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.
Equitable health services
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.
Researchers examined how well Lusakan health services met the safe motherhood and reproductive health care needs of women with disabilities, using in-depth tape-recorded interviews with 24 women with disabilities and 25 safe motherhood service providers. Social, attitudinal, and physical barriers to accessing safe motherhood and reproductive health services in this particular setting were experienced by the women, such as assumption among reproductive health service providers that women with disabilities will not be sexually active and will not require reproductive health services. Beliefs about transmission of disabilities were also experienced, and nurse-midwives' feared delivery complications in women with physical impairments.
This paper explores access barriers to effective malaria treatment among the poorest population in four malaria endemic districts in Kenya. The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: a cross-sectional survey of 708 households; 24 focus group discussions; semi-structured interviews with 34 health workers; and 359 patient exit interviews. The paper found that multiple factors related to affordability, acceptability and availability interact to influence access to prompt and effective treatment. Regarding affordability, about 40% of individuals who self-treated using shop-bought drugs and 42% who visited a formal health facility reported not having enough money to pay for treatment and other factors influencing affordability included seasonality of illness and income sources, transport costs, and unofficial payments. Regarding acceptability, the major interrelated factors identified were provider patient relationship, patient expectations, beliefs on illness causation, perceived effectiveness of treatment, distrust in the quality of care and poor adherence to treatment regimes. Availability barriers identified were related to facility opening hours, organisation of health care services, drug and staff shortages.
In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. In targeted areas, 67.5% of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4 % of all households with CU5s had an ITN. Over half of CU5s (51.7%) slept under an ITN during the previous evening. Nearly 40% of all households received a campaign net, elevating overall household ownership of ITNs to 50.7%. The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.
The use of insecticide-treated bed nets (ITNs) to protect children from malaria has risen six-fold in the past seven years, but 90 million children still do not have access to this simple protective tool, and remain at risk from the life-threatening disease. When African heads of state met in 2000, the Abuja Declaration stated that they would work towards protecting 60% of their vulnerable populations with insecticide treated nets. This study examines what has been achieved since. Data from 40 African countries which shows that at the time of the Abuja meeting in 2000 just over 3% of Africa’s young children were protected by a treated mosquito net. Seven years later this increased to only 18.5%. The authors report that bed net use increases faster in countries that distribute them free of charge by an average of 25% compared to 4% when people have to pay for them.
Mental health service planners face critical decisions regarding appropriate and affordable inpatient care. Before a fashion of deinstitutionalisation is followed, effective community services should be in place and sufficient psychiatric beds should remain in hospitals for those who cannot be catered for in the community. In order to maintain the delicate balance between hospital and community-based services, it is essential that useful indicators of inpatient care are established. This study documents current bed/population ratios per 100 000 population in public sector mental health services in South Africa. It found low levels of inpatient service provision in South Africa, and considerable variability between provinces. This study gives further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services. It is crucial to develop accurate indicators to monitor this process.
Chronic Myeloid Leukemia (CML), a rare disease, can be treated effectively, but the pharmaceutical treatment available (imatinib) is costly and unaffordable by most patients. 'GIPAP' is a programme set up between a manufacturer and a non-governmental organisation to provide free treatment to eligible CML patients in 80 countries worldwide. This study discusses the socio-economic and demographic characteristics of patients participating in GIPAP. It researches the impact GIPAP is having on health outcomes (survival) of assistance-eligible CML patients and discusses the determinants of such outcomes and whether there are any variations according to socio-economic, demographic, or geographical criteria. Data for 13,568 patients across 15 countries, available quarterly, was analysed over the 2005-2007 period. GIPAP was found to have a significant positive effect on patient access to medicines for CML and on survival rates.
Insecticide-treated bed nets are the preeminent malaria control means, although there is no consensus as to a best practice for large-scale insecticide-treated bed net distribution. In order to determine the paramount distribution method, the author of this review assessed literature on recent insecticide treated bed net distribution programmes throughout sub-Saharan Eastern Africa. She included all studies that had taken place in sub-Saharan Eastern Africa, targeted malaria prevention and control, and occurred between 1996 and 2007. Forty-two studies were identified and reviewed. The results indicate that distribution frameworks varied greatly, and so did outcomes of insecticide-treated bed net use. Studies revealed consistent inequities between urban and rural populations, which were most effectively alleviated through a free insecticide-treated bed net delivery and distribution framework. Cost sharing through subsidies was shown to increase programme sustainability, which may lead to more long-term coverage. Thus, distribution should employ a catch up/keep up programme strategy, the author argues. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels.
Malaria is one of the main reasons why people use health services in sub-Saharan Africa, placing a considerable burden on primary health care. The Affordable Medicines Facility-malaria (AMFm) is a supply-side intervention designed to reduce malaria mortality by improving the availability and affordability of effective treatment. It also aims to delay the development of drug resistance through the use of artemisinin, in combination with other medicines, rather than as a monotherapy. Access to artemisinin-based combination therapies by people living in poverty – those without public facilities and unable to afford artemisinin-based combination therapies at subsidised prices – is a concern. The AMFm will support an enhanced public sector and NGO distribution of artemisinin-based combination therapies, often without charge but supplementary initiatives at PHC level, such as home-based management of malaria, will still be needed.