Background Nigeria has one of the highest maternal mortality rates (MMR) worldwide, which is largely due to complications during pregnancy, delivery, and the postpartum period. Focused antennal clinic (ANC) visits are pivoted to reduce MMR. This study provides detailed baseline and demographic information of pregnant women from a large malaria in pregnancy study. Methods Pregnant women of 16–29 weeks gestation receiving care at our study sites were enrolled. At enrolment, the following data were collected: baseline demographic data (age, weight, educational status, ethnicity, and use of malaria preventive measures), obstetric information (gravidity, parity, history of adverse pregnancy outcomes [APOCs] and surgeries), laboratory investigations (haemoglobin levels, blood group, genotype, proteinuria, and glycosuria), and malaria parasitology evaluation. Data were analysed using Stata 17® and Microsoft Excel 2021®. Results A total of 520 pregnant women were enrolled, with an average age of 28.8 years and gestational age of 22 weeks. More participants had tertiary education and were of Yoruba heritage. Obstetric information revealed that 165 (32.0%) of the women were primigravidae, whereas 42.1% of the women had had more than 2 pregnancies. Half (178) of the women who were pregnant previously reported having at least one APOC, with miscarriage being the most prominent, and 101 had undergone previous surgical procedures. The prevalence of anaemia, proteinuria, and glucosuria were 62.3%, 13%, and 3.5%, respectively. Malaria positivity at enrolment was 27.3% (142), with 71.1% of the diagnosed cases being asymptomatic, whereas 28.9% were symptomatic. There was poor utilisation of malaria preventive measures (insecticide treated nets, insecticide sprays, and indoor residue spraying) with only 1 participant using all three methods and 41.2% using none. Conclusion Epidemiological data obtained from this study revealed that participants had high anaemia, previous APOC, high malaria parasite positivity, and low utilisation of malaria preventive measures. These may be strong indicators of why Nigeria has a very high MMR.

Introduction: The effectiveness of the uterine tourniquet alone for securing hemostasis during abdominal myomectomy remains debatable; however, its combination with uterine compression though popular has very scanty documented evidence of hemostatic efficacy. Aim: To determine the effect of uterine incision compression (UIC) combined with tourniquet on operative blood loss associated with abdominal myomectomy. Materials and Methods: A multicenter randomized double blind, controlled trial involving 184 participants randomized into two groups: 92 in the UIC and 92 in the control arm. UIC was administered in the interval from release of the uterine tourniquet to palpation of contraction. Data were analyzed using the Statistical Package for the Social Sciences (SPSS), version 21. Results: The mean intraoperative blood loss was lower in the UIC group (951.41 ± 362.32 mL) than in the control group (1051.30 ± 427.77 mL), but did not reach statistical significance (p = 0.125). The observed mean duration of myomectomy was, however, longer among the controls (152.95 ± 32.67 min, compared with 119.70 ± 23.96 min, p = 0.001). The control group also had significantly higher rates of deployment of additional hemostatic measures (OR = 4.68, 95% CI = 2.304–12.784, p = 0.001), occurrence of postoperative pyrexia (OR = 1.65, 95% CI = 1.256–2.154, p = 0.002), and greater mean postoperative blood loss (p = 0.003). Conclusion: Although no statistically significant difference occurred in intraoperative blood loss, adjunctive UIC was useful in reducing operating time and postoperative blood loss.

