This study is a review of public health perspectives of preeclampsia in developing countries and implications for health system strengthening. Literature from Pubmed (MEDLINE), AJOL, Google Scholar, and Cochrane database were reviewed. Results showed that the prevalence of preeclampsia in developing countries ranges from 1.8% to 16.7%. Many challenges exist in the prediction, prevention, and management of preeclampsia. Promising prophylactic measures like low-dose aspirin and calcium supplementation need further evidence before recommendation for use in developing countries. Treatment remains prenatal care, timely diagnosis, proper management, and timely delivery. Overcoming the prevailing challenges in the control of preeclampsia in developing countries hinges on the ability of health care systems to identify and manage women at high risk, the authors conclude.
Equitable health services
Coverage for the recommended two intermittent preventive treatment during pregnancy (IPTp) IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage. Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. Simplified IPTp guidelines for front-line health workers as recommended by the World Health Organisation (WHO) could lead to a 20% increase in IPTp coverage. Pregnant women also need to be educated about the risks of malaria during pregnancy and their right to receive health services.
Malaria vector control by indoor residual spraying was reinitiated in 2006 with DDT in Zambezia province, Mozambique. In 2007, these efforts were strengthened by the President's Malaria Initiative. This paper reports on the monitoring and evaluation of this programme as carried out by the Malaria Decision Support Project. Annual cross sectional household parasite surveys were carried out to monitor the impact of the control programme on prevalence of Plasmodium falciparum in children aged 1 to 15 years. In 2006, the sporozoite rate in Anopheles gambiae s.s. was 4% and this reduced to 1% over 4 rounds of spraying. The sporozoite rate for An. funestus was also reduced from 2% to 0 by 2008. Of the 437 Anopheles arabiensis identified, none were infectious. Overall prevalence of P. falciparum in the sentinel sites fell from 60% to 32% between October 2006 and October 2008. In conclusion, it appears that both An. gambiae s.s. and An. funestus were controlled effectively with the DDT-based IRS programme in Zambezia, reducing disease transmission and burden. However, the discovery of pyrethroid resistance in the province and Mozambique's policy change away from DDT to pyrethroids for IRS may threaten the gains made.
According to this article, inequity is built into western health systems, due to the disease focus that they have. Diseases are only a partial picture of peoples health, and low income populations experience multiple diseases. The author argues that the problems that bother and disable people, such as chronic pain, deserve more attention because many of these problems cannot be related to specific diseases. It is thus more useful for health services to focus on population health, and manage the multiple health challenges that people, especially poor people have, rather than tackle single diseases and leave the wider ill health burden unmanaged. The author calls on primary care physicians to take leadership in moving medical care where it needs to be: to the care of patients and populations and not the care of diseases. Primary health care that integrates disease with other aspects of patient health is seen as the way forward.
Surveys of medicine prices and availability, conducted using a standard methodology, have shown that poor medicine availability, particularly in the public sector, is a key barrier to access to medicines. Public sector availability of generic medicines is less than 60% across WHO regions, ranging from 32% in the Eastern Mediterranean Region to 58% in the European Region. Private sector availability of generic medicines is higher that in the public sector in all regions. However, availability is still less than 60% in the Western Pacific, South-East Asia and Africa Regions. Due to low availability of medicines in the public sector, patients are often forced to purchase medicines in the private sector. When originator brands are prescribed and dispensed for products that are also available in generic form, patients are paying four times more, on average, to purchase the brand. High medicine prices increase the cost of treatment. Low public sector availability can be addressed through improved procurement efficiency, and adequate, equitable and sustainable financing. Medicine prices can be reduced by eliminating duties and taxes on medicines and promoting the use of quality-assured generic medicines. Mark-ups can also be regulated to avoid excessive add-on costs in the supply chain. The most appropriate actions to follow depend on a country’s individual survey results and their underlying determinants, as well as local factors including existing pharmaceutical policies and market situations.
Irrational use of medicines is an extremely serious global problem that is wasteful and harmful, according to the authors of this paper. In developing and transitional countries, in primary care less than 40% of patients in the public sector and 30% of patients in the private sector are treated in accordance with standard treatment guidelines. Antibiotics are misused and over-used in all regions. In developing and transitional countries, while only 70% of pneumonia cases receive an appropriate antibiotic, about half of all acute viral upper respiratory tract infection and viral diarrhoea cases receive antibiotics inappropriately. Patient adherence to treatment regimes is about 50% worldwide and lower in developing and transitional countries. Harmful consequences of irrational use of medicines include unnecessary adverse medicines events, rapidly increasing antimicrobial resistance (due to over-use of antibiotics) and the spread of blood-borne infections such as HIV and hepatitis B/C (due to unsterile injections) all of which cause serious morbidity and mortality and cost billions of dollars per year. Effective interventions to improve use of medicines are generally multi-faceted. They include provider and consumer education with supervision, group process strategies (such as peer review and self-monitoring), community case management (where community members are trained to treat childhood illness in their communities and provided with medicines and supervision to do it) and essential medicines programmes with an essential medicine supply element.
Many developing countries stressed the importance of access to medicines and of addressing the social determinants of health in order to prevent and control non-communicable diseases. Interventions also called for more funding and political commitment, better private sector regulation and policy-making free of conflict of interests. Several Member States also supported the inclusion of mental health in the context of NCDs. This was at the 64th World Health Assembly (WHA) meeting in Geneva on 16-24 May, during a discussion on the prevention and control of non-communicable diseases (NCDs) that considered the WHO Secretariat report on the matter and adopted a resolution sponsored by 61 Member States including EU member countries. The article reports on the debates and the resolution.
After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidised insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania. The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions.
The aim of this study was to synthesise knowledge concerning various models for the integrated delivery of TB/HIV services at health facility level in low- and middle-income countries. The authors conducted a systematic review of literature, selecting 63 papers and 70 abstracts for inclusion, which described 136 examples of models of integration. Strengths and weaknesses of different models of integration are identified. Models based on referral only are easiest to implement, requiring as little as additional staff training and supervision, if a functional referral system exists, but optimal communication is necessary. Models with closer integration are more efficient but require more staff training and may also require additional infrastructure, e.g. private space for HIV counselling. The authors conclude that their comparison of different models of integration of tuberculosis and HIV services was undermined by a lack of rigorous studies. More research is needed to investigate potential efficiencies of integrated care from the perspective of both provider and service user.
The objective of this study was to establish the feasibility and reliability of a questionnaire for healthcare service satisfaction and a questionnaire for satisfaction with information received about TB medicines among adult TB patients attending public and private programme clinics in Kampala, Uganda. Researchers recruited 133 patients of known HIV status and confirmed pulmonary TB who were receiving care at public and private hospitals in Kampala, Uganda. A translated and standardised 13-item patient healthcare service satisfaction questionnaire (PS-13) and the Satisfaction with Information about Medicines Scale (SIMS) tool were administered by trained interviewers. Of the 133 participants, 35% were starting, 33% had completed two months, and 32% had completed eight months of TB therapy. The male to female and public to private hospital ratios in the study population were 1:1. The PS-13 and the SIMS tools were highly acceptable and easily administered. Patients that were enrolled at the public hospital had relatively lower PS-13 satisfaction scores for technical quality of care and responsiveness to patient preferences when compared to patients that were enrolled at the private hospital. The authors conclude that their study provides preliminary evidence that the PS-13 service satisfaction and the SIMS tools are reliable measures of patient satisfaction in TB programmes. Satisfaction score findings suggest differences in patient satisfaction levels between public and private hospitals, as well as between patients starting and those completing TB therapy.