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Keywords:

  • pneumonia mortality;
  • under-fives;
  • Zambia;
  • low birth weight;
  • distance;
  • Mother and Child Health

Summary

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

objective  To determine factors contributing to high mortality caused by pneumonia among children under 5 years of age in Kalabo District.

methods  In a cross-sectional descriptive study 78 mothers and 16 health workers were interviewed using structured questionnaires. Focus group discussions were held with groups of women who did not take part in the survey. Registers, patient records, drug stock control cards, drug stores and equipment were reviewed or checked.

results  Pneumonia is an important public health problem in Kalabo District. Knowledge about the disease and its treatment is inadequate, both in health workers and in mothers. Low birth weight and distance contribute to high mortality. Mother and Child Health (MCH) clinic visits protect against mortality.

conclusion  The community should be educated to recognize the signs and symptoms of pneumonia and to understand the importance of early and adequate treatment. As MCH clinics can play an important role, health workers, especially at rural health centre level, should be re-trained in case definition, case management and the use of available protocols. Strategies to fight the impact of pneumonia in the district should be part of an integrated package of care focusing on all prevalent childhood diseases, as they overlap in many cases.


Introduction

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Kalabo District is one of the seven districts in the Western Province of Zambia, bordering with Lukulu District in the north, Mongu District in the west, Senanga and Shangombo Districts in the south and Angola in the east. The district covers an area of 17 447 square kilometres and has a population density of 7 per km2, with a total population of 114 996 (CSO 1996). There are no tar roads, no organized public transport, very few vehicles and poor communication infrastructure.

The district has two hospitals and 14 rural health centres, where 146 community health workers (CHWs) and 76 trained traditional birth attendants (tTBAs) deliver health services at community level. The district health services are facing a critical shortage of staff, resulting in only three of the rural health centres being staffed by a clinical officer. In all other centres, other cadres deliver curative services, including the treatment of pneumonia.

Recent global estimates indicate that 10 million children aged below 5 years die annually and that 99% of these deaths occur in developing countries, with 70% caused by infections. According to 1985 estimates by the World Health Organization and the United Nations Children's Fund, acute respiratory infections are the primary cause of mortality in children under 5 years (4.1 m p.a.), followed by diarrhoeal diseases (3 m), measles (1.16 m), and malaria (0.9 m). Malnutrition contributes to about one-third (29%) of these deaths (WHO 1995a).

The annual reports of Kalabo District Health Service document pneumonia as the primary cause of mortality and the second largest cause of morbidity in children under 5 years of age, ever since proper data became available in 1992. The case fatality rate in the health institutions in Kalabo District has been between 10% and 15% (Kalabo District Health Services Year?).

The 1990s have seen a remarkable decrease in mortality among infants and children in most developing countries. In some countries, particularly in sub-Saharan Africa including Zambia, decline in mortality among children has slowed and is now increasing again (Rutstein 2000). The pandemic of HIV/AIDS, which also affects children, plays an important, although not yet measured role. Zambia is badly affected by HIV/AIDS. The HIV prevalence in the population aged 15–49 years in Zambia was estimated to be 19.7% in 1998, and is still increasing (CBoH 1999).

Much research has been carried out to identify risk factors and contributing factors for pneumonia. These are numerous and vary between studies: chest indrawings, raised respiratory count, hepatomegaly, age < 1 year, grunting, malnutrition, low birth weight, history of previous admission, smoking caretakers, underlying heart disease and day-care attendance are among the most mentioned factors (Deivanayagam et al. 1992; Suwanjutha et al. 1994; Gupta et al. 1996; Demers et al. 2000; Rice et al. 2000).

