Equitable health services

Why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition
Oni T; Unwin N: International Health 7(4), June 2015

In today’s globalised world, rapid urbanisation, mechanisation of the rural economy, and the activities of transnational food, drink and tobacco corporations are associated with an increased risk of chronic non-communicable diseases (NCDs). As a result, population health profiles are rapidly changing. Many low and middle income countries (LMICs) are undergoing rapid changes associated with developing high rates of NCD while concomitantly battling high levels of communicable diseases. This review synthesises evidence on the overlap and interactions between established communicable and emerging non-communicable disease epidemics in LMICs. The review focuses on HIV, TB and malaria and explores the disease-specific interactions with prevalent NCDs in LMICs. The authors highlight the complexity, bi-directionality and heterogeneity of these interactions and discuss the implications for health systems. It is argued to require breaking down barriers between departments within
health ministries that have traditionally designed services and
programs for communicable and NCD separately and integrated multi-sectoral action addressing determinants across the life course.

Do antenatal care visits always contribute to facility-based delivery in Tanzania? A study of repeated cross-sectional data
Choe SA; Kim J; Kim S; Park Y; Kullaya SM; Kim CY: Health Policy and Planning, June 2015, doi: 10.1093/heapol/czv054

There is a high disparity in access to perinatal care services between urban and rural areas in Tanzania. This study analysed repeated cross-sectional data from Tanzania to explore the relationship between antenatal care (ANC) visits, facility-based delivery and the reasons for home births in women who had made ANC visits. The relationship between the number of ANC visits (up to four) and facility delivery in the latest pregnancy was explored. For rural women, there was no significant relationship between the number of ANC visits and facility delivery rate. The most frequent reason for home delivery was ‘physical distance to facility’, and a significant proportion of rural women reported that they were ‘not allowed to deliver in facility’. The disconnect between ANC visits and facility delivery in rural areas may be attributable to physical, cultural or familial barriers, and quality of care in health facilities. This suggests that improving access to ANC may not be enough to motivate facility-based delivery, especially in rural areas.

Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania
Baker U; Peterson S; Marchant T; Mbaruku G; Temu S; Manzi F; Hanson C: Bulletin of World Health Organization 93, 22 April 2015, http://dx.doi.org/10.2471/BLT.14.141879

The authors aimed to estimate the effective coverage of key maternal and newborn health interventions in rural parts of the United Republic of Tanzania and to identify bottlenecks in implementation. They used data from an observational, cross-sectional study that was performed in Tandahimba and Newala districts in south-eastern United Republic of Tanzania. They investigated five key maternal and newborn health interventions: (i) syphilis screening; (ii) pre-eclampsia screening; (iii) use of a partograph to monitor labour; (iv) active management of the third stage of labour; and (v) postpartum care in a health facility. The largest bottleneck in Tandahimba was health facility readiness, which was associated with a 52% reduction in coverage. Clinical practice was another large bottleneck, with an attrition of 35%. In Newala, clinical practice was the largest bottleneck, causing an attrition of 57%. The authors provide a framework that could help operationalize measurements and track progress towards universal health coverage in all areas of health care.

Determinants of access to healthcare by older persons in Uganda: a cross-sectional study
Wandera SO; Kwagala B; Ntozi J: International Journal for Equity in Health, 14(26), 2015

Older persons report poor health status and greater need for healthcare. However, there is limited research on older persons’ healthcare disparities in Uganda. This paper reports on factors associated with older persons’ healthcare access in Uganda, using a nationally representative sample. The authors conducted secondary analysis of data from a sample of 1602 older persons who reported being sick in the last 30 days preceding the Uganda National Household Survey. They used frequency distributions for descriptive data analysis and chi-square tests to identify initial associations and fit generalised linear models (GLM) with the poisson family and the log link function, to obtain incidence risk ratios (RR) of accessing healthcare in the last 30 days, by older persons in Uganda. More than three quarters (76%) of the older persons accessed healthcare in the last 30 days. Access to healthcare in the last 30 days was reduced for older persons from poor households; and with some or with a lot of walking difficulty. Conversely, accessing healthcare in the last 30 days for older persons increased for those who earned wages and missed work due to illness for 1–7 and 8–14 days. In addition, those who reported non-communicable diseases (NCDs) such as heart disease, hypertension or diabetes were more likely to access healthcare during the last 30 days. In the Ugandan context, health need factors (self-reported NCDs, severity of illness and mobility limitations) and enabling factors (household wealth status and earning wages in particular) were the most important determinants of accessing healthcare in the last 30 days among older persons.

