Programme activities: a major burden for district health systems?

The dual nature of dealing with health problems has been recognized since antiquity. Asklepios, the god of medicine in ancient Greece, had two daughters: Panacea – the goddess of healing and cures, and Hygeia – the goddess of welfare and hygiene, symbolizing curative and preventive medicine respectively. It is well understood nowadays that these two approaches blend: the range from primary and secondary prevention over curative to rehabilitative and promotive action is a continuum rather than a series of neatly separated concepts and activities. Nevertheless, there is a fundamental difference in the people the two approaches are dealing with: curative medicine deals with people who are ill, often acutely so, whereas preventive activities are largely directed at people who are not (yet) ill or only slightly so. Therefore, preventive activities can be organized in a periodic fashion, but curative activities are timely only when carried out at the moment people are ill and thus need to be permanently available – ideally. In present day health services, certainly in developing countries, both approaches are combined, most often in the same health structure and by the same health personnel (WHO 2006). Over the last decades an increasing number of health problems have been identified as priorities, based on their estimated contribution to the overall burden of disease and the availability of cost-effective measures, many of which are related to secondary prevention (Hotez et al. 2007, Johns & Tan Torres Edejer 2003). In a typical West-African country, a list of such problems and measures may (and often does) include Guinea worm, tuberculosis, vitamin A supplementation, schistosomiasis, soil transmitted helminthiasis, trachoma, vaccine preventable child illnesses, reproductive health and malaria, with variable importance given to HIV. All these health priorities are implemented at regional and district level through various strategies such as punctuated mass campaigns or regular outreach activities, each of which requires specific training and temporary mobilization of health workers, and thus valuable time and attention. In Douentza, a rural health district in Mali, we determined the relative importance of the time spent by qualified staff in charge of first line health services on activities requiring their absence from the health centre. We distinguished activities related to their general duties, and specific programme activities, including district mass campaigns. Data for the year 2006 were collected from district reports and administrative district and regional documents. The information concerned first line health care structures (a total of 15 health centres, with 14 situated in rural areas and one in the district’s central town) and their nurses in charge. Table 1 shows that in 2006 the nurse in charge of the health centre was absent during 81 working days in the case of the district central town health centre, and during 118 working days in the case of rural centres. This difference in days of absence is related to the time needed for the nurses in rural areas to reach the district’s central town, where training activities generally take place. In the ‘worst case’ scenario, which applies to the majority of health centres situated outside the district’s central town, the total annual nurse’s absence (118 working days) represents more than half (52%) of the annual total number of working days (225 days per year). Of these 118 days, 69 (58%) were directly attributable to specific programme activities, with mass campaigns being the principal component (Table 1). Mass drug distributions to control and eliminate trachoma, schistosomiasis and soil-transmitted helminthiasis as well as vitamin A distribution campaigns were carried out in the district in 2006. The nurses in charge were instructed to participate in Tropical Medicine and International Health doi:10.1111/j.1365-3156.2008.02174.x