The District Health Management Team has made use of assumptions to develop strategies to reduce the morbidity and mortality caused by pneumonia for many years, without exactly knowing the important factors in Kalabo District. Findings from supervision visits by members of the District Health Management Team led to retraining of health workers, with emphasis on the treatment of dual infection with malaria and pneumonia, a combination which is also mentioned in the literature as important with regard to mortality caused by pneumonia (English et al. 1996). The possible important role of CHWs in case detection and management of pneumonia (Mehnaz et al. 1997) was also acknowledged. CHWs and rural health centre staff were re-trained in case definition, case management and the indications for referral between 1997 and 1999. Emphasis was placed on the use of simple clinical signs, such as counting the respiration rate and checking for chest indrawings. Although some authors complain about the insufficient sensitivity of such signs (Falade et al. 1995), it is the only possible method in a rural district like Kalabo. Buffer stocks of essential drugs for treatment of pneumonia were secured and the referral system for patients suffering from severe pneumonia – another important step to decrease mortality figures (Rasmussen et al. 2000) – was improved at all levels. Nevertheless, there was no improvement in mortality and morbidity figures and case fatality rates (Kalabo District Health Services Year?).

Objectives

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

This study aimed to identify the factors that contribute to high mortality of pneumonia among under-fives in Kalabo District, with the final objective to formulate feasible recommendations to the District Health Management Team to reduce pneumonia mortality and to reduce the case fatality rate for pneumonia from 12% to 5% in the coming 2 years. Specific objectives were to confirm and determine the magnitude of pneumonia mortality in under-fives and to get a holistic picture of factors contributing to mortality by using several sources of qualitative and quantitative data.

Methods

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

A cross-sectional descriptive study was conducted. The relationship between the problem and contributing factors was studied in a range of communities with different views, perspectives and environments. A team of four specially trained health workers who used standardized methods collected all data. Questionnaires were pre-tested in the catchment area of one rural health centre that was not included in the study, to enable the researchers to try out and revise the methods and logistics for data collection. Appointments for interviews were made well in advance. Village headmen and rural health centre staff were the first contacts. They were informed in advance, seeking authority to conduct the study in their areas. The local language (Silozi) was used in all interviews and discussions.

We cluster-sampled the catchment areas to determine the study unit. Six of 14 rural health centres in the district were selected by lottery: Sihole, Liumba, Tapo, Kuuli, Kaluwe and Mambolomoka. Each health centre was visited once. Mothers or caretakers of patients under 5 years of age, diagnosed with pneumonia, were randomly selected from the rural health centres' outpatient registers and then visited at home for interviews. The caretakers of every third child were selected. Interviewers received full-day interview training.

Three groups were interviewed, using structured questionnaires: (1) 78 mothers of children under 5 years of age who suffered from pneumonia in 1999, (2) four health workers from the two hospitals and (3) all 12 health workers from the six selected rural health centres in the district. The sample size of mothers was conveniently determined as 20% of the total number of pneumonia cases in 1997. The health workers at the hospitals were randomly selected and interviewed to determine the quality of case management standards. No untrained health workers were included in the study. Possible answers to ‘knowledge-questions’ were categorized in advance. To determine knowledge about the case definition of pneumonia among health workers, a standardized grading, in line with the standard case definition from the WHO (1995b), was used. A comparable grading was used for testing mothers' knowledge about the signs and symptoms of pneumonia. Those who mentioned four or more correct signs or symptoms were counted as having good knowledge; less than two were counted as bad and 2–4 as scanty.

Six focus group discussions were also held with 15 mothers each, who were found at the rural health centres' premises at the time of the visit. The participants in the focus group discussions were not included in the interview group. The focus group discussions served to discuss some of the findings from the questionnaires with mothers in a friendly, protected and traditional atmosphere, thus encouraging the mothers to talk freely. The principal investigator chaired the discussions and one of the other research team members recorded. The other two members of the research team recorded their observations. After the meeting, the full discussions were transcribed and analysed by the entire team.

Registers, outpatient records, quarterly returns and inpatient records at the six selected rural health centres were checked to establish the diagnostic skills, case management and prescription habits of health care personnel. The findings were used to evaluate the results from the questionnaires and as a starting point in discussions with the health workers. Stock control cards and drug stores were checked to see the stock levels of drugs (antibiotics) used in the treatment of pneumonia.

Data were analysed using frequency and cross tabulation tables. Chi-squares were calculated by hand for most correlations. As the study was conducted without computers, no further statistical programmes could be used.

