The objective of this paper was to compare three methods for evaluating treatment adherence in a seven-day controlled treatment period for malaria in children in Rwanda. Fifty-six children younger than five years old with malaria were recruited at the University Hospital of Butare, Rwanda. Three methods to evaluate medication adherence among patients were compared: manual pill count of returned tablets, patient self-report and electronic pill-box monitoring. Medication adherence data were available for 54 of the 56 patients. Manual pill count and patient self-report yielded a medication adherence of 100% for the in- and out-patient treatment periods. Based on electronic pill-box monitoring, medication adherence during the seven-day treatment period was 90.5%. Based on electronic pill-box monitoring inpatient medication adherence (99.3%) was markedly higher than out-patient adherence (82.7%), showing a clear difference between health workers' and consumers' medication adherence. In conclusion, health workers' medication adherence was good. However, a significant lower medication adherence was observed for consumers' adherence in the outpatient setting. This was only detected by electronic pill-box monitoring. Therefore, this latter method is more accurate than the two other methods used in this study.
Equitable health services
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 people aged 15–30 years who had attended trial schools on sexual education during the first phase of the MEMA kwa Vijana sexual health intervention trial (1999–2002). Prevalences of the primary outcomes HIV and herpes simplex 2 (HSV-2) were 1.8% and 25.9% in males and 4% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV or HSV-2 but was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime and an increase in reported condom use at last sex with a non-regular partner among females. There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study concluded that knowledge of sexual and reproductive health can be improved and retained long-term, but this intervention had only a limited effect on sexual behaviour. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
The aim of this paper is to reconsider established practices and policies for HIV and tuberculosis epidemic control, aiming at delivering better results and value for money. This may be achieved by promoting greater integration of HIV and tuberculosis control programme activities within a strengthened health system. The current health system approach to HIV and tuberculosis control often involves separate specialised services. Despite some recent progress, collaboration between the programmes remains inadequate, progress in obtaining synergies has been slow, and results remain far below those needed to achieve universal access to key interventions. A fundamental re-think of the current strategic approach involves promoting integrated delivery of HIV and tuberculosis programme activities as part of strengthened general health services: epidemiological surveillance, programme monitoring and evaluation, community awareness of health-seeking behavior, risk behaviour modification, infection control, treatment scale-up (first-line treatment regimens), drug-resistance surveillance, containing and countering drug-resistance (second-line treatment regimens), research and development, global advocacy and global partnership. Health agencies should review policies and progress in HIV and tuberculosis epidemic control, learn mutual lessons for policy development and scaling up interventions, and identify ways of joint planning and joint funding of integrated delivery as part of strengthened health systems.
This research, set in public primary care services in Cape Town, South Africa, set out to determine how middle level managers could be empowered to monitor the implementation of an effective, integrated HIV/TB/STI service. A team of managers and researchers designed an evaluation tool to measure implementation of key components of an integrated HIV/TB/STI package with a focus on integration. The tool was extensively piloted in two rounds involving 49 clinics in 2003 and 2004 to identify data necessary for effective facility-level management. A subsequent evaluation of 16 clinics (2 per health sub district, 12% of all public primary care facilities) was done in February 2006. While the physical infrastructure and staff were available, there was problem with capacity in that there was insufficient staff training (for example, only 40% of clinical staff trained in HIV care). Weaknesses were identified in quality of care (for example, only 57% of HIV clients were staged in accordance with protocols) and continuity of care (for example, only 24% of VCT clients diagnosed with HIV were followed up for medical assessment). Facility and programme managers felt that the evaluation tool generated information that was useful to manage the programmes at facility and district level. On the basis of the results facility managers drew up action plans to address three areas of weakness within their own facility.
