In this interview with Dr Lucica Ditiu, newly appointed executive secretary of the Stop TB Partnership, she reports that global tuberculosis (TB) control is reaching a plateau, especially in case detection, due to the fact that the most vulnerable, marginalised, high-risk populations are still not being reached. She argues that TB cannot be tackled without looking at the bigger picture, as it is a disease of poverty and is directly linked to poor nutrition and living conditions, as well as other social determinants of health, like education. These factors, combined with a lack of awareness and the stigma of TB, mean people often delay seeking care. Countries still face problems in planning, forecasting their needs, with supply shortages throughout the developing world, and Ditiu calls on civil society organisations and activists to continue to help flag these shortages. She praised current collaboration and integration efforts for HIV and TB health services, which were already showing results, but pointed to the need to scale up services and funding.
Equitable health services
This report released by the World Health Organisation (WHO) reveals that a third of 306 anti-malarial medicines collected and tested from six African countries failed to meet international quality standards. Reasons for this failure include insufficient active pharmaceutical ingredient (API), an excess of degradation substances, and poor dissolution. In fact in two samples one of the APIs was totally absent. The countries surveyed were Cameroon, Ethiopia, Ghana, Kenya, Nigeria and Tanzania. The quality of anti-malarial medicines varied across countries, from Ethiopia – where no samples failed quality testing – to Nigeria, where the highest incidence of failure occurred (64%). This result implies that a patient in Nigeria is more likely to be treated with a substandard anti-malarial than a patient in a country that complies with international quality standards. Failure rates were noticeably low for WHO-prequalified medicines available in these countries (less than 4%) as well as for imported products manufactured by well-established manufacturers. The report concludes that WHO prequalification is a highly effective mechanism for verifying the quality of medicines.
The Angolan government is preparing to renew efforts to eradicate polio with support from global partners, including the Bill and Melinda Gates Foundation, which has made polio eradication its top priority. Angola succeeded in stamping out polio for three consecutive years at the beginning of the century, but a strain of the virus prevalent in India reappeared in 2005 and has since spread to the neighbouring countries of Namibia, the Democratic Republic of Congo and the Republic of Congo. In 2010, 32 people in Angola contracted the highly infectious and incurable disease. Angola's health system, still recovering from years of war, only managed to fully vaccinate 35% of infants in 2009. According to UNICEF, supplementary immunisation campaigns have been beset by a lack of manpower, technical capacity and planning, particularly in Luanda where most of the polio cases in recent years have been concentrated. Since the war, Luanda's population has boomed, and many of the rural migrants live in cramped conditions with little access to safe water and sanitation. Such conditions are ideal for spreading polio, which is transmitted through faecal-oral contact. During a meeting on 24 January 2011 with Anthony Lake, UNICEF Executive Director, and Tachi Yamada, president of The Gates Foundation's global health programme, José Eduardo dos Santos, Angola’s president, reaffirmed the government's commitment to eradicating polio. The government's strategy consists of better surveillance of new polio cases, accelerated routine immunisation of children, better-quality vaccination campaigns and a campaign to promote household water treatment and hygiene.
The world risks losing its most potent treatment for malaria unless steps are quickly taken to prevent the development and spread of drug-resistant parasites, according to this action plan by the World Health Organization (WHO) and Roll Back Malaria partnership (RBM). The plan outlines the necessary actions to contain and prevent resistance to artemisinins, which are the critical component of artemisinin-based combination therapies (ACTs), the most potent weapon in treating falciparum malaria, the deadliest form of the disease. Resistance to artemisinins has already emerged in areas on the Cambodia-Thailand border. Although ACTs are currently more than 90% efficacious around the world, quick action is essential, WHO and RBM argue. If these treatments fail, many countries will have nothing to fall back on. The global plan aims to contain and prevent artemisinin resistance through a five-step action plan. 1. Stop the spread of resistant parasites through a fully funded and implemented malaria control agenda. 2. Increase monitoring and surveillance for artemisinin resistance. 3. Improve access to malaria diagnostic testing and rational treatment with ACTs and reduce unnecessary use of ACTs – WHO recommends diagnostic testing of all suspected malaria cases prior to treatment. 4. Invest in artemisinin resistance-related research, especially with regard to developing more rapid techniques for detecting resistant parasites, and to developing new classes of antimalarial medicines to eventually replace the ACTs. 5. Motivate action and mobilise resources.
The objective of this study was to establish the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private programme clinics in Kampala, Uganda. Researchers recruited 133 patients of known HIV status and confirmed pulmonary TB who were receiving care at public and private hospitals in Kampala, Uganda. A translated and standardised 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Of the 133 participants, 35% were starting, 33% had completed two months, and 32% had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores for technical quality of care and responsiveness to patient preferences when compared to patients that were enrolled at the private hospital. The authors conclude that their study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programmes. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals, as well as between patients starting and those completing TB therapy.
