Attention-deficit/hyperactivity disorder (AD/HD) is a multidimensional disorder that, although commonest in childhood and adolescence, can be diagnosed across the age span. Worldwide prevalence is about 5%. This study recommends an appropriate package of treatment for AD/HD in low- and middle-income countries (LMICs), which should include screening of high-risk groups, psychoeducational interventions with caregivers, methylphenidate, and behavioural interventions. Strategies to facilitate the delivery of effective interventions in LMICs should increase demand for services, access to AD/HD interventions, and the capacity of health care teams, as well as improve recognition of AD/HD, develop community-based and practice-based programs, and address the impact of AD/HD on other health and social outcomes. Interventions to address AD/HD should be part of a more comprehensive package of services for mental disorders.
Equitable health services
Epilepsy is the most common chronic neurological disorder, affecting over 65 million people worldwide, of whom 80% are estimated to live in low- or middle-income countries (LMICs). Anti-epileptic drugs are very effective in controlling seizures, but most people with epilepsy in LMICs do not receive appropriate treatment. According to this review, this 'treatment gap' is influenced by factors such as limited knowledge, poverty, cultural beliefs, stigma, poor health delivery infrastructure, and shortage of trained health care workers. Several studies implementing interventions at the community level (for example, training programmes for primary health care workers) have successfully improved the identification of people with epilepsy and reduced the treatment gap. The sustainability of these interventions needs to be addressed, however, and efforts must be made to ensure a continuous supply of anti-epileptic drugs.
This study had three aims: to measure agreement between nine structured approaches for diagnosing childhood tuberculosis; to quantify differences in the number of tuberculosis cases diagnosed with the different approaches, and to determine the distribution of cases in different categories of diagnostic certainty. It investigated 1,445 children aged less than two during a vaccine trial held in a rural South African community from 2001 to 2006. Clinical, radiological and microbiological data were collected prospectively. Tuberculosis case status was determined using each of the nine diagnostic approaches. Tuberculosis case frequency ranged from 6.9% to 89.2%. Significant differences in case frequency occurred in 34 of the 36 pair-wise comparisons between structured diagnostic approaches. There was only slight agreement between structured approaches for the screening and diagnosis of childhood tuberculosis and high variability between them in terms of case yield. Diagnostic systems that yield similarly low case frequencies may be identifying different subpopulations of children. The study findings do not support the routine clinical use of structured approaches for the definitive diagnosis of childhood tuberculosis, although high-yielding systems may be useful screening tools.
According to this information sheet, within the public sector, the poor benefit relatively more than the rich from outpatient services at lower levels of care (i.e., district hospitals, clinics and community health centres). The rich benefit considerably more than the poor from regional and central hospital services (both outpatient and inpatient services) and also benefit more from public sector inpatient services overall. The rich benefit far more from private sector services than the poor; the richest 40% of the population receive about 70% of the benefits of private outpatient services (from general practitioners, specialists, dentists and retail pharmacies) and nearly 80% of the benefits of inpatient care in private hospitals. Overall, health care benefits in South Africa are very ‘pro-rich’, with the richest 20% of the population receiving more than a third of total benefits while the poorest 20% receive less than 13% of the benefits, despite the poor bearing a much greater share of the burden of ill-health than the rich.
With at least 67,000 refugees in southwest Uganda, the government and aid workers are still battling inadequate resources in what a United Nations (UN) official described as a ‘silent emergency’. ‘We can hardly meet international standards of indicators such as water, health and food,’ reported Nemia Temporal, deputy representative of the UN Refugee Agency (UNHCR) in Uganda. ‘For instance, we are delivering fifteen litres [of water] per person per day instead of the standard twenty litres.’ After years of protracted conflict in eastern Democratic Republic of Congo (DRC), with large influxes to neighbouring countries, the situation of the majority Congolese refugees is no longer considered that urgent by the wider aid community, Temporal said. At least 45,000 Congolese live in the 217sqkm Nakivale settlement in Isingiro District and Kyaka II in Kyegegwa District, where, thanks to the Ugandan government's refugee-friendly policy, they cultivate small pieces of land. Among the aid delivery gaps were the provision of shelter (plastic sheeting), water, health and sanitation, infrastructure and refugee protection. She urged a shift in humanitarian assistance so that relief aid goes hand-in-hand with livelihood support ‘right from day one'.
