Equitable health services

Antimicrobial-resistant infections among postpartum women at a Ugandan referral hospital
Bebell L; Ngonzi J; Bazira J et al.: PLoS ONE 12(4) 2017, doi: https://doi.org/10.1371/journal.pone.0175456

Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. The authors performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care. The study found for women in rural Uganda with postpartum fever, a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. They recommend that increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.

Apocalypse or redemption? Responding to extensively drug-resistant tuberculosis
Upshur R, Singh J and Ford N: World Health Organization Bulletin, June 2009

The World Health Organization (WHO) has launched an eight-point plan to respond to extensively drug-resistant tuberculosis (XDR-TB): strengthen the quality of basic TB and HIV/AIDS control; scale up programmatic management of multi-drug-resistant TB (MDR-TB) and XDR-TB; strengthen laboratory services; expand MDR-TB and XDR-TB surveillance; develop and implement infection control measures; strengthen advocacy, communication and social mobilization; pursue resource mobilisation at all levels; and promote research and development of new tools. Additional considerations included: conducting adherence research; building the evidence-base for infection control practices; supporting communities affected by TB; enhancing public health response, while addressing the social determinants of health; embracing palliative care; and advocacy for research.

Appeal to the World Health Organisation on the health situation in Zimbabwe
Community Working on Health: December 2008

The Community Working Group on Health (CWGH) in Zimbabwe, with a membership of about 35 civil society organisations representing a wide range of constituent groups, has called on the World Health Organisation to address the severe decline in heath and in the health system in Zimbabwe. It recognises that the current health crisis does not emanate from the health sector but from wider economic collapse. The CWGH urges WHO and partners to more widely address what needs to be done and what resources and support are needed to rebuild health systems from primary health care level upwards, and to involve communities in deliberations and plans on the way forward. Zimbabweans, they indicate, are not numbers of cholera cases or fatalities but people who have responded to an increasingly difficult situation, who are entitled to health as a right and who should be central in any response and rehabilitation of the health system.

Further details: /newsletter/id/33701
Approaches to ensuring and improving quality in the context of health system strengthening: a cross-site analysis of the five African Health Initiative Partnership programmes
Hirschhorn LR, Baynes C, Sherr K, Chintu N, Awoonor-Williams J, Finnegan K et al: BMC Health Services Research 13(Suppl 2):S8, 31 May 2013

In this study, researchers describe the approaches to defining and improving quality of health services across the five country programmes funded through the Doris Duke Charitable Foundation African Health Initiative. They describe the differences and similarities across the programmes in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programmes measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality. Learning the value and challenges of these approaches to measuring and improving quality across the key components of health system strengthening as the projects continue their work, the authors conclude.

Are vaccination programmes delivered by lay health workers cost-effective? A systematic review
Corluka A, Walker DG, Lewin S, Glenton C and Scheel IB: Human Resources for Health 2009, 7(81), 3 November 2009

This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving lay or community health workers (LHWs). Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Of the 2,616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. There was insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.

Are We Prepared for the Next Global Epidemic? The Public Doesn't Think So
Kim JY: World Post, 5 August 2015

This article incudes evidence from a public opinion poll on pandemic preparedness.
It highlights three concrete actions on how we can be better prepared for the next global epidemic. The author states "First, let's ensure that all countries invest in better preparedness. This starts with a strong health system that can deliver essential, quality care; disease surveillance; and diagnostic capabilities. We should expand successful efforts such as those by Ethiopia and Rwanda to train cadres of community health workers, who can expand access to care and serve as the frontline response to future disease outbreaks. The goal must be universal health coverage - both to ensure everyone can get the care they need, and also because those areas without adequate coverage put everyone at risk." He also calls for a smarter, better coordinated global epidemic preparedness and response system that draws upon the expertise of many more players - including a better-resourced WHO; and a pandemic emergency financing facility that can respond more quickly to epidemics.

Assessing bed net use and non-use after long-lasting insecticidal net distribution: A simple framework to guide programmatic strategies
Van den Eng JL, Thwing J, Wolkon A, Kulkarni MA, Manya A, Erskine M, Hightower A, Slutsker L: Malaria Journal 9(133), 18 May 2010

In this paper, a simple method based on the end-user as the denominator was employed to classify individuals into one of four insecticide-treated net (ITN) use categories: living in households not owning an ITN; living in households owning, but not hanging an ITN; living in households owning and hanging an ITN, but who are not sleeping under one; and sleeping under an ITN. This framework was applied to survey data designed to evaluate distribution of long-lasting insecticidal nets (LLINs) following integrated campaigns in five African countries, including Madagascar and Kenya. The study found that the percentage of children <5 years of age sleeping under an ITN ranged from 51.5% in Kenya to 81.1% in Madagascar. Among the three categories of non-use, children living in households without an ITN make up largest group, despite the efforts of the integrated child health campaigns. The percentage of children who live in households that own but do not hang an ITN ranged from 5.1% to 16.1%. The percentage of children living in households where an ITN was suspended, but who were not sleeping under it ranged from 4.3% to 16.4%. Use by all household members in Madagascar (60.4%) indicate that integrated campaigns reach beyond their desired target populations. The framework outlined in this paper may provide a helpful tool to examine the deficiencies in ITN use. Monitoring and evaluation strategies designed to assess ITN ownership and use can easily incorporate this approach using existing data collection instruments that measure the standard indicators.

Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal
Loveday M, Scott V, McLoughlin J, Amien F, Zweigenthal V: South African Medical Journal, 101(12): 887-890, December 2011

This study reported on a participatory quality improvement intervention designed to evaluate TB, HIV and STI priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal, South Africa. A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. The researchers highlighted weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. Eighty percent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for anti-retroviral therapy and starting treatment was 47 days. Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.

Assessing Coverage, Equity and Quality Gaps in Maternal and Neonatal Care in Sub-Saharan Africa: An Integrated Approach
Wilunda C; Putoto G; Dalla Riva D; Manenti F; Atzori A; Calia F; Assefa T; Turri B; Emmanuel O; Straneo M; Kisika F; Tamburlini G; Tarmbulini G: PloS one 10(6), May 2015

The authors present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries. Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level. The authors findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.

Assessing equity in the geographical distribution of community pharmacies in South Africa in preparation for a national health insurance scheme
Ward K, Sanders D, Leng H, Pollock A: Bulletin of the World Health Organization 92:482-489; 2014

The green paper for the national health insurance scheme in South Africa has identified private community pharmacies as potential access points for medicines, in combination with public clinics. This study examined changes in the ownership and geographical distribution of community pharmacies between 1994 and 2012 using routine national data. The authors summed community pharmacies and public clinics to assess their combined provincial distribution patterns against a South African benchmark of one clinic per 10000 residents. The study shows that monitoring trends in the distribution of community pharmacies is feasible. It shows that the increase in the number of community pharmacies has not kept pace with population growth and there are differences between urban and rural provinces and between the most and least deprived districts. Although corporations have seen substantial growth, this has not resulted in improved density ratios or equity in distribution.

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