Master of International Health Qualifying Exam Part Ii

What do you think are the governance challenges in global health?

I think globalization is the major challenge in global health. According to Dodgson et. al., (2002) globalization as an historical process characterized by changes in the nature of human interaction across a range of social spheres including the economic, political, technological, cultural and environmental.

Additionally, globalization has introduced or intensified transborder health risks defined as risks to human health that transcend national borders in their origin or impact. Such risks may include emerging and reemerging infectious diseases, various non-communicable diseases (e.g. lung cancer, obesity, and hypertension) and environmental degradation (e.g. global climate change).Moreover, globalization is characterized by a growth in the number, and degree of influence, of non state actors in health governance. Many argue that the relative authority and capacity of national governments to protect and promote the health of domestic populations has declined in the face of globalizing forces beyond national borders that affect the basic determinants of health as well as erode national resources for addressing their consequences. Finally, current forms of globalization appear to be problematic for sustaining, and even worsening existing socioeconomic, political and environmental problems. For example, reports that neoliberal forms of globalization have been accompanied by widening inequalities between rich and poor within and across countries. (Dodgson &WHO, 2002)

What are the pros and cons of development assistance in International Health? Use a country comparison in answering this question.

Pros of Foreign Aid

Help Meet SDG Targets, which aim universal call to action to end poverty, protect planet and ensure that all people enjoy peace and prosperity. Aid For Trade, in addition to the standard channels for disbursing official development assistance, Aid for Trade for LDCs is also provided through the Enhanced Integrated Framework. Most bilateral donors provide support in the form of grants. Developing-country providers of assistance, such as the United Arab Emirates and Kuwait, increased their commitments in 2013, reaching $1.8 billion and $832 million respectively. Most AfT since 2006 has been disbursed in Asia and Africa, albeit with important year-on-year variations. In 2013, commitments to Africa stood at $19.3 billion, while flows to Asia reached $22.6 billion, or 41 per cent of total AfT that year. It’s Humanitarian, the Ebola crisis has thus underlined the urgent need for intensified international and national action to improve access to health care and medicines. Many countries have materially contributed to the emergency response to the Ebola epidemic. Eradicate Disease, most of the 5 million deaths occurring every year from epidemics of the major infectious diseases—such as HIV/AIDS, tuberculosis, malaria and viral hepatitis—occur in low- and middle-income countries. At the same time, 80 per cent of the deaths in 2013 from non-communicable diseases—such as cardiovascular disease, cancers, chronic respiratory diseases and diabetes—occurred in low- and middle-income countries. Lack of access to essential medicines is one of the contributing factors to these deaths, many of which were preventable. The recent Ebola crisis in West Africa only underlines the imperative to collectively address the problems not only of access but also of innovation. (Force, 2015)

Cons of Foreign Aid

Foreign aid is wasted, such as the post-tsunami reconstruction fund for Aceh and Nias in Indonesia and the Afghanistan Reconstruction Fund- were originally designed to promote ownership and co-ordination, but faulty design features or donor behaviours, such as the use of parallel structures and earmarking of resources within the pooled fund, have at times undermined ownership. These funds have been only marginally able to innovate and leverage resources and knowledge from providers beyond DAC. Foreign aid promotes favoritism, many other countries remain under-aided. In a 2014 survey, the OECD identified seven countries that were under-aided in 2012, considering ODA received from DAC donors. These were the Gambia, Guinea, Madagascar, Nepal, Niger, Togo and Sierra Leone. Bilateral ODA allocations are based on donor-country priorities, often influenced by historic ties with recipient countries, as well as political considerations. Giving financial aid like loans only leave these poor countries deeper in debt and poverty, group of heavily indebted poor countries

The HIPCs also remain vulnerable to natural and man-made shocks. The Ebola outbreak put severe pressure on already fragile infrastructure and health care systems in Guinea, Liberia and Sierra Leone. The International Monetary Fund (IMF), recognizing the urgency of the situation, established a Catastrophe Containment and Relief Trust to provide grants for debt relief to the poorest and most vulnerable countries hit by catastrophic natural disasters or public health disasters, including epidemics. The new trust is intended to complement donor financing and IMF concessional lending. The new instrument has been used to provide debt relief to the three West African countries struck most severely by the Ebola outbreak (Guinea, Liberia and Sierra Leone). (Force, 2015)

What do you think are the top three challenges in the management (including prevention and reducing risk) of PHEIC’s today? Use EBOLA as reference mark.