Global evidence on inequities in rural health protection
Scheil-Adlung X; ILO: ILO ESS Paper Series, 2015

This paper presents global estimates on rural/urban disparities in access to health-care services. The report uses proxy indicators to assess key dimensions of coverage and access involving the core principles of universality and equity. Based on the results of the estimates, policy options are discussed to close the gaps in a multi-sectoral approach addressing issues and their root causes both within and beyond the health sector. The paper presents global evidence that suggests significant differences between rural and urban populations in health coverage
and access at global, regional and national levels. Based on the evidence provided, place of residence largely determines coverage and access to health care in all regions and within all countries. . Efficient and effective multisectoral policies to address the root causes of rural inequities should consider the specific living and working characteristics of rural populations. The authors argue that if not addressed, the rural/urban disparities identified in access to health care carry the potential to considerably hamper overall socio-economic development in many developing countries.

Innocent lives lost and saved: the importance of blood transfusion for children in sub-Saharan Africa
Dzik WH: BMC Medicine 13(22), 2015

Severe anemia in children is a leading indication for blood transfusion worldwide. Severe anemia, defined by the World Health Organization as a hemoglobin level&#8201;<5 g/dL, is particularly common throughout sub-Saharan Africa. Analysis of data from the Fluid Expansion as Supportive Therapy trial offers new insights into the importance of blood transfusion for children with severe anemia. This analysis found that life-threatening anemia in children is a frequent presenting condition in East Africa; that delays in transfusion therapy are lethal; and that inadequate transfusion is probably more common than currently recognized. The findings of this study highlight the need for changes in blood inventory management in sub-Saharan hospitals and the need for more research on transfusion therapy for children in peril.

Management of severe paediatric malaria in resource-limited settings
Maitland K: BMC Medicine 13(42), 2015

Over 90% of the world’s severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the AQUAMAT trial in 2010 showing that in artesunate-treated children, the relative risk of death was 22.5% lower than in those receiving quinine. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.

A Wake-up Call - Lessons from Ebola for the world's health systems
Wright S; Hanna L; Mailfert M; Gushulvili D; Kite G: Save the Children 2015

Ebola has taken a dreadful toll in the three West African countries hit by the current outbreak – Guinea, Sierra Leone and Liberia. In this report, Save the Children documents the existing weaknesses of the health services in the three main countries affected by Ebola. There is broad agreement that the Ebola crisis was not quickly contained, reversed or mitigated because national health systems in these countries were dangerously under-resourced, under-staffed and poorly equipped. The virus was able to spread, in part, due to the poor state of these health services, which were quickly overwhelmed and lacked the ability to cope with a major disease outbreak. This inability to cope with a major health emergency reflects a similar inability to cope with the daily health needs of their populations over the longer term. The authors argue that one of the most important lessons from the Ebola crisis is the need to build comprehensive health services with sufficient funding, staff and equipment, to deal with everyday problems as well as infectious
disease outbreaks.

Drivers of routine immunisation coverage improvement in Africa: findings from district-level case studies
LaFond A; Kanagat N; Steinglass R; Fields R; Sequeira J; Mookherji S: Health Policy and Planning 30(3) 298-308, 2014

There is limited understanding of why routine immunisation (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, the authors conducted in-depth case studies to understand pathways to coverage improvement by comparing immunisation programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques the authors compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunisation services and drivers of coverage improvement. The results informed a model for immunisation coverage improvement that emphasises the dynamics of immunisation systems at district level. In all districts, whether improving or steady, the authors found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. They found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness and identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasise the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunisation system performance.

E-procurement in support of universal health coverage
Humphreys G: Bulletin of the World Health Organization, 93(3) 138-139, 2015

Kenya is gearing up for digital bidding on essential medicines’ contracts, part of a wave of African countries looking at procurement to improve transparency, bring down costs and support universal health coverage. John Kabuchi, procurement manager for the Kenya Medical Supplies Authority, notes: “We are currently gearing up for full e-procurement functionality, including electronic bidding, and I am hopeful that supporting legislation will be passed before next June.” Kenya hopes to make the most of new technologies and approaches, such as e-procurement, to support efforts to make essential health care more widely available.

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