Households in malaria endemic countries experience considerable costs in accessing formal health facilities because of childhood malaria. The Ministry of Health in Malawi has defined certain villages as hard-to-reach (HTR) on the basis of either their distance from health facilities or inaccessibility. Some of these villages have been assigned a community health worker, responsible for referring febrile children to a health facility. In this study, researchers compared health facility utilisation and household costs of attending a health facility between individuals living near the district hospital and those in HTR villages. Two cross-sectional household surveys were conducted in the Chikhwawa district of Malawi; one during each of the wet and dry seasons. Half the participating villages were located near the hospital, the others were in HTR areas. The researchers found that those people living in HTR villages were less likely to attend a formal health facility compared to those living near the hospital. Analyses including community health workers (CHWs) as a source of formal health-care decreased the strength of this relationship, and suggested that consulting a CHW may reduce attendance at health facilities, even if indicated. Household costs for those who attended a health facility were greater for those in HTR villages than for those living near the district hospital. The researchers call on health service planners to consider geographic and financial barriers to accessing public health facilities in designing appropriate interventions.
The authors of this study set out to explore the relationship between homestead distance to hospital and access to care and to estimate the sensitivity of hospital-based surveillance in Kilifi district, Kenya. In 2002–2006, clinical information was obtained from all children admitted to Kilifi District Hospital and linked to demographic surveillance data. Travel times to the hospital were calculated and the relationships between travel time, cause-specific hospitalization rates and probability of death in hospital were examined. The analysis included 7,200 admissions (64 per 1,000 child-years). Median pedestrian and vehicular travel times to hospital were 237 and 61 minutes, respectively. Hospitalisation rates decreased by 21% per hour of travel by foot and 28% per half hour of travel by vehicle. Distance was positively associated with the probability of dying in hospital. In this setting, hospital utilisation rates decreased and the severity of cases admitted to hospital increased as distance between homestead and hospital increased. Access to hospital care for children living in remote areas was low, particularly for those with less severe conditions. Distance decay was attenuated by increased levels of maternal education. Hospital-based surveillance underestimated pneumonia and meningitis incidence by more than 45% and 30%, respectively, the researchers found.
Despite more than half a century of advocacy for safe water, sanitation and hygiene, approximately 100,000 cholera cases and 5,000 deaths were reported in Zimbabwe between August 2008 and by July 2009. Safe and effective oral cholera vaccines have been licensed and used by affluent tourists for more than a decade to prevent cholera. The authors of this study investigated whether oral cholera vaccines could be used to protect high risk populations at a time of cholera. They calculated how many cholera cases could have been prevented if mass cholera vaccinations would have been implemented in reaction to past cholera outbreaks, estimating that determined, well-organised mass vaccination campaigns could have prevented 34,900 (40%) cholera cases and 1,695 deaths (40%) in Zimbabwe. They identify barriers to implementation of mass vaccinations, particularly the cost of the vaccine.
This study examined 'stigmatising' ideas and the view that TB patients should queue with other chronically ill patients at health facilities. Data was gathered through a survey administered to respondents from 1,020 households in Grahamstown, South Africa. The survey measured stigmatisation surrounding TB and HIV and AIDS, and determined perceptions of respondents whether TB patients should queue with other chronically ill patients. Results showed that respondents with TB-stigmatising ideas held positive attitudes toward volunteer support, special TB queues, and treatment at clinics, but held negative attitudes toward temporary disability grants, provision of information at work or school, and treatment at the TB hospital. Respondents who felt it beneficial for TB patients to queue with other chronically ill patients conversely held positive attitudes toward provision of porridge and disability grants, and treatment at the TB hospital, while they held negative attitudes toward volunteer support, special TB queues, information provision at work or school, and treatment at clinics. The authors conclude that TB stigma and the view that TB patients should queue with other chronically ill patients are associated with opposing attitudes and preferences towards TB treatment. These opposing attitudes complicate treatment outcomes, and the authors suggest that complex behaviours must be taken into account when designing health policy.
This report, compiled annually by Human Rights Watch (HRW), is focused on human rights, but it makes a number of observations about the state of health services in several east, central and southern African countries. It notes that, partly due to health care system failures, tens of thousands of Kenyan women and girls die each year in childbirth and pregnancy, while more suffer preventable injuries, serious infections, and disabilities. Maternal deaths represent 15% of all deaths for women of reproductive age, while an estimated 300,000 women and girls are living with untreated fistula. Kenya’s restrictive abortion laws, which criminalise abortion generally, are argued to contribute to maternal death and disability, as unsafe abortions account for 30% of maternal deaths. HRW also alleges that the Kenyan government fails to provide adequate pain treatment and palliative care for hundreds of thousands of children with diseases such as cancer or HIV and AIDS. Oral morphine, an essential medicine for pain treatment, is currently out of stock. Kenya’s few palliative care services, which provide pain treatment but also counselling and support to families of chronically ill patients, lack programmes for children. In South Africa, millions of suffer from inadequate access to shelter, water, education, and health care, according to the report. South Africa is unlikely to meet the health-related Millennium Development Goals, and is one of only eight countries in the region where the rate of maternal deaths seems to be increasing. The South African government estimates that the maternal mortality ratio was 625 deaths per 100,000 live births in 2007, up from 150 deaths per 100,000 live births in 1998. In Uganda, women face numerous obstacles to reproductive health products and services such as contraception, voluntary sterilisation procedures, and abortion after rape. The most common barriers are long delays in obtaining services, unnecessary referrals to other clinics, demands for spousal permission contrary to law, financial barriers, and, in some cases, arbitrary denials. As a direct result of these barriers, women and girls may face unwanted or unhealthy pregnancies. Unsafe abortions have been a leading cause of maternal mortality for decades. HRW argues that government oversight of reproductive health care and accountability practices is seriously deficient.