NEEDS ASSESSMENT OF MATERNAL AND NEONATAL HEALTH IN EQUATORIAL GUINEA:
TRIP REPORT
CONDUCTED FOR EG LNG BY ENGENDERHEALTH
NEW YORK, NEW YORK
OCTOBER 15-23, 2007
Pr. Robert Leke
Suzanne Stalls, CNM
TABLE OF CONTENTS
I. Acknowledgements…………………………………………………………………………..3
II. Acronyms……………………………………………………………………………………..3
III. Background…………………………………………………………………………………...4
IV. Scope of Work/Methodology………………………………………………………………..5
V. Key Informant Interviews/Site visits………………………………………………………..5
VI. Findings…………………………………………………………………………………….....9
A. General Information…………………………………………………………………....9
B. Maternity Unit…………………………………………………………………………...9
C. Family Planning Unit………………………………………………………………….10
D. Pediatric/Neonatology Unit…………………………………………………………..11
VII. Conclusions/Recommendations…………………………………………………………..12
A. Physical Plant…………………………………………………………………………12
B. Equipment……………………………………………………………………………..12
C. Management/organization…………………………………………………………...13
D. Training and education……………………………………………………………….14
VIII. Appendices………………………………………………………………………………….16
A. Persons contacted……………………………………………………………………16
B. Questionnaires………………………………………………………………………..17
C. Equipment list…………………………………………………………………………26
D. WHO documents……………………………………………………………………..27
I. ACKNOWLEDGEMENTS
The consultants for EngenderHealth, Pr. Robert Leke and Suzanne Stalls, CNM, are indebted to multiple organizations and people for the support and assistance they received during their visit to Malabo, Equatorial Guinea. Our deepest gratitude goes to the personnel of EGLNG for their patience and vision: Drew Scoggins, Community and Public Relations Coordinator and his able team, Jeremías Nimo Barleycorn (Community Development) and Teofilo Dougan Champion (Community Relations). We are grateful that the leadership of EGLNG, Ken Woodworth, Managing Director, and Bonifacio Monsuy Nsue, Deputy Managing Director, has the willingness to serve the community and country of Malabo, Equatorial Guinea. Our thanks go to the many clients, providers and administrators of the hospitals, health centers and clinics that we visited and who were so gracious in answering our many questions and taking time during their busy days.
Our desire is that from this work will spring ideas that become the reality of improving the health of the women and children of Equatorial Guinea. We dedicate this report to them.
II. ACRONYMS
ACNM American College of Nurse Midwives
ART Anti-retroviral therapy
ATS Asistente tecnico sanitario (diplomate nurse)
BAD African Development Bank
CEMAC Comisión Económica y Monetaria de Africa Central
CFA Franco de Africa Central (monetary unit)
HIV/AIDS Human Immuno-Deficiency Virus/Acquired Immuno-
Deficiency Syndrome
STI Sexually transmitted infections
VCT Voluntary counseling and testing (for HIV)
WHO World Health Organization
III. BACKGROUND
A. General information
Equatorial Guinea is one of the smallest countries on the African Continent with a total surface area of 28051 square km. It gained its independence from Spain on 12 October 1968. The country is composed of a mainland portion and five inhabited islands. Administratively the country is subdivided into seven provinces and Malabo is its capital.
The present ruler has been in power for 28 years (since 1979). Equatorial Guinea has experienced rapid economic growth due to the discovery of large offshore oil reserves within the last decade and has become the 3rd leading sub-Saharan Africa’s oil exporter. It now has the 4th highest per capita income in the world after Luxemburg, Bermuda and Jersey.
Nevertheless the living conditions of the populations do not reflect this massive oil boom and massive increase in government revenue. And despite the wealth generation, it is still essentially an agricultural country where subsistence farming predominates. Government officials and their families own most of businesses in the country. Equatorial Guinea is a member of the Central Africa economic union (CEMAC). Its natural resources include: petroleum; natural gas, timber, gold, bauxite, diamonds, gravel and sand. Several sources cited the population of Equatorial Guinea from between 551,201 to one million inhabitants, of which 41.5% is below 14 years of age. Substantiated data is difficult to obtain regarding health statistics, both nationally and regionally.
B. Health statistics
Life expectancy in Equatorial Guinea is low at 45 years for males; 47 years for females.
The country has the highest rate of malaria in Sub-Saharan Africa. Total fertility rate is 4.48 children per woman. The HIV/AIDS prevalence rate is 3.4 % with 5900 people living with HIV/AIDS. Maternal mortality ratio in Equatorial Guinea is 880 per 100,000 live births. Infant mortality is very high at 87 per 1000 births. General expenditure on health as a percentage of total government expenditure is 7%.
