, when the retirement of FDs and population growth are considered, the scale-up will result only in maintaining the current level of FDs working and not solve the country's FD shortage. The PUST FDs demonstrated significantly better clinical skills than the conventionally trained interns, scoring 60 and 45% of OSCE points, respectively. Theoretical knowledge showed a similar trend; PUST FDs answered 44% and interns 38% of the questions correctly.Conclusions: The two-year PUST programme has clearly demonstrated it produces better skilled family doctors than the conventional one-year internship, albeit some enduring quality concerns do still prevail. The discontinuation of international support for PUST would be a major setback and risks potentially losing the benefits of the programme for family medicine and also other specialities. To guarantee the supply of adequately trained FDs and address the FD shortage, the PUST should be continued and scaled up. Therefore, it is essential that international support is extended and a gradual transition to sustainable national financing gets underway. [ABSTRACT FROM AUTHOR]

Background: The Republic of Moldova is faced with a high prevalence of non-communicable diseases (NCDs) related to lifestyle and health behavioural factors. Within the frame of the decentralisation reform, the primary health care system has been tasked to play an important role in the provision of preventative and curative NCD health services. There is however limited evidence available on the actual coverage and quality of care provided. Our paper aims to provide an updated overview of the coverage and quality of service provision in rural and urban regions of Moldova.Methods: We designed a facility-based survey to measure aspects of coverage and quality of care of NCD services across 20 districts of the Republic of Moldova. This study presents descriptive data on the structural, procedural and clinical aspects of primary healthcare delivery at health centre and family doctor office level. Adjacent private pharmacies were also assessed for the availability of essential NCD medicine.Results: Organised under the WHO Health Systems Framework, our findings highlight that service provision and information were generally the strongest among the six health systems building blocks, with more weaknesses found in the area of the health workforce, medical products, financing, and leadership/governance. Urban facilities generally fared better across all indicators.Conclusions: The gaps in service provision identified by this study require broad health system improvements to ensure NCD related policies and strategies are embedded in primary health care service provision. This likely calls for stronger coordination and collaboration between the public and private sectors and the different levels of government working towards ensuring universal health coverage in Moldova. [ABSTRACT FROM AUTHOR]

Background: Many countries are responding to the global shortage of midwives by increasing the student intake to their midwifery schools. At the same time, attention must be paid to the quality of education being provided, so that quality of midwifery care can be assured. Methods of assuring quality of education include accreditation schemes, but capacity to implement such schemes is weak in many countries. Objective: This paper describes the process of developing and pilot testing the International Confederation of Midwives' Midwifery Education Accreditation Programme (ICM MEAP), based on global standards for midwifery education, and discusses the potential contribution it can make to building capacity and improving quality of care for mothers and their newborns. Methods: A review of relevant global, regional and national standards and tools informed the development of a set of assessment criteria (which was validated during an international consultation exercise) and a process for applying these criteria to midwifery schools. The process was pilot tested in two countries: Comoros and Trinidad and Tobago. Results: The assessment criteria and accreditation process were found to be appropriate in both country contexts, but both were refined after the pilot to make them more user-friendly. Conclusion: The ICM MEAP has the potential to contribute to improving health outcomes for women and newborns by building institutional capacity for the provision of high-quality midwifery education and thus improved quality of midwifery care, via improved accountability for the quality of midwifery education. [ABSTRACT FROM AUTHOR]