Introduction: Preeclampsia is an important cause of adverse maternal and perinatal outcomes. However, this condition remains poorly understood, and since the only cure is delivery, prediction and prevention are crucial to prevent preterm birth or maternal compromise. Aim: To determine the levels of acute phase reactants, namely high-sensitivity C-reactive Protein (hsCRP) and fibrinogen, between preeclamptic and non preeclamptic pregnancies. Additionally, the study aims to determine the predictive value of these acute phase reactants for preeclampsia. Materials and Methods: A prospective mixed methods study was conducted in two tertiary hospitals and two specialist hospitals in the Ijebu/Remo axis of Ogun state, Nigeria. Preeclamptic participants were recruited during pregnancy and postpartum and matched with non preeclamptic controls (case-control arm, n=179, comprised of 87 preeclamptics and 92 controls). Additionally, a cohort of non preeclamptic women (n=71) was recruited and biomarker-assayed before 20 weeks gestation, followed-up for the development of preeclampsia. The biomarker assay was performed using the ELISA technique. The Student's t-test was used to compare the mean levels of markers between the studied groups. Categorical data were compared using the Chi-square test. A p-value <0.05 was considered to be statistically significant Results: The levels of hsCRP were significantly higher in pregnant preeclamptic women (12.71±1.99 mg/L) compared to non preeclamptic women (4.39±3.41 mg/L) (p-value=0.001). Similarly, fibrinogen levels were elevated in preeclamptic women (9.45±1.28 g/L) compared to non preeclamptic women (7.19±1.86 g/L) (p-value =0.001). This trend was also observed among postpartum women, with hsCRP levels of 10.39±2.43 mg/L in preeclamptics compared to 2.53±2.06 mg/L in non preeclamptics (p-value=0.001). The mean fibrinogen level was 8.63±1.91 g/L in preeclamptics compared to 4.09±1.66 g/L in non preeclamptics. Fibrinogen demonstrated a higher specificity (88.9%) and Negative Predictive Value (NPV) of 100% compared to hsCRP (specificity=47.1% and NPV=76.1%). The biomarker levels also correlated significantly with the severity of preeclampsia. For hsCRP, there was a correlation with Systolic Blood Pressure (SBP) (r-value=0.385, p-value=0.001), Diastolic Blood Pressure (DBP) (r-value=0.364, p-value=0.001), and proteinuria (r-value=0.314, p-value=0.001). For fibrinogen, there was a correlation with SBP (r-value=0.252, p-value=0.014), DBP (r-value=0.378, p-value=0.001), and proteinuria (r-value=0.356, p-value=0.001). Conclusion: Although hsCRP and fibrinogen levels were significantly higher and correlated well with the severity of preeclampsia, their use for prediction may be limited. However, fibrinogen appears to have better prospects.

Background The devastating effect of malaria in pregnancy (MIP) is mitigated by periodical administration of intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP). Possibility of emergence of Plasmodium parasites resistant to SP portends a threat to pregnant women living in malaria endemic regions. This was an EDTCP2 funded study to assess the effect and prevalence of Plasmodia resistance to SP in selected Nigerian communities. Methods Consenting pregnant, gestational age 16–29 weeks, having met the inclusion/exclusion criteria were enrolled into one of the 5 study centres within Ikenne and Remo North LGA, Ogun State. Subjects were screened for malaria using microscopy, RDT and PCR, from enrolment to delivery. Positive malaria parasite samples were further analysed for Plasmodium falciparum dihydrofolate-reductase (Pfdhfr) and Plasmodium falciparum dihydropteroate-synthase (Pfdhps) mutations. All result were entered into REDCap® database and statistical analysis done using Microsoft Excel® 2019 and Stata 17®. Results A total of 520 women, mean gestational age of 21 weeks were enrolled. Participants had average of 4 visits and 4 doses of SP before delivery. The prevalence of malaria parasitaemia was 2.9%, 4.8% and 35.5% using microscopy, RDT and PCR analysis respectively. There were 87 (19.4%) clinical malaria and 361 (80.6%) asymptomatic cases during the study. A total of 114 malaria positive samples were analysed for mutations. 51.8% were positive for mutations, while 4-points mutations were most prevalent (14.0%) and 4.4% had all 10-points mutations for Pfdhfr and Pfdhps. There were significantly more Pfdhfr mutations than Pfdhps and significantly higher mutations at enrolment. Conclusion The prevalence of clinical malaria was low considering Nigeria is endemic for the disease, but high asymptomatic cases. Higher Pfdhfr/Pfdhps mutations were seen at enrolment. This study is the first to report the use of 6 doses of IPT-SP and all 10-points mutations for Pfdhfr/Pfdhps, which are definitive markers for SP resistance.

Microscopic evaluation of parasite clearance is the gold standard in antimalarial drug efficacy trials. However, the presence of sub-microscopic residual parasitemia after artemisinin-based combination therapy (ACT) needs to be investigated. One hundred and twenty (AL: n = 60, PA: n = 60) days 3 and 14 dried blood spots, negative by microscopy were analysed for residual parasitemia using nested PCR. Isolates with residual parasitemia on days 3 and 14 were further genotyped with their corresponding day-0 isolates using merozoite surface proteins msp-1, msp-2, and glurp genes for allelic similarity. Persistent PCR-determined sub-microscopic residual parasitemia at day 3 post ACT treatment was 83.3 (AL) and 88.3

