A two-day long People’s Commission of Inquiry into the Free State Health System was held in Bloemfontein, Free State on July 7th and 8th 2015. The inquiry was organised and hosted by the Treatment Action Campaign (TAC) but was set up as a public forum to enable people in the province to give testimony in front of an independent commission of inquiry through verbal and written testimony from more than 60 people representing 15 communities in the province. Civil society, activists and healthcare professionals also spoke or made submissions to the commissioners and the Free State Department of Health was also invited to testify and to make submissions. The key findings that emerged from the testimonies were that: The South African government, in particular the provincial Free State government, are failing to assume their responsibility to protect access to healthcare services, especially for the poor in the province. It reports shortages and stock outs of medication and medical supplies; broken or unavailable equipment; inadequate health workers; long waiting times for provincial emergency medical services and patient transport systems and unreliability and indignity experienced in these services. Many of the oral testimonies spoke of people having to pay out-of-pocket payments for transport to health facilities. Whistle-blowing and engagement is reported to be discouraged and at times met with intimidation. The report offers recommendations to improve access to quality services. The report indicates that the commission is committed to working together with communities, healthcare professionals, the provincial government and all other interested parties to improve conditions.
Equitable health services
Global governance and market failures mean that it is not possible to ensure access to antimicrobial medicines of sustainable effectiveness. Many people work to overcome these failures, but their institutions and initiatives are insufficiently coordinated, led and financed. Options for promoting global collective action on antimicrobial access and effectiveness include building institutions, crafting incentives and mobilising interests. No single option is sufficient to tackle all the challenges associated with antimicrobial resistance. Promising institutional options include monitored milestones and an inter-agency task force. A global pooled fund could be used to craft incentives and a special representative nominated as an interest mobiliser. There are three policy components to the problem of antimicrobials – ensuring access, conservation and innovation. To address all three components, the right mix of options needs to be matched with an effective forum and may need to be supported by an international legal framework.
The 2015 UHC day comes after a year of the international community being busy in producing numerous reports on learning from the Ebola crisis. Most of the learning from these documents has focused on mechanisms for effective global response to outbreaks. However, the author argues that more attention should be directed to learning from the role of local institutions in tackling the Ebola outbreak including how critically needed advances towards UHC can be achieved. Two key ingredients for effective epidemic prevention and response require particular focus: community engagement and health systems strengthening. The WHO interim panel’s report on Ebola recognised that “Risk assessment was complicated by factors such as weak health systems, poor surveillance, little early awareness of population mobility, spread of the virus in urban areas, poor public messaging, lack of community engagement, hiding of cases, and continuing unsafe (e.g. burial) practices”.
For almost 70 years, the World Health Organisation (WHO) has coordinated the norms and technical standards required to improve global health. This is the role people most often associate with WHO. However, the organisation’s constitution also calls on it to “furnish technical assistance and, in emergencies, necessary aid” to governments, a role WHO has played on countless occasions. Despite initial delays in the western Africa Ebola outbreak response, the tide of this unprecedented health crisis has now been turned. While still requiring intense and focused action to bring new cases to zero, the outbreak is now limited to only a few cases per week. Deficiencies in capacity, expertise and approach revealed by WHO’s response to Ebola suggest that organisation-wide change is needed:WHO must ensure it can prepare for and respond to outbreaks and emergencies in a way that genuinely supports national efforts and fully integrates with international partners. WHO has begun reviewing systems and capacities throughout the organisation to streamline the way it works in outbreaks and emergencies.These changes focus on six key areas: (i) a unified WHO platform for outbreaks and emergencies with health and humanitarian consequences; (ii) a global health emergency workforce, to be effectively deployed in support of countries; (iii) core capacities at country-level under the International Health Regulations; (iv) functioning, transparency, effectiveness and efficiency of the International Health Regulations; (v) a framework for research and development preparedness and capacity during outbreaks or emergencies; and (vi) adequate international financing for pandemics and other health emergencies, including a 100 million United States dollars contingency fund and a pandemic emergency financing facility. No single organisation can deliver the wide range of services and systems needed for a truly global mechanism that prepares for and responds to outbreaks and emergencies. This is why WHO will continue seeking advice from our partners inside and outside the UN system to make needed change. With their collaboration and support, WHO will be well positioned to deliver what the world needs when outbreaks and emergencies occur: a timely response that rapidly contains the consequences – for economies and societies as well as for human health.
The Ideal Clinic programme was initiated by the South African National Department of Health (NDoH) in July 2013 in order to systematically improve Primary Health Care (PHC) facilities and the quality of care they provide. Provinces have submitted their three-year scale-up plans that indicate in which year each facility will reach Ideal Clinic status. Typically, the purpose of a health facility is to promote health and prevent illness and further complications through early detection, treatment and appropriate referral. An Ideal Clinic is defined as a clinic with good infrastructure, adequate staff, adequate medicine and supplies, good administrative processes, and sufficient adequate bulk supplies. It uses applicable clinical policies, protocols and guidelines, and it harnesses partner and stakeholder support. It also collaborates with other government departments, the private sector and non-governmental organisations to address the social determinants of health.
Mozambique’s health system reconstruction supports the team’s conclusion that the reconstruction of health systems is mainly “gender blind”. In order to review whether the health system is gender equitable, the team assessed the country’s progress against the framework of WHO’s six aspirational building blocks of the health system. From the evidence the authors suggest that policy-makers in Mozambique have not adequately considered the role of gender in contributing to health or addressed women’s and men’s different health needs. Despite government commitment to gender mainstreaming, the health system is far from gender equitable. Donors have shied away from tackling the thorny issue of the social and cultural norms, including gender, which drive ill health.
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.
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.