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.
Equitable health services
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.
The authors of this article challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment in poor countries. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deploying primary and secondary caregivers, using off-patent drugs, and applying regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage, with a focus on people living in poverty. These strategies can reduce costs, increase access to health services and strengthen health systems to meet the challenge of cancer and other diseases, the authors argue. To promote cancer treatment in poor countries, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries was formed in 2009. It is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation and evaluation of strategies to advance this agenda.
Eclampsia is the commonest direct cause of maternal death in South Africa. The latest Saving Mothers Report (2005-2007) indicates that there were 622 maternal deaths due to hypertensive disorders of pregnancy. Of these, 334 (55.3%) were due to eclampsia; of the eclamptic deaths, 50 were over the age of 35 years and 83 were under 20 years old. Avoidable factors involved patient related factors (mainly delay in seeking help), administrative factors (mainly delay in transport) and health personnel issues (mainly due to delay in referring patients). The major causes of death were cerebrovascular accidents and cardiac failure. The majority of deaths due to cardiac failure were due to pulmonary oedema. To reduce deaths from eclampsia, this study argues that more attention must be given to the detection of pre-eclampsia; the provision of information on the advantages of antenatal care to the population at large and training of health professions in the management of obstetric emergencies.
The United Nations Economic Commission for Africa (UNECA) and the World Health Organization (WHO) are joining forces to establish an African-owned and -governed initiative to promote innovation for the research and development of pharmaceuticals and other products to meet the health needs of the continent. The African Network for Drugs and Diagnostics Innovation (ANDI) will be based in Ethiopia and will help build research capacity on the continent and link biomedical innovation to development and public health. Overall, ANDI aims to mobilise Africa health research capability, uncapping African health innovation potential and expanding global partnerships and regional collaborations to accelerate the delivery of quality health care in Africa. Specific goals include increasing research and development collaboration among African institutions and countries, and fostering public-private partnerships within Africa to support the development and manufacture of new drugs and health products. It also aims to generate and manage intellectual property, explore innovative mechanisms to encourage and reward local innovation – including research drawing on traditional medicine – and promote long-term economic sustainability by supporting research and development.