Equitable health services

World Health Organisation: What is people-centred care?
World Health Organisation: WHO, Geneva, 2017

This video from WHO introduces the concept of people-centred care. Globally, one in 20 people still lack access to essential health services that could be delivered at a local clinic instead of a hospital. And where services are accessible, they are often fragmented and of poor quality. WHO is supporting countries to progress towards universal health coverage by designing health systems around the needs of people instead of diseases and health institutions, so that everyone gets the right care, at the right time, in the right place.

“I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia
Asher L; Fekadu A; Teferra S; De Silva M; Pathare S; Hanlon C: Globalisation and Health 13(47), doi: 10.1186/s12992-017-0273-1, 2017

A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mensystetal illness and their families, are rarely heard. This study aimed to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions. A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment, calling for the scale up of accessible and affordable mental health care.

Non-communicable diseases and HIV care and treatment: models of integrated service delivery
Duffy M; Ojikutu B; Andrian S; Sohng E; Minior T; Hirschhorn L: Tropical Medicine and International Health 00(00), doi:10.1111/tmi.12901, 2017

Non-communicable diseases (NCD) are a growing cause of morbidity in low-income countries including in people living with human immunodeficiency virus (HIV). Integration of NCD and HIV services can build upon experience with chronic care models from HIV programmes. The authors described the models of NCD and HIV integration, challenges and lessons learned. A literature review of published articles on integrated NCD and HIV programs in low-income countries and key informant interviews were conducted with leaders of identified integrated NCD and HIV programs. Information was synthesised to identify models of NCD and HIV service delivery integration. Three models of integration were identified as follows: NCD services integrated into centres originally providing HIV care; HIV care integrated into primary health care (PHC) already offering NCD services; and simultaneous introduction of integrated HIV and NCD services. Major challenges identified included NCD supply chain, human resources, referral systems, patient education, stigma, patient records and monitoring and evaluation. The range of HIV and NCD services varied widely within and across models. conclusions Regardless of model of integration, leveraging experience from HIV care models and adapting existing systems and tools is a feasible method to provide efficient care and treatment for the growing numbers of patients with NCDs. The authors argue that operational research should be conducted to further study how successful models of HIV and NCD integration can be expanded in scope and scaled-up by managers and policymakers seeking to address all the chronic care needs of their patients.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania
Kruk M; Chukwuma A; Mbaruku G; Leslie H: Bulletin of the World Health Organisation 95(6), 389-480, 2017

This study analysed factors affecting variations in the quality of antenatal and sick-child care in primary-care facilities in seven African countries, using service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania in 2006–2014. Based on World Health Organization protocols, they created indices of process quality for antenatal care (first visits) and for sick-child visits and assessed national, facility, provider and patient factors that might explain variations in quality of care. Overall, health-care providers performed a mean of 62% of eight recommended antenatal care actions and 55% of nine sick-child care actions at observed visits. The quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The authors conclude that the quality of two essential primary-care services for women and children was weak and varied across and within the countries. They observe that analysis of reasons for variations in quality could identify strategies for improving care.

Capacity for diagnosis and treatment of heart failure in sub-Saharan Africa
Carlson S; Duber H; Achan J; Ikilezi G; Mokdad A; Stergachis A; Gollum A; Bushman G; Roth G: Heart, doi: http://dx.doi.org/10.1136/heartjnl-2016-310913, 2017

Heart failure is a major cause of disease burden in sub-Saharan Africa. The authors aim to provide a better understanding of the capacity to diagnose and treat heart failure in Kenya and Uganda to inform policy planning and interventions. They analysed data from a nationally representative survey of health facilities in Kenya and Uganda (197 health facilities in Uganda and 143 in Kenya) and report on the availability of cardiac diagnostic technologies and select medications for heart failure. Facility-level data were analysed by country and platform type (hospital vs ambulatory facilities). Functional and staffed radiography, ultrasound and ECG were available in less than half of hospitals in Kenya and Uganda combined. Of the hospitals surveyed, 49% of Kenyan and 77% of Ugandan hospitals reported availability of the heart failure medication package. ACE inhibitors were only available in 51% of Kenyan and 79% of Ugandan hospitals. Almost one-third of the hospitals in each country had a stock-out of at least one of the medication classes in the prior quarter. Few facilities in Kenya and Uganda were prepared to diagnose and manage heart failure. Medication shortages and stock-outs were common. The authors’ findings call for increased investment in cardiac care to reduce the growing burden of heart failure.

