Breast and cervical cancer are major threats to the health of women globally, particularly in low-income and middle-income countries. Radical progress to close the global cancer divide for women requires not only evidence-based policy making, but also broad multisectoral collaboration that capitalises on recent progress in the associated domains of women’s health and innovative public health approaches to cancer care and control. Such multisectoral collaboration can serve to build health systems for cancer, and more broadly for primary care, surgery, and pathology. This Series paper explores the global health and public policy landscapes that intersect with women’s health and global cancer control, with new approaches to bringing policy to action. .
Equitable health services
The tools presented in this publication assess mother and child health (RMNCH) change over time and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, results are presented from Tanzania and Peru. The Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. All lifesaving RMNCH commodities were included on their essential medicines lists, but the health worker density (7.1/10,000 population), is below the 22.8 WHO minimum threshold.
Director General of the World Health Organisation, Dr Margaret Chan, addressed the Tokyo International Conference of Africa's Development (TICAD) held in Nairobi, Kenya, in August 2016. She raised the issue of Ebola as an example of the consequences of failing to invest in the community and resilient health systems. Dr Chan noted that well-functioning health systems that cover entire populations are now regarded as the first line of defence against the threat from emerging and re-emerging diseases. Apart from strengthened health security, Africa has much to gain from its commitment to universal health coverage (UHC). For decades, the biggest barriers to better health in Africa have been weak health systems and inadequate human and financial resources. A commitment to UHC means a commitment to address these barriers. UHC also addresses a third barrier to progress of dire poverty, including poverty caused by catastrophic spending on health care. A commitment to UHC, backed by country-specific plans for implementation gives African countries a huge opportunity to leap ahead. Dr Chan offered three pieces of advice. First, to understand that UHC is a direction for a journey, not a destination. Second, use the power of robust data to shape equitable policies in line with national contexts. For example, Kenya used the results from a survey of public expenditure to launch its innovative Health Sector Services Fund that provides direct cash transfers to primary health care facilities. Third, if UHC is to work as both a poverty-reduction strategy and a boost to health security, countries need to ensure that reforms reach health systems at the district level that support impoverished communities, and are best placed to engage them in health promotion, prevention, and the delivery of services that match perceived needs.
In Tanzania, the prevention of mother to child transmission of HIV (PMTCT) is a health sector priority, but there is very little information on how well gender mainstreamed in relation to national PMTCT guidelines. In this paper the authors research assessed the gender content of key policy documents in order to better understand how this area could be strengthened, using a WHO Gender Responsive Assessment Scale (GRAS). The GRAS divides gender responsiveness into 5 levels. Level 1, gender unequal, contains content which perpetuates gender inequality by reinforcing unbalanced norms, roles and relations. Level 2, gender blind, contains content which ignores gender norms, roles and relations and differences in opportunities and resource allocation for women and men. Level 3, gender sensitive, contains content which indicates awareness of the impact of gender norms, roles, and relations, but no remedial actions are developed. Level 4, gender specific, contains content which goes beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. Level 5, gender transformative, contains content which includes ways to transform harmful gender norms, roles and relations. The findings showed that gender-related issues are mentioned in all of the guidelines, indicating some degree of gender responsiveness. The level of gender responsiveness of PMTCT policy documents, however, varies, with some graded at GRAS level 3 (gender sensitive), and others at GRAS level 4 (gender specific). None of the reviewed policy documents could be graded as gender transformative. While the policy documents indicate recognition of gender inequality in decision-making and access to resources as a barrier to accessing PMTCT services by women, no attempt is made to transform harmful gender norms, roles, or relations. Overall, gender was not mainstreamed into any of the documents in the sense that gender was not considered in all key sections. Overall, the study revealed limited integration of gender concerns (less or lack of attention on the disadvantageous position of women in terms of inequality in ownership of resources, power imbalance in decision making, asymmetrical division of roles, and masculine norms that distance men from maternal and child care) in PMTCT guidelines. The authors suggest that revision of guidelines to mainstream gender is greatly needed if PMTCT services are to effectively contribute towards a reduction of child and maternal morbidity and mortality in Tanzania
The South African parliament’s social services select committee has welcomed the investigation into the death of 36 psychiatric patients in Gauteng. This comes after Gauteng Health MEC Qedani Mahlangu revealed during an oral reply to questions in the legislature that 36 psychiatric patients, who had been transferred from Life Healthcare Esidimeni, had died while in the care of NGOs. The psychiatric patients were relocated to 122 NGOs after the department cancelled its contract with Life Healthcare, which looked after almost 2 000 patients. Health Minister Aaron Motsoaledi has called for the Office of the Health Ombudsman to investigate the allegations. The committee conveyed its condolences to the families of the patients. "While the Committee is cognisant of the need to find alternative measures to care for patients, these measures should have been made with the clear understanding and guarantees that the care of patients will not deteriorate. Every decision that is made must have as its central pillar the delivery of quality care for our people," committee chairperson Cathy Dlamini said in a statement. The committee called for the investigation to be sped up, in order to avoid further loss of life. They would engage with the health department at national and provincial levels to ensure quality care of all patients, the committee said.
