Primary health care in rural South Africa is predominantly provided by remote clinics and health centres. In 1994, health centres were upgraded and new health centres developed to serve as a health care filter between community clinics and district hospitals. This study set out to describe the spectrum of clinical problems encountered at a new health centre in an area of high economic deprivation and compare this with an adjacent community clinic and district hospital. The International Classification of Primary Care-2 (ICPC-2) was used to code data collected over a 13-week period from patients presenting at a community clinic, health centre and district hospital. Altogether, 4,383 patient encounters were recorded across all three sites in 2001. Most contacts at the clinic (97%) and the health centre (80%) were with a nurse. Females over 15 years of age comprised over half of all contacts at health facilities (53%). The most common diagnosis category was respiratory (23%). Cough was the most common symptom. Thirty per cent of children up to 5 years of age were seen for immunisations. Most childhood immunisations (79%) were carried out at the health centre. The study concluded that, of all the health care facilities surveyed, the health centre had the highest throughput of patients, indicating that the health centre is an efficient filter between the community and hospital. In this light, the ICPC-2 system can be successfully used to monitor encounters at similar African health care facilities.
Equitable health services
This study aimed to describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. It conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. It identified 1,701 malaria cases, of which 1,548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals, while 1,149 (68%) patients were male. Most (84%) infections were acquired in Mozambique. While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. The study recommends that providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
Oral polio vaccine (OPV) is recommended to be given at birth together with BCG vaccine. This study investigated the effect of OPV given simultaneously with BCG at birth on the immune response to BCG vaccine. It compared the in vitro and the in vivo response to PPD in the infants who received OPV and BCG with that of infants who received BCG only. The study is the first to address the consequences for the immune response to BCG of simultaneous administration with OPV. The authors expressed concern that the results indicate that the common practice in low-income countries of administering OPV together with BCG at birth may down-regulate the response to BCG vaccine.
This study sought to describe the magnitude and variation of the epilepsy treatment gap worldwide. A systematic review of the peer-reviewed literature published from 1 January 1987 to 1 September 2007 in all languages was conducted, using PubMed and EMBASE. The purpose was to identify population-based studies of epilepsy prevalence that reported the epilepsy treatment gap, defined as the proportion of people with epilepsy who require but do not receive treatment. The study found that the treatment gap was over 75% in low-income countries and over 50% in most lower middle- and upper middle-income countries, while many high-income countries had gaps of less than 10%. However, treatment gaps varied widely both between and within countries. The dramatic global disparity in the care for epilepsy between high- and low- income countries, and between rural and urban settings, calls for immediate attention, according to the study. It urged for a broadening of current understanding of the factors affecting the treatment gap and recommended that future investigations should explore other potential explanations of this gap.
A Kenyan initiative to use mobile phones to improve health systems indicates that the use of mobile phones to track patients may help relieve the burden of overworked health workers. 'Eighty percent of those [health workers] we talked to in Nairobi and Kajiado said they feel relieved - health workers need that kind of relief,' said Sarah Karanja, study coordinator of the Weltel Project. 'Patients, on the other hand, feel they are cared for which is good for their health and wellbeing.' Weltel uses a weekly text message to study mobile-phone effectiveness for health. The message to the patient reads 'Mambo', Swahili for 'How are you?' to which the patients can respond 'Sawa' ('OK') to show they are fine, or 'Shida', which means 'problem', to show they need attention. Patients who respond Shida and non-responders are followed up with a call from the clinic nurse to identify and handle any problems. Initial study findings reveal that 80% of patients are comfortable with the use of mobile phones to manage their HIV care and treatment. Mobile phone use in Kenya has risen rapidly from 200,000 users in 2000 to an estimated 17.5 million today, offering great potential for expanding the use of mobile phones for health services.
This report presents for the first time the treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.
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.
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.