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.
Equitable health services
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.
This survey was conducted in October 2010 in Zimbabwe. Afrobarometer found that access to modern medical care and medicine improved in 2009 and 2010, although 39% of respondents often or always went without modern medical care and medicine in 2010. One in five had access to traditional medicines, while more than half of respondents (55%) experienced difficulty when seeking treatment at a clinic. A third and a quarter of respondents always or often went without food and water respectively in 2010, increasing potential for malnutrition and cholera. Seven out of ten (71%) regularly had no cash, curtailing their ability to pay for treatment or even transport to a health facility. One in five Zimbabweans (20%) made illegal payments to public health facilities. The high cost of medical care was identified as the most important health problem in the country, followed by shortages of supplies, poor infrastructure and insufficient staff. One in three was not satisfied with maternal and child health care services, and the same number was dissatisfied with nurses and midwives, while one in four was dissatisfied with the village health workers network. Reports of dirty facilities and illegal payments increased since 2005. There was some improvement with the availability of medical supplies and doctors in public clinics since 2005 and widespread satisfaction with government performance on HIV and AIDS, but most respondents (58%) did not want government to prioritise HIV and AIDS above other health problems.
This study aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy (ART) in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. Between May 2007 and October 2008, a total of 538 randomly assigned HIV-infected adults who initiated ART in three clinics in Kenya were selected. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 hours. Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group. Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group. The number needed to treat (NNT) to achieve greater than 95% adherence was nine and the NNT to achieve viral load suppression was 11. The study concludes that patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcomes in resource-limited settings.
Sub-Saharan Africa is undergoing health transition as increased globalisation and accompanying urbanisation are causing a double burden of communicable and non-communicable diseases. This study indicates that rates of communicable diseases such as HIV and AIDS, tuberculosis and malaria in Africa are the highest in the world and the impact of non-communicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on non-communicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. The study puts forward several policy proposals to improve the primary-care response to the problems posed by health transition. Governments should improve data on communicable and non-communicable diseases and implement a structured approach to the improved delivery of primary care. They should also focus on quality of clinical care, align the response to health transition with health system strengthening and capitalise on a favourable global policy environment.
This study aimed to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. A total of 39 papers were selected, which related to delivery at scale of intermittent preventive treatment in pregnancy, artemisinin combination therapy (ACT) or insecticide treated nets (ITNs). In terms of coverage and equity, the review found that the evidence to link changes in coverage to any specific strategy is weak: only 3 of 24 studies reporting coverage had a concurrent comparison group, and only one was classified as high-level evidence using the GRADE criteria. For ACT, an associated increase in treatment among children (73% to 88%) was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, instances where household ownership or use of nets reached targets of 80% were associated with free delivery of nets through campaigns. The study identifies barriers and facilitators to interventions, notably cost as a barrier. The study cautions that, to prioritise strengthening of health system elements for scale up, systematic reviews alone are not sufficient and additional research methods are needed.
Examining vulnerabilities within the world’s current public healthcare systems, the authors of this study propose borrowing two tools from the fields of engineering and design: A systems approach, as advocated by Reason in 1990, and a user-centered design, as advocated by Norman and Draper. Both approaches are human-centered in that they consider common patterns of human behaviour when analysing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in relation to health care systems. It argues that maintaining a human-centered orientation in clinical care, research, training and governance is critical to the evolution of an effective and sustainable health care system.
This paper was commissioned as a background paper for discussion at the First Global Symposium on Health Systems Research, held 16-19 November, 2010, in Montreux, Switzerland. It argues that, to advance towards universal coverage, decision-makers have to determine ways to incentivise providers and patients alike to increase access to good quality health services and promote efficient modes of delivery that can be sustainable. It found little rigorous evidence to guide policymakers on how the theoretical incentives created by different payment mechanisms for individual providers or facilities operate in practice. Available data indicates that fee-for-service systems (for individuals or facilities) result in higher rates of utilisation and resource use. Limited evidence on reimbursement mechanisms for facilities suggests that case-based payments are efficiency enhancing, but important questions remain about their impact on quality of care and the possibility of implementing them in systems or facilities where capacity is low. The evidence in support of pay-for-performance (P4P) mechanisms was found to be mixed and the paper advises policymakers seeking to implement P4P schemes to proceed with caution. Conditional cash transfers (CCT) were found to have been effective in increasing uptake of health services, but continued success is likely to be dependent on adequate infrastructure, reliable funding and technical capacity. Key questions remain about the desirability and cost-effectiveness of CCTs, in particular in low-income settings.