Malaria in pregnancy (MiP) remains a key cause of poor maternal and neonatal health outcomes, particularly in the African region. Two strategies globally promoted to address MiP require pregnant women in malaria-endemic regions to sleep under insecticide-treated bed nets (ITNs) and take at least three doses of intermittent preventive treatment (IPTp) during pregnancy. Yet, several multilevel factors influence the effective uptake of these strategies. This study explored the factors for the poor uptake of IPTp and use of ITNs in lower socio-economic communities in Nigeria. We conducted semi-structured interviews (SSI) and focus group discussions (FGD) with a total of 201 key stakeholders in six communities in Ogun State, South-Western Nigeria. Twelve SSIs were conducted with traditional birth attendants (TBAs), faith-based birth attendants and healthcare providers operating in public health facilities. Community leaders (7), pregnant women (30) and 20 caregivers were individually interviewed. Sixteen FGDs were conducted with multi- and first-time pregnant women grouped by location and pregnancy experiences. A thematic approach was used for data analysis. At the individual and social levels, there is a high general awareness of MiP, its consequences and ITNs but low awareness of IPTp, with type of antenatal care (ANC) provider being a key factor influencing access to IPTp. The choice of ANC provider, which facilitates access to IPTp and ITNs, is influenced by the experiences of women, relatives and friends, as well as the attitudes of ANC providers and community perceptions of the type of ANC providers. Concurrent use of multiple ANC providers and ANC providers’ relationships further influence acceptability and coverage for IPTp and ITN use. At the health sector level, there is low awareness about preventive malarial strategies including IPTp among TBAs and faith-based birth attendants, in contrast to high IPTp awareness among public healthcare providers. The findings highlight several factors that influence the utilisation of IPTp services and call for greater synergy and collaboration between the three groups of healthcare providers towards enhancing access to and acceptability of IPTp for improving maternal and child outcomes.

Malaria in pregnancy is a public health challenge with serious negative maternal and newborn consequences. Intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine is recommended for the control of malaria during pregnancy within endemic areas, but coverage for the recommended ≥3 doses IPTp regimen has remained suboptimal. We searched PubMed, Cochrane library, and HINARI database from 1 January 2010 to 23 May 2020, for studies investigating the effect of the health system on IPTp implementation. Data extraction was independently performed by two investigators and evaluated for quality and content. Health system barriers and facilitators were explored using thematic analysis and narrative synthesis. Thirty-four out of 1032 screened articles were included. Key health system issues affecting the provision and uptake of IPTp were the ambiguity of policy and guidelines for IPTp administration, human resource shortages, drug stock-outs, conflicting policy implementation on free IPTp provision, hidden costs, unclear data recording and reporting guidelines, and poor quality of care. Factors affecting the supply and demand for IPTp services involve all pillars of the health system across different countries. The success of health programs such as IPTp will thus depend on how well the different pillars of the health system are articulated towards the success of each program.

Background: An ongoing outbreak of pneumonia associated with a novel coronavirus was reported in Wuhan city, China. This new virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses. That disease, caused by the SARS-CoV-2, has been named coronavirus disease 2019 (COVID-19) by the WHO. The outbreak has since spread across the globe, including countries in Africa. Main body: The dominant mode of transmission is from the respiratory tract, via droplets or indirectly via fomites, and to a lesser extent via aerosols. The rapidity with which the infection spread throughout the world was unexpected. The disease has now affected 212 countries, areas, or territories, with more than 2.1 million total confirmed cases and over 144 thousand fatalities as at the time of writing. It, therefore, behooves countries of the world to take firm public health measures for the pandemic is to be contained. Conclusion: Nigeria, with a population of at least 170 million people, is of global interest because a rapid rise in the number of infected people will have serious implications not only for the country but for the whole African continent.%MCEPASTEBIN%

Background: An ongoing outbreak of pneumonia associated with a novel coronavirus was reported in Wuhan city, China. This new virus was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the Coronavirus Study Group (CSG) of the International Committee on Taxonomy of Viruses. That disease, caused by the SARS-CoV-2, has been named coronavirus disease 2019 (COVID-19) by the WHO. The outbreak has since spread across the globe, including countries in Africa. Main body: The dominant mode of transmission is from the respiratory tract, via droplets or indirectly via fomites, and to a lesser extent via aerosols.  The rapidity with which the infection spread throughout the world was unexpected. The disease has now affected 212 countries, areas, or territories, with more than 2.1 million total confirmed cases and over 144 thousand fatalities as at the time of writing. It, therefore, behooves countries of the world to take firm public health measures for the pandemic is to be contained. Conclusion: Nigeria, with a population of at least 170 million people, is of global interest because a rapid rise in the number of infected people will have serious implications not only for the country but for the whole African continent.%MCEPASTEBIN%

