The authors of this article argue that surgery can and should be recognised as an important global health intervention. To achieve this goal, they emphasise that it is critical to improve the local surgical capacity in low- and middle-income countries. While the accomplishment of this goal will not be easy it is certainly possible, especially when doctors join forces with providers and policy-makers that set the direction of a public health movement that has seen a dramatic change and increase in its authority over the past decade. The authors call on the World Health Organisation to exercise its leadership in advancing the status of surgical care in global health by organising action plans to meet unmet surgical burdens.
Equitable health services
Surgery as a public health intervention: Common misconceptions versus the truth
Bae JY, Groen RS and Kushner AL: Bulletin of the World Health Organisation 89(6): 395, June 2011
The World Medicines Situation 2011: Traditional medicines: global situation, issues and challenges
Robinson MM and Xiaorui Z: World Health Organisation, 2011
Traditional medicines, including herbal medicines, have been, and continue to be, used in every country around the world in some way. In much of the developing world, a large share of the population rely on these traditional medicines for primary care. The global market for traditional medicines was estimated at US$ 83 billion annually in 2008, with an exponential rate of increase. Traditional medicines are used as prescription or over-the-counter (OTC) medications, as self-medication or self-care, as home remedies, or as dietary supplements, health foods, functional foods, phytoprotectants, and under any of many other titles in different jurisdictions, with only minimal consistency between the definitions of these terms from country to country and significant communication issues as a result. It is difficult to control quality and to ensure safety and efficacy in production of traditional medicines. WHO, in cooperation with the WHO Regional Offices and Member States, has produced a series of technical documents in this field, including publications on Good Agricultural and Collection Practices (GACP) and Good Manufacturing Practices (GMP), along with other technical support, to assist with standardization and creation of high quality products. Regulation of traditional medicines is a complicated and challenging issue as it is highly dependent upon experience with use of these products. Model countries such as China, India, and South Africa present usable templates, as do the guidelines on regulation and registration of traditional or herbal medicines produced in the WHO African, Eastern Mediterranean, and South-East Asian regions and in the European Union.
Treatment delay among tuberculosis patients in Tanzania: Data from the FIDELIS Initiative
Hinderaker S, Madland S, Ullenes M, Enarson DA, Rusen ID and Kamara DV: BMC Public Health 11(306), May 2011
During 2004-2008, several FIDELIS projects (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) in Tanzania were conducted by the National Tuberculosis and Leprosy Programme to strengthen tuberculosis (TB) diagnostic and treatment services. The authors of this study assessed the duration and determinants of treatment delay among new smear-positive pulmonary TB patients in FIDELIS projects, and compared delay according to provider visited prior to diagnosis. They included 1,161 cases, 10% of all patients recruited in the FIDELIS projects in Tanzania. Median delay was 12 weeks. Compared to Hai district, Handeni had patients with longer delays and Mbozi had patients with shorter delays. Urban and rural patients reported similar delays. In conclusion, half of the new smear positive pulmonary tuberculosis patients had a treatment delay longer than 12 weeks. Delay was similar in men and women and among urban and rural patients, but longer in the young and older age groups. Patients using traditional healers had a 25% longer median delay.
Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review
Ngo TD, Park MH, Shakur H and Free C: Bulletin of the World Health Organisation 89(5): 360-370, May 2011
The authors of this study compared medical abortion practised at home and in clinics in terms of effectiveness, safety and acceptability. A systematic search for randomized controlled trials and prospective cohort studies comparing home-based and clinic-based medical abortion was conducted. Nine studies met the inclusion criteria. Complete abortion was achieved by 86–97% of the women who underwent home-based abortion and by 80–99% of those who underwent clinic-based abortion. Pooled analyses from all studies revealed no difference in complete abortion rates between groups. Serious complications from abortion were rare. Women who chose home-based medical abortion were more likely to be satisfied, to choose the method again and to recommend it to a friend than women who opted for medical abortion in a clinic.
Developing effective chronic disease interventions in Africa: insights from Ghana and Cameroon
Atanga LL, Boynton P and Aikins A: Globalization and Health 6(6), 2010
In this paper, using in-depth case studies of Ghanaian and Cameroonian responses, the authors discuss the challenge of developing effective primary and secondary prevention to tackle chronic diseases such as stroke, hypertension, diabetes and cancers. They observe fundamental differences between Ghana and Cameroon in terms of "multi-institutional and multi-faceted responses" to chronic diseases. Whereas Ghana does not have a chronic disease policy, the authors note that it has a national health insurance policy that covers drug treatment of some chronic diseases, a culture of patient advocacy for a broad range of chronic conditions and mass media involvement in chronic disease education. On the other hand, the authors note that Cameroon has a policy on diabetes and hypertension as well as established diabetes clinics across the country and provides training to health workers to improve treatment and education despit lack of community and media engagement. In both countries churches provide public education on major chronic diseases, but neither country has conducted systematic evaluation of the impact of interventions on health outcomes and cost-effectiveness. In conclusion, the authors recommend a comprehensive and integrative approach to chronic disease intervention that combines structural, community and individual strategies. To this end, they outline research and practice gaps and best practice models within and outside Africa that can instruct the development of future interventions.
ICT applications as e-health solutions in rural healthcare in the Eastern Cape Province of South Africa
Ruxwana NL, Herselman ME and Conradie DP: Health Information Management Journal 39(1), January 2010
Information and Communication Technology (ICT) solutions (e.g. e-health, telemedicine, e-education) are often viewed as vehicles to bridge the digital divide between rural and urban healthcare centres and to resolve shortcomings in the rural health sector. This study focused on factors perceived to influence the uptake and use of ICTs as e-health solutions in selected rural Eastern Cape healthcare centres, and on structural variables relating to these facilities and processes. Attention was also given to two psychological variables that may underlie an individual’s acceptance and use of ICTs: usefulness and ease of use. It is evident that more effective use of ICTs as part of e-health initiatives at the rural healthcare centres was seen to be distinctly possible, but only if perceived shortcomings with regard to structural variables were addressed. Especially relevant was better access to more e-facilities, more health-related information made available via ICTs, ongoing ICT skills training programs and policies for improved technology maintenance and support. In conclusion, all structural and psychological factors investigated were seen to impinge to some extent on effective use of ICT applications as e-health solutions in the rural healthcare centres involved in the study. Furthermore, there was a distinct interplay between the various variables, with perceived ICT-related shortcomings having a negative impact on perceived usefulness and ease-of-use variables and thus decreasing the likelihood of effective e-health solutions. This means that to increase effective use of ICTs that form part of e-health initiatives in the healthcare centres, a vital first step is to address reported perceived shortcomings.
Public health perspectives of preeclampsia in developing countries: Implication for health system strengthening
Osungbade KO and Olusimbo KJ: Pregnancy 2011(481095), 4 April 2011
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.
The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania
Gross K, Alba S, Schellenberg J, Kessy F, Mayumana I and Obrist B: Malaria Journal 10(140), May 2011
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.
The emergence of insecticide resistance in central Mozambique and potential threat on the successful indoor residual spraying malaria control programme
Abilio AP, Kleinschmidt I, Coleman M et al: Malaria Journal 10(110), May 2011
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.
The hidden inequity in health care
Starfield B: International Journal for Equity in Health 10:15, 2011
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.