Equitable health services

What Is COVID-19 Teaching Us About Community Health Systems? A Reflection From a Rapid Community-Led Mutual Aid Response in Cape Town, South Africa’
Van Ryneveld M; Whyle E; Brady L; Int Jo Health Policy and Management x(x), 1-4, doi: 10.34172/ijhpm.2020.167, 2020

COVID-19 has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of self- organising, neighbourhood-level community action networks (CANs) has contributed significantly to the community- based response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential.

Wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions in 36 countries in the African Region
Wehrmeister F; Mbacké Fayé C; da Silva I; et al: Bulletin of the World Health Organization 98(6), 2020

The authors investigated whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions, using post 1995 survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions. Wealth-related inequalities were prevalent in all subregions, highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as higher coverage was observed in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and no evidence was found of inequality reduction in Central Africa. The data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability

A scoping review on family medicine in sub-Saharan Africa: practice, positioning and impact in African health care systems
Flinkenflögel M; Sethlare V; Cubaka V; Makasa M; et al: Human Resources for Health 18(27), 1-18, 2020

This review describes, from a systematic review, the current status of family medicine in sub-Saharan Africa and maps existing evidence of its strengths, weaknesses, effectiveness and impact, and identifies knowledge gaps. Family medicine was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. Implementation varies between and within countries. The strengths were found to be having “all- round specialists”, providing mentorship and supervision, and there were positive perceptions of the impact of family medicine. Family medicine was found to be a developing discipline in sub-Saharan Africa. The authors indicate that assessing its impact on the health of populations requires a more critical mass of family physicians and clarity on their position in the health system and their role in universal health coverage.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study
Kimani S; Kabiru C; Muteshi J; Guyo J: BMC International Health and Human Rights 20(3), 1-12, 2020

This paper explored barriers to care seeking in public health facilities in Kenya among Somali women after complications related to female genital mutilation/cutting (FGM/C). The authors used interviews and focus group discussions to collect data from women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Barriers to care-seeking included the high cost of care, distance from health facilities, lack of a referral system and concerns on quality and privacy of care. Women faced cultural taboos in discussing sexual health with male clinicians, while fear of legal sanctions given the anti-FGM/C laws deterred women with complications from seeking healthcare. The authors suggest that the health system consider integrating FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care, address health-related financial, physical and communication barriers, and ensure culturally-sensitive and confidential care.

Overcoming the ‘tyranny of the urgent’: integrating gender into disease outbreak preparedness and response
Smith K: Gender and Development 27(2) 355-369, 2019

This article provides a multi-level analysis of gender-related gaps in outbreak responses and illustrates the national and local impacts of failures to challenge gender assumptions and incorporate gender as a priority. The implications of neglecting gender dynamics, as well as the potential of equity-based approaches to disease outbreak responses, is illustrated through a case study of the Social Enterprise Network for Development (SEND) Sierra Leone, a non-government organisation (NGO) based in Kailahun, during the Ebola outbreak. Global policy responses can learn from examples such as SEND Sierra Leone. SEND did not include a gendered approach in its response as an afterthought; it was at the heart of the response because SEND had an established gender strategy. The authors argue that all levels of outbreak response need specific policies to ensure sexual and reproductive health.

Uganda’s experience in Ebola virus disease outbreak preparedness, 2018–2019
Aceng J; Ario A; Muruta A; Makumbi I; et al: Globalization and Health 16(24), 1-12, 2020

In August 2018, the Uganda Ministry of Health activated the Public Health Emergency Operations Centre and the National Task Force for public health emergencies to plan, guide, and coordinate Ebola Virus Disease (EVD) preparedness in the country. The National Task Force selected an Incident Management Team, constituting a National Rapid Response Team that supported activation of the District Task Forces and District Rapid Response Teams that jointly assessed levels of preparedness in 30 designated high-risk districts. The Ministry of Health, with technical guidance from the World Health Organisation, led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at points of entry and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms. As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. The authors observe the need to sustain these efforts as a multi-hazard framework to avail resources for preparedness and management of incidents at the source, effectively cutting costs of using a “fire-fighting” approach during public health emergencies.

