This study conducted an audit of outcomes of cervical cancer screening and prevention services for HIV-positive women in Cape Town, South Africa. It took the form of a retrospective review of clinic registers, patient records and pathology databases at three HIV primary health clinics and a tertiary colposcopy referral centre. The proportion of women undergoing at least one Pap smear at HIV primary health clinics after HIV diagnosis was low (13.1%). Women referred for colposcopy tended to be HIV-positive and over the age of 30 years, and in most (70.2%) cytological examination revealed high-grade cervical dysplasia. HIV-positive women treated with excision for precancerous lesions of the cervix were significantly more likely than their HIV-negative counterparts to undergo incomplete excision, experience persistent cervical disease after treatment, and be lost to follow-up. The study concludes that cervical cancer screening efforts must be scaled up for women with HIV. Treatment and surveillance guidelines for cervical intraepithelial neoplasia in HIV-positive women may need to be revised and new interventions developed to reduce incomplete treatment and patient default.
Equitable health services
This paper reviews the costs and cost-effectiveness of vaccination programme interventions involving lay or community health workers (LHWs). Articles were retrieved if the title, keywords or abstract included terms related to 'lay health workers', 'vaccination' and 'economics'. Reference lists of studies assessed for inclusion were also searched and attempts were made to contact authors of all studies included in the Cochrane review. Of the 2,616 records identified, only three studies fully met the inclusion criteria, while an additional 11 were retained as they included some cost data. There was insufficient data to allow any conclusions to be drawn regarding the cost-effectiveness of LHW interventions to promote vaccination uptake. Studies focused largely on health outcomes and did illustrate to some extent how the institutional characteristics of communities, such as governance and sources of financial support, influence sustainability. Further studies on the costs and cost-effectiveness of vaccination programmes involving LHWs should be conducted, and these studies should adopt a broader and more holistic approach.
An unsafe environment is a risk factor for child injury and violence. Among those injuries that are caused by an unsafe environment, the accidental ingestion of corrosive substances is significant, especially in developing countries where it is generally underreported. By reviewing current literature and field trials from developing countries, the authors of this study developed a flowchart for management of this clinical condition. Timely admission was observed in 19.5% of 148 patients studied. A gastrostomy was performed on 62.1% of patients, 42.8% had recurrent strictures and 19% were still on a continuous dilatation programme. Perforation and death rate were respectively 5.6% and 4%. The majority of oesophageal caustic strictures in children are observed late, when dilatation procedures are likely to be more difficult and carry a significantly higher recurrence rate.
Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. This audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape Province. The usual steps in the quality improvement cycle were followed. Data was obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% a self-management plan. In conclusion, the availability of medication and prescription of inhaled steroids is reasonable and yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.
This study assessed whether home-based HIV care was as effective as was facility-based care. It undertook a cluster-randomised equivalence trial in Jinja, Uganda. Forty-four geographical areas in nine strata, defined according to ratio of urban and rural participants and distance from the clinic, were randomised to home-based or facility-based care by drawing sealed cards from a box. The trial was integrated into normal service delivery. Of the total patients, 859 patients (22 clusters) were randomly assigned to home and 594 (22 clusters) to facility care. During the first year, 93 (11%) receiving home care and 66 (11%) receiving facility care died, 29 (3%) receiving home and 36 (6%) receiving facility care withdrew, and 8 (1%) receiving home and 9 (2%) receiving facility care were lost to follow-up. Mortality rates were similar between groups, and 97 of 857 (11%) patients in home and 75 of 592 (13%) in facility care were admitted at least once. In conclusion, this home-based HIV-care strategy is as effective as is a clinic-based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care.
Many practitioners may dismiss systems thinking as too complicated or unsuited for any practical purpose or application. But many developing countries are looking to scale-up ‘what works’ through major systems strengthening investments. With leadership, conviction and commitment, systems thinking can accelerate the strengthening of systems better able to produce health with equity and deliver interventions to those in need. Systems thinking does not mean that resolving problems and weaknesses will come easily or naturally or without overcoming the inertia of the established way of doing things. But it will identify, with more precision, where some of the true blockages and challenges lie. It will help to: explore these problems from a systems perspective; show potentials of solutions that work across sub-systems; promote dynamic networks of diverse stakeholders; inspire learning; and foster more system-wide planning, evaluation and research.
Using case studies, the authors of this study collated and analysed practical examples of operational research projects on health in sub-Saharan Africa that demonstrate how the links between research, policy and action can be strengthened to build effective and pro-poor health systems. Three operational research projects met the case study criteria: HIV counselling and testing services in Kenya; provision of TB services in grocery stores in Malawi; and community diagnostics for anaemia, TB and malaria in Nigeria. The authors found that building equitable health systems means considering equity at different stages of the research cycle. Partnerships for capacity building promotes demand, delivery and uptake of research. Links with those who use and benefit from research, such as communities, service providers and policy makers, contribute to the timeliness and relevance of the research agenda and a receptive research-policy-practice interface. The study highlights the need to advocate for a global research culture that values and funds these multiple levels of engagement.
The overarching aim of this study was to develop a GIS-based planning approach that contributes to equitable and efficient provision of urban health services in cities in sub-Saharan Africa. The broader context of the study is the 'urban health crisis'; a term that refers to the disparity between the increasing need for medical care in urban areas against the declining carrying capacity of existing public health systems. The analysis illustrates how more sophisticated GIS-based analytical techniques can be usefully applied in support of strategic spatial planning of urban health services delivery. The study offers two frameworks for analysis. Its evaluation framework appraises the performance of the existing Dar es Salaam governmental health delivery system on the basis of generic quantitative accessibility indicators, while its intervention framework explores how existing health needs can better be served by proposing alternative spatial arrangements of provision using scarce health resources. When used together, these two planning instruments offer a flexible framework with which health planners can formulate and evaluate alternative intervention scenarios and deal with the most important problems involved in the spatial planning of urban health services.
The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV and AIDS, and for advancing other development goals. However, combating HIV remains a separate project with malaria and tuberculosis. This paper presents a brief history of key decisions made by major international donors that have led to the separation of HIV and AIDS from its logical programmatic base in sexual and reproductive health and rights. In urging a return to the original ICPD construct as a framework for action, the paper calls for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model.
The control of sexually transmitted infections (STIs) is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: targeting and outreach to populations at greatest risk; promoting and providing condoms and other means of prevention; effective clinical interventions; an enabling environment; and reliable data. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.