This book discusses a range of case studies in trauma care, including pre-hospital, hospital-based, rehabilitation and system-wide settings, from all regions of the world and at all socioeconomic levels. It aims to share some of the valuable lessons learned and focuses on practical, affordable and sustainable efforts to improve trauma care, identifying useful methods and strategies that could be adapted for use in other places. It also seeks to dispel the view that little can be done to improve trauma care in low- and middle-income countries. Improvements in care may be measured using outcomes data on decreased mortality or other tangible patient benefits, such as decreased morbidity, improved functional outcome or decreased costs. Performance may also be measured in terms of how much time is devoted to emergency procedures, appropriate use of particular life-saving procedures and greater availability of the human and physical resources needed to provide quality care. The book calls for improvements in training, supervision and monitoring of staff, increased political commitment and timely and accurate data to better inform policy decisions.
Although progress has been made in strengthening laboratory capacity to support programmes such as poliomyelitis eradication, HIV prevention and control, and measles elimination, this study notes that challenges remain. These include the lack of national policy and strategy for laboratory services, insufficient funding, inadequately trained laboratory staff, weak laboratory infrastructure, old or inadequately serviced equipment, lack of essential reagents and consumables, and limited quality assurance and control protocols. Laboratories are usually given low priority and recognition in most national health delivery systems. The study identifies the main challenge as the need to develop a comprehensive national laboratory policy that addresses the above issues. Other recommendations include improving laboratory leadership, strengthening the laboratory supply and distribution system, improving monitoring, providing adequate training for staff, strengthening information systems and putting in place effective monitoring and evaluation systems.
According to this report, 4.4 million children and 265,000 mothers die in sub-Saharan Africa every year, which amounts to half of the world's maternal, newborn and child deaths. It identifies the five biggest challenges for maternal, newborn and child health in sub-Saharan Africa as pregnancy and childbirth complications, newborn illness, childhood infections, malnutrition, and HIV and AIDS. Many scientifically proven health interventions are available for maternal, newborn, and child health such as medicines, immunisations, insecticide-treated bed nets, and equipment for emergency obstetric care. Yet many African governments are currently underutilising existing scientific knowledge to save women's and children's lives. The report recommends a scientific approach based on local epidemiological and coverage data that will prioritise the highest impact and most appropriate interventions in a given context. Although most countries in sub-Saharan Africa are behind in achieving the Millennium Development Goals (MDGs) for maternal and child health by 2015, progress in several low-income countries demonstrates that the MDGs could still be attained through immediate strategic investments in selected evidence-based interventions and targeted health systems strengthening.
A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five are evaluated in this study, four to nine months after implementation. Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. The overall proportion of children under five sleeping under any type of treated net was 83.7% in MI and 91.8% in NA. The LLIN usage was 56.8% in MI and 86.9% in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was because caretakers had received a LLIN or considered LLINs to be better than conventional nets. In conclusion, targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.
The Algiers Declaration on Narrowing the Knowledge Gap to Improve Africa’s Health was adopted during a Conference held in Algiers, Algeria, in June 2008. The Conference, which brought Ministers from the African Region together with researchers, non-governmental organisations, donors and the private sector, renewed commitments to narrow the knowledge gap in order to improve health development and health equity in the Region. This paper describes the background to the Algiers Declaration and the Framework for its implementation and their significance in assisting efforts by countries in the Region to strengthen their health systems. The paper argues that countries should implement the series of steps in the Algiers Framework to strengthen their health systems. These steps will help them to develop the content, processes and use of technology aimed at improving: the availability of relevant and timely health information; the management of health information through better analysis and interpretation of data; the availability of relevant, ethical and timely research evidence; the use of evidence by policy-makers and decision-makers; improving dissemination and sharing of information, evidence and knowledge; access to global health information; and the use of information and communication technologies.
In this study, limited autopsies were conducted on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis. A representative sample was taken of 240 adult inpatients (aged 20–45 years) who died after admission to Edendale Hospital. Ninety-four% of the study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were multidrug resistant and 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli. The findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal, as well as suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection for many of the individuals. The study also revealed a significant burden of undetected multidrug-resistant tuberculosis among HIV-co-infected individuals dying in this setting. It recommends new public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment.