This survey was conducted in October 2010 in Zimbabwe. Afrobarometer found that access to modern medical care and medicine improved in 2009 and 2010, although 39% of respondents often or always went without modern medical care and medicine in 2010. One in five had access to traditional medicines, while more than half of respondents (55%) experienced difficulty when seeking treatment at a clinic. A third and a quarter of respondents always or often went without food and water respectively in 2010, increasing potential for malnutrition and cholera. Seven out of ten (71%) regularly had no cash, curtailing their ability to pay for treatment or even transport to a health facility. One in five Zimbabweans (20%) made illegal payments to public health facilities. The high cost of medical care was identified as the most important health problem in the country, followed by shortages of supplies, poor infrastructure and insufficient staff. One in three was not satisfied with maternal and child health care services, and the same number was dissatisfied with nurses and midwives, while one in four was dissatisfied with the village health workers network. Reports of dirty facilities and illegal payments increased since 2005. There was some improvement with the availability of medical supplies and doctors in public clinics since 2005 and widespread satisfaction with government performance on HIV and AIDS, but most respondents (58%) did not want government to prioritise HIV and AIDS above other health problems.
Equitable health services
This study aimed to assess whether mobile phone communication between health-care workers and patients starting antiretroviral therapy (ART) in Kenya improved drug adherence and suppression of plasma HIV-1 RNA load. Between May 2007 and October 2008, a total of 538 randomly assigned HIV-infected adults who initiated ART in three clinics in Kenya were selected. Patients in the intervention group received weekly SMS messages from a clinic nurse and were required to respond within 48 hours. Adherence to ART was reported in 168 of 273 patients receiving the SMS intervention compared with 132 of 265 in the control group. Suppressed viral loads were reported in 156 of 273 patients in the SMS group and 128 of 265 in the control group. The number needed to treat (NNT) to achieve greater than 95% adherence was nine and the NNT to achieve viral load suppression was 11. The study concludes that patients who received SMS support had significantly improved ART adherence and rates of viral suppression compared with the control individuals. Mobile phones might be effective tools to improve patient outcomes in resource-limited settings.
Sub-Saharan Africa is undergoing health transition as increased globalisation and accompanying urbanisation are causing a double burden of communicable and non-communicable diseases. This study indicates that rates of communicable diseases such as HIV and AIDS, tuberculosis and malaria in Africa are the highest in the world and the impact of non-communicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on non-communicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. The study puts forward several policy proposals to improve the primary-care response to the problems posed by health transition. Governments should improve data on communicable and non-communicable diseases and implement a structured approach to the improved delivery of primary care. They should also focus on quality of clinical care, align the response to health transition with health system strengthening and capitalise on a favourable global policy environment.
This study aimed to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. A total of 39 papers were selected, which related to delivery at scale of intermittent preventive treatment in pregnancy, artemisinin combination therapy (ACT) or insecticide treated nets (ITNs). In terms of coverage and equity, the review found that the evidence to link changes in coverage to any specific strategy is weak: only 3 of 24 studies reporting coverage had a concurrent comparison group, and only one was classified as high-level evidence using the GRADE criteria. For ACT, an associated increase in treatment among children (73% to 88%) was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, instances where household ownership or use of nets reached targets of 80% were associated with free delivery of nets through campaigns. The study identifies barriers and facilitators to interventions, notably cost as a barrier. The study cautions that, to prioritise strengthening of health system elements for scale up, systematic reviews alone are not sufficient and additional research methods are needed.
Examining vulnerabilities within the world’s current public healthcare systems, the authors of this study propose borrowing two tools from the fields of engineering and design: A systems approach, as advocated by Reason in 1990, and a user-centered design, as advocated by Norman and Draper. Both approaches are human-centered in that they consider common patterns of human behaviour when analysing systems to identify problems and generate solutions. This paper examines these two human-centered approaches in relation to health care systems. It argues that maintaining a human-centered orientation in clinical care, research, training and governance is critical to the evolution of an effective and sustainable health care system.
