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.
Equitable health services
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.
This article provides a multi-level analysis of gender-related gaps in outbreak responses and illustrates the national and local impacts of failures to challenge gender assumptions and incorporate gender as a priority. The implications of neglecting gender dynamics, as well as the potential of equity-based approaches to disease outbreak responses, is illustrated through a case study of the Social Enterprise Network for Development (SEND) Sierra Leone, a non-government organisation (NGO) based in Kailahun, during the Ebola outbreak. Global policy responses can learn from examples such as SEND Sierra Leone. SEND did not include a gendered approach in its response as an afterthought; it was at the heart of the response because SEND had an established gender strategy. The authors argue that all levels of outbreak response need specific policies to ensure sexual and reproductive health.
In August 2018, the Uganda Ministry of Health activated the Public Health Emergency Operations Centre and the National Task Force for public health emergencies to plan, guide, and coordinate Ebola Virus Disease (EVD) preparedness in the country. The National Task Force selected an Incident Management Team, constituting a National Rapid Response Team that supported activation of the District Task Forces and District Rapid Response Teams that jointly assessed levels of preparedness in 30 designated high-risk districts. The Ministry of Health, with technical guidance from the World Health Organisation, led EVD preparedness activities and worked together with other ministries and partner organisations to enhance community-based surveillance systems, develop and disseminate risk communication messages, engage communities, reinforce EVD screening and infection prevention measures at points of entry and in high-risk health facilities, construct and equip EVD isolation and treatment units, and establish coordination and procurement mechanisms. As of 31 May 2019, there was no confirmed case of EVD as Uganda has continued to make significant and verifiable progress in EVD preparedness. The authors observe the need to sustain these efforts as a multi-hazard framework to avail resources for preparedness and management of incidents at the source, effectively cutting costs of using a “fire-fighting” approach during public health emergencies.
This study assessed the feasibility and impact of decentralised care for non-communicable diseases (NCDs) within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings. In collaboration with the Eswatini Ministry of Health, the authors developed and implemented a package of interventions to support nurse-led delivery of care, including clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. One thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean blood pressure among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic, and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l. Key components of non-communicable disease care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines. The findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.