Equitable health services

Social innovation for health-care delivery in Africa
Keeton C: Bulletin of the World Health Organisation 95(4)246–247, 2017

Millie Balamu goes from door to door providing life-saving health care for about 200 households in the Wakiso district of Uganda. Villagers call her masawu (“doctor” in the local Luganda language), but she is a community health worker. She has tests and drugs with her to diagnose and treat malaria, diarrhoea and pneumonia and uses her mobile phone to diagnose these diseases and register pregnant women for follow up. This paper reports on the Social Innovation in Health Initiative. The concept of social innovation is taken from economics and business studies and refers to efforts to mobilise and incentivise communities. In health, social innovation may refer to low-fee private delivery of health care, using mobile phone applications – such as the one Balamu uses to diagnose common childhood diseases – and other novel ways to make health-care delivery more accessible and affordable in low-income communities. According to a working paper presenting the results of a randomised controlled trial in Uganda of more than 8000 households, published in 2016 the social innovation project helped to reduce child mortality across those households by 27% between 2011 and 2013.

10 Ways to improve the quality of care in health facilities
World Health Organisation: WHO Geneva, 2017

In this article, a photo story is used to describe some of WHO’s recommendations on how countries can improve quality of care in their health facilities and prevent maternal and newborn deaths, based on its standards for improving quality of maternal and newborn care in health facilities. The photo story shows that health facilities must have an appropriate physical environment and that communication with women and their families must be effective and respond to their needs. The story shows further that women and newborns who need referrals should obtain them without delay, no woman should be subjected to harmful practices during labour, childbirth and the early postnatal period, and that health facilities need well-trained and motivated staff consistently available to provide care. Lastly, the story presents images showing that every woman and newborn should have a complete, accurate, and standardised medical record.

Antimicrobial resistance: translating political commitment into national action
Inoue H; Minghui R: Bulletin of the World Health Organisation 95(4) 241-312, 2017

Antimicrobial resistance is one of the most complex global health challenges today. Worsening antimicrobial resistance could have serious public health, economic and social implications around the world and could cause as much damage to the global economy as the 2008 financial crisis. Since May 2015, progress has also been made in the implementation of global commitments in this area. Over one hundred countries have completed, or are about to complete, their national multi-sectoral action plans. WHO has established a global antimicrobial resistance surveillance system to track which drug-resistant pathogens are posing the biggest challenge. Based on a review and analysis of national guidelines and prescribing practices for 20 common syndromes, WHO is revising the antibiotics included in the WHO model list of essential medicines. The organisation has also rolled out a global awareness-raising campaign targeting policy-makers, health and agriculture workers and communities. To scale up activities, the authors suggest that governments can build on existing regulatory frameworks, surveillance systems, laboratory and infection control infrastructure and human resources that are already in place to manage drug resistance in tuberculosis, HIV and malaria. Both at global and country level, much more still needs to be done. An ad hoc interagency coordination group is being established by the United Nations (UN) Secretary-General, in consultation with WHO, the Food and Agriculture Organisation of the UN and the World Organisation for Animal Health. WHO is preparing proposals for a global development and stewardship framework to support the development, control, distribution and appropriate use of new antimicrobial medicines, diagnostic tools, vaccines and other interventions. By May 2017, all countries should have their national action plans ready, as called for by World Health Assembly resolution 68.7. To see tangible progress, the authors argue that these global commitments must be translated into coherent regional and national action across the entire spectrum of diseases and pathogens.

Antimicrobial-resistant infections among postpartum women at a Ugandan referral hospital
Bebell L; Ngonzi J; Bazira J et al.: PLoS ONE 12(4) 2017, doi: https://doi.org/10.1371/journal.pone.0175456

Puerperal sepsis causes 10% of maternal deaths in Africa, but prospective studies on incidence, microbiology and antimicrobial resistance are lacking. The authors performed a prospective cohort study of 4,231 Ugandan women presenting to a regional referral hospital for delivery or postpartum care. The study found for women in rural Uganda with postpartum fever, a high rate of antibiotic resistance among cultured urinary and bloodstream infections, including cephalosporin-resistant Acinetobacter species. They recommend that increasing availability of microbiology testing to inform appropriate antibiotic use, development of antimicrobial stewardship programs, and strengthening infection control practices should be high priorities.

