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.
Equitable health services
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 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.
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.
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.
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.
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.
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 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.
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.