Ebola has taken a dreadful toll in the three West African countries hit by the current outbreak – Guinea, Sierra Leone and Liberia. In this report, Save the Children documents the existing weaknesses of the health services in the three main countries affected by Ebola. There is broad agreement that the Ebola crisis was not quickly contained, reversed or mitigated because national health systems in these countries were dangerously under-resourced, under-staffed and poorly equipped. The virus was able to spread, in part, due to the poor state of these health services, which were quickly overwhelmed and lacked the ability to cope with a major disease outbreak. This inability to cope with a major health emergency reflects a similar inability to cope with the daily health needs of their populations over the longer term. The authors argue that one of the most important lessons from the Ebola crisis is the need to build comprehensive health services with sufficient funding, staff and equipment, to deal with everyday problems as well as infectious
disease outbreaks.
Equitable health services
There is limited understanding of why routine immunisation (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, the authors conducted in-depth case studies to understand pathways to coverage improvement by comparing immunisation programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques the authors compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunisation services and drivers of coverage improvement. The results informed a model for immunisation coverage improvement that emphasises the dynamics of immunisation systems at district level. In all districts, whether improving or steady, the authors found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. They found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness and identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasise the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunisation system performance.
Kenya is gearing up for digital bidding on essential medicines’ contracts, part of a wave of African countries looking at procurement to improve transparency, bring down costs and support universal health coverage. John Kabuchi, procurement manager for the Kenya Medical Supplies Authority, notes: “We are currently gearing up for full e-procurement functionality, including electronic bidding, and I am hopeful that supporting legislation will be passed before next June.” Kenya hopes to make the most of new technologies and approaches, such as e-procurement, to support efforts to make essential health care more widely available.
This study examined the factors that influence the use of maternal healthcare services and childhood immunization in Swaziland. The study used secondary data from the Swaziland Demographic and Health Survey 2006–07 using univariate, bivariate and multivariate analysis. The study findings showed a high use rate of antenatal care and delivery care and a low rate of postnatal care use. The uptake of childhood immunization is high, averaging more than 80%. Factors found to be influencing the use of maternal healthcare and childhood immunization included: woman’s age, parity, media exposure, maternal education, wealth quintile, and residence. Programs to educate families about the importance of maternal and child healthcare services should be implemented and should focus on: (a) age differentials in use of maternal and child health services, (b) women with higher parities, (c) women in rural areas, and (d) women from the poor quintiles.
Despite the recent innovations in tuberculosis (TB) and multi-drug resistant TB (MDR-TB) diagnosis, culture remains vital for difficult-to-diagnose patients, baseline and end-point determination for novel vaccines and drug trials. The authors share their experience of establishing a BSL-3 culture facility in Uganda as well as 3-years performance indicators and post-TB vaccine trials (pioneer) and funding experience of sustaining such a facility. Between September 2008 and April 2009, the laboratory was set-up with financial support from external partners. After an initial procedure validation phase in parallel with the National TB Reference Laboratory and legal approvals, the laboratory registered for external quality assessment and instituted a functional quality management system. Pioneer funding ended in 2012 and the laboratory remained self-sustainable with internationally acceptable standards in both structural and biosafety requirements. With the demonstrated quality of work, the laboratory attracted more research groups and post-pioneer funding, which helped to ensure sustainability. The high skilled experts in this research laboratory provide an excellent resource for national discussion of laboratory and quality management systems.
In 2007, the World Health Organization (WHO) launched the ‘make medicines child size’ (MMCS) campaign by urging countries to prioritize procurement of medicines with appropriate strengths for children’s age and weight and, in child-friendly formulations of rectal and flexible oral solid formulations. This study examined policy provisions for MMCS recommendations in Uganda. This was an in-depth case study of the Ugandan health policy documents to assess provisions for MMCS recommendations in respect to oral and rectal medicine formulations for malaria, pneumonia and diarrhea, the major causes of morbidity and mortality among children in Uganda- diseases that were also emphasized in the MMCS campaign. Asthma and epilepsy were included as conditions that require long term care. Schistomiasis was included as a neglected tropical disease. Content analysis was used to assess evidence of policy provisions for the MMCS recommendations. For most medicines for the selected diseases, appropriate strength for children’s age and weight was addressed. However, policy documents neither referred to ‘child size medicines’ concept nor provided for flexible oral solid dosage formulations like dispersible tablets, pellets and granules- indicating limited adherence to MMCS recommendations. Some of the medicines recommended in the clinical guidelines as first line treatment for malaria and pneumonia among children were not evidence-based. The Ugandan health policy documents reflected limited adherence to the MMCS recommendations. This and failure to use evidence based medicines may result into treatment failure and or death. A revision of the current policies and guidelines to better reflect ‘child size’, child appropriate and evidence based medicines for children is recommended.
Despite being central to achieving improved population health outcomes, primary health centres in low- and middle-income settings continue to underperform. Little research exists to adequately explain how and why this is the case. This study aimed to test the relevance and usefulness of an adapted conceptual framework for improving understanding of the mechanisms and causal pathways influencing primary health centre performance. A theory-driven, case-study approach was adopted. Four Zambian health centres were purposefully selected with case data including health-care worker, patient and key informant interviews; direct observation of facility operations. Structural constraints included limited resources creating challenging service environments in which work overload and stockouts were common. Health workers’ frustration with such conditions interacted with dissatisfaction with salary levels eroding service values and acting as a catalyst for different forms of absenteeism. Such behaviours exacerbated patient–provider ratios and increased the frequency of clinical and administrative shortcuts. Weak health information systems and lack of performance data undermined providers’ answerability to their employer and clients, and a lack of effective sanctions undermined supervisors’ ability to hold providers accountable for these transgressions. Weak answerability and enforceability contributed to a culture of impunity that masked and condoned weak service performance in all four sites.
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.
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.