In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. The author of this paper probed the role of inter-facility transport in effecting this reduction in mortality. The author conducted a before-after analysis of data from two separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Results showed that the maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7%. Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. The author concludes that effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.
Equitable health services
Genetic testing for BRCA mutations has been available in the Western Cape of South Africa since 2005, but practical implementation of genetic counselling and testing has been challenging. The authors of this paper describe an approach to breast cancer genetic counselling and testing developed in a resource-constrained environment at Tygerberg Hospital in Cape Town, Western Cape. Genetic counselling was offered in a stepwise manner to our diverse patient population, with a focus on affected probands, and subsequent cascade testing. A record review of BRCA testing between 2005 and 2011 was performed. During this period 302 probands received genetic testing, with increasing numbers tested over time. Of 1,520 women treated for breast cancer since 2008, 226 (14.9%) accepted BRCA testing, and 39 tested positive (17.3% of those tested, and 2.6% of all women). Common founder mutations were detected in 11.9% of women, and comprised 73% of mutations detected. Cascade testing increased after 2010: 16 female and 4 male family members of 19 probands accepted testing, with 6 positives being detected. In conclusion, this protocol-driven approach focusing on probands, with initial pre-test counselling by primary care staff was proven effective in establishing the service.
Ethiopia has one of the highest maternal mortality ratios (673 per 100,000 live births) in the world, and unsafe abortion was estimated to account for 32% of all maternal deaths in Ethiopia. The objective of this study was to assess post-abortion care quality status in health facilities of Guraghe zone, in Ethiopia. A facility based cross-sectional study design with both quantitative and qualitative methods was conducted, which included six health centres, two hospitals and 422 post-abortion patients. Patient-provider interaction was generally satisfactory from the patient’s perspective as, overall, 83.5% of the patients were satisfied with the services. Those who said waiting time was long were less satisfied and unemployed women were more satisfied than others. However, from a clinical service delivery stand point, important medical information on danger signs, follow-up needs of post abortion clients and care associated pain management were neglected by most of the health professionals. Almost all of the health facilities had basic and appropriate medical equipment and supplies required for providing post-abortion services. This study has also shown that significant proportions of providers were trained on important aspects of pregnancy and ante-natal care.
To better understand trends in the burden of malaria and their temporal relationship to control activities, a survey was conducted to assess reported cases of malaria and malaria control activities in Mutasa District, Zimbabwe. Data on reported malaria cases were abstracted from available records at all three district hospitals, three rural hospitals and 25 rural health clinics in Mutasa District from 2003 to 2011. Results showed that malaria control interventions were scaled up through the support of several global initiatives, the newer artemisinin-based combination therapy was adopted by all health clinics by 2010, diagnostic capacity improved and vector control was implemented. The number of reported malaria cases initially increased from levels in 2003 to a peak in 2008 but then declined 39% from 2008 to 2010. The proportion of suspected cases of malaria in older children and adults remained high, ranging from 75% to 80%. From 2008 to 2010, the number of RDT positive cases of malaria decreased 35% but the decrease was greater for children younger than five years of age (60%) compared to older children and adults (26%). In conclusions, the burden of malaria in Mutasa District decreased following the scale up of malaria control interventions. However, the persistent high number of cases in older children and adults highlights the need for strategies to identify locally effective control measures that target all age groups.
The authors of this study undertook a programme evaluation of HIV and TB prevention and therapeutic services at facility level in South Africa to describe integration and how it is implemented. They evaluated 26 rural and 146 urban public primary-care facilities using secondary data generated from December 2008 and May 2009. Evidence of integration was found across two dimensions: disease programmes and the prevention–therapeutic axis. Smaller rural facilities did not always have staff trained in all the required services, nurses worked without the support of a doctor and supervision was weaker, threatening quality of care. However, in the rural district there were instances of clients receiving more integrated services. The quality of care in the TB programme was high in both districts. In both the districts evaluated, integration across programmes and the prevention-care-rehabilitation axis of services was achieved through co-location at primary-care level. Coupled with health system strengthening, this has the potential to improve access across the HIV/TB/STI cluster of services. The benefit is likely to be greater in rural areas. Quality of care was maintained in the long-established TB programmes in both settings.