Evidence for scaling up HIV treatment in sub-Saharan Africa: A call for incorporating health system constraints
Mikkelsen E; Hontelez J; Jansen M et al.: PLoS Medical Journal 14(2), 2017, doi:10.1371/journal.pmed.1002240

The scale-up of antiretroviral therapy (ART) for HIV-infected people in sub-Saharan Africa (SSA) over the past 15 years is one of the most remarkable achievements in public health. With approximately 12 million people on treatment in 2015, life expectancy on the subcontinent has vastly improved. Nevertheless, ART coverage in SSA is still suboptimal, HIV incidence remains high, and improved survival due to ART implies ever increasing numbers of people on treatment. Substantial additional resources are needed to further scale up ART, yet funding has recently levelled off, increasing the need to optimise the allocation of limited resources. This presents local policy makers with complex dilemmas. The authors argue that the current evidence base for prioritising ART scale-up strategies leads to recommendations that are theoretically optimal but practically infeasible to implement. They argue that cost-effectiveness analyses of scaling up ART in SSA take into account the local health system by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.

South Africa District Health Barometer 2015/16
Massyn N; Peer N; English R; Padarath A; Barron P; Day C: Health Systems Trust, South Africa, 2016

The District Health Barometer (DHB) 2015/16, in its 11th edition, seeks to highlight, health system performance, inequities in health outcomes, and health-resource allocation and delivery, and to track the efficiency of healthcare delivery processes across all provinces and districts in South Africa. It has become a planning and management resource for health service providers, managers, researchers and policy-makers. This DHB contains 44 indicators, with trend illustrations and health profiles across South Africa’s nine provinces and 52 health districts. It includes a chapter on the burden of disease, as well as seven additional indicators, including: inpatient under 5 years death rate, percentage of ideal clinics, percentage of assessed PHC facilities with patients who have access to a medical practitioner and the MDR-TB treatment success rate.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa
Opoku D; Stephani V; Quentin W: BMC Medicine 15 (24), doi: 10.1186/s12916-017-0782-z, 2017

The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework. The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. The authors propose that policy makers and program managers consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. They argue that researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

Establishing the Africa Centres for Disease Control and Prevention: responding to Africa's health threat
Nkengasong J; Maiyegun O; Moeti M: The Lancet Global Health 5(3), e246-247, 2017

On Jan 31, 2017, heads of states and governments of the African Union and the leadership of the African Union Commission officially launched the Africa Centres for Disease Control and Prevention (Africa CDC) in Addis Ababa, Ethiopia. As detailed in the African Union's Africa Agenda 2063—a roadmap for the development of the continent—some of the concerns that justified the establishment and initiation of an Africa-wide public health agency include rapid population growth; increasing and intensive population movement across Africa, with increased potential for new or re-emerging pathogens to turn into pandemics; existing endemic and emerging infectious diseases, including Ebola; antimicrobial resistance; increasing incidence of non-communicable diseases and injuries; high maternal mortality rates; and threats posed by environmental toxins.

Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa
Lafort Y; Greener R: Roy A: et al.: Reproductive Health 14 (13) DOI: 10.1186/s12978-017-0277-6, 2017

Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, this paper identified gaps in service utilization in four different. A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 ‘seeds’ identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs’ sociodemographic characteristics. The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. The authors advise that intervention packages to improve use of contraceptives and SRH services be tailored to gaps in each city.

Using mHealth for HIV/TB Treatment Support in Lesotho: Enhancing Patient–Provider Communication in the START Study
Hirsch-overman Y; Daftary A; Yuengling K; Saito S; Ntoane M; Frederix K; Maama B; Howard A: Journal of Acquired Immune Deficiency Syndromes 74, S37–S43, 2017

mHealth is a promising means of supporting adherence to treatment. The Start TB patients on ART and Retain on Treatment (START) study included real-time adherence support using short-text messaging service (SMS) text messaging and trained village health workers (VHWs). The authors describe the use and acceptability of mHealth by patients with HIV/tuberculosis and health care providers. Patients and treatment supporters received automated, coded medication and appointment reminders at their preferred time and frequency, using their own phones, and $3.70 in monthly airtime. Facility-based VHWs were trained to log patient information and text message preferences into a mobile application and were given a password-protected mobile phone and airtime to communicate with community-based VHWs. The use of mHealth tools was analysed from process data over the study course. Acceptability was evaluated during monthly follow-up interviews with all participants and during qualitative interviews with a subset of 30 patients and 30 health care providers at intervention sites. Use and acceptability were contextualised by monthly adherence data. From April 2013 to August 2015, the automated SMS system successfully delivered 39,528 messages to 835 individuals, including 633 patients and 202 treatment supporters. Uptake of the SMS intervention was high, with 92.1% of 713 eligible patients choosing to receive SMS messages. Patient and provider interviews yielded insight into barriers and facilitators to mHealth utilisation. The intervention improved the quality of health communication between patients, treatment supporters, and providers. HIV-related stigma and technical challenges were identified as potential barriers. The mHealth intervention for HIV/tuberculosis treatment support in Lesotho was found to be a low-tech, user-friendly intervention, which was acceptable to patients and health care providers.

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