BackgroundMalaria in pregnancy carries a risk of significant adverse maternal and infant outcomes. Intermittent preventive treatment in pregnancy (IPTp) is advocated to reduce its occurrence, but resistance to sulphadoxine-pyrimethamine (SP) is being reported. This study aims to describe the burden of SP resistance and determinants of its occurrence among pregnant women receiving IPTp in Nigeria.MethodsA prospective observational study is to be conducted in Ogun State over 24 months. Pregnant women 16–28 weeks gestation meeting the eligibility criteria are being enrolled; blood samples are taken for analysis pre- and post- IPTp-SP administration at scheduled intervals. Microscopy-confirmed parasitaemic samples will be analysed using PCR to detect drug resistance markers (pfdhfr and pfdhps). Participants will be followed up until 28 days post-delivery and assessed for maternal and foetal outcomes (anaemia, low birth weight, preterm delivery, placental parasitaemia, stillbirth, neonatal death). The primary endpoint is the prevalence of the SP resistance gene markers. Secondary endpoints include the prevalence of peripheral and placental parasitaemia at delivery; incidence of maternal and newborn morbidity; parasitaemia pre-IPTp and day 28 post-IPTp; risk factors for SP resistance and haemoglobin changes at delivery.ResultsFollowing statistical analysis with STATA 14, results will be displayed in appropriate formats. Geometric mean parasite densities with 95% confidence intervals will be calculated, and proportions compared using the t-test, Chi-square or Fisher’s exact tests as appropriate. Multivariate analysis including logistic regression models will be used to test for associations between maternal characteristics and SP resistance. Level of significance will be set at p<0.05.ConclusionIn a malaria-endemic country like Nigeria with a large at-risk population, information on the effectiveness of chemoprevention is essential. Determining the proportion and extent of relevant molecular markers within the population offers an invaluable tool for epidemiological surveillance of SP resistance within this endemic setting.

Background. During the first introduction of a group A meningococcal vaccine (PsA-TT) in 2010-2011 and its rollout from 2011 to 2013, >150 million eligible people, representing 12 hyperendemic meningitis countries, have been vaccinated.Methods. The new vaccine effectiveness evaluation framework was established by the World Health Organization and partners. Meningitis case-based surveillance was strengthened in PsA-TT first-introducer countries, and several evaluation studies were conducted to estimate the vaccination coverage and to measure the impact of vaccine introduction on meningococcal carriage and disease incidence.Results. PsA-TT implementation achieved high vaccination coverage, and results from studies conducted showed significant decrease of disease incidence as well as significant reduction of oropharyngeal carriage of group A meningococci in vaccinated and unvaccinated individuals, demonstrating the vaccine's ability to generate herd protection and prevent group A epidemics.Conclusions. Lessons learned from this experience provide useful insights in how to guide and better prepare for future new vaccine introductions in resource-limited settings.

BACKGROUND:Between the late 1980s and 2000s, Northern Uganda experienced over twenty years of armed conflict between the Government of Uganda and Lord's Resistance Army. The resulting humanitarian crisis led to displacement of a large percentage of the population and disruption of the health care system of the area. To better coordinate the emergency health response to the crisis, the humanitarian cluster approach was rolled out in Uganda in October 2005. The health, nutrition and HIV/AIDS cluster became fully operational at the national level and in all the conflict affected districts of Acholi and Lango in April 2006. It was phased out in 2011 following the return of the internally displaced persons to their original homelands. CONCLUSIONS:The implementation of the health cluster approach in the northern Uganda and other humanitarian crises in Africa highlights a few issues which are important for strengthening health coordination in similar settings. While health clusters are often welcome during humanitarian crises because they have the possibility to improve health coordination, their potential to create an additional layer of bureaucracy into already complex and bureaucratic humanitarian response architecture is a real concern. Although anecdotal evidence has showed that implementation of the humanitarian reforms and the roll out of the cluster approach did improve humanitarian response in northern Uganda; it is critical to establish a mechanism for measuring the direct impact of health clusters on improving health outcomes, and in reducing morbidity and mortality during humanitarian crisis. Successful implementation of health clusters requires availability of other components of the humanitarian reforms such as predictable funding, strong humanitarian coordination system and strong partnerships. Importantly, successful health clusters require political commitment of national humanitarian and government stakeholders. RECOMMENDATIONS:Although leaving health coordination entirely to governments (in crises where they exist) may result in political interference and ineffectiveness of the aid response efforts, the role of government in health coordination cannot be overemphasized. Health clusters must respond to the rapidly changing humanitarian environment and the changing needs of populations affected by humanitarian crises as they evolve from emergency towards transition, early recovery and development.

