The State of the World’s Antibiotics summarises the status of antibiotic use and resistance around the globe. The report challenges the prevailing argument that the biggest obstacle facing antibiotic resistance is a lack of new drugs in the “antibiotic pipeline.” New antibiotics are part of the solution, but only when coupled with conservation: strong antibiotic stewardship in its broadest sense, which involves limiting overuse of antibiotics in humans and livestock. CDDEP’s Global Antibiotic Resistance Partnership (GARP) of low- and middle-income countries provided both data and insight into the challenges in those countries and how they can be met successfully. Chapters cover human antibiotic resistance and use, resistance and use in agriculture and the environmental consequences of all use, maintaining the supply of antibiotic effectiveness and what works at the country level to minimise the spread of antibiotic resistance and maximise the positive impact of antibiotics.
Equitable health services
Growing international concern about the need for improved health systems in Africa has catalysed an expansion of the health systems literature. This review applies a bibliometric procedure to analyse the acceleration of scientific writing on this theme. The authors focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, the authors analysed the incidence and associations of keywords and phrases to generate and visualise topical foci on health systems as clusters of themes. Results show that African health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organisational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organisational malaise or corruption are virtually absent. Trend analysis shows the emergence of organisational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organisational change research must be a more concerted focus in the future than has been the case in the past.
The United Republic of Tanzania has implemented countrywide anti-malarial interventions over more than a decade, including national insecticide-treated net (ITN) rollouts and subsequent monitoring. While previous analyses have compared spatial variation in malaria endemicity with ITN distributions, no study has yet compared Anopheles habitat suitability to determine proper allocation of ITNs. This study assesses where mosquitoes were most likely to thrive before implementation of large-scale ITN interventions in Tanzania and determine if ITN distributions successfully targeted those areas. The spatial distribution of ITN ownership across Tanzania was near-random spatially. Mosquito habitat suitability was statistically unrelated to reported ITN ownership and very weakly to the proportion of households with ≥1 ITN. ITN ownership declined significantly toward areas with the highest vector habitat suitability among households with lowest ITN ownership. In areas with lowest habitat suitability, ITN ownership was consistently higher. Insecticide-treated net ownership is critical for malaria control. While Tanzania-wide efforts to distribute ITNs has reduced malaria impacts, gaps and variance in ITN ownership are unexpectedly large in areas where malaria risk is highest. Supplemental ITN distributions targeting prime Anopheles habitats are likely to have disproportionate human health benefits.
The objective of this study was to assess the cost–effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Incremental cost–effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective. Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. The authors suggest that community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.
A cross-sectional survey was conducted in neonatal and maternity units of five Kenyan district public hospitals. Data for 1 year were obtained: A fifth of the admitted neonates died. Compared with normal birth weight, odds of death were significantly higher in all of the low birth weight (LBW, <2500 g) categories, with the highest odds for the extremely LBW (<1000 g) category. The observed maternal mortality, stillbirths and neonatal mortality rates are argued to call for implementation of the continuum of care approach to intervention delivery with particular emphasis on LBW babies.
This systematic review of emergency care in low- and middle-income countries (LMICs) analysed reports published from 1990 onwards. The authors identified 195 reports concerning 192 facilities in 59 countries. Most were academically-affiliated hospitals in urban areas. Most facilities were staffed either by physicians-in-training or by physicians whose level of training was unspecified. Very few of these providers had specialist training in emergency care. Available data on emergency care in LMICs indicate high patient loads and mortality, particularly in sub-Saharan Africa, where a substantial proportion of all deaths may occur in emergency departments. The combination of high volume and the urgency of treatment make emergency care an important area of focus for interventions aimed at reducing mortality in these settings.
Diabetes and hypertension constitute a significant and growing burden of disease in South Africa. Presently, few patients are achieving adequate levels of control. In an effort to improve outcomes, the Department of Health is proposing a shift to a patient-centred model of chronic care, which empowers patients to play an active role in self-management by enhancing their knowledge, motivation and skills. This study explored patients’ current experiences of chronic care, as well as their motivation and capacity for self-management and lifestyle change. The study involved 22 individual, qualitative interviews with a purposive sample of hypertensive and diabetic patients attending three public sector community health centres in Cape Town. Participants were a mix of Xhosa and Afrikaans speaking patients and were of low socio-economic status. The concepts of relatedness, competency and autonomy from Self Determination Theory proved valuable in exploring patients’ perspectives on what a patient-centred model of care may mean and what they needed from their healthcare providers. Overall, the findings indicate that patients experience multiple impediments to effective self-management and behaviour change, including poor health literacy, a lack of self-efficacy and perceived social support. With some exceptions, the majority of patients reported not having received adequate information; counselling or autonomy support from their healthcare providers. Their experiences suggests that the current approach to chronic care largely fails to meet patients’ motivation needs, leaving many of them feeling anxious about their state of health and frustrated with the quality of their care. In accordance with other similar studies, most of the hypertensive and diabetic patients interviewed were found to be ill equipped to play an active and empowered role in self-care. It was clear that patients desire greater assistance and support from their healthcare providers.
This article incudes evidence from a public opinion poll on pandemic preparedness.
It highlights three concrete actions on how we can be better prepared for the next global epidemic. The author states "First, let's ensure that all countries invest in better preparedness. This starts with a strong health system that can deliver essential, quality care; disease surveillance; and diagnostic capabilities. We should expand successful efforts such as those by Ethiopia and Rwanda to train cadres of community health workers, who can expand access to care and serve as the frontline response to future disease outbreaks. The goal must be universal health coverage - both to ensure everyone can get the care they need, and also because those areas without adequate coverage put everyone at risk." He also calls for a smarter, better coordinated global epidemic preparedness and response system that draws upon the expertise of many more players - including a better-resourced WHO; and a pandemic emergency financing facility that can respond more quickly to epidemics.
The world’s first malaria vaccine has been given the green light by European regulators and could protect millions of children in sub-Saharan Africa from the life-threatening disease. The European Medicines Agency (EMA) recommended that RTS,S, or Mosquirix, should be licensed for use in young children in Africa who are at risk of the mosquito-borne disease. The shot has been developed by GlaxoSmithKline (GSK) and part-funded by the Bill and Melinda Gates Foundation. It has taken 30 years to develop vaccine, at a cost of more than $565m (£364m) to date. It will now be assessed by the World Health Organisation, which has promised to give its guidance on how and where it should be used before the end of the year. GSK will then apply to the WHO for a scientific review of the vaccine, which will be used by the UN and other agencies to help make purchasing decisions. The roll-out of the vaccine, which also has to be approved by national health authorities in sub-Saharan Africa, is likely to be funded by GAVI.
Without addressing HIV among marginalized populations and human rights, this report argues that it will not be possible to end the AIDS epidemic as a public health threat by 2030. A high-level panel, which included UNAIDS Executive Director Michel Sidibé, called on health ministers to remove structural barriers to accessing HIV services and health care for all. Ensuring that marginalized populations are not excluded from the universal health coverage target of the next sustainable development goals was noted to be vital, noting a risk that countries could seek to advance progress towards universal health coverage by focusing on easier to reach populations. In order to ensure that no one is left behind, the report argues that measures will be needed to reduce the discrimination facing all marginalized groups and to ensure their meaningful participation in the development and implementation of health strategies.