Results

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

Structured interviews with 16 health workers showed that they considered pneumonia to be one of the major causes of death and disease in the district. Of the health workers, 81% mentioned pneumonia as one of the top five causes of morbidity and 88% mentioned pneumonia as one of the top five causes of mortality in Kalabo District. In focus group discussions mothers also confirmed that pneumonia is one of the major causes of death and disease of their children.

The same health workers were asked to give the case definition for pneumonia. Only four respondents had full knowledge of the case definition, nine had scanty and three no knowledge at all. Regarding the question how to diagnose pneumonia in young children only two mentioned counting the respiration rate.

The case management for pneumonia turned out to be unstandardized. Only three respondents said they had treatment protocols in their institution. Indications for admission to the ward were also not clear; eight respondents said they always admitted patients with pneumonia, the other eight did not. The drug of choice was benzylpenicillin for 14 of the interviewed health workers, which is still the first choice according to the National Guidelines [Central Board of Health (CBoH) 1996]. Other drugs that were mentioned were cotrimoxazole, amoxycillin and procaine penicillin. Ten health workers gave benzylpenicillin injections four times daily (the correct treatment regime), one three times daily, one two times daily and four once a day. The duration of the treatment was 5 days in 14 and 3 days in two cases, according to the health workers.

Because of the critical shortage of trained staff in the district, only eight of 16 prescribers interviewed were clinical officers, which is still an overestimation of the real situation. Other cadres who prescribe drugs, including antibiotics, were nurses (6) and environmental health technicians (2). The drug position was good in four of the rural health centres that were visited, with sufficient stocks of eight essential drugs from a monitoring list throughout the year. In one health centre, it was bad (absence of at least two essential drugs in all quarters of the year) and in one, it was fair. The main reasons mentioned for the poor drug situation were insufficient distribution because of long distances and floods.

Eighty-eight per cent of interviewed health workers valued the referral system as poor. They said that many mothers go back to their village with their children after they have been referred to the District Hospital caused by long distances, poor transport system, financial problems and poor communication between the units.

Comparable variables that were investigated in interviews with health workers were also tested in the community. In 96% of cases, the respondent was the mother of the child, in 4% it was an aunt. All respondents were taking or took care of a child below 5 years who suffered from pneumonia in the year before. In 47% of cases, the child was <1-year-old on the day of the interview, in 28% between 13 and 24 months and in 19% between 25 and 60 months. Twenty-seven per cent of respondents were 16–25 years and 65% 26–49 years old. Differences in mortality and case fatality rates for housing standards, distance to the health institution, delay in seeking medical care, low birth weight, Mother and Child Health (MCH) attendance and nutrition status are summarized in Table 1.

Table 1.  Potential factors associated with mortality from pneumonia in under-fives in Kalabo, Zambia
 FrequencyPercentageCases of deathCase fatality
Housing standards and pneumonia mortality (type of house) (χ2 = 0.166)
 Unventilated57 73712/100
 Ventilated21 27210/100
Distance and pneumonia mortality (walking time) (χ2 = 15.251; P < 0.001)
 <1 h49 6336/100
 >1 h29 37621/100
Number of days before seeking medical care (delay in days) and pneumonia mortality (χ2 = 2.031)
 113 1700
 213 17215/100
 >252 66713/100
Low birth weight and pneumonia mortality (χ2 = 14.9; P < 0.001)
 Birth weight <2500 g18 23422/100
 Birth weight >2500 g23 2929/100
 Birth weight not known37 4738/100
MCH attendance and pneumonia mortality (χ2 = 16.632; P < 0.001)
 Attended68 8746/100
 Did not attend10 13550/100
Nutrition status and pneumonia mortality (χ2 = 2.241)
 Above third centile58 7423/100
 Below third centile10 13220/100
 No growth card10 13550/100
 Total78100912/100

The socio-economic situation of most respondents and their children turned out to be poor, with 73% of respondents living in temporary and unventilated accommodation, but type of housing was not correlated to mortality and did not influence the case fatality (Table 1). Mortality and distance are strongly correlated; the difference between mortality in the ‘less than 1 h group’ and the ‘more than 1 h group’ was statistically significant. Delay in seeking medical care at a health institution was prevalent with 66% of respondents delaying more than 2 days before going to the clinic. However, the differences found in mortality were not significant.

