The authors of this study set out to assess the prevalence of cardiovascular (CV) risk factors in Seychelles, a middle-income African country, and compare the cost-effectiveness of single-risk-factor management with management based on total CV risk. CV risk factor prevalence and a CV risk prediction chart for Africa were used to estimate the 10-year risk of suffering a fatal or non-fatal CV event among individuals aged 40–64 years. These figures were used to compare single-risk-factor management with total risk management in terms of the number of people requiring treatment to avert one CV event and the number of events potentially averted over 10 years. With single-risk-factor management, 60% of adults would need to be treated and 157 cardiovascular events per 100,000 population would be averted per year, as opposed to 5% of adults and 92 events with total CV risk management. Management based on high total CV risk optimizes the balance between the number requiring treatment and the number of CV events averted. In conclusion, total CV risk management is much more cost-effective than single-risk-factor management. These findings are relevant for all countries, but especially for those economically and demographically similar to Seychelles.
Equitable health services
On 14 February 2011, the GAVI Alliance rolled out its plan for a new pneumococcal vaccine for children, which it aims to administer in 19 countries by 2012 and in more than 40 countries by 2015. GAVI’s plan is part of the global drive to reach the Millennium Development Goals for Maternal and Child Health. The Kenya Medical Research Institute in Kilifi has welcomed the vaccine's rollout in the fight against penicillin-resistant and multi-drug resistant pneumococcal strains of the disease that are emerging in Africa. The Institute noted that the disease also causes severe financial difficulties and emotional burdens for families and communities, most of whom never have sufficient funding to treat their affected children. At US$3.50 per dose, the vaccine being issued in developing countries is about 90% cheaper than in the developed world. GAVI and its partner countries will co-finance the rollout, with governments in the poorest income bracket paying US$0.15 per dose. GAVI warned that participating countries would need to step up their health system capacity to achieve this. In addition, the Alliance’s plans to roll out this and other vaccines for major killer diseases are threatened by a funding gap of US$3.7 billion over the next five years.
Antimicrobial resistance is a global problem that affects all countries. This year’s World Health Day on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat. According to this article, clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. Data is lacking, they say. The problem of microbial resistance is significant in middle- and low-income countries: for example, poor children in Africa, Asia and Latin America suffering from pneumonia, meningitis or blood stream infections are often given old drugs rendered ineffective by resistance since they are the only available treatment options. For some, simply restricting over-the-counter sales of antimicrobials does not go far enough, and they suggest that more is needed to curb the use of second-line antibiotics, which should be used to treat infections when first-line antibiotics fail and may be the last resort. They argue that the beneficial effect of restriction of first-line antibiotics sold over the counter will be evident in the long term, but what is needed most is restriction of higher-end antibiotics used in hospitals.
In Zanzibar, the Ministry of Health and its partners accelerated malaria control from September 2003 onwards by scaling up provision of insecticide-treated nets, indoor-residual spraying and artemisinin-combination therapy. The authors of this study assessed the impact of the scale up on malaria burden at six out of seven in-patient health facilities in Zanzibar by comparing numbers of out-patient and in-patient cases and deaths between 2008 and the pre-intervention period 1999-2003. They found that, in 2008, for all age groups combined, malaria deaths had fallen by an estimated 90%, malaria in-patient cases by 78% and parasitologically confirmed malaria out-patient cases by 99.5%. Anaemia in-patient cases decreased by 87%, but declines in anaemia deaths and out-patient cases were statistically insignificant due to small numbers. Reductions were similar for children under-five and older ages. The authors conclude that the government’s scaling up effective malaria interventions reduced malaria-related burden at health facilities by over 75% over a period of five years. They argue that, in high-malaria settings, intensified malaria control can substantially contribute to reaching the Millennium Development Goal 4 target of reducing under-five mortality by two-thirds between 1990 and 2015.
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.
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.