In this study, the Lives Saved Tool (LiST) model was used to quantify the likely impact that malaria prevention intervention scale-up has had on malaria mortality over the past decade (2001-2010) across 43 malaria endemic countries in sub-Saharan African. The likely impact of insecticide-treated nets (ITNs) and malaria prevention interventions in pregnancy (intermittent preventive treatment [IPTp] and ITNs used during pregnancy) over this period was assessed. Results indicated that malaria prevention intervention scale-up over the past decade has prevented 842,800 child deaths due to malaria in the 43 countries, compared to a baseline of the year 2000. Over the entire decade, this represents an 8.2% decrease in the number of malaria-caused child deaths that would have occurred over this period had malaria prevention coverage remained unchanged since 2000. The biggest impact occurred in 2010 with a 24.4% decrease in malaria-caused child deaths compared to what would have happened had malaria prevention interventions not been scaled-up beyond 2000 coverage levels. ITNs accounted for 99% of the lives saved. The results suggest that funding for malaria prevention in Africa over the past decade has had a substantial impact on decreasing child deaths due to malaria. Rapidly achieving and then maintaining universal coverage of these interventions should be an urgent priority for malaria control programmes in the future, the authors argue. Successful scale-up in many African countries will likely contribute substantially to meeting Millennium Development Goal (MDG) 4 to reduce child mortality, as well as succeed in meeting MDG 6 (Target 1) to halt and reverse malaria incidence by 2015.
Monitoring equity and research policy
Little is known about the burden of influenza in sub-Saharan Africa. Routine influenza surveillance is key to getting a better understanding of the impact of acute respiratory infections on sub-Saharan African populations. To address this gap, a project called Strengthening Influenza Sentinel Surveillance in Africa (SISA) was launched in Angola, Cameroon, Ghana, Nigeria, Rwanda, Senegal, Sierra Leone and Zambia. It aimed to help improve influenza sentinel surveillance, including both epidemiological and virological data collection, and to develop routine national, regional and international reporting mechanisms. These countries received technical support through remote supervision and onsite visits. Consultants worked closely with health ministries, the World Health Organization, national influenza laboratories and other stakeholders involved in influenza surveillance. Working documents such as national surveillance protocols and procedures were developed or updated and training for sentinel site staff and data managers was organised. The main lesson emerging from SISA is that targeted support to countries can help them strengthen national influenza surveillance, but long-term sustainability can only be achieved with external funding and strong national government leadership.
In this paper, the authors outline the process of developing country-specific spreadsheet-based models to explore the financial resource requirements of health system reform options in South Africa and Tanzania. Their intention is to provide guidance for analysts who wish to develop their own models, and to illustrate, with reference to the South African and Tanzanian modelling experience, how one has to adapt to data constraints and context-specific modelling requirements. They found that using modelling to assess the financial feasibility and implications of alternative health system reform paths can be of great value in supporting evidence-informed policy-making. Developing one's own spreadsheet model has a number of advantages, including allowing greater flexibility to reflect specific country circumstances and requiring the analyst to carefully evaluate the assumptions built into the model. A pragmatic approach should be adopted in data scarce contexts, but all assumptions should be made explicit and justified. A major advantage of the modelling process is that it can highlight priority areas for improved data collection.
Recent estimates of malaria-attributable under-five deaths prevented using the Lives Saved Tool (LiST) confirm the substantial impact and good cost-effectiveness that insecticide-treated nets (ITNs) and indoor residual spraying have achieved in high-endemic sub-Saharan Africa. ITNs, the author argues, have an additional indirect mortality impact by preventing deaths from other common child illnesses, to which malaria contributes as a risk factor. As conventional ITNs are being replaced by long-lasting insecticidal nets and scale-up is expanded, additional lives may be saved, and these figures may be calculated using LiST. LiSt combines key indicators for time trend analysis with dynamic transmission models, fitted to long-term trend data on vector, parasite and human populations over successive phases of malaria control and elimination. The author argues that policy makers and programme planners should use LiST as a planning tool, but notes that this will require enhanced monitoring and evaluation of the national programme and its impact.
Because of increased global trade and travel, micro-organisms now travel globally faster than before. To track these microorganisms, whole genome sequence analysis is the ideal instrument, but to make effective use of the results a global genomic database for microorganisms is needed. In this editorial, the author argues that the introduction of genomic testing represents a giant step forward for developing countries in the fight against infectious diseases. He compares the introduction of this new technology to the spread of cellphones, which made expensive and exclusive landlines unnecessary and made communication possible for everybody. Similarly, identification and typing of microorganisms will suddenly become technically and economically feasible, enabling control and prevention efforts previously missing in many regions. At the same time, developing countries moving to use this technology will not need to develop expensive, specialised lab systems, since microbiological lab work will basically be the same for TB, enterobacteria, viruses, etc. The author calls on developing countries to participate in this process from the start.
