This review indicates that universal health coverage (UHC) interventions in low- and middle-income countries improve access to health care. It also shows, though less convincingly, that UHC often has a positive effect on financial protection, and that, in some cases it seems to have a positive impact on health status. The effect of UHC schemes on access, financial protection, and health status varies across contexts, UHC scheme design, and UHC scheme implementation processes. Regarding UHC design features, there are several common features across countries and regions, such as the coexistence of UHC schemes, heterogeneity in design and organisation, a widespread effort to include the poor in the schemes, and the prevalence of mixed financing sources (contributions plus taxes). Yet, in most cases, evidence is scarce and inconclusive on the impact of specific UHC design features on their intended outcomes. Four lessons are highlighted: affordability is important but may not be enough; target the poor, but keep an eye on the non-poor; benefits should be closely linked to target populations' needs; and highly focused interventions can be a useful initial step toward UHC.
Equitable health services
This paper reports on yellow fever vaccination coverage following massive emergency immunisation campaigns in the Pader district, northern Uganda, in 2010. A total of 680 respondents were included in the sample and vaccination status was assessed in a survey using self reports and vaccination card evidence. Of the 680 respondents, 654 (96.3%) reported being vaccinated during the last campaign but only 353 (51.6%) had valid yellow fever vaccination cards. Of the 280 children below five years of age, 96.1% were vaccinated. The main reasons for not being vaccinated were: having travelled out of Pader district during the campaign period (40%), lack of transport to immunisation posts (28%) and sickness at the time of vaccination (16%). These results show that actual yellow fever vaccination coverage was high and met the desired minimum threshold coverage of 80% designated by the World Health Organisation. Active surveillance is necessary for early detection of yellow fever cases.
This film examines the barriers that people face in accessing healthcare in rural Mozambique, specifically the rural area of Tsangano in the province of Tete, a huge region in the centre of the country. In the film, you can see how the examples of Tsangano and Tete clearly show that all parts of a health system need to come together in order for the system as a whole to function. The film advocates for an end to out-of-pocket payments by health service users. To ensure this, the ‘key ingredients’ that will make user fee removal a success must also be addressed – the financing for the system as a whole and ensuring increased investment in transport and infrastructure – particularly in rural areas – a bigger, stronger health workforce, universal access to medicines and better information for the population to demand their right to health.
In this study, researchers aimed to estimate the prevalence, awareness, management and control of hypertension and associated factors in an adult population in Dande, Northern Angola. They conducted a community-based survey of 1,464 adults, following the World Health Organisation's Stepwise Approach to Chronic Disease Risk Factor Surveillance, and selected a representative sample of subjects, stratified by sex and age (18–40 and 41–64 years old). Prevalence of hypertension was 23% in the sample. A follow-up consultation confirmed the hypertensive status in 82% of the subjects who had a second measurement on average 23 days after the first. Amongst hypertensive individuals, 21.6% were aware of their status. Only 13.9% of those who were aware of their condition were under pharmacological treatment, of which approximately one-third were controlled. Greater age, lower level of education, higher body mass index and abdominal obesity were found to be significantly associated with hypertension. The authors conclude that there is an urgent need for strategies to improve prevention, diagnosis and access to adequate treatment in Angola, where massive economic growth and its consequent impact on lifestyle risk factors could lead to an increase in the prevalence of hypertension and cardiovascular disease.
In this study, researchers assessed knowledge of tuberculosis (TB) and HIV, and perceptions about provider-initiated testing and counselling (PITC) among TB patients attending health facilities in Harar town, Eastern Ethiopia. Using a semi-structured questionnaire, a total of 415 study participants were interviewed about their knowledge of TB and HIV as well as the impact of HIV testing on their treatment-seeking behaviour. Results showed that living more than 10 km from a health facility was associated with low knowledge of TB and low knowledge of HIV testing. Delay in treatment was more likely among female participants, single participants and those living more than 10 km from a health facility. Most of the study participants (70%) believed that there was no association between TB and HIV and AIDS, while most (81.6%) of the study participants who were 21 years old or younger believed that fear of PITC could cause delay in treatment seeking. The authors recommend that emphasis should be given to improving knowledge of TB and HIV among residents living far from a health facility, as well as to improving the negative perceptions of PITC among young adults.
Little conceptual or empirical work exists on the measurement of antenatal care (ANC) quality at health facilities in low-income countries. To address this gap, researchers in this study developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers. They included 1,299 antenatal facilities in the study and compared the quality of ANC received by 4,148 mothers between 2002 and 2007. Results showed that only 45 antenatal facilities (3%) fulfilled the study’s developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. The authors argue that these results indicate missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect the “quality gap” where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.
Commonly available malaria maps are based on parasite rate, a poor metric for measuring malaria at extremely low prevalence. New approaches are required to provide case-based risk maps to countries seeking to identify remaining hotspots of transmission while managing the risk of transmission from imported cases. In this study, household locations and travel histories of confirmed malaria patients during 2011 were recorded for the higher transmission months of January to April and the lower transmission months of May to December. Data was gathered and used to generate maps predicting the probability of a locally acquired case at 100 m resolution across Swaziland for each season. Results indicated that case households during the high transmission season tended to be located in areas of lower elevation, closer to bodies of water, in more sparsely populated areas, with lower rainfall and warmer temperatures, and closer to imported cases. The high-resolution mapping approaches described here can help elimination programmes understand the epidemiology of a disappearing disease. The authors argue that generating case-based risk maps at high spatial and temporal resolution will allow control programmes to direct interventions proactively according to evidence-based measures of risk and ensure that the impact of limited resources is maximised to achieve and maintain malaria elimination.
The authors of this study synthesised the findings of all relevant qualitative studies reporting on the views and experiences of women in low- and middle-income countries (LMICs) who received inadequate antenatal care. The synthesis revealed that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. These findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.
Despite Malawi government’s policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care. This study explored the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. Results indicated that onset of labour at night, rainy season, rapid labour, socio-cultural factors and health workers’ attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbours. Most women went to the health facility the same day after delivery. This study reveals beliefs about labour and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. There is a need for further exploration of barriers that prevent women from accessing health care.
This review examined approaches for delivering child and newborn interventions to large populations and how research can help achieve universal coverage of essential maternal, newborn and child health interventions. The literature review included 87 articles, which described 79 discrete studies, mostly in developing countries. The authors found that interventions are available that can prevent serious illness and save the lives of millions of infants and children living in low- and middle-income countries but achieving universal coverage of these interventions depends on a functional health system, the delivery approach used by that system, and community or individual considerations such as access, demand for and acceptability of the intervention, and ability to comply. The authors found that little is known about the process of scaling up, namely, moving from delivery in one district to national coverage – more research is needed. They recommend that any intervention aimed at reducing financial or physical barriers should consider questions of affordability, equity and sustainability. Strategies taking health interventions directly to communities and individual homes can increase the uptake and improve the quality of local services, helping to reduce maternal, newborn and infant mortality, though findings were inconsistent. The authors call for knowledge and training to be linked with establishing conditions that encourage health workers to change their practices in terms of leadership, motivation, opportunity and accountability.