This in-depth country case study aimed to explain Malawi's success in improving child survival. The authors estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. They documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths per 1000 livebirths in 1990 to 71 deaths in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly, representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280 000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The funding allocated to the health sector increased substantially, particularly to child health and HIV and from external sources, albeit below internationally agreed targets. This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. The authors’ findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth.
Equitable health services
Every year, nearly 200,000 women die during childbirth in sub-Saharan Africa in part due to poor access to basic reproductive and maternal health services. The author argues that Over 80 percent of these deaths could have been prevented with the assistance of a midwife. This campaign, Stand Up for African Mothers. aims to ensure that more African women can count on the assistance of a trained midwife during pregnancy and childbirth, and promotes reproductive rights and education to help women and their partners make informed choices about family planning. Through campaign, Amref is training 15,000 midwives to reduce the high rate of maternal mortality in sub-Saharan Africa through both traditional classroom-based teaching, and innovative methods such as distance learning and mLearning, which allows midwives to study using basic mobile phone technology. With a skilled midwife providing care to 500 mothers annually, over seven million African women each year could benefit from this campaign in 13 African countries. By 2016, almost 7,000 midwives had been trained since the campaign began in 2010.
Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status, and a shortage of health professionals. This article explores rural areas of Sub-Saharan Africa (SSA). Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from under-serviced areas to deliver quality health care in rural community settings.
Response to the 2014–2015 Ebola outbreak in West Africa overwhelmed the healthcare systems of Guinea, Liberia, and Sierra Leone, reducing access to health services for diagnosis and treatment for the major diseases that are endemic to the region: malaria, HIV/AIDS, and tuberculosis. To estimate the repercussions of the Ebola outbreak on the populations at risk for these diseases, the authors developed computational models for disease transmission and infection progression. They estimated that a 50% reduction in access to healthcare services during the Ebola outbreak exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates by additional death counts of 6,269 (2,564–12,407) in Guinea; 1,535 (522–2,8780) in Liberia; and 2,819 (844–4,844) in Sierra Leone. The authors report that the 2014–2015 Ebola outbreak was catastrophic in these countries, and its indirect impact of increasing the mortality rates of other diseases was also substantial.
This paper presents trends in equity in contraceptive use and contraceptive-prevalence rates in six East African countries. In this repeated cross-sectional study, Demographic and Health Survey data from women aged 15–49 years in Ethiopia, Kenya, Malawi, Rwanda, Tanzania, and Uganda between 2000 and 2010 were analysed. Individuals were ranked according to wealth quintile, urban/rural populations stratified, and a concentration index calculated. Equity and contraceptive-prevalence rates increased in most country regions over the study period. In rural Rwanda, contraceptive-prevalence rates increased from 3.9 to 44.0. Urban Kenya showed highest equity with a concentration index of 0.02. The Pearson correlation coefficient between improvements in concentration index and contraceptive-prevalence rates was significant. The results indicate that countries seeking to increase contraceptive use should also prioritize equity in access.
The authors note the emerging epidemic of yellow fever in Angola and spread of similar Aedes aegypti mosquito-borne viruses including dengue, chikungunya, and now Zika, albeit with differences noted. Yellow fever was first identified as a viral infection in 1900, has been reported from more than 57 countries and yellow fever outbreaks have case fatality rates as high as 75% in hospitalised cases. There has been an effective yellow fever vaccine since the late 1930s, but with outbreaks in unvaccinated populations in 1987 in urban Nigeria, despite a mass vaccination campaign. According to WHO, the current yellow fever outbreak is in more than six of Angola's 18 provinces, and there has been movement of unvaccinated travellers from Angola to neighbouring Democratic Republic of the Congo, but also to further states, including Mauritania, and China. Southeast Asian countries are now considered at risk because the Aedes vector is present and the population is unvaccinated. However should yellow fever outbreaks occur elsewhere in Africa, in Latin America, or in Asia, the authors note that the current global supplies of yellow fever vaccine may be inadequate.
The authors present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries. Data were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. All the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level. The authors findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.
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.
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”.