The challenges observed included the wide geographical dispersion of cases in both Guinea and Liberia, cases in the capital city, Conakry. The population movements along porous boarder were interfering to control measures especially in during 21 days incubation period. Second, the community resistance had joined inadequate treatment facilities and insufficient human resources as a major barrier to control. The importance of community engagement were recognized. Without community engagement and cooperation technical interventions were doomed to fail. Third, strengthening primary health care together with essential capacities to detect and respond to health emergencies. (WHO, 2015)

Research Proposal

Tuberculosis notification in Qatar, 2011-2015: exploration of the completeness and timeliness of data provided by health Care provider.

Introduction

Background

Tuberculosis (TB) is a highly infectious disease and major public health concern globally. According to World Health Organization, 9.6 million people developed TB in 2014 and 1.5 million died from the disease worldwide. (WHO, 2015)

TB is a notifiable disease in Qatar. Any suspected case or confirmed case of TB must notify to Ministry of Public Health to begin investigation and control measu res. Complete and timely notification of TB to the public health authorities is one of the essential components to control Tb. This is done in order to detect any case or any outbreak and prevent further transmission; and to monitor rate of treatment completion and cure rate of TB. (WHO, 1998 p.9).

Tuberculosis is one of the 67 notifiable communicable diseases in Qatar. There are two types of notifications of communicable disease in Qatar. Category one: the incidence is to notify immediately by telephone or fax or email (within 24hrs) and category two is notification as soon as possible (not less than 72hrs). TB belongs to the category one that is notified immediately by telephone or fax or email within 24 hours of identification.

So far, there has been only one study in Qatar (Garcell et al. 2014) that assessed the quality of notifications of data for all communicable diseases. No specific study has explored notification specific to Tuberculosis in terms of timeliness and completeness and there’s no qualitative studies that explored the reasons for poor reporting of TB notification data in Qatar.

Research questions: What is the quality of Tuberculosis notification in terms of completeness and timeliness provided by Health care provider to the Ministry of Public Health in Qatar for 2011-2015? And what are the reasons for the poor quality of reporting?

Objective of the study

1. To explore the completeness and timeliness of Tuberculosis notifications data by the health care provider to the Ministry of Public Health in Qatar in 2011-2015.
2. To explore the reasons for poor reporting of TB notification data
3. To make recommendations about improving the quality of TB data provided by health care provider.

Literature Review

In Global Tuberculosis (TB) 2015 report, out of estimated 9.6 million incident cases of TB globally in 2014, and 1.5 million died of the disease. Compared to other infectious disease, Tuberculosis has been identified as being increase worldwide. Likewise, according to WHO (2015), “despite the advances and despite the fact that nearly all cases can be cured, TB remains one of the world’s biggest threats.”

In Qatar, although, TB is not the main problem but high number of migrant workers from high prevalence of TB contributes to this. The total numbers of cases in 2013 are 465; 97.9 % expatriates mainly young males and 2.1 % were local. Out of this 33.4 % Nepal, 21.1 % Indian, 16.6 % Philippine and other national 23.2 %. (SCH, 2014).

Surveillance is one of the five essential components in the original World Health Organization (WHO) Framework for Effective Tuberculosis Control (the DOTS Strategy). Furthermore, WHO define public health surveillance is the “continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice.” The quality of data of reported cases is essential, hence it is important to report it accurately and completely in timely manner to begin epidemiological evaluation and implement control measures as early as possible (WHO, 2006).

Incompleteness and late reporting of notifiable infectious diseases has been testified previously. Several studies observed late and incomplete notification of infectious diseases (Doyle et al., 2002; Fahey, 2011; Jajosky & Groseclose, 2004; Lo et. al., 2011; Yoo et al., 2009). In Ireland even though infectious disease notification is a mandatory, Nicolay et. al. (2010) point out that incompleteness and timeliness notification also noted. Furthermore, some states enforce a penalty for persons failing to report as required by law (CDC, n.d.). However, according to WHO (2012) TB reporting is not mandatory in all countries, despite the public health importance of TB. Although, TB notification is mandated by law in some states but the enforcement of the law is weak.