The birth weight of children was known in 53% of cases, which means that they were born in a health centre, hospital or under the supervision of a tTBA or a CHW. The relation between low birth weight and mortality caused by pneumonia was quite clearly confirmed in the study. Of a sample of 18 children born with low birth weight (<2500 g) 14 were alive. The other four had died of pneumonia, giving a case fatality rate of 22%, which is significantly higher than the other groups (birth weight unknown and >2500 g) with case fatality rates of 9% and 8%, respectively.

The relation between nutrition and pneumonia was investigated by comparing findings from the growth monitoring cards with mortality caused by pneumonia. A significant correlation was found between MCH care attendance and pneumonia mortality (Table 1) with the highest case fatality rate (50/100) in the group of children who did not come for growth monitoring. No significant difference was found between children above and below the third percentile in weight and height for age curves, although a clear difference in case fatality rate was found.

The mothers, who mentioned treatment with injections in 83% of cases, confirmed the finding among health workers that 88% use benzylpenicillin injection as the treatment of choice. The answers about frequency of treatment, although, showed remarkable differences with information provided by health workers, 63% of whom said they give benzylpenicillin injections four times daily, 6% three times daily, 6% two times daily and 25% once a day. However, only 35% of the mothers mentioned to have received treatment for their children four times a day, 23% three times daily, 24% two times daily and 17% one time daily. In focus group discussions, mothers mentioned that health workers sometimes just leave the station, so that injectables are not given.

The mothers' knowledge of signs and symptoms of pneumonia was also tested. Only 23% were very familiar with the cardinal signs and symptoms of pneumonia (mentioning at least four signs and symptoms); 58% had scanty information (mentioning two or three) and 19% of respondents had no knowledge (mentioning less than two signs and symptoms). Hence less than a quarter of caretakers can take a correct and timely decision about attending a clinic. In focus group discussions, mothers, including the group with good knowledge of signs and symptoms of pneumonia, mentioned that pneumonia and severe malaria are difficult to distinguish.

The guardians were also asked about the barriers to visit health institutions. No money to pay user fees was mentioned as an obstacle by 36% of the caretakers and lack of transport possibilities by 4% of respondents. Fifty-nine per cent did not perceive any barriers. The issue of ‘no money to pay the user fees’ was intensively discussed with the mothers in the focus groups, as, according to the policy, children below the age of 5 years are excluded from paying medical fees. It was mentioned that some health workers, especially in the health centres, do charge a fee, even for small children. Most mothers did not know that they did not need to pay for treatment of their under-fives.

Patient satisfaction was high, with 94% of respondents appreciating the treatment. Even some of the mothers who lost a child acknowledged that the health staff did everything possible, but said that ‘the child had not come to stay with them’, showing fatalism in a society with child mortality exceeding 10%.

Discussion

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

The small sample size, especially regarding health workers, combined with the low number of deaths, resulted in limited statistical power. As a result, only marked associations were significant. All data analyses, frequencies, cross-tabulations and chi-squares, were carried by hand and confounding was not examined. For some of the tables chi-squares were not valid because of low cell frequencies. Nevertheless, the use of both quantitative and qualitative methods complementing each other, in this simple health system research, allows the reader to draw some conclusions concerning factors contributing to high mortality caused by pneumonia among under-fives in Kalabo District. This is an example of demand-driven research conducted by locally trained health managers, which was conducted with a very low budget and led to results and recommendations which could immediately be implemented at the same local level. As such, it shows progress in the Zambian health system, where local health workers at the district level were trained to use health system research as a tool for policy and planning purposes.

