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.
Equitable health services
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.
Lesotho has one of the highest maternal mortality rates in the world, Partners In Health (PIH) has included maternity waiting homes since 2009 as part of a comprehensive effort to increase facility-based deliveries and reduce maternal mortality. The maternity waiting homes are located at seven PIH-supported health centres in some of the most remote, underserved areas of rural Lesotho. The homes provide food and shelter for women who live far away from the health centre or have risk factors for potential obstetric complications, and are well-regarded by both health centre staff and pregnant women. Since the implementation of the Maternal Mortality Reduction Project, PIH has seen waiting home admissions and the number of monthly deliveries at health centres increase dramatically. The authors suggest that failure of previous studies to demonstrate a positive impact of maternity waiting homes may reflect the failure to successfully implement other supporting components of a larger, comprehensive strategy to increase access to maternal health services.
This study contributes to the health policy debate on medical systems integration by describing and analysing the interactions between health-care users, indigenous healers, and the biomedical public health system, in the so far rarely documented case of post-conflict Burundi. The authors adopted a mixed-methods approach combining (1) data from an existing survey on access to health-care, with 6,690 individuals, and (2) original interviews and focus groups conducted in 2014 with 121 respondents, including indigenous healers, biomedical staff, and health-care users. The findings reveal pluralistic patterns of health-care seeking behaviour, which are not primarily based on economic convenience or level of education. Indigenous healers’ diagnosis is shown to revolve around the concept of ‘enemy’ and the need for protection against it. The authors suggest ways in which this category may intersect with the widespread experience of trauma following the civil conflict. They find that, while biomedical staff display ambivalent attitudes towards healers, cross-referrals occasionally take place between healers and health centres. The authors emphasise healers’ psychological support role in helping communities deal with trauma.
The Executive Secretary of the East African Health Research Commission (EAHRC), Professor Gibson Kibiki, has decried the high number of East Africans going to India to seek medical services which can be accessed in hospitals in the region. Prof. Kibiki attributed the huge exodus of patients to India to the lack of information on health services that were available at referral hospitals in the region. He revealed that East Africans may soon be able to access treatment across national borders in addition to enjoying portable health insurance across the region, adding that the Commission would soon undertake research to gauge the feasibility of a regional health insurance scheme before piloting the scheme. He described as counterproductive the tendency by health researchers and medics in the Partner States to work in silos since the region was one and that diseases did not know national borders.
This paper synthesizes findings from nine studies focusing on four health systems domains, namely human resources, service delivery, governance and financing. It provides examples of how a gender approach can be applied by researchers in a range of low- and middle-income settings to these domains and demonstrates that this can uncover new ways of viewing seemingly intractable problems. The studies used a combination of mixed, quantitative, qualitative and participatory methods, including photovoice and life histories, to prompt deeper and more personal reflections on gender norms. Five core themes that cut across the different studies were the intersection of gender with other social stratifiers, the importance of male involvement, the influence of gendered social norms on health system structures and processes, the reliance on unpaid carers within the health system and the role of gender within policy and practice. These themes indicate the relevance of and need for gender analysis by researchers, policy-makers and health practitioners.
This study measures and describes socioeconomic inequality in self-reported unmet need for oral health services in adults aged 50 years and over, in China, Ghana and India. The prevalence of unmet need was 60, 80, and 62% in China, Ghana and India respectively. The adjusted relative index of inequality for education was statistically significant for China, Ghana, and India, whereas the adjusted relative index of inequality for wealth was significant only in Ghana. Male sex was significantly associated with self-reported unmet need for oral health services in India. Given rapid population ageing, the author argues that further evidence of socioeconomic inequalities in unmet need for oral health services by older adults in low to medium income countries are needed to inform policies to mitigate inequalities in the availability of oral health services.
With limited global supplies of oral cholera vaccine, countries need to identify priority areas for vaccination while longer-term solutions, such as water and sanitation infrastructure, are being developed. In 2017, Malawi integrated oral cholera vaccine into its national cholera control plan. The process started with a desk review and analysis of previous surveillance and risk factor data. At a consultative meeting, researchers, national health and water officials and representatives from nongovernmental and international organizations reviewed the data and local epidemiological knowledge to determine priority districts for oral cholera vaccination. The final stage was preparation of an application to the global oral cholera vaccine stockpile for non-emergency use. Malawi collects annual data on cholera and most districts have reported cases at least once since the 1970s. The government’s application for 3.2 million doses of vaccine to be provided over 20 months in 12 districts was accepted in April 2017. By April 2018, over 1 million doses had been administered in five districts. Continuing surveillance in districts showed that cholera outbreaks were notably absent in vaccinated high-risk areas, despite a national outbreak in 2017–2018. Augmenting advanced mapping techniques with local information helped to extend priority areas beyond those identified as high-risk based on cholera incidence reported at the district level. Involvement of the water, sanitation and hygiene sectors is key to ensuring that short-term gains from cholera vaccine are backed by longer-term progress in reducing cholera transmission.