Little is known about the health conditions and support needs of people living with intellectual disability (ID) in the African context. To address this gap, the authors conducted this study in residential facilities in the Western Cape Province, South Africa, for people over the age of 18 years with ID. They conducted in face-to-face interviews with the managers of 37 out of 41 identified facilities, as well as a survey of 2,098 residents (54% of them female), representing less than 2% of the estimated population of persons with ID in the province. The survey suggests that such persons experience a wide range of health conditions (notably mental health and behavioural issues) but have limited access to general healthcare and rehabilitation services. Furthermore, the daily living supports required for an acceptable quality of life are limited. The findings highlight the need for better health and support provision to persons with ID.
The authors of this paper hypothesised that just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. They present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. Between April 2009 and September 2010, we conducted their study in six rural public primary healthcare facilities and found that one-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. They observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing) but despite these improvements, no progress attributable to one-stop, integrated MCH services was observed. Structural healthcare system limitations, such as staff absences and an irregular supply of essential commodities, appear to have a larger effect. Regular technical support and adequate basic working conditions form valuable motivators and are of critical importance for improved staff performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.
Malaria importation from neighbouring high-endemic Mozambique through Swaziland’s eastern border remains a major factor that could prevent elimination from being achieved. A nationwide formative assessment was conducted over eight weeks to determine if the imported cases of malaria identified by the Swaziland National Malaria Control Programme could be linked to broader social networks and to explore methods to access these networks. Interviews were carried out with malaria surveillance agents (6), health providers (10), previously identified imported malaria cases (19) and people belonging to the networks identified through these interviews (25). Network members and key informants revealed common congregation points, such as the urban market places in Manzini and Malkerns, as well as certain bus stations, where people with similar travel patterns and malaria risk behaviours could be located and tested for malaria. The authors of this study conclude that imported cases of malaria belong to networks of people with similar travel patterns. This study may provide novel methods for screening high-risk groups of travellers using both snowball sampling and time-location sampling of networks to identify and treat additional malaria cases. The authors argue that implementation of a proactive screening programme of importation networks may help Swaziland halt transmission and achieve malaria elimination by 2015.
In this study, the authors collected data as part of a multi-site cross sectional study, Researching Equity in Access to Healthcare (REACH), to examine HIV testing coverage in tuberculosis (TB) patients. They administered a structured questionnaire to 300 patients accessing TB treatment in five rural primary health care clinics in Hlabisa subdistrict, KwaZulu-Natal, South Africa, a high TB and HIV burden area. Results showed high HIV testing rates among TB patients, suggesting that TB-HIV co-infected patients can be managed appropriately for treatment of both infections. The decentralised programme appears largely successful in attaining universal HIV testing in TB patients in this resource-limited setting. However, there is scope for further improvement such as in DOTS delivery, which is a sustainable and effective way of ensuring good adherence to TB treatment, the authors argue. Patients mostly use the closest clinic for both TB treatment and HIV testing, suggesting a receding fear of stigma of HIV. But the small number of patients not using the closest clinic are far less likely to undergo HIV testing, possibly indicating vulnerability expressed both in the location of seeking TB treatment and HIV testing uptake. Policy makers should encourage integration of services and cross-testing in HIV-TB facilities, the authors conclude.
In this study, researchers describe the approaches to defining and improving quality of health services across the five country programmes funded through the Doris Duke Charitable Foundation African Health Initiative. They describe the differences and similarities across the programmes in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programmes measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality. Learning the value and challenges of these approaches to measuring and improving quality across the key components of health system strengthening as the projects continue their work, the authors conclude.