This paper was commissioned as a background paper for discussion at the First Global Symposium on Health Systems Research, held 16-19 November, 2010, in Montreux, Switzerland. It argues that, to advance towards universal coverage, decision-makers have to determine ways to incentivise providers and patients alike to increase access to good quality health services and promote efficient modes of delivery that can be sustainable. It found little rigorous evidence to guide policymakers on how the theoretical incentives created by different payment mechanisms for individual providers or facilities operate in practice. Available data indicates that fee-for-service systems (for individuals or facilities) result in higher rates of utilisation and resource use. Limited evidence on reimbursement mechanisms for facilities suggests that case-based payments are efficiency enhancing, but important questions remain about their impact on quality of care and the possibility of implementing them in systems or facilities where capacity is low. The evidence in support of pay-for-performance (P4P) mechanisms was found to be mixed and the paper advises policymakers seeking to implement P4P schemes to proceed with caution. Conditional cash transfers (CCT) were found to have been effective in increasing uptake of health services, but continued success is likely to be dependent on adequate infrastructure, reliable funding and technical capacity. Key questions remain about the desirability and cost-effectiveness of CCTs, in particular in low-income settings.
The objective of this study was to assess the quality of child health services provided at primary health care (PHC) facilities in Johannesburg, South Africa. Sixteen PHC clinics were surveyed, using a researcher-developed structured checklist based on national guidelines and protocols. Most facilities were found to be adequately equipped and well stocked with drugs. A total of 141 sick child and 149 well child visits were observed. Caregivers experienced long waiting times (mean length of 135 minutes). Many routine examination procedures were poorly performed, with an adequate diagnosis established in 108 of 141 consultations (77%), even though health professionals were experienced and well trained. Triage and attention to danger signs were poor. An antibiotic was prescribed in almost half of the consultations, but antibiotic use was unwarranted in one-third of these cases. Health promotion activities (such as growth monitoring) were consistently ignored during sick child visits. HIV status was seldom asked about or investigated, for the mother or for the child. Growth monitoring and nutritional counselling at well child visits was generally inadequate, with not one of 11 children who qualified for food supplementation receiving it. In conclusion, the findings indicate that PHC offered to children in Johannesburg is seriously inadequate. The study urges for a deliberate and radical restructuring of PHC for children, with clearly defined and monitored standard clinical practice routines and norms.
In this report, research findings from a population-based household survey are presented on the general health status of infants, children, and adolescents in South Africa including morbidity, utilisation of health facilities, immunisation coverage, HIV status and associated risk factors. It also investigates the exposure of children and adolescents to HIV communication programmes. Close to 90% of children visited a public or private outpatient clinic the last time they were sick, indicating a high rate of utilisation for health services in South Africa. However, more than 20% of children were hospitalised for an average duration of 6.9 days. This demonstrates both the failure of the primary health care system to prevent and adequately manage diseases and the low quality of care provided in these services. This report is intended to play a vital role in assisting policy makers and stakeholders in targeting and prioritising key issues in planning and programming efforts focusing on the broad health issues of South African children.
Malnutrition in Congo-Brazzaville causes more than a quarter of deaths among children under five, according to United Nations Children's Fund (UNICEF). In response, on 20 October 2010, the Act Now, No Woman Should Die Giving Life campaign was launched across the country. It aims to reduce maternal and child mortality, and involves the government, three United Nations (UN) agencies, civil society and private partners. It aims to reduce the maternal mortality rate of 781 per 100,000 live births, as well as child mortality. UNICEF also pointed out health inequities, as the rich have access to faster essential interventions than the poor and stressed that reducing this inequality is essential to achieve the Millennium Development Goals related to health. The Congolese Minister for Health and Population assured that adoption of the new national roadmap will accelerate reduction in mortality rates. He said that since 2008 pregnant women and children aged 5-15 have been able to access free malaria treatment, and from January 2011 pregnant women will be able to get free Caesarean sections.
The objective of the East Africa Public Health Laboratory Networking Project for Africa is to establish a network of efficient, high quality, accessible public health laboratories for the diagnosis and surveillance of tuberculosis and other communicable diseases. There are three components to the project, the first component being regional diagnostic and surveillance capacity. This component will provide targeted support to create and render functional the regional laboratory network. Uganda, working in close collaboration with the East, Central and Southern African Health Community (ECSA-HC), will lead the establishment of the network. The second component is joint training and capacity building. The project will support training in a range of institutions in the four countries and across the region. Tanzania will provide leadership in this area and establish a regional training hub. It will provide practical training at its state-of-the-art national health laboratory quality assurance and training centre and in-service training and post-graduate mentorships at the Muhimbili University of Health and Allied Sciences. Finally, the third component includes joint operational research, knowledge sharing and regional co-ordination, and programme management.