Evaluation of the influenza sentinel surveillance system in Madagascar, 2009–2014
Rakotoarisoa A; Randrianasolo L; Tempia S; Guillebaud J; Razanajatovo N; Randriamampionona L; Piola P; Halm A; Heraud JM: Bulletin of the World Health Organisation 95(5) 375–381, 2017

Evaluation of influenza surveillance systems is poor, especially in Africa. In 2007, the Institut Pasteur de Madagascar and the Malagasy Ministry of Public Health implemented a countrywide system for the prospective syndromic and virological surveillance of influenza-like illnesses. In assessing this system’s performance, the authors identified gaps and ways to promote the best use of resources. The authors investigated acceptability, data quality, flexibility, representativeness, simplicity, stability, timeliness and usefulness and developed qualitative and/or quantitative indicators for each of these attributes. Until 2007, the influenza surveillance system in Madagascar was only operational in Antananarivo and the observations made could not be extrapolated to the entire country. By 2014, the system covered 34 sentinel sites across the country. At 12 sites, nasopharyngeal and/or oropharyngeal samples were collected and tested for influenza virus. Between 2009 and 2014, 177 718 fever cases were detected, 25 809 (14.5%) of these fever cases were classified as cases of influenza-like illness. Of the 9192 samples from patients with influenza-like illness that were tested for influenza viruses, 3573 (38.9%) tested positive. Data quality for all evaluated indicators was categorised as above 90% and the system also appeared to be strong in terms of its acceptability, simplicity and stability. However, sample collection needed improvement. The influenza surveillance system in Madagascar performed well and provided reliable and timely data for public health interventions. Given its flexibility and overall moderate cost, the authors argue that this system may become a useful platform for syndromic and laboratory-based surveillance in other low-resource settings.

Three African countries chosen to test first malaria vaccine
Prinsloo K: Associated Press, 24 April 2017

Three African countries have been chosen to test the world’s first malaria vaccine, the World Health Organisation announced in April 2017. Ghana, Kenya, and Malawi will begin piloting the injectable vaccine next year with hundreds of thousands of young children, who have been at highest risk of death. The vaccine, which has partial effectiveness, has the potential to save tens of thousands of lives if used with existing measures, the WHO regional director for Africa, Dr. Matshidiso Moeti, said in a statement. The challenge is whether impoverished countries can deliver the required four doses of the vaccine for each child. Malaria remains one of the world’s most stubborn health challenges, infecting more than 200 million people every year and killing about half a million, most of them children in Africa. Bed netting and insecticides are the chief protection. A global effort to counter malaria has led to a 62 percent cut in deaths between 2000 and 2015, WHO said. But the U.N. agency has said in the past that such estimates are based mostly on modelling and that data is so bad for 31 countries in Africa — including those believed to have the worst outbreaks — that it couldn’t tell if cases have been rising or falling in the last 15 years. The vaccine will be tested on children five to 17 months old to see whether its protective effects shown so far in clinical trials can hold up under real-life conditions. At least 120,000 children in each of the three countries will receive the vaccine, which has taken decades of work and hundreds of millions of dollars to develop. Kenya, Ghana and Malawi were chosen for the vaccine pilot because all have strong prevention and vaccination programs but continue to have high numbers of malaria cases, WHO said. The countries will deliver the vaccine through their existing vaccination programs. WHO is hoping to wipe out malaria by 2040 despite increasing resistance problems to both drugs and insecticides used to kill mosquitoes. The malaria vaccine has been developed by pharmaceutical company GlaxoSmithKline, and the $49 million for the first phase of the pilot is being funded by the global vaccine alliance GAVI, UNITAID and Global Fund to Fight AIDS, Tuberculosis and Malaria.

Country-specific data on the contraceptive needs of adolescents
Hindin M; Kalamar A: Bulletin of the World Health Organisation 95(166) 2017