C. Health personnel
According to estimates developed by WHO/ UNICEF/ UNFPA the health personnel is distributed as follows:
Number of physicians 153 (2004)
Number of Nurses 218 (2004)
Number of Midwives 53 (2004)
Number of Pharmacists 121 (2004)
Number of Dentists 15 (2004)
Number of Community Health Workers 1275
Health Management and Support workers 74
According to estimates, 64.5% of births are attended by skilled providers and the vaccination coverage for children is 54%.
It is also important to note that a recent presidential decree of November 2006 increased the budget to fight HIV/AIDS by HIV testing in all the districts and makes anti-retroviral drugs accessible and free of charge for all, especially for pregnant women and children under 5 years of age.
IV. SCOPE OF WORK/METHODOLOGY OF THE NEEDS ASSESSMENT:
A. Preparation phase:
During this phase of the study the team conducted desk research on Equatorial Guinea, which yielded the demographic and health data presented here in the introduction. The team then developed different questionnaires, which were used as guides in semi-structured interviews with key informants during the site visits. (See Appendix A).
The list of the key informants drawn up by the team included:
· The Director of Medical Services in the Ministry of Health
· The Director of Reproductive Health in the Ministry of Health
· The Director of the Malabo General Hospital
· The Technical Director (Medical Advisor) of the hospital
· The Director of Nursing of Malabo Hospital
· The Chief of Service at the Malabo Hospital Maternity Unit
· The Chief Nurse of the Prenatal and Family Planning Clinic
· The head of Pediatrics and Neonatal Services of Malabo Hospital
· The Head of Statistics and Health Information Services of the hospital
· The head of the Blood Bank of Malabo Hospital
· The Head of Policlinic Dr. Loeri Comba
· The community and social coordinator of EG-LNG
After the preparation phase, site visits and observational evaluations started on Monday, 15 October 2007.
V. KEY INFORMANT INTERVIEWS/SITE VISITS
A. Director General, Technical Director, Malabo Regional Hospital
During the inaugural meeting, the consultants met with Mr. Domingo Ndong Mba, director general and Dr. Andrés Nguema, technical director. Mr. Ndong had been appointed to his position the week prior to the consultants’ arrival. Before that time, Dr. Nguema was acting director general. Mr. Ndong comes to his post with an academic background of forestry, environmental studies and accounting. Dr. Nguema is a pediatrician who completed his studies in Russia.
Malabo Regional Hospital is the largest hospital in Malabo and serves as the referral hospital. It has a 300 bed capacity, with an occupancy rate of approximately 70%. The hospital is government owned, though semi-autonomous and salaries for employees (including providers) are paid by the government. At this time, the cleaning services for the hospital are contracted to a privately-owned cleaning service. The hospital offers 26 specialties with a total of 60 physicians and has 24 specialists on staff, most of whom are Cubans. However, there are no pathologists or laboratories on the island. The governments of Equatorial Guinea and Cuba have an agreement, which permits Cuban physicians to spend two years in the country, at which point they rotate back to Cuba. In the last six years, a medical school has been established in Bata, the second major city of Equatorial Guinea, located on the mainland. Approximately 25 students recently completed their six-year course of study and some of them were placed at the hospital for their final year of clinical rotation. Medical school for these students begins the year after completion of secondary school, if they are able to pass a qualifying exam. According to interviews conducted by the consultants, the Cuban physicians were primarily responsible for the supervision of these students. Most physicians who were interviewed received their training in a variety of other countries, including China, Russia and Cuba.
When questioned regarding the biggest challenges facing them as administrators, both Dr. Nguema and Mr. Ndong replied that the condition of the building where the maternity unit is housed is of utmost priority. They would like to see the building renovated or destroyed and rebuilt. They also agreed that updated equipment and personnel training is needed.