Structured interviews with 16 health workers showed that they considered pneumonia to be one of the major causes of death and disease in the district. Focus group discussions with mothers revealed that they recognized pneumonia as a serious disease and perceived it to be an important cause of death of children in the community. The case fatality rate in this study was 12%. Case management of pneumonia was inconsistent and not standardized, which shows that former training programmes, preservice and in-service, have been ineffective, although turnover of staff should be considered, as far as efficacy of in-service training is concerned. Half of the respondents answered that they do not usually admit under-fives with pneumonia, which probably means that many patients die in the community. This indicates that institutional data can never give a full picture of the situation. We also discovered that some health workers do things differently from what they say: 87% recommended the use of benzylpenicillin as a first-choice treatment, but one wonders how this treatment regime (four times daily) can be followed in outpatients. Only 35% of the mothers confirmed that their children had received the injections six-hourly.

Half of the rural health centres visited are operated by personnel who are not adequately trained to run curative health services. Surprisingly health workers do not appreciate the Integrated Technical Guidelines for frontline health workers, provided by the Central Board of Health (CBoH 1996) and available in all institutions, as a treatment protocol.

An alarming finding is that there is hardly any difference between knowledge about the case definition of pneumonia between health workers and mothers. This means that making an informed, timely and correct decision about seeking care or referring a patient is not possible in many cases. Other authors have mentioned comparable findings. In Bangladesh 8.5% of 56 physicians were found not to record any signs of severe pneumonia to support their diagnoses. A majority of Pakistani mothers were found to recognize the most important risk factors for pneumonia, but were not able to see the seriousness of the signs (Kundi et al. 1993; Mull et al. 1994).

Inadequate growth (below the third percentile on the growth chart) was not likely to be a risk factor in this study, but not attending the MCH clinics at all showed a very strong correlation with pneumonia mortality. It means that efforts to encourage mothers to visit the clinics should be continued and intensified, especially if education about the prevention of pneumonia and the recognition of early signs can be integrated in the education sessions. Knowledge of health workers, the facilitators during the education sessions, should be improved first.

The birth weight was known in 53% of cases, which means that the percentage of mothers who delivered under supervision of a trained health worker (hospital, health centre, trained traditional health worker, CHW) was quite high in this selection, compared with other available data, giving the percentage of supervised deliveries as 25–40% in Kalabo District. The sampling method probably resulted in selecting respondents familiar with the delivery of health services at the health centres, thus leading to better use of services. However, birth weight <2500 g was an important contributing factor to pneumonia mortality. It must be borne in mind that other adverse factors such as HIV/AIDS, tuberculosis, syphilis, malaria and anaemia, which are associated with low birth weight and malnutrition, can also contribute to this finding (Perry et al. 2000; Graham et al. 2001; Zar et al. 2001). Reliability of clinical diagnoses of rural health centre staff is limited as was concluded earlier. Differentiation between malaria, tuberculosis and severe anaemia can be difficult.

Selection criteria for community respondents were based on the history of pneumonia in one of their children, diagnosed by a health worker in one of the Clinics. As diagnostic skills of health workers were found to be poor, it is possible that some of the respondents' children suffered and died from a disease other than pneumonia, implying that mothers were selected wrongly because of insufficient diagnostic skills of health workers. Most probably, mothers of children who once suffered from pneumonia but never attended a clinic were not included in the study.

Shortage of drugs was not a contributing factor. Most rural health centres had had sufficient stocks of essential drugs in the previous four quarters. However, it is a known fact that supply of drugs in Zambia is not reliable. Shortage of drugs can still be an important contributing factor to mortality from pneumonia at other times. Distance patterns were not studied and no literature data from Zambian studies could be found, but penicillin resistance, especially for Streptococcus pneumoniae, could be another factor of concern. More research is needed in Zambia to investigate the possibility of resistance contributing to treatment failures and mortality.

There was no clear relation between housing and pneumonia case fatality rate, although the overall picture of a very poor socio-economic situation and poverty definitely contributes to high incidence and mortality caused by pneumonia. The ventilation of houses did not show a significant correlation with pneumonia mortality. One might question whether ventilation is a true indicator for socio-economic development or not. On the other hand, the direct effect of ventilation could be an increase in morbidity, but not in mortality.

