South Africa (SA) has the highest prevalence of HIV/AIDS of any country in the world, which adds complexity to a health system already overwhelmed by chronic kidney disease, particularly that due to hypertension, diabetes and chronic glomerulonephritis. Renal disease is common in HIV-infected individuals. Prior to availability of ART, HIV was a death sentence for individuals with chronic kidney disease (CKD). However, since ART roll-out there is growing evidence of little difference in survival between HIV-infected patients who are receiving efficacious ART compared with the general population on dialysis. In this issue of the SAMJ, Fabian et al. demonstrate that haemodialysis in black African HIV-positive patients in the private sector in SA imparts excellent overall survival. This study contributes to the growing data reflecting good outcomes for HIV-positive patients on dialysis. However, transplantation is regarded as the best treatment option for CKD in patients without HIV, and we ask whether we should not be striving for dialysis to be the bridge to transplantation in HIV-positive patients. Also, importantly, attention needs to be geared towards prevention of CKD and slowing progression towards end-stage renal disease (ESRD). Those who provide healthcare to HIV-positive patients need to be aware of the special renal issues relevant to HIV, and the potential for evolution to ESRD.
Equitable health services
This paper argues that the global health agenda tends to privilege short-term global interests at the expense of long-term capacity building within national and community health systems. The Health Systems Strengthening (HSS) movement needs to focus on developing the capacity of local organisations and the institutions that influence how such organisations interact with local and international stakeholders. While institutions can enable organisations, they too often apply requirements to follow paths that can stifle learning and development. Global health actors have recognised the importance of supporting local organisations in HSS activities. However, this recognition has yet to translate adequately into actual policies to influence funding and practice. While there is not a single approach to HSS that can be uniformly applied to all contexts, several messages emerge from the experience of successful health systems presented in this paper using case studies through a complex adaptive systems lens. Two key messages deserve special attention: the need for donors and recipient organisations to work as equal partners, and the need for strong and diffuse leadership in low-income countries. An increasingly dynamic and interdependent post-Millennium Development Goals (post-MDG) world requires new ways of working to improve global health, underpinned by a complex adaptive systems lens and approaches that build local organisational capacity.
According to the World Health Organization, cancer is one of the leading causes of death around the world, with 8.2 million deaths in 2012. More than 60 percent of the world’s new cases of cancer occur in Africa, Asia, and Central and South America and these regions account for 70 percent of the world’s cancer deaths. In low- and middle-income countries, expensive treatments for cancer are not widely available. Unsustainable cancer medication pricing has increasingly become a global issue, creating access challenges in low-and middle-income but also high-income countries. This report describes recent developments within the pricing of medicines for the treatment of cancer, discusses what lessons can be drawn from HIV/AIDS treatment scale-up and makes recommendations to help increase access to treatment for people with cancer.
This paper illustrates unintended consequences of apparently rational allocations to curative and preventive services, using computer modelling. The model exhibits a “spend more get less” equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease leads paradoxically to a higher overall disease burden of unprevented cases of other diseases. The authors suggest that this paradoxical behaviour of the model can be stopped by eliminating lobbying, eliminating fees for curative services and ring-fencing public health funding. The authors have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.
In response to requests for the funding of new drugs, reimbursement agencies are re-evaluating some of the methods used in assessing these products. Many trials submitted for the regulatory review of new drugs do not provide adequate data for subsidy decisions. The authors argue that all involved in bringing medicines to market need to be explicit about the additional information required, decide how these data should be collected and assessed and the methods that should be used to set a fair price for a new drug.
In this study the authors use facility-level data from nationally representative surveys conducted in Ghana, Kenya, and Uganda in 2012 to understand pharmaceutical availability within the three countries. The authors both availability of essential medicines, as defined by the various essential medicine lists (EMLs) of each respective country, and availability of all surveyed pharmaceuticals deemed important for treatment of various high-burden diseases, including those on the EMLs. The authors find that there is heterogeneity with respect to availability across the three countries with Ghana generally having better availability than Uganda and Kenya. They found that the factors associated with stock-out vary by country, but across all countries both presence of a laboratory at the facility and of a vehicle at the facility are significantly associated with reduced stock-out. The study highlights poor availability of essential medicines across these three countries and suggest more needs to be done to strengthen the supply system so that stock remains uninterrupted.
The incidence of cervical cancer in South Africa remains high, and the current screening programme has had limited success. New approaches to prevention and screening tactics are needed to investigate acceptance of school-based human papillomavirus (HPV) vaccination, as well as the information provided, methods of obtaining consent and assent, and completion rates achieved. Information on cervical cancer and HPV vaccination was provided to 19 primary schools in Western Cape and Gauteng provinces participating in the study. Girls with parental consent and child assent were vaccinated during school hours at their schools. A total of 3 465 girls were invited to receive HPV vaccine, of whom 2 046 provided written parental consent as well as child assent. Sufficient vaccination was achieved in 92% of the vaccinated cohort. The implementation project demonstrated that HPV vaccination is practical and safe in SA schools. Political and community acceptance was good, and positive attitudes towards vaccination were encountered. During the study, which mimicked a governmental vaccine roll-out programme, high completion rates were achieved in spite of several challenges encountered.
As part of maternal mortality reducing strategies, coverage of delivery care among sub-Saharan African rural poor will improve, with a range of facilities providing services. Whether high coverage will benefit all socio-economic groups is unknown. Iringa rural District, Southern Tanzania, with high facility delivery coverage, offers a place to address this question. Delivery services are available in first-line facilities (dispensaries, health centres) and one hospital. The authors assessed whether all socio-economic groups access the only comprehensive emergency obstetric care facility equally, and surveyed existing delivery services. Hospital population socio-demographic characteristics were compared to District population using multivariable logistic regression. Women from the hospital compared to the district population were more likely to be wealthier. Poorer women remain disadvantaged even where coverage is high, as they access lower level facilities and are under-represented where life-saving transfusions and caesarean sections are available.
A recent survey carried out by the Center for Health, Human Rights and Development (CEHURD) with support from United Nations Development Program (UNDP) Uganda country office on the prevalence of risk factors for non communicable diseases among university students in and around Kampala found that up to 67% of the respondents did not know what NCDs were, 12% of students have used drugs, particularly Marijuana, 15% were current tobacco smokers, 9% smoked Shisha. More than 40% of the respondents were staying with parents who smoke, 10% have friends who smoke, 60% have smoked for less and 57% exposed to pro-cigarette advertisements. In areas where NCD services are available, these are often hampered by access to essential medicines.
A recent visit by the author to communities of Nyenga and Najja sub-counties of Buikwe district revealed that a huge percentage of the community members find no point in visiting health facilities for early screening for NCDs. The author suggests that government strengthen existing health facilities by providing essential NCD medicines and NCD screening services for at least all health center IVs.
This study presents a new approach to defining high and low motivation groups of contraceptive users by stated intention to use, past use, and unmet need, to determine how these groups differ in characteristics and in region of residence. Data came from 23 DHS surveys in sub-Saharan countries. The low motivation non-users, with less past use and less intention to use in the future, are more rural, less educated, and closer to poverty. When used to guide planning, unmet need should be augmented with motivation, since the two classifications do not entirely overlap. Between 10 and 17 percent of current non-users of family planning are likely highly motivated to use, but are not captured in the unmet need classification. Programme implications for these non-using groups are discussed.