The first-ever ministerial conference on immunization in Africa was held in February in Addis Ababa. According to the author it presents the perfect opportunity to acknowledge the benefits of vaccine programs, celebrate the successes on the continent, look seriously at what needs to be done to make sure all children get the vaccines they need, and then commit to making that happen. A new study from the Johns Hopkins Bloomberg School of Public Health estimates that between 2011 and 2020, the majority of countries in Africa will collectively see a net economic benefit of $224 billion by investing in immunization programs. The study also found that, in 94 low- and middle-income countries around the world, for every dollar invested in vaccines during the decade, there will be an estimated return of 16 times the costs, taking into account treatment costs and productivity losses. Unfortunately, at the current rate of progress, we are not on track to meet the ultimate goal of reaching all children with vaccines. Right now, one in five African children still do not receive the vaccinations they need. Of the 10 countries around the world with the most unvaccinated children, five are African: the Democratic Republic of the Congo, Ethiopia, Nigeria, South Africa and Uganda.
Equitable health services
As the Ebola outbreak in West Africa wanes, the author argues that it is time for the international scientific community to reflect on how to improve the detection of and coordinated response to future epidemics. The interdisciplinary author team identified key lessons learned from the Ebola outbreak that can be clustered into three areas: environmental conditions related to early warning systems, host characteristics related to public health, and agent issues that can be addressed through the laboratory sciences. In particular, they argue there is a need to increase zoonotic surveillance activities, implement more effective ecological health interventions, expand prediction modeling, support medical and public health systems in order to improve local and international responses to epidemics, improve risk communication, better understand the role of social media in outbreak awareness and response, produce better diagnostic tools, create better therapeutic medications, and design better vaccines. This list highlights research priorities and policy actions the global community can take now to be better prepared for future emerging infectious disease outbreaks that threaten global public health and security.
The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.
South African health authorities say the visitor diagnosed with the mosquito-spread Zika virus has recovered and there is minimal likelihood of a local outbreak. The visiting Colombian businessperson who was diagnosed with the Zika virus in South Africa last week is “completely well” and “poses no risk to anybody”, says Lucille Blumberg, the deputy director of the National Institute for Communicable Diseases. Blumberg says the man presented with a mild illness four days after his arrival in the country. After he underwent a number of tests, “Zika was confirmed as the cause of his illness”. Blumberg further confirmed, “We’re not going to have local transmissions because of one incoming traveller with Zika. You’ll need multiple people with the virus in their blood and many mosquitoes around with the competent vectors to set off a local outbreak.”
Medicine availability is improving in sub-Saharan Africa for palliative care services. There is a need to develop strong and sustainable pharmaceutical systems to enhance the proper management of palliative care medicines, some of which are controlled. One approach to addressing these needs is the use of mobile technology to support data capture, storage and retrieval. Utilizing mobile technology in healthcare (mHealth) has recently been highlighted as an approach to enhancing palliative care services but development is at an early stage. An electronic application was implemented as part of palliative care services at two settings in Uganda; a rural hospital and an urban hospice. Measures of the completeness of data capture, time efficiency of activities and medicines stock and waste management were taken pre- and post-implementation to identify changes to practice arising from the introduction of the application. Improvements in all measures were identified at both sites. The application supported the registration and management of 455 patients and a total of 565 consultations. Improvements in both time efficiency and medicines management were noted. Time taken to collect and report pharmaceuticals data was reduced from 7 days to 30 min and 10 days to 1 h at the urban hospice and rural hospital respectively. Stock expiration reduced from 3 to 0.5 % at the urban hospice and from 58 to 0 % at the rural hospital. Additional observations relating to the use of the application across the two sites are reported. A mHealth approach adopted in this study was shown to improve existing processes for patient record management, pharmacy forecasting and supply planning, procurement, and distribution of essential health commodities for palliative care services. An important next step will be to identify where and how such mHealth approaches can be implemented more widely to improve pharmaceutical systems for palliative care services in resource limited settings.
African Ministers of Health, Finance, Education, Social Affairs, Local Governments attended the Ministerial Conference on Immunization in Africa in February 2016 in Addis Ababa, Ethiopia, convened by the World Health Organization in collaboration with the African Union Commission. The ministers collectively and individually commited themselves to keeping universal access to immunisation at the forefront of efforts to reduce child mortality, morbidity and disability; to increasing and sustaining domestic investments and funding, including innovative financing, to meet the cost of traditional vaccines and fulfil new vaccine financing requirements, and to support EPI programs. They sought to address persistent barriers in vaccine and healthcare delivery systems, especially in the poorest, vulnerable and most marginalized communities, including through strengthening data collection, reporting and use and building effective and efficient supply chains and integrated procurement systems as part of strong and sustainable primary health care systems. The agreed to develop a capacitated African research sector and to work with communities, civil society organizations, traditional and religious leaders, health professional associations and parliamentarians to promote universal access to vaccines, and to invest in regional capacities for the development and production of vaccines in line with the African Union Pharmaceutical Manufacturing Plan. They called on African development banks and regional economic communities to support the implementation of the Declaration, and on member states and partners to negotiate with vaccine manufacturers to facilitate access to vaccines at affordable prices and to increase price transparency in line with resolution WHA68.6. They called on GAVI to consider refugees and internally displaced populations as eligible recipients of support for vaccines and operational costs.
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.
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.