B. Director of Nursing, Malabo Regional Hospital
The consultants then met with Luis Manuel Suakin, the director of nursing. Mr. Suakin advised that the nursing staff total 303, with 40 diplomate nurses and 262 auxiliary nurses. Two schools of nursing for auxiliary nurses are found in Malabo and one school of nursing for diplomate nurses (called ATS by the Guineans) is associated with the medical school in Bata. Auxiliary nurses are eligible to begin nursing training after completing four of the six years of secondary school; diplomate nurses complete a 3 year course of study after finishing all six years of secondary school. Because of the paucity of diplomate nurses, many are placed in administrative positions so that auxiliary nurses are primarily responsible for direct patient care. These auxiliary nurses, by default, then have the same scope of care as diplomate nurses. The director is attempting to keep nurses working in the same unit for extended periods of time so that there is not constant turnover. He is currently working with a Spanish foundation (FUDEN) to begin a project to upgrade auxiliary nursing skills with the ultimate goal of sending promising nurses to complete their “diplomado”. Mr. Suakin did state that there are four bachelor’s degreed nurses but they are Cuban and function as specialists. The salary of an auxiliary nurse is ~100,00CFA per month and that of a diplomate nurse is ~120,000CFA per month. His biggest challenges are on-going training/upgrading skill level and the lack of materiel. He said that nurses often lack the most basic of equipment, such as thermometers.
C. WHO Country Representative, Dr. Pierre Mpele
The team, accompanied by Mr. Drew Scoggins and Jeremias Barleycorn, met with the WHO representative in Equatorial Guinea, Dr. Pierre Mpele. During this meeting, many discussion points arose and Dr. Mpele was helpful in providing information regarding maternal child health, and public and private sector policies, in Equatorial Guinea. There is a lack of health statistics and health information in EQ, which unfortunately hinders realistic evaluation. One of Dr. Mpele’s urgent proposals is that of conducting a countrywide Demographic and Health Survey (DHS). WHO is also strongly advocating for involvement by the Ministry of Social Affairs and the Promotion of Women (Ministerio de Asuntos Sociales y Promcion de la Mujer) with any maternal child health policy or project. The Ministry of Health, in conjunction with WHO, and in conformance with the African Road to Health (La Hoja de Ruta Africana) adopted by the African Union in 2004, has published a Road to Health document which pledges to reduce maternal mortality by 75% by the year 2015.. Dr. Mpele solicited EG-LNG as a partner in this road map, which will include other allied ministries, such as the Ministry of Health. The priority intervention that WHO is suggesting for EGLNG is in the domain of training. This training should include monitoring and supervising the trainees for about six months. The WHO representative further advised that the intervention of EG-LNG at the Malabo Regional Hospital should be considered as a pilot program, with the ultimate goal of linking and upgrading outlying health centers to the referral hospital.
The other priority projects that WHO and the other partners are following are: vaccination coverage (Currently at 54%) with a target of 80% of all children by the end of the year and a reinforcement of management systems in the hospitals. In conclusion, the consultants recognize the good working relationship between EG-LNG and WHO and are pleased to note that the proposals of the WHO representative correspond well with those proposed by the assessment team in the area of training, management and organization.
D. WHO Reproductive Health Coordinator, Dra. Mercedes Bori
The consultants, in conjunction with the EG-LNG community development team, also met with Dra. Mercedes Bori, a Guinean physician who trained in Spain and who has worked many years in the Malabo maternity unit before coming to WHO. We reviewed with her our findings to date and she made a number of very pertinent comments. She confirmed that reliable statistics are unavailable but in talking about the volume of births per year, she estimated that it was likely to be upwards of 3,000 births annually, rather than 2,000. We also reviewed with her the list of materiel from the Ministry of Health and the hospital and a number of adjustments were made. Please see Appendix C. She reinforced the statements of all the other key informants by stating that health personnel need updated training. Most particularly, she said, one of the most pressing needs was the education and training of midwives. At this time, there are only five nurse midwives working in the entire country. Her opinion is, to assure that the caliber of training matches the responsibility inherent within the profession, that the school of midwifery in Bata needs a review of curriculum and technical assistance for the professors.
E. Site Visit to Dr. Alfredo Alogo Mba, Private Clinic
Dr. Alfredo ALOGO MBA is a Pediatrician trained in China and Cuba. He runs a private clinic but works half time at the social insurance hospital, Loeri Comba. He has been director of the social insurance hospital for six years so his opinion was critical for the assessment.
In the opinion of Dr. Alfredo the priority intervention of EG-LNG should by the training of health personnel including in-service training. He does not advise that this training be left solely in the hands of the Cuban doctors. He laments the lack of a college of doctors or medical association that could help to regulate the private sector of medical practice. In commenting on the situation of the very young inexperienced indigenous doctors, who are chiefs of services, but who work alongside the Cuban specialists who are also their professors, Dr. Alfredo believes that such a system cannot work and is doom to fail. The consultants also recognize the difficulty of exercising authority by the very young chiefs of services, most of who are still in specialty training, and propose that they be supported in their difficult task through management and organization training.