As the sustainable development goals (SDGs) require country-level tracking of indicators related to contraception, including met need, a key question is “What can be done to support adolescents to prevent unintended pregnancy? To answer this question, the authors developed country-specific fact sheets describing adolescent contraceptive use and non-use in 58 low- and middle-income countries spanning all six World Health Organisation Regions. The authors report the top three reasons adolescent girls give for why they are not currently using contraception, even though they do not want to become pregnant in the next two years. The data are based on responses from 15–19 year old adolescent girls, and are presented separately for those unmarried and sexually active and those in a union. Reasons for non-use vary considerably but among the most common reported are, being “not married” and infrequent sexual relations for unmarried, sexually active adolescents. In contrast, currently breastfeeding or postpartum abstinence are among the most common reasons for non-use reported by adolescents in a union. Fear of side-effects or health concerns was commonly reported by both groups of adolescent girls.The authors report on the two most common sources from which adolescents who are currently using a modern method most recently obtained that contraceptive method. The sources are driven by the types of contraceptive methods available, as well as those that are easy for adolescents to access. In some settings most sources are in the formal sector, including government facilities, private facilities and pharmacies. In other settings most adolescents obtain contraceptive commodities in the informal sector, such as shops, kiosks or roadside stands, or from friends. The data from the fact sheets indicate where best to target investments to improve access to – and quality of – contraceptive services for adolescents. The data provided in these fact sheets are disaggregated by age and marital status to address the calls for ensuring that no one is left behind. These data can help policy-makers and programme planners reduce inequities in service provision and access, and to make evidence-based decisions about how to better address adolescents’ contraceptive needs.

Impact of telemonitoring approaches on integrated HIV and TB diagnosis and treatment interventions in sub-Saharan Africa: a scoping review
Yah S; Tambo E; Khayeka-Wandabwa C; Ngogang J: Health Promotion Perspectives 7(2) 60-65, 2017

This paper explores telemonitoring/mhealth approaches as a promising real time and contextual strategy in HIV and TB interventions access and uptake, retention, adherence and coverage impact in endemic and prone-epidemic prevention and control in sub-Sahara Africa. A scoping review was applied to identify relevant articles on the theme. The authors found tele monitoring/mhealth approach as a more efficient and sustained proxy in HIV and TB risk reduction strategies for early diagnosis and prompt quality clinical outcomes. It was found to significantly contribute to decreasing health systems/patients cost, long waiting time in clinics, hospital visits, travels and time off/on from work. Improved integrated HIV and TB telemonitoring systems sustainability are thus argued to hold promise in health systems strengthening, including patient-centred early diagnosis and care delivery systems, uptake and retention to medications/services and improving patients’ survival and quality of life. Tele monitoring/mhealth (electronic phone text/video/materials messaging) acceptability, access and uptake are reported to be crucial in monitoring and improving uptake, retention, adherence and coverage in both local and national integrated HIV and TB programs and interventions. Telemonitoring is also argued to be crucial in patient-providers-health professional partnership, real-time quality care and service delivery, antiretroviral and anti-tuberculous drugs improvement, susceptibility monitoring and prescription choice, reinforcing cost effective HIV and TB integrated therapy model and survival rate.

Individual and contextual factors associated with appropriate healthcare seeking behavior among febrile children in Tanzania
Adinan J; Damian D; Mosha N; Mboya I; Mamseri R; Msuya S: PLoS ONE 12(4) 2017, doi; https://doi.org/10.1371/journal.pone.0175446,

Fever in malaria endemic areas, has been shown to strongly predict malaria infection and is a key symptom influencing malaria treatment. WHO recommended confirmation testing for Plasmodium spp. before initiation of antimalarials due to increased evidence of the decrease of morbidity and mortality from malaria, decreased malaria associated fever, and increased evidence of high prevalence of non-malaria fever. To immediately diagnose and promptly offer appropriate management, caretakers of children with fever should seek care where these services can be offered; in health facilities. This study was conducted to describe healthcare seeking behaviours among caretakers of febrile under five years, in Tanzania, and to determine children’s, household and community-level factors associated with parents’ healthcare seeking behaviour in health facilities. Of the 8573 children under the age of five years surveyed, 19.5% had a history of fever two weeks preceding the survey. Of these, 56.8% sought appropriate healthcare. Febrile children aged less than a year have 2.7 times higher odds of being taken to the health facilities compared to children with two or more years of age. Febrile children from households headed by female caretakers have almost three times higher odds of being taken to the health facilities compared to households headed by men. Febrile children with caretakers exposed to mass media (radio, television and newspaper) have more than two times higher odds of being taken to health facilities compared to those not exposed to mass media. Febrile children from regions with malaria prevalence above national level have 41% less odds of being taken to health facilities compared to those febrile children coming from areas with malaria prevalence below the national level. Furthermore, febrile children coming from areas with higher community education levels have 57% higher odds of being taken to health facilities compared to their counterparts coming from areas with low levels of community education. To effectively and appropriately manage and control febrile illnesses, the authors propose that the low proportion of febrile children taken to health facilities by their caretakers should be addressed through frequent advocacy of the importance of appropriate healthcare seeking behaviour, using mass media particularly in areas with high malaria prevalence. They recommend that a multifaceted approach be used in malaria control and eradication as multiple factors are associated with appropriate healthcare seeking behaviour.

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