INTRODUCTION:In seven southern African countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland and Zimbabwe), following implementation of a measles mortality reduction strategy starting in 1996, the number of annually reported measles cases decreased sharply to less than one per million population during 2006-2008. However, during 2009-2010, large outbreaks occurred in these countries. In 2011, a goal for measles elimination by 2020 was set in the World Health Organization (WHO) African Region (AFR). We reviewed the implementation of the measles control strategy and measles epidemiology during the resurgence in the seven southern African countries. METHODS:Estimated coverage with routine measles vaccination, supplemental immunization activities (SIA), annually reported measles cases by country, and measles surveillance and laboratory data were analyzed using descriptive analysis. RESULTS:In the seven countries, coverage with the routine first dose of measles-containing vaccine (MCV1) decreased from 80% to 65% during 1996-2004, then increased to 84% in 2011; during 1996-2011, 79,696,523 people were reached with measles vaccination during 45 SIAs. Annually reported measles cases decreased from 61,160 cases to 60 cases and measles incidence decreased to <1 case per million during 1996-2008. During 2009-2010, large outbreaks that included cases among older children and adults were reported in all seven countries, starting in South Africa and Namibia in mid-2009 and in the other five countries by early 2010. The measles virus genotype detected was predominantly genotype B3. CONCLUSION:The measles resurgence highlighted challenges to achieving measles elimination in AFR by 2020. To achieve this goal, high two-dose measles vaccine coverage by strengthening routine immunization systems and conducting timely SIAs targeting expanded age groups, potentially including young adults, and maintaining outbreak preparedness to rapidly respond to outbreaks will be needed.

OBJECTIVE:To review the cholera epidemiology in Zambia from 2000 to 2010 in order to highlight the key lessons learned. Based on our findings, we make recommendations for improving cholera prevention and control in country.DESIGN:Ten years descriptive cholera data was extracted from the national IDSR database and analysed.SETTING:The study was conducted in Zambia using national epidemiology data which were disaggregated by Province.SUBJECTS:None.RESULTS:Starting from 2003, there has been a progressive increase in yearly incidence of cholera in the country. In 2010, 6794 cases (500% increase compared to 2003) and 115 deaths (CFR 1.6%) of the disease were reported with Lusaka Province accounting for 85% of the total cases. Outbreaks start between epidemiological weeks 40 to 45 of the year and ends between weeks 20 to 25 of the following year (which corresponds to the Zambian rainy season). Outbreaks are largely confined to the peri-urban areas of Lusaka, Luapula, Southern and Copperbelt Provinces.CONCLUSION:In the last 10-20 years, the epidemiology of cholera in Zambia has changed; Laboratory confirmation of Vibrio cholerae in the country on a yearly basis in the last ten years suggests that the country is now endemic for cholera hence the need to review current cholera prevention and control strategies.

The burden of malaria is a key challenge to both human and economic development in malaria endemic countries. The impact of malaria can be categorized from three dimensions, namely: health, social and economic. The objective of this study was to estimate the impact of malaria morbidity on gross domestic product (GDP) of Uganda.

BACKGROUND:National health accounts provide useful information to understand the functioning of a health financing system. This article attempts to present a profile of the health system financing in Malawi using data from NHA. It specifically attempts to document the health financing situation in the country and proposes recommendations relevant for developing a comprehensive health financing policy and strategic plan.METHODS:Data from three rounds of national health accounts covering the Financial Years 1998/1999 to 2005/2006 was used to describe the flow of funds and their uses in the health system. Analysis was performed in line with the various NHA entities and health system financing functions.RESULTS:The total health expenditure per capita increased from US$ 12 in 1998/1999 to US$25 in 2005/2006. In 2005/2006 public, external and private contributions to the total health expenditure were 21.6%, 60.7% and 18.2% respectively. The country had not met the Abuja of allocating at least 15% of national budget on health. The percentage of total health expenditure from households' direct out-of-pocket payments decreased from 26% in 1998/99 to 12.1% in 2005/2006.CONCLUSION:There is a need to increase government contribution to the total health expenditure to at least the levels of the Abuja Declaration of 15% of the national budget. In addition, the country urgently needs to develop and implement a prepaid health financing system within a comprehensive health financing policy and strategy with a view to assuring universal access to essential health services for all citizens.

