This paper explores access barriers to effective malaria treatment among the poorest population in four malaria endemic districts in Kenya. The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: a cross-sectional survey of 708 households; 24 focus group discussions; semi-structured interviews with 34 health workers; and 359 patient exit interviews. The paper found that multiple factors related to affordability, acceptability and availability interact to influence access to prompt and effective treatment. Regarding affordability, about 40% of individuals who self-treated using shop-bought drugs and 42% who visited a formal health facility reported not having enough money to pay for treatment and other factors influencing affordability included seasonality of illness and income sources, transport costs, and unofficial payments. Regarding acceptability, the major interrelated factors identified were provider patient relationship, patient expectations, beliefs on illness causation, perceived effectiveness of treatment, distrust in the quality of care and poor adherence to treatment regimes. Availability barriers identified were related to facility opening hours, organisation of health care services, drug and staff shortages.
Equitable health services
In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. In targeted areas, 67.5% of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4 % of all households with CU5s had an ITN. Over half of CU5s (51.7%) slept under an ITN during the previous evening. Nearly 40% of all households received a campaign net, elevating overall household ownership of ITNs to 50.7%. The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.
To date, no study has yet looked at the effect of incentives on the use of insecticide-treated nets (ITNs). This study aims to fill the research gap. It took the form of a cluster randomised controlled trial testing household-level incentives for ITN use following a free ITN distribution campaign in Madagascar. The study took place from July 2007 until February 2008. Twenty-one villages were randomised to either intervention or control clusters. At baseline, 8.5% of households owned an ITN and 6% were observed to have a net mounted over a bed in the household. At one month, there were no differences in ownership between the intervention and control groups, but net use was substantially higher in the intervention group (99% vs. 78%). After six months, net ownership had decreased in the intervention compared to the control group (96.7% vs. 99.7%). There was no difference between the groups in terms of ITN use at six months; however, intervention households were more likely to use a net that they owned (96% vs. 90%). The study concludes that providing incentives for behaviour change is a promising tool that can complement traditional ITN distribution programmes and improve the effectiveness of ITN programmes in protecting vulnerable populations, especially in the short-term.
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.
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.