Health policy has tended to export models of health systems from developed nations to low-income countries without questioning their appropriateness and adaptability. Debates about the roles of public and private providers are meaningless in poor countries that do not have the institutional framework to govern a market economy and where government has little capacity to regulate providers of health services. The lack of appropriately contextualised debate and language hampers national and international efforts to address major health challenges. Health systems, like other systems of producing social goods, are ways of producing and organising access to expert knowledge and the technologies that derive from it. Their failure, in many contexts, to serve the interests of the poor means we should also be exploring different ways of producing and delivering services rather than simply intensifying efforts to recreate existing ones.
Equitable health services
Government, business and civil society leaders gathered at the United Nations to launch a global campaign to reduce malaria deaths, currently at more than 1 million each year, to near zero by 2015, with an initial commitment of nearly a $3 billion. The Global Malaria Action Plan (GMAP) aims to cuts deaths and illness by 2010 to half their 2000 levels by scaling up access to insecticide-treated bed nets, indoor spraying and treatment, and achieve the near-zero goal through sustained universal coverage. Ultimately it seeks to eradicate the disease completely with new tools and strategies.
This report aimed to identify health-care and provider-related determinants of diabetes and hypertension patients attending public sector community health centres (CHCs). A random sample of eighteen CHCs in the Cape Peninsula, South Africa, providing hypertension and diabetes care was selected. Twenty-five diabetes and 35 hypertension patients were selected per clinic and interviewed by trained fieldworkers and their medical records audited. Knowledge about their conditions was poor. Prescriptions for drugs were not recorded in medical records of 22.6% of the diabetes and 11.4% of the hypertension patients. Primary care for patients with hypertension and diabetes at public sector CHCs is suboptimal. This highlights the urgent need to improve health care for patients with these conditions in the public sector of the Cape Peninsula.
Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care (PHC) and achieving the vision of the Alma-Ata Declaration. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to PHC in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades.
Medecins Sans Frontieres (MSF) has made an urgent call for the wider implementation of the newer and more effective anti-malaria strategies in an effort to save lives. Malaria still kills a child every 30 seconds worldwide while nine out 10 of these deaths occur in sub-Saharan Africa, predominantly among young children. According to the World Health Organisation, one in every five childhood deaths is due to the effects of malaria. An MSF report released in Johannesburg on 31 September shows that unnecessary illness and death can be avoided with simple, affordable treatment and diagnostic tools that are currently available. The report follows the launch of an ambitious new Global Malaria Action Plan aimed at reducing the number of malaria deaths to near zero by 2015, with world leaders committing nearly US$3-billion to ensure it succeeds.
Nearly 60 million women will give birth without any medical assistance this year, the World Health Organisation (WHO) has said in a report calling for an overhaul of how health care is financed and managed globally. The United Nations agency said in its annual World Health Report that the billions of aid dollars devoted to fight specific epidemics like AIDS had distracted attention from providing comprehensive care to mothers and children. The difference in life expectancy between the richest and poorest countries still exceeds 40 years, said the report, whose launch coincided with a global financial crisis that could freeze aid flows and squeeze government budgets for health care. Increasingly specialised and technical medicine in wealthy nations has also excluded and impoverished millions of patients, exposing failures of ‘laissez-faire’ governance in health. WHO is encouraging countries to go ‘back to the basics’.
This paper assesses the progress towards meeting the goals of the African Regional Strategic Plan of the Expanded Programme on Immunisation between 2001 and 2005. These goals include: to interrupt the circulation of wild polio virus in all countries; eliminate maternal and neonatal tetanus in all high-risk districts; 80% of the countries to have reached at least 80% diphtheria-tetanus-pertissus-3 (DTP-3) coverage; and measles to be controlled and eliminated in Southern Africa. The paper finds that although more infants had been immunised by 2005, most of the targets had been missed by at least half of the region’s countries. The authors estimate that DTP-3 coverage increased from 54% in 2000 to 69% in 2004, and as a result the number of non-immunised children declined from 1.4 million in 2002 to 900,000 in 2004. Reported measles cases dropped from 520,000 in 2000 to 316,000 in 2005 and mortality was reduced by approximately 60%. The paper concludes that the rates of immunisation coverage are improving dramatically in the WHO African region. The huge increases in spending on immunisation and the related improvements in programme performance are linked predominantly to increases in donor funding.
Kenyan health activists last week slammed the country’s proposed anti-counterfeiting law, saying that provisions had been slipped into it to prevent the importation of cheap generic medicines. They say the Kenya Anti-Counterfeit Bill 2008 does not distinguish between medicines and ordinary items such items as pens, DVDs and batteries, and also contravenes the provisions of the 2001 Industrial Property Act (IPA), which paved the way for the widespread use of generic ARVs to manage HIV/AIDS. The Bill contains various ambiguities, which, if misinterpreted or abused, would be detrimental to the government’s ongoing efforts to ensure access to essential medicines for all Kenyans. These ambiguities should be addressed in order to ensure that interested parties, including the multinational pharmaceutical industry, do not misuse the Bill as a front to discriminate against more affordable generic competition.
Is scaled-up investment in HIV/AIDS programmes strengthening or weakening fragile health systems of developing countries? Among the positive impacts are the increased awareness of and priority given to public health by governments, some primary health care services have been inmproved, services to people living with HIV/AIDS have rapidly expanded, and in many countries infrastructure and laboratories have been strengthened. The effect of AIDS on the health work force has been lessened by the provision of antiretroviral treatment to HIV-infected health care workers, by training, and task-shifting. However, there are concerns about a temporal association between increased AIDS funding and stagnant reproductive health funding, and accusations that scarce personnel are siphoned off from other health care services by offers of better-paying jobs in HIV/AIDS programmes - with limited hard evidence. Because service delivery for AIDS has not reached a level close to Universal Access, countries and development partners must maintain the momentum of investment in HIV/AIDS programmes. At the same time, global action for health is even more underfunded than the response to the HIV epidemic. The real issue is therefore not whether to fund AIDS or health systems, but how to increase funding for both.
This paper aimed to provide a better understanding of obstacles to accessing malaria treatment so as to develop practical and cost-effective interventions. After intensive health education, the biomedical concept of malaria has largely been adopted by the community. At last 80% of the fever cases in children and adults were treated with one of the recommended antimalarials. But only 22.5% of children and 10.5% of adults received prompt and appropriate antimalarial treatment. A clear preference for modern medicine was reflected in frequent use of antimalarials. Yet, case-management and functioning exemption mechanims were far from satisfactory for the main risk group. Private drug retailers played a central role in complementing existing formal health services. Health system factors like these must be tackled urgently to translate the high efficacy of artemisinin-based combination therapy into equitable community-effectiveness and health-impact.