Equitable health services

Assessing health systems for type 1 diabetes in sub-Saharan Africa: developing a 'Rapid Assessment Protocol for Insulin Access'
Beran D, Yudkin JS, de Courten M: BioMed Central Health Services Research 2006; 6: 17

In order to improve the health of people with Type 1 diabetes in developing countries, a clear analysis of the constraints to insulin access and diabetes care is needed. We developed a Rapid Assessment Protocol for Insulin Access, comprising a series of questionnaires as well as a protocol for the gathering of other data through site visits, discussions, and document reviews. The Protocol was piloted in Mozambique then refined and had two further iterations in Zambia and Mali.

Assessment of eight HPV vaccination programmes implemented in lowest-income countries
Ladner J, Besson M, Hampshire R, Tapert L, Chirenje M and Saba J: BMC Public Health 12(370), 23 May 2012

The purpose of this study was to describe the results of eight human papillovirus (HPV) vaccination programmes conducted in seven lowest-income countries, including Lesotho, through the Gardasil Access Programme (GAP), which provides free HPV vaccines to organisations and institutions working in those countries. The eight programmes initially targeted a total of 87,580 girls, of which 76,983 received the full three-dose vaccine course, with mean programme vaccination coverage of 87.8%, while the mean adherence between the first and third doses of vaccine was 90.9%. Mixed models consisting of school-based and health facility-based vaccinations were found to record better overall performance compared with models using just one of the methods. Increased rates of programme coverage and adherence were positively correlated with the number of vaccination sites. Qualitative key insights from the school models showed a high level of coordination and logistics to facilitate vaccination administration, a lower risk of girls being lost to follow-up and vaccinations conducted within the academic year to limit the number of girls lost to follow-up. This study is intended to provide lessons for development of public health programmes and policies as countries go forward in national decision-making for HPV vaccination.

Assessment of psychological barriers to cervical cancer screening among women in Kumasi, Ghana using a mixed methods approach
Williams M, Kuffour G, Ekuadzi E, Yeboah M, ElDuah M, Tuffour P: African Health Sciences 13; 4; 1054-1061, December 2013

Cervical cancer is the leading cause of cancer death among women in Ghana, West Africa. The cervical cancer mortality rate in Ghana is more than three times the global cervical cancer mortality rate. Pap tests and visual inspection with acetic acid wash are widely available throughout Ghana, yet less that 3% of Ghanaian women get a cervical cancer screening at regular intervals. This exploratory study identified psychological barriers to cervical cancer screening among Ghanaian women with and without cancer using a mixed methods approach.Semi-structured interviews were conducted with 49 Ghanaian women with cancer and 171 Ghanaian women who did not have cancer. The results of the quantitative analysis indicated that cancer patients were not more likely to have greater knowledge of cancer signs and symptoms than women without cancer. Analysis of the qualitative data revealed several psychological barriers to cervical cancer screening including, common myths about cervical cancer, misconceptions about cervical cancer screening, the lack of spousal support for screening, cultural taboos regarding the gender of healthcare providers, and the stigmatization of women with cervical cancer.

Assessment of the health care waste generation rates and its management system in hospitals of Addis Ababa, Ethiopia, 2011
Debere MK, Gelaye KA, Alamdo AG and Trifa ZM: BMC Public Health 13(28), 12 January 2013

This study aimed to assess the health care waste generation rate and its management system in some selected hospitals located in Addis Ababa, Ethiopia. Researchers randomly selected six hospitals in Addis Ababa, three private and three public. Data was recorded by using an appropriately designed questionnaire. Results revealed that the management of health care waste at hospitals in Addis Ababa city was poor. The median waste generation rate was found to be varied from 0.361- 0.669 kg/patient/day, consisting of 58.69% non-hazardous and 41.31% hazardous wastes. The amount of waste generated was increased as the number of patients flow increased, and it was positively correlated with the number of patients. Public hospitals generated high proportion of total health care wastes (59.22%) in comparison with private hospitals (40.48%). The waste separation and treatment practices were very poor. The authors recommend that other alternatives for waste treatment rather than incineration such as a locally made autoclave should be evaluated and implemented.

Assessment of universal health coverage for adults aged 50 years or older with chronic illness in six middle-income countries
Goeppel C; Frenz P; Grdabenhenrich L; Keil T; Tinnemann P: Bulletin of the World Health Organization, 94(4), 276-285C, 2016

This study assesses universal health coverage for adults aged 50 years or older with chronic illness in China, Ghana, India, Mexico, the Russian Federation and South Africa. The authors obtained data on 16 631 participants aged 50 years or older who had at least one diagnosed chronic condition from the World Health Organization Study on Global Ageing and Adult Health. Access to basic chronic care and financial hardship were assessed and the influence of health insurance and rural or urban residence was determined by logistic regression analysis. The weighted proportion of participants with access to basic chronic care ranged from 21% in Mexico to 48% in South Africa. Access rates were unequally distributed and disadvantaged poor people, except in South Africa where primary health care is free to all. Rural residence did not affect access. The proportion with catastrophic out-of-pocket expenditure for the last outpatient visit ranged from 15% in China to 55% in Ghana. Financial hardship was more common among poor people in most countries but affected all income groups. Health insurance generally increased access to care but gave insufficient protection against financial hardship. No country provided access to basic chronic care for more than half of the participants with chronic illness. Poor people were less likely to receive care and more likely to face financial hardship in most countries. However, inequity of access was not fully determined by the level of economic development or insurance coverage. The authors argue that future health reforms should aim to improve service quality and increase democratic oversight of health care.

Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries
Owili P; Muga M; Chou YJ; Elsa Hau YH; Huang N; Chien LY: BMC Public Health 16(414), 2016

Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). In this study, the authors explored the distributions in the utilisation MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH as key for health equity, using Demographic and Health Surveys data of 12 countries in SSA. Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilisation in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunisation’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunisation’ (0.15) were positively associated and statistically significant. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunisation’ (−0.02) was negatively associated and significant. In conclusion, utilisation of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunisation. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunisation program could serve towards improving maternal and infant health outcomes and equity.

Asthma still a big killer
Thom A: Health-e, 6 May 2008

Under-treatment, inappropriate treatment and lack of education for asthma patients in South Africa are contributing to still unacceptably high morbidity rates. The most recent figures reveal that at least 10 percent of South Africans have asthma with many still dying unnecessarily, especially people in poorer households. Asthma deaths are almost all preventable and a 2004 report by the Global Initiative for Asthma found that South Africa has the world's fourth highest asthma death rate among five- to 35-year-olds. Out of every 100 000 South Africans with asthma, 18,5 die of the illness. Asthma therapy is freely available in the government health service. The most effective means of controlling asthma is to use a preventer pump containing an anti-inflammatory. The most cost-effective way of relieving an attack is a pump with a bronchodilator. A study by the University of Pretoria to understand the impact (including the impact on health-related quality of life) of asthma on South African asthmatics found that patients were not accessing treatment or were being inappropriately treated.

Attitudes towards African traditional medicine and Christian spiritual healing regarding treatment of epilepsy in a rural community of northern Tanzania
Winkler AS, Mayer M, Ombay M, Mathias B, Schmutzhard E and Jilek-Aall L: African Journal of Traditional, Complementary and Alternative Medicines 7(2): 2010

In this study, 167 people (59 people with epilepsy [PWE], 62 relatives of PWEs and 46 villagers) were interviewed at a local hospital and in the community with a semi-structured validated questionnaire regarding the prevailing attitude towards traditional medicine for treatment of epilepsy in a rural area of northern Tanzania. Various traditional healing methods (THM) could be ascertained, namely traditional herbal medicine, spiritual healing, scarifications and spitting. In total, 44.3% the interviewed people were convinced that epilepsy could be treated successfully with THM. Interestingly, 34.1% thought that Christian prayers could cure the cause and/or treat symptoms of epilepsy. Significantly more PWE and their relatives were in favour of THM compared to villagers not knowing about or not immediately affected by epilepsy. Further factors influencing people’s attitudes towards THM were gender, tribe, religion and urbanity of people’s dwellings. This study demonstrates that not only THM but also prayers in the Christian sense seem to play an important role in people’s beliefs regarding successful treatment of epilepsy. Factors influencing this belief system have been identified and are discussed.

Back to basics: HIV/AIDS belongs with sexual and reproductive health
Germain A, Dixon-Mueller R and Sen G: Bulletin of the World Health Organization 87(11): 840–845, November 2009

The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV and AIDS, and for advancing other development goals. However, combating HIV remains a separate project with malaria and tuberculosis. This paper presents a brief history of key decisions made by major international donors that have led to the separation of HIV and AIDS from its logical programmatic base in sexual and reproductive health and rights. In urging a return to the original ICPD construct as a framework for action, the paper calls for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model.

Bacteraemia in Kenyan children with sickle-cell anaemia: A retrospective cohort and case-control study
Williams T, Uyoga S, Macharia A, Ndila C, McAuley CF, Opi DH, Mwarumba S, Makani J, Komba A, Ndiritu MN, Sharif SK, Marsh K, Berkley JA and Scott JAG: The Lancet 374(9698): 1364–1370, 17 October 2009

In sub-Saharan Africa, more than 90% of children with sickle-cell anaemia die before the diagnosis can be made. The causes of death are poorly documented, but bacterial sepsis is probably important. This study examined the risk of invasive bacterial diseases in children with sickle-cell anaemia. It was undertaken in a rural area on the coast of Kenya, with a case-control approach. Blood cultures were undertaken on all children younger than 14 years who were admitted from within a defined study area to Kilifi District Hospital between 1 August 1998 and 31 March 2008 – those with bacteraemia were defined as cases. The study detected 2,157 episodes of bacteraemia in 38,441 admissions (6%). 1,749 of these children with bacteraemia (81%) were typed for sickle-cell anaemia, of whom 108 (6%) were positive as were 89 of 13,492 controls (1%). The study concludes that the organisms causing bacteraemia in African children with sickle-cell anaemia are the same as those in developed countries. Introduction of conjugate vaccines against S pneumoniae and H influenzae into the childhood immunisation schedules of African countries could substantially affect survival of children with sickle-cell anaemia.

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