The main aim of this study was to determine how data on water source quality affect assessments of progress towards the 2015 Millennium Development Goal (MDG) target on access to safe drinking-water. Data was collected from five countries on whether drinking-water sources complied with World Health Organisation water quality guidelines on contamination with thermotolerant coliform bacteria, arsenic, fluoride and nitrates in 2004 and 2005. Taking account of data on water source quality resulted in substantially lower estimates of the percentage of the population with access to safe drinking-water in 2008 in four of the five study countries: the absolute reduction was 11% in Ethiopia, 16% in Nicaragua, 15% in Nigeria and 7% in Tajikistan. There was only a slight reduction in Jordan. Microbial contamination was more common than chemical contamination. The authors warn that the WHO criteria used to determine whether a water source is safe can lead to substantial overestimates of the population with access to safe drinking-water and, consequently, also overestimates the progress made towards the 2015 MDG target. Monitoring drinking-water supplies by recording both access to water sources and their safety would be a substantial improvement.
The authors of this study assessed the feasibility of using birth attendants instead of bereaved mothers as perinatal verbal autopsy respondents in low- and middle-income countries. Verbal autopsy interviews for early neonatal deaths and stillbirths were conducted separately among mothers (reference standard) and birth attendants in 38 communities in four developing countries, including the Democratic Republic of Congo and Zambia. For early neonatal deaths, concordance between maternal and attendant responses across all questions was 94%. Concordance was at least 95% for more than half the questions on maternal medical history, birth attendance and neonate characteristics. Concordance on any given question was never less than 80%. For stillbirths, concordance across all questions was 93%. Concordance was 95% or greater more than half the time for questions on birth attendance, site of delivery and stillborn characteristics. Overall, the causes of death established through verbal autopsy were similar, regardless of respondent. In conclusion, birth attendants can substitute for bereaved mothers as verbal autopsy respondents.
Incidence is a better measure than prevalence for monitoring AIDS, but it is not often used because longitudinal HIV data from which incidence can be computed is scarce. The objective of this study was to estimate the force of infection and incidence of HIV in Malawi using crosssectional HIV sero-prevalence data from the Malawi Demographic and Health Survey conducted in 2004. The researchers estimated population incidence from the force of infection by accounting for the prevalence, as the force of infection applies only to the HIV-negative part of the population. The estimated HIV population incidence per 100,000 person-years among men is 610 for the 15–24 year age range, 2,700 for the 25–34 group and 1,320 for 35–49 year olds. For females, the estimates are 2,030 for 15–24 year olds, 1,710 for 25–34 year olds and 1,730 for 35–49 year olds. In conclusion, the researchers assert that their method provides a simple way of simultaneously estimating the incidence rate of HIV and the age-specific population prevalence for single ages using population-based crosssectional sero-prevalence data. The estimated incidence rates depend on the HIV and natural mortalities used in the estimation process.
In this study, researchers evaluated the effect of an intervention to improve the quality of data used to monitor the prevention of mother-to-child transmission (PMTCT) of HIV in South Africa. The study involved 58 antenatal clinics and 20 delivery wards (37 urban, 21 rural and 20 semi-urban) in KwaZulu-Natal province that provided PMTCT services and reported data to the District Health Information System. The data improvement intervention, which was implemented between May 2008 and March 2009, involved training on data collection and feedback for health information personnel and programme managers, monthly data reviews and data audits at health-care facilities. Data on six data elements used to monitor PMTCT services and recorded in the information system were compared with source data from health facility registers before, during and after the intervention. Findings suggested that the level of data completeness increased from 26% before to 64% after the intervention. Similarly, the proportion of data in the information system considered accurate increased from 37% to 65%. Moreover, the correlation between data in the information system and those from facility registers rose from 0.54 to 0.92.
RESYST is a new international research consortium funded by the United Kingdom’s Department for International Development. It aims to enhance the resilience and responsiveness of health systems globally to promote health and health equity and reduce poverty. RESYST conducts research in a variety of countries in Africa and Asia, including low- and middle-income countries, seeking to identify lessons that are transferable across contexts. Research is conducted in three areas: financing (focusing on how best to finance universal health coverage in low and middle-income countries); health workforce (identifying effective, practical interventions to address human resource constraints); and governance (studying the relationships among frontline actors and mid-level management, and leadership in health policy implementation processes).