Methodology

Design

This study will be quantitative study followed by qualitative study among health care workers. First, we will explore the quality of TB notification form in terms of timeliness and completeness provided by health care provider from different hospital and clinics in Qatar in 2011 to 2015 using secondary data available from the Ministry of Public Health (MoPH). Second, target the health care worker in the health facilities or institutions that has high percentage of incomplete and late notification using individual interview explore the reasons for poor reporting of TB notification data. And make recommendations about improving the quality of TB data provided by health care provider.

Setting

The data with be extracted from TB notification surveillance records held by the MoPH in Qatar provided by the Hamad Medical Corporation (HMC), Primary Health Center Corporation (PHCC), private hospitals and clinics from 1st January 2011 to 31st December 2015.

Inclusion criteria

All suspected or confirmed TB case, resident of Qatar, any national seen by the physician in the government or private hospitals or clinics.

Exclusion criteria

Expatriate who are visitor, nonresident of Qatar and already screened in the medical commission with undetermined TB result.

Data Collection

Data will be extracted from the actual TB notification form forwarded by the consulting physician upon diagnosis of a TB case. A random sample of will be selected for data extraction for this study. The sample of forms will consist of 30% of all forms received by the MoPH 30% in 2011, 30% in 2012, 30% in 2013, 30% in 2014 and 30% in 2015. On yearly basis, the MoPH are notified of 87% cases of TB. Hence, it is estimated that data will be extracted 30% from 487 forms.

The demographic data such as ID, sex, age, marital status, nationality, occupation, place of work, contact number, travel history, immunization status, date of onset of disease, date of notification, referral intuitions and laboratory tests conducted at the time of diagnosis will be extracted from the TB notification form received during the period of 1st January 2011 to 31st December 2015 received by Communicable Disease Control (CDC) surveillance section in MoPH.

The top 4 highest percent of incomplete and late notification in different hospitals and clinic will conduct to the health care workers (2 doctors and 2 nurses/infectious control) an in-depth interview to explore the poor reporting of TB notification data.

Data Analysis

Data will be entered using Microsoft Excel and converted to STATA format and data will be analyzed using STATA version 13.0. The frequency with percentages will be calculated for categorical variable and the mean time and standard deviation from the time of consultation and notification will be calculated to determine the timeliness reporting.

The Chi-square test to be performed to test for differences in proportions of categorical variables between two or more groups. To check for the completeness of the TB notification, the demographic data (such as ID, sex, age, nationality, occupation, place of work, contact number and laboratory tests conducted at the time of diagnosis will be identified through multivariable logistic regression analysis. P value < 0.05 will be regarded as statistically significant.

For the in depth interview, audio-taped will be transcribed and quotes from respondents will be included in the text.

Ethical Consideration

The permission to study and use the data in Surveillance section will be obtained from the Ministry of Public Health, State of Qatar. Patient consent will be taken to the health care worker that will be included in the in depth interviews and explain the purpose of the study. If either they will join or decline; information identity, confidentiality and anonymity of the patient (by code number) are maintained according to proposed protocol. All data with code number will be in secure or locked place where there is no chance that other people could use the information. The notification center will be identified by code only. The data will be saved on password protected computer.

Challenges of the Study

There will be several challenges to this study that include time, money and person. Time, this will be my first and foremost challenges but I can manage it because I already choose and I am determine to my topic. Second challenge is money, in every research it need funds. But if my research proposal will pass to our department protocol they will provide funds for me. This is one of reason I choose topic related to my daily work in our public health department. Third challenges will be health care workers. Here in Qatar, most of the health care worker are busy but I think if my manager will support and make endorsement it will go smoothly.

Expected Outcome

The findings will have direct implications for data quality of communicable disease surveillance system, only in Qatar. It will inform the public health to implement policy and improve clinical practice targeting the hospitals and health centers with significant result of incomplete TB or communicable disease notification. And initiate workshops and training for the HCW appreciate the importance of data quality in health system.