Decentralising Non-Communicable Diseases (NCD) management in rural southern Africa: evaluation of a pilot implementation study
Sharp A; Riches N; Mims A; Ntshalintshali S; et al: BMC Public Health 20(44)1-8, 2020

This study assessed the feasibility and impact of decentralised care for non-communicable diseases (NCDs) within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings. In collaboration with the Eswatini Ministry of Health, the authors developed and implemented a package of interventions to support nurse-led delivery of care, including clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. One thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean blood pressure among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic, and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l. Key components of non-communicable disease care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines. The findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.

The effects of maternity waiting homes on the health workforce and maternal health service delivery in rural Zambia: a qualitative analysis
Kaiser J; Fong R; Ngoma T; McGlasson K; et al: Human Resources for Health 17(93) 1-12; 2019

This study assessed how maternity waiting homes (MWHs) affect the health workforce and maternal health service delivery at their associated rural health centres. Four rounds of in-depth interviews with district health staff and health centre staff were conducted at intervention and control sites over 24 months. Nearly all respondents expressed challenges with understaffing and overwork and reported that increasing numbers of facility-based deliveries driven by MWHs contributed substantively to their workload. Women waiting at MWHs allow staff to monitor a woman’s final stage of pregnancy and labour onset, detect complications earlier, and either more confidently manage those complications at the health centre or refer to higher level care. District, intervention, and control site respondents passionately discussed this benefit over all time points, describing it as outweighing challenges of additional work associated with MWHs. Intervention site staff repeatedly discussed the benefit of MWHs in providing a space for postpartum women to wait after the first few hours of clinical observation through the first 48 h after delivery. Additionally, intervention site staff perceived the ability to observe women for longer before and after delivery allowed them to better anticipate and plan their own work, adjust their workloads and mindset accordingly, and provide better and more timely care. The authors recommend future studies consider how MWHs impact the workforce, operations, and service delivery at their associated health facilities and strategic selection of locations for new MWHs.

User-provider experiences of the implementation of KidzAlive-driven child-friendly spaces in KwaZulu-Natal, South Africa
Mutambo C; Shumba K; Hlongwana K: BMC Public Health 20(91) 1-15, 2020

KidzAlive is a child-centred intervention aimed at improving the quality of HIV care for children in South Africa. The authors conducted qualitative interviews with children, their primary caregivers, and KidzAlive trained healthcare workers using and providing child-friendly spaces, respectively. Child-friendly spaces contributed to child-centred care in primary healthcare centres. This was evidenced by the increased involvement and participation of children, increased primary caregivers participation in the care of their children and a positive transformation of the primary healthcare centre to a therapeutic environment for children. Several barriers impeding the success of child-friendly spaces were reported including space challenges; clashing health facility priorities; inadequate management support; inadequate training on how to maximise the child-friendly spaces and lastly the inappropriateness of existing child-friendly spaces for much older children. Child-friendly spaces are observed to promote HIV positive children’s right to participation and agency in accessing care. However, more rigorous quantitative evaluation is required to determine their impact on children’s HIV-related health outcomes.

Disrespectful treatment in primary care in rural Tanzania: beyond any single health issue
Larson E; Mbaruku G; Kujawski A; Mashasi I; et al.: Health Policy and Planning 34(7) 508–513, 2019

Little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. Data from a household survey of 2002 women living in rural Tanzania was used to describe the extent of disrespectful care during outpatient visits, who receives disrespectful care and the association with patient satisfaction, rating of quality and recommendation of the facility to others. Women were asked about their most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. The most common reasons for seeking care were fever or malaria, vaccination and non-emergent check-up. Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic. While there is currently a lot of attention on disrespectful maternity care, the authors suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.