Chronic Myeloid Leukemia (CML), a rare disease, can be treated effectively, but the pharmaceutical treatment available (imatinib) is costly and unaffordable by most patients. 'GIPAP' is a programme set up between a manufacturer and a non-governmental organisation to provide free treatment to eligible CML patients in 80 countries worldwide. This study discusses the socio-economic and demographic characteristics of patients participating in GIPAP. It researches the impact GIPAP is having on health outcomes (survival) of assistance-eligible CML patients and discusses the determinants of such outcomes and whether there are any variations according to socio-economic, demographic, or geographical criteria. Data for 13,568 patients across 15 countries, available quarterly, was analysed over the 2005-2007 period. GIPAP was found to have a significant positive effect on patient access to medicines for CML and on survival rates.
Malawi's government has set itself a major challenge this year, announcing plans to more than double the number of people receiving antiretroviral (ARV) drugs to half a million by the end of 2010. The country recently adopted new World Health Organization (WHO) guidelines that raise the threshold for ARV therapy from a CD4 count (a measure of immune system strength) of less than 200, to a CD4 count of 350, regardless of whether the patient is displaying symptoms. Some experts argue that starting patients on ARVs earlier could save the government money in the long term by reducing opportunistic infections such as tuberculosis. UNAIDS Country Coordinator, Patrick Brenny, said the targets were reachable, provided the country could mobilise the resources, including money, drugs and manpower. He noted that the Global Fund to Fight AIDS, Tuberculosis and Malaria had expressed willingness to fund implementation of new WHO treatment guidelines. Malawi has just had its funding extended by the Fund for a further six years and is now looking at how to make best use of the money in relation to the new guidelines. Brenny said Malawi was also researching ways to reduce its high dependence on foreign aid, including the possibility of building a local ARV manufacturing plant in partnership with Indian drug companies.
Adequate ventilation can reduce the transmission of infection in health-care settings. Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections in health care. This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings.
Alcohol use disorders (AUDs) – conditions that range from hazardous and harmful alcohol use to alcohol dependence – are a low priority in low- and middle-income countries (LMICs), despite causing a large health burden. Most alcohol-related harm is attributable to hazardous/harmful drinkers who make disproportionate use of primary health care systems, but often go undetected and untreated for long periods, even though brief, easily delivered interventions are effective in this group of people. Health care systems in LMICs currently focus on providing tertiary care services for the treatment of dependence (where there is often a poor outcome). This study indicates that the focus needs to shift towards the cost-effective strategy of providing brief interventions for early AUDs. Effective evidence-based combinations of psychosocial and pharmacological treatments for AUDs are available in LMICs but are costly to implement. Policy makers need to ensure that people with AUDs are offered the most appropriate services using stepped-care solutions that start with simple, structured advice for risky drinkers and progress to specialist treatment services for more serious AUDs. LMICs also need to improve their implementation of proven population-level preventive measures to reduce the health burden due to AUDs. An international Framework Convention on Alcohol Control may help them do this.
Two-thirds of people with dementia live in low- and middle-income countries (LMICs), where there are few services available and levels of awareness and help-seeking are low. After early diagnosis, the principal goals for management of dementia are optimising physical health, cognition, activity, and wellbeing; detecting and treating behavioural and psychological symptoms (BPSD); and providing information and long-term support to carers. This study recommends that routine packages of continuing care should comprise diagnosis coupled with information, regular needs assessments, physical health checks, and carer support, and where necessary carer training, respite care, and assessment and treatment of BPSD. Care can be delivered by trained primary care teams working in a collaborative care framework. Continuing care with practice-based care coordination, and community outreach are essential components of this model. Efficient care delivery in LMICs involves integrating dementia care with that of other chronic diseases and community-support programmes for the elderly and disabled.