The importance of poor-quality anti-tuberculosis drugs cannot be underestimated, as they may disrupt all major complex interventions to ensure treatment efficacy. Not only treatment failure may ensue, but, more importantly, rapid emergence of acquired drug resistances can also be favoured. The authors raise that a relevant proportion of underqualified medicines could be detected through relatively inexpensive and simple assays at destination countries, based on chromatographic techniques. Such tests are able to identify the type and concentrations of the various components. They note that their execution is not compulsory and only rarely pursued. They describe a vicious cycle where local regulatory authorities fail to implement controls of fraudulent manufacturers being encouraged to enter the market.
Equitable health services
This study described the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto, South Africa. The study instrument was administered to 1102 caregivers. Over half the respondents reported having at least one chronic non-communicable disease (NCD), only a third of whom reported accessing a healthcare service in the last six months. Reported availability of private medical practice and government clinics was high (75% and 62% respectively). The low utilisation of healthcare services by women with NCDs is a concern for health care management.
Inequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi. This study is a before-and-after evaluation of Malawi's Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviours and assess women and newborns for danger signs requiring referral to a facility. Core groups of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviours for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. Although these results indicate promising improvements for newborn health in Malawi, the extent to which the programme contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and monitoring are needed to ensure that the poorest households are reached by community-based health programs.
The authors conducted this review to identify articles published in English from 1995-2011 that reported on original research into facility-based delivery (FBD) conducted entirely or in part in sub-Saharan Africa. Sixty-five studies met inclusion criteria, 62 of which were cross-sectional, and 58 of 65 relied upon household survey data. Fewer than two-thirds (43) included multivariate analyses. The factors associated with facility delivery were categorised as maternal, social, antenatal-related, facility-related, and macro-level factors. Maternal factors were the most commonly studied, probably due to overwhelming reliance on household survey data. Multivariate analysis suggests that maternal education, parity / birth order, rural / urban residence, household wealth / socioeconomic status, distance to the nearest facility, and number of antenatal care visits were the factors most consistently associated with FBD. In conclusion, FBD is a complex issue that is influenced by characteristics of the pregnant woman herself, her immediate social circle, the community in which she lives, the facility that is closest to her, and context of the country in which she lives. More research is needed that explores regional variability, examines longitudinal trends, and studies the impact of interventions to boost rates of facility delivery in sub-Saharan Africa.
Though there is an evidence of increased overall contraceptive prevalence, a substantial effort remains behind in Ethiopia. This study aimed to identify factors associated with modern contraceptive use and to examine its geographical variations among 15–49 married women in Ethiopia. Researchers conducted secondary analysis of 10,204 reproductive age women included in the 2011 Ethiopia Demographic and Health Survey (DHS). Results indicated that being wealthy, more educated, being employed, higher number of living children, being in a monogamous relationship, attending community conversation, being visited by health worker at home strongly predicted use of modern contraception. While living in rural areas, older age, being in polygamous relationship, and witnessing one’s own child’s death were found negatively influence modern contraceptive use. The central and south-western parts of the country had higher prevalence of modern contraceptive use than that of the eastern and western parts. The findings indicate significant socio-economic, urban–rural and regional variation in modern contraceptive use among reproductive age women in Ethiopia. Strengthening community conversation programmes and female education should be given top priority.
Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. According to this paper, brokerage inherent in hospital-to-hospital partnerships can boost relationships between ‘evidence’ and ‘policy’ communities and move developing countries towards evidence-based patient safety policy. In particular, the authors use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. The rapidly expanding field of towards evidence-based patient safety policy calls shared learning across continents, the authors conclude, in keeping with the principles and spirit of health systems development in a globalised world.
In this paper the author argues that antibiotic resistance is now recognized as a major global health security issue that threatens a return to the pre-antibiotic era, with potentially catastrophic economic, social and political ramifications. An extra burden is likely to hit resource-poor countries. Although bacteria naturally adapt to outsmart antibiotics, human actions accelerate the development and spread of resistance. Antibiotics need to be used judiciously, with effective stewardship and infection prevention and control, and a harmonized approach to their use in animal and human health should be fostered. There is also a need for practical economic models to develop new products that avoid rewarding researchers for what they do already. Choosing the right paradigms for sustainably stimulating R&D requires new measures to align the financial incentives for drug and diagnostic test development with public health needs. Incentives for infection control and appropriate stewardship are equally important. Integrated efforts involving academia, policy-makers, industry and interest groups will be required to produce a global political response with strong leadership, based on a coherent set of priorities and actions.
Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefit incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefit distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such differences. The authors investigate how results would differ if geographical inequalities were taken into account for outpatient public health-care expenditure in Manica Province, Mozambique using data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records. The analysis showed that the gap in benefit from public expenditure between highest and lowest quintiles widened substantially if differences in health status and expenditure across districts are taken into account, increasing from a ratio of 1.2 to 2.0. Results suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refinement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems' strengthening, and ultimately provide insights for a more equitable and efficient allocation of resources.
Kenya is characterized by high unmet need for family planning (FP) and high unplanned pregnancy, in a context of urban population explosion and increased urban poverty. It witnessed an improvement of its FP and reproductive health (RH) indicators in the recent past, after a period of stalled progress. The paper describes inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya; examines the extent to which differences in contraceptive use between the poor and the rich widened or shrank over time; and attempts to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor. It uses data from the 1993, 1998, 2003 and 2008/09 Kenya demographic and health survey. The authors found a dramatic change in contraceptive use between 2003 and 2008/09 that resulted in virtually no gap between the poor and the rich in 2008/09, by contrast to the period 1993–1998 during which the improvement in contraceptive use did not significantly benefit the urban poor.
Access to health care is a particular concern given the centrality of poor access in perpetuating poverty and inequality. Even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using new data from the first nationally representative panel survey in South Africa together with administrative geographic data from the Department of Health, the authors investigate the role of distance to the nearest facility on patterns of health care utilization. Ninety percent of South Africans live within 7km of the nearest public clinic, and two-thirds live less than 2km away. However, 15% of Black African adults live more than 5km from the nearest facility, in contrast to only 7% of coloureds and 4% of whites. There is a clear income gradient in proximity to public clinics. The poorest people tend to reside furthest from the nearest clinic and an inability to bear travel costs constrains them to lower quality health care facilities. Within this general picture, men and women have different patterns of health care utilization, with the reduction in utilization of health care associated with distance being larger for men than it is for women.