Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades – including 13 wars during 1990–2015 – than any other part of the world, and this has had an adverse effect on health systems in the region. This study aimed to understand the best health system practices in five SSA countries that experienced wars during 1990–2015, and yet managed to achieve a maternal mortality reduction – equal to or greater than 50% during the same period – according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). The study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars.
Equitable health services
This study synthesised the best available evidence on effectiveness of maternity waiting homes on the reduction of maternal mortality and stillbirth in developing countries. In developing countries, maternity waiting homes users were 80% less likely to die than non-users and there was 73% less occurrence of stillbirth among users. In Ethiopia, there was a 91% reduction of maternal death among maternity waiting homes users unlike non-users and it contributes to the reduction of 83% stillbirth unlike non-users. Maternity waiting home contributes more than 80% to the reduction of maternal death among users in developing countries and Ethiopia. Its contribution for reduction of stillbirth is good. More than 70% of stillbirth is reduced among the users of maternity waiting homes. In Ethiopia maternity waiting homes contributes to the reduction of more than two third of stillbirths.
Female sex workers in many settings have restricted access to sexual and reproductive health services. This paper tested a diagonal intervention which combined strengthening of female sex workers targeted services with making public health facilities more female sex worker-friendly. It was piloted over 18 months and then its performance assessed. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure that female sex workers have access to sexual reproductive health services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by the national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.
This study explored refugee caregivers’ perceptions of their children’s access to quality health service delivery to their young children in Durban, South Africa. This study used an explanatory mixed methods design, purposively sampling 120 and 10 participants for the quantitative and qualitative phases, respectively. The majority (89%) of caregivers were women, with over 70% of them aged between 30 and 35 years. Over 74% of caregivers visited public clinics for their children’s healthcare needs. The majority of caregivers (95%) were not satisfied with healthcare services delivery to their children due to the long waiting hours and the negative attitudes and discriminatory behaviours of healthcare workers, particularly in public healthcare facilities. These findings underscore the need to address health professionals’ attitudes when providing healthcare for refugees. The authors suggest that attitudinal change may improve the relationship between service providers and caregivers of refugee children in South Africa, which may improve the health-related outcomes in refugee children.
This paper aimed to assess whether horizontal and vertical equity were being met in the healthcare utilisation among adults aged 50 years and above. The paper was based on a secondary cross-sectional data from the World Health Organization’s Study on global AGEing and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Horizontal and vertical inequities were found in the use of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The paper reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access.
During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. The authors describe the scope and characteristics of this contact tracing and assess its performance during the 2014–2015 epidemic in six counties. Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during the period covered, with a PPV of 1.4%. Potential cases were more likely to be detected early in the outbreak; to hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness, as compared to contacts who completed monitoring. Contact tracing was identified to be a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, the study data suggest there were limitations to its performance—particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.
The month-old Ebola outbreak in the Democratic Republic of Congo, which rose quickly to over 100 cases appears to be fading. More than 3,500 contacts of known cases are being followed, more than 4,000 doses of vaccine have been given and officials reported feeling hopeful enough to allow schools in the area — North Kivu Province, on the eastern border with Uganda — to open as usual. Although five experimental treatments for infected patients recently won approval for emergency use, the author reports that so far too few patients have received them to draw conclusions about how well they may work. One reason experts are reluctant to declare the outbreak contained is that some remote towns have not been visited because of armed groups in the area. Ebola experts also said they would not let down their guard because they remembered a brief, deceptive lull in the early days of the 2014 West African outbreak before it reached three capital cities and exploded, killing more than 11,000 people. Medically, the most exciting prospect on the horizon is that, as of Aug. 22, DRC has approved the emergency use of five potential treatments: two antiviral drugs, remdesivir and favipiravir; and three cocktails of antibodies originally found in recovered patients, including ZMapp, mAb114 and Regn3450-3471-3479. Previously, only about half of Ebola patients were saved if they got supportive treatment, including fluid replacement and fever control, in time. Being consistently able to cure most patients is reported to be an important advance.
In low-and-middle-income countries (LMICs), epidemiologic transition is taking place very rapidly from communicable diseases to non-communicable diseases (NCDs). NCD mortality rates are increasing faster and nearly 80% of NCDs deaths occur in LMICs, with human and economic costs, increasing treatment costs and losses to productivity. At the same time, the increasing penetration of mobile phone technology and the spread of cellular network and infrastructure have led to the introduction of the mHealth. While mHealth offers a promising approach in prevention and control of NCDs, it is unclear how ready health systems are to adopt it for this. The authors raise a number of factors which determine health systems readiness and response for adoption of mHealth technology including preparedness of healthcare institutions, availability of the resources, willingness of healthcare providers and communities. They discuss these factors and suggest that they be dealt up-front through constant effort to improve health systems response for NCDs.
A Maternity Waiting Home (MWH) is a facility, within easy reach of a hospital or health centre which provides Emergency Obstetric Care (EmOC). The aim of the MWH is to improve accessibility and thus reduce morbidity and mortality for mother and neonate should complications arise. This study assessed the effects of a maternity waiting facility on maternal and perinatal health. The authors searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), African Journals Online (AJOL) (April 2009), POPLINE (April 2009), Dissertation Abstracts (April 2009) and the National Research Register archive (March 2008) for conducted randomised controlled trials that compared perinatal and maternal outcome in women using a MWH and women who did not. There were no randomised controlled trials or cluster-randomised trials identified from the search. They found from this evidence that there is insufficient evidence to determine the effectiveness of Maternity Waiting Facilities for improving maternal and neonatal outcomes.
This study explored self-management practices of patients with different chronic conditions, and their strategies to overcome care challenges in a resource constrained setting in Malawi. A qualitative study was conducted which involved patients with different chronic conditions from one rural district in Malawi. Data are drawn from semi-structured questions of a survey with 129 patients, 14 in-depth interviews, and four focus-group discussions with patients. Patients demonstrated ability to self-manage their conditions, though this varied between conditions, and was influenced by individual and external factors. Factors included ability to acquire appropriate disease knowledge, poverty level, the presence of support from family caregivers and community-based support initiatives, the nature of one’s social relations; and the ability to deal with stressors and stigma. Non-communicable diseases and HIV co-infected people were more disadvantaged in their access to care, as they experienced frequent drug stockouts and incurred additional costs when referred. These barriers contributed to delayed care, poorer treatment adherence, and likelihood of poorer treatment outcomes. Patients proved resourceful and made adjustments in the face of care challenges. The authors’ findings complement other research on self-management experiences in chronically ill patients with its analysis on factors and barriers that influence patient self-management capacity in a resource-constrained setting. They recommended expanding current peer-patient and support group initiatives to patients with non-communicable diseases, and further investments in the decentralization of integrated health services to primary care level in Malawi.