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.
Equitable health services
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.
Over 4,000 men are diagnosed with prostate cancer every year in South Africa and more than half of them die, according to the Cancer Association of South Africa (CANSA). These numbers could be reduced if more men were screened. Vanitha Naidoo, head of health programmes at CANSA in KwaZulu Natal, explained that screening for prostate cancer was expensive, making it difficult for more men to access it. ‘Unfortunately there is currently no institution that offers free screenings for prostate cancer to our knowledge, which means people have to go to private care to be screened and not everyone can afford that. Most people are dependent on public hospitals and clinics for their health needs,’ she said. According to the National Cancer Registry (NCR) prostate cancer is the first of the five leading male cancers and it affects one in 23 men. ‘If screening was applied to prostate cancer as it is with other cancers such as breast and cervical cancer there would be a greater chance of diagnosing more men and offering them treatment. If a day was set aside for men to get free screening at hospitals we could see a reduction in men who die from the condition,’ said Dr Tjaart Fourie, head of Urology at the University of KwaZulu Natal.
This paper briefly reviews global progress and challenges with respect to public vaccination programmes. The most striking recent achievement has been that of reduction of global measles mortality from an estimated 750,000 deaths in 2000 down to 197,000 in 2007. Global vaccination coverage trends continued to be positive. In 2007 most regions reached more than 80% of their target populations with three doses of DPT containing vaccines. However, the coverage remains well short of the 2010 goal on 90% coverage, particularly in the WHO region of Africa, while had only 74% coverage. Remaining challenges include the need to: develop and implement strategies for reaching the difficult to reach; support evidence-based decisions to prioritise new vaccines for introduction; strengthening immunisation systems to deliver new vaccines; expand vaccination to include older age groups; scale up vaccine preventable disease surveillance; improve quality of immunisation coverage monitoring and use the data to improve programme performance; and explore financing options for reaching the GIVS goals, particularly in lower middle-income countries.
Landmines are the third leading cause of amputations in Mozambique, after diabetes and road accidents, and the threat they still pose – more than 17 years after peace came to the country following four decades of independence and civil wars – still looms large. There are no benefits for the survivors of landmine blasts, nor for those who died or their next of kin, so there is no incentive to report incidents of landmine accidents to the authorities. In one of the world's poorest nations, assistance for the disabled is often far down the list of priorities. There are government-run orthopaedic centres in the ten provincial capitals, except Manica Province, where it is situated in Chimoio, but essential equipment is faulty or lacking entirely. For example, in Inhambane (in central Mozambique, currently the most mined province) the orthopaedic centre is not open. In Beira, Mozambique's second-largest city, the oven to make prosthetics is broken and has not been replaced. The situation at orthopaedic centres in Mozambique does not meet minimum standards.