Malawi has been the only country in Sub-Saharan Africa to provide universal free health services throughout its public health system and never charge user fees – with the exception of some recent worrying user fee experiments. Conversely in Nigeria, which only spends 0.9% of its GDP in the form of public health financing and where user fees are charged at all levels, private out-of-pocket health financing accounts for 72% of total health expenditure – one of the highest rates in the world. Perhaps the most stark illustration of the difference in performance between these two countries at the opposite ends of this curve, is that whereas Nigeria is 8 times richer than Malawi, Nigeria’s child mortality rate (109 deaths per 1000 live births) is 70% higher than Malawi ’s (64 deaths). In reviewing these records, the obvious policy recommendation for Nigeria is that it too should increase its public health spending and abolish user fees in its public health system. And for Malawi, the authors argue that the lesson should be to build on this success and use further increases in public financing to improve the availability and quality of free services.
Cardiovascular diseases are the leading cause of death globally, killing 17.5 million people per year and 80% of deaths from these diseases occur in low- and middle-income countries. Evidence suggests that the main drivers of the global cardiovascular disease epidemic are urbanisation and industrialisation, which lead to an increase in sedentary lifestyles, unhealthy dietary patterns, tobacco consumption and increased alcohol consumption. Hypertension is a leading risk factor for cardiovascular diseases, and its prevalence is increasing worldwide – from 25% in 2000 to a projected 40% in 2025. The rising burden of hypertension in low- and middle-income countries is amplified by the public’s low levels of awareness, treatment and control of this condition, particularly among slum residents, who typically constitute a large portion of neglected urban populations in such settings. Studies in slum populations suggest that when people are made aware of having hypertension they do tend to seek care. However, the level of adherence to treatment for hypertension remains low for several reasons, including, but not limited to, the high costs of treatment and to patients’ perceptions of a low risk of cardiovascular diseases and belief in a one-time cure for disease rather than to lifelong preventive treatment and monitoring. In response to the rising burden of cardiovascular disease risk factors in slum populations in Kenya, a community-based intervention was developed and implemented in the capital city, Nairobi. This intervention, known as SCALE UP (the sustainable model for cardiovascular health by adjusting lifestyle and treatment with economic perspective in settings of urban poverty), has been described in detail elsewhere. The intervention had multiple components with the overall aim of reducing cardiovascular diseases risk through awareness campaigns, improvements in access to screening and standardised clinical management of hypertension. This paper shares experiences of implementing a comprehensive intervention for primary prevention of hypertension in a slum setting and to examine the processes, outcomes and costs of the intervention. It raises lessons for policy-makers and other stakeholders looking to implement similar interventions in highly resource-constrained settings.
Sub-Saharan Africa (SSA) communities suffer a disease burden that is aggravated by shortage of medical personnel and medical supplies such as medical devices. This paper outlines how for a long time, observation and practical experiences meant that people learned to use different plant species that led to the emergence of traditional medicine (TM) systems. The ancient Pharaonic Egyptian TM system is for example, said to be one of the oldest documented forms of TM practice in Africa and a pioneer of world’s medical science. These medical practices diffused to other continents and were accelerated by advancement of technologies while leaving Africa lagging behind in the integration of the practice in formal health-care system. The author raises issues that drag back integration, such as the lack of development of education curricula for training TM experts as the way of disseminating the traditional medical knowledge and practices. A few African countries such as Ghana have managed to integrate TM products in the National Essential Medicine List while South Africa, Sierra Leone, and Tanzania have TM products being sold over the counters due to the availability of education training programs. This paper analyses the contribution of TM practice and products in modern medicine and gives recommendations that Africa should take in the integration process to safeguard the SSA population from disease burdens.
Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). In this study, the authors explored the distributions in the utilisation MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH as key for health equity, using Demographic and Health Surveys data of 12 countries in SSA. Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilisation in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunisation’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunisation’ (0.15) were positively associated and statistically significant. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunisation’ (−0.02) was negatively associated and significant. In conclusion, utilisation of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunisation. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunisation program could serve towards improving maternal and infant health outcomes and equity.
The needs of caregivers of children with disability may not be recognized despite evidence to suggest that they experience increased strain because of their care-giving role. This strain may be exacerbated if they live in under-resourced areas. The authors set out to establish the well-being of caregivers of children with Cerebral Palsy (CP) living in high-density areas of Harare, Zimbabwe. In addition, the authors wished to identify factors that might be predictive of caregivers’ well-being. Finally, they examined the psychometric properties of the Caregiver Strain Index (CSI) within the context of the study. Caregivers of 46 children with CP were assessed twice, at baseline, and after three months, for perceived burden of care and health-related quality of life. The psychometric properties of the CSI were assessed post hoc. The caregivers reported considerable caregiver burden with half of the caregivers reporting CSI scores in the ‘clinical distress’ range. Many of the caregivers experienced some form of pain, depression and expressed that they were overwhelmed by the care-giving role. No variable was found to be associated with clinical distress. The authors propose that caregivers be monitored routinely for their level of distress and that there is an urgent need to provide them with support. The CSI is likely to be a valid measure of distress in this population.