Background Inequities in the utilization of maternal health services impede progress towards the MDG 5 target of reducing the maternal mortality ratio by three quarters, between 1990 and 2015. In Namibia, despite increasing investments in the health sector, the maternal mortality ratio has increased from 271 per 100,000 live births in the period 1991-2000 to 449 per 100,000 live births in 1998-2007. Monitoring equity in the use of maternal health services is important to target scarce resources to those with more need and expedite the progress towards the MDG 5 target. The objective of this study is to measure socio-economic inequalities in access to maternal health services and propose recommendations relevant for policy and planning. Methods Data from the Namibia Demographic and Health Survey 2006-07 are analyzed for inequities in the utilization of maternal health. In measuring the inequities, rate-ratios, concentration curves and concentration indices are used. Results Regions with relatively high human development index have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. The rich use the public health facilities 30% more than the poor for child delivery. Conclusion Most of the indicators such as delivery by trained health providers, delivery by caesarean section and postnatal care show inequities favoring the most educated, urban areas, regions with high human development indices and the wealthy. In the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realize the MDG 5 targets so long as a large segment of society has inadequate access to essential maternal health services and other basic social services. Addressing inequities in access to maternal health services should not only be seen as a health systems issue. The social determinants of health have to be tackled through multi-sectoral approaches in line with the principles of Primary Health Care and the recommendations of the Commission on Social Determinants of Health.

BACKGROUND:It has been argued that quality improvements that result from user charges reduce their negative impact on utilization especially of the poor. In Uganda, because there was no concrete evidence for improvements in quality of care following the introduction of user charges, the government abolished user fees in all public health units on 1st March 2001. This gave us the opportunity to prospectively study how different aspects of quality of care change, as a country changes its health financing options from user charges to free services, in a developing country setting. The outcome of the study may then provide insights into policy actions to maintain quality of care following removal of user fees.METHODS:A population cohort and representative health facilities were studied longitudinally over 3 years after the abolition of user fees. Quantitative and qualitative methods were used to obtain data. Parameters evaluated in relation to quality of care included availability of drugs and supplies and; health worker variables.RESULTS:Different quality variables assessed showed that interventions that were put in place were able to maintain, or improve the technical quality of services. There were significant increases in utilization of services, average drug quantities and stock out days improved, and communities reported health workers to be hardworking, good and dedicated to their work to mention but a few. Communities were more appreciative of the services, though expectations were lower. However, health workers felt they were not adequately motivated given the increased workload.CONCLUSION:The levels of technical quality of care attained in a system with user fees can be maintained, or even improved without the fees through adoption of basic, sustainable system modifications that are within the reach of developing countries. However, a trade-off between residual perceptions of reduced service quality, and the welfare gains from removal of user fees should guide such a policy change.

OBJECTIVES:To assess the impact of HIV/AIDS on household welfare. Explore the relationship between HIV/AIDS and poverty especially in relation to the Poverty Eradication Action Plan as well as make policy recommendations regarding action necessary to reverse or reduce the impact of HIV/AIDS on households (HHs).DATA SOURCES:A cross-sectional study that utilised qualitative and quantitative research methods. Data were collected on the socio demographic profile; level of income; illness incidence and failure to work; loss of income due to illness; health expenditures for the last two months and modes of coping with health care costs.STUDY SELECTION:Study districts were selected based on regional representation and the HIV seroprevalence rates. The country is divided in four regions and the district with the highest seroprevalence in each region was selected.DATA EXTRACTION:Data was entered and analysed using EPINFO and proportions expressed as percentages.DATA SYNTHESIS:There were no children headed HHs among the controls and female and widowed HHs heads were more among the infected/affected HHs. The total average two months' expenditure on health care for control HHs was US $25 compared to US $95, for infected/affected HHs. Thirty two point two percent of HH heads who had missed work in the previous month gave illness as reason in the control group compared to 77.2% among infected/affected HHs. Fifty nine percent of these reported to have lost all their source of income as a result of the illness and 2.3% had salaries reduced. Twenty seven percent of the control HHs had children of school going age not attending school compared to 49% among the infected/affected HHs. Only 1.2% among the controls and 8.1% in the affected gave looking after the sick as reason. Methods of coping with cost of health care included sale of assets and withdrawing savings.CONCLUSION:The study shows that HIV/AIDS impoverishes affected/infected households.