The authors investigated an anthrax outbreak in Makoni District, Zimbabwe, and assessed the environment, district preparedness and response, and outbreak prevention and control measures. They found that most of the cases were managed according to the national guidelines. Multivariable analysis demonstrated that meat sourced from other villages, skinning, and belonging to religions that permit eating meat from cattle killed due to unknown causes or butchered after unobserved death were associated with contracting anthrax. The poor availability of resources in the district caused a delayed response to the outbreak. Although the outbreak was eventually controlled through cattle vaccination and health education and awareness campaigns, the authors report that the response of the district office was initially delayed and insufficient. They call for strengthened emergency preparedness and response capacity at district level, for revival of zoonotic committees, awareness campaigns and improved surveillance, especially during outbreak seasons.
Equitable health services
In December, the IWG hosted an event with health professionals with experience in different fields to better understand leadership in health systems, and consolidated the reflections from the discussions. The discussion raised several key features, including: Investing in gender, racial, and geographic equity among global health leaders and health activists; improving teamwork and multidisciplinary collaborations between individuals and communities of diverse skills, capabilities and backgrounds; networking across health leaders and communities and promoting local ownership and leadership. The session also pointed to the importance for the success of public health interventions and initiatives that those affected and implementing them be at the centre of the design and interactions.
This study assessed the preparedness of the health care facilities for the Ebola (EVD) outbreak response in Kasese and Rubirizi districts in western Uganda. It involved interviews with 189 health care workers and visits to 22 health facilities. Twelve out of the 22 of the health facilities did not have a line budget to respond to EVD and the majority of the facilities did not have case definition books, rapid response teams and/or committees, burial teams, and simulation drills. There were no personal protective equipment that could be used within 8 h in case of an EVD outbreak in fourteen of the 22 health facilities. All facilities did not have viral haemorrhagic fever incident management centers, isolation units, guidelines for burial, and one-meter distance between a health care worker and a patient during triage. The authors recommend proactively tracking the level of preparedness to inform strategies for building capacity of health centers in terms of infrastructure, logistics and improving knowledge of health care workers.
With much of the world’s population still lacking access to basic health services, evidence shows that community-based interventions are effective for improving health-care utilization and outcomes when integrated with facility-based services. Community involvement is the cornerstone of local, equitable and integrated primary health care (PHC). Policies and actions to improve PHC must regard community members as more than passive recipients of health care. Instead, they should be leaders with a substantive role in planning, decision-making, implementation and evaluation. Metrics used for evaluating PHC and Universal health coverage largely focus on clinical health outcomes and the inputs and activities for achieving them. Little attention is paid to indicators of equitable coverage or measures of overall well-being, ownership, control or priority-setting, or to the extent to which communities have agency. In the future, communities must become more involved in evaluating the success of efforts to expand PHC.
Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The authors outline how the COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. The lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. They argue for a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. The authors propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.
In this paper, the primary health-care (PHC) systems in 20 low- and middle-income countries were analysed using a semi-grounded approach. Options for strengthening PHC were identified by thematic content analysis. The authors found that despite the growing burden of non-communicable disease, many low- and middle-income countries lacked funds for preventive services; community health workers were often under-resourced, poorly supported and lacked training; out-of-pocket expenditure exceeded 40% of total health expenditure in half the countries studied, which affected equity; and health insurance schemes were hampered by the fragmentation of public and private systems, underfunding, corruption and poor engagement of informal workers. In 14 countries, the private sector was largely unregulated. Moreover, community engagement in PHC was weak in countries where services were largely privatized. In some countries, decentralization led to the fragmentation of PHC. Performance improved when financial incentives were linked to regulation and quality improvement, and community involvement was strong. The authors argue for policy-making to be supported by adequate resources for PHC implementation and that government spending on PHC should be increased by at least 1% of gross domestic product. Devising equity-enhancing financing schemes and improving the accountability of PHC management is also said to be needed.
COVID-19 has exposed the wide gaps in South Africa’s formal social safety net, with the country’s high levels of inequality, unemployment and poor public infrastructure combining to produce devastating consequences for a vast majority in the country living through lockdown. In Cape Town, a movement of self- organising, neighbourhood-level community action networks (CANs) has contributed significantly to the community- based response to COVID-19 and the ensuing epidemiological and social challenges it has wrought. This article describes and explains the organising principles that inform this community response, with the view to reflect on the possibilities and limits of such movements as they interface with the state and its top-down ways of working, often producing contradictions and complexities. This presents an opportunity for recognising and understanding the power of informal networks and collective action in community health systems in times of unprecedented crisis, and brings into focus the importance of finding ways to engage with the state and its formal health system response that do not jeopardise this potential.
The authors investigated whether sub-Saharan African countries have succeeded in reducing wealth-related inequalities in the coverage of reproductive, maternal, newborn and child health interventions, using post 1995 survey data from 36 countries, grouped into Central, East, Southern and West Africa subregions. Wealth-related inequalities were prevalent in all subregions, highest for West Africa and lowest for Southern Africa. Absolute income was not a predictor of coverage, as higher coverage was observed in Southern (around 70%) compared with Central and West (around 40%) subregions for the same income. Wealth-related inequalities in coverage were reduced by the greatest amount in Southern Africa, and no evidence was found of inequality reduction in Central Africa. The data show that most countries in sub-Saharan Africa have succeeded in reducing wealth-related inequalities in the coverage of essential health services, even in the presence of conflict, economic hardship or political instability
This review describes, from a systematic review, the current status of family medicine in sub-Saharan Africa and maps existing evidence of its strengths, weaknesses, effectiveness and impact, and identifies knowledge gaps. Family medicine was first established in South Africa and Nigeria, followed by Ghana, several East African countries and more recently additional Southern African countries. Implementation varies between and within countries. The strengths were found to be having “all- round specialists”, providing mentorship and supervision, and there were positive perceptions of the impact of family medicine. Family medicine was found to be a developing discipline in sub-Saharan Africa. The authors indicate that assessing its impact on the health of populations requires a more critical mass of family physicians and clarity on their position in the health system and their role in universal health coverage.
This paper explored barriers to care seeking in public health facilities in Kenya among Somali women after complications related to female genital mutilation/cutting (FGM/C). The authors used interviews and focus group discussions to collect data from women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Barriers to care-seeking included the high cost of care, distance from health facilities, lack of a referral system and concerns on quality and privacy of care. Women faced cultural taboos in discussing sexual health with male clinicians, while fear of legal sanctions given the anti-FGM/C laws deterred women with complications from seeking healthcare. The authors suggest that the health system consider integrating FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care, address health-related financial, physical and communication barriers, and ensure culturally-sensitive and confidential care.