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.
Equitable health services
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.
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.
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.
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.
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.
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.
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.
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.
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.