Delay in receiving adequate medical care did not make a statistically significant difference. However, one of the reasons for delay, distance, does have a significant impact on mortality. Those who have to walk more than 1 h have a higher risk of dying. In focus group discussions, other reasons for delay were mentioned: long waiting hours in the institutions and user fees; they prefer to wait to see whether the child will recover on its own. Leaving other children at home, an unwilling husband and shortage of food to eat during travelling and blankets form other barriers for women to travel to a clinic. Mothers confirmed in focus group discussions that on most occasions they do not follow the advice of CHWs to go to the clinic. The same situation counts for referrals from rural health centres to the hospitals, distance and lack of transport again being the most mentioned reasons. Apparently, a combination of rather practical reasons forms barriers for women to travel to and visit health institutions.

The performance of available CHWs and the possibilities for training more of them were not assessed in this research because of limitations in resources. Another study in 2000 showed performance problems of CHWs in Kalabo District, mainly because of poor selection criteria and overemphasis on curative services. But input of CHWs is a possible way of closing the gap between supply and demand of health care. As distance remains an important factor related to morbidity and mortality caused by pneumonia in Kalabo District, the health system should continue to concentrate on the performance of CHWs. Their active case finding and case management has a significant impact on mortality (Dutta 1978). In rural districts in Zambia and other countries of sub-Saharan Africa heavily suffering from the HIV/AIDS pandemic, the human resource crisis will not be solved in the next 10–20 years (Stekelenburg & Sikanda 1998). Training and use of CHWs remains one of the few achievable, affordable and sustainable solutions, to contribute to achieving a situation of ‘equity of access to a cost-effective quality health care’, as close to the family as possible.

Conclusions

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

The problem of high mortality caused by pneumonia is generally perceived as a public health problem, from both the health service and community point of view. Incidences, mortality and case fatality are high. The disease deserves full attention from the District Health Management Team. Because of the HIV/AIDS epidemic the burden of diseases caused by or related with HIV will continue to play a major contributing role to high mortality in under-fives, including mortality from pneumonia (Taha et al. 1999; Mahdi et al. 2000). In Kalabo District, knowledge about pneumonia, both in the communities and in health workers, is inadequate. This leads to a situation where mothers are not able to decide when to seek medical care and health workers do not know when to refer the patient to higher levels of care. Diagnostic and treatment skills are also poor. None of the health workers use treatment protocols, though available in all institutions. Low birth weight and long distances from home to the health institution, in combination with several rather practical barriers, are contributing to mortality. Children who do not visit the MCH clinics have a higher risk to die from pneumonia.

Recommendations were formulated to the Central Board of Health, the District Health Management Team, and the rural health centre staff, to redress the problems and weaknesses identified in the study. The District Health Management Team should concentrate on education of the community (Muhe 1996; Van Ginneken et al. 1996), CHWs and rural health centre staff (trained health workers). Strategies to fight the impact of pneumonia in the district should be part of an integrated package of care, focusing on all prevalent childhood diseases, as they often overlap (WHO 1995b). The community should be further educated to recognize the signs and symptoms of pneumonia, to know and interpret danger signs adequately and to understand the importance of early and adequate treatment. Health workers should be re-trained in case definition, case management and the use of available protocols. Many studies have shown a positive impact on pneumonia mortality from training health workers and communities (Mtango & Neuvians 1986; Sazawal & Black 1992). Further research is necessary to find out why earlier training sessions were not effective in Kalabo.

The history of the epidemiology of diseases shows the key of success in decreasing mortality. Between 1939 and 1996, the mortality from pneumonia in children in the United States declined markedly. After the introduction of penicillin, improved access to medical care for poor children has played the most important role (Dowell et al. 2000). Poverty reduction in developing countries, as a long-term strategy for development of co-operation policies, will improve access to medical care, positively influence many other factors contributing to high incidence of pneumonia and, thus, eventually decrease mortality.

Acknowledgements

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References

We thank the Central Board of Health and the Royal Netherlands Embassy for facilitating the course in District Health Management; Mr H.E. Sawyer and Dr H. Vandenhoudt for supervision during the study; late Mr C.W. Wakung'oli, late Mr M. Saeli, Mr Junior Sitali, Mr M.M. Mukelabai and Mr C. Munalula for their support.

References

  1. Top of page
  2. Summary
  3. Introduction
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Conclusions
  9. Acknowledgements
  10. References
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