Equitable health services

Chile and Costa Rica: Different Roads to Universal Health in Latin America
Hernández LO, Salgado DP: MSP Occasional Paper May 2014

There are many roads to ‘universal health’, and many different outcomes. This paper compares the experiences of Chile and Costa Rica, countries that have come to epitomize opposite approaches to health policy in Latin America. Chile represents the Universal Health Coverage (UHC) model promoted by global health agencies, which focus on public-private insurance schemes covering a limited package of services. Costa Rica represents a Universal Health System (UHS) approach that provides and funds all medical and preventive services to citizens through a single public entity. The authors demonstrate how the insurance-based health system in Chile has underperformed on most accounts when compared to the publicly financed and operated model in Costa Rica. Although both countries have seen major advances in primary care, Chile’s health ‘market’ has led to inefficient use of resources, with higher administrative costs and more irrational medical procedures resulting from oligopolies and collusion among private providers. In terms of affordability, Chileans incur significant out-of-pocket health payments and are more likely to face catastrophic health expenditures. Both countries have good scores on access to basic care, but people in Chile generally face more access barriers, including distance to facilities, wait times and cost. Finally, Costa Ricans continue to be largely satisfied with the quality of their healthcare services, more so than Chileans.

Cholera crosses the border from Zimbabwe to South Africa
PlusNews: 19 November 2008

Zimbabwe's cholera epidemic has crossed into South Africa, with four confirmed diagnoses in a total of 68 suspected cases in the border town of Musina, according to aid workers as of 19 November 2008. The cholera epidemic in Zimbabwe has flared up in several parts of the country, including the capital, Harare, and its satellite town of Chitungwiza, as a result of the collapse of water and sewerage services, worsened by uncollected refuse and the start of the rainy season. Humanitarian officials have reported that a total of 2,893 people were infected by the waterborne disease between the beginning of August and mid-November, with at least 115 deaths. The UN children's agency, UNICEF, and the World Health Organisation (WHO) have also been assisting in the provision of drinking water.

Cholera infection continues to slow in southern Africa, UN says
United Nations: 22 April 2009

The cholera epidemic in southern Africa continues to abate, but international and local health authorities stress the need to remain vigilant, the United Nations has reported. There were a total of 4,579 new cases between 3 and 17 April in the nine countries – Angola, Botswana, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe – affected by the often fatal disease since August 2008. During the two weeks preceding 3 April, 6,460 new cases were reported. Authorities warn, however, that cholera could re-appear in the coming one to three weeks, when waters from flooding in the region, which has affected more than 1.2 million people, subside and become stagnant.

Chronic non-communicable disease and healthcare access in middle-aged and older women living in Soweto, South Africa
Lopes Ibanez-Gonzalez D and Norris SA: PLoS One 8(10), 29 October 2013

This study described the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto, South Africa. The study instrument was administered to 1102 caregivers. Over half the respondents reported having at least one chronic non-communicable disease (NCD), only a third of whom reported accessing a healthcare service in the last six months. Reported availability of private medical practice and government clinics was high (75% and 62% respectively). The low utilisation of healthcare services by women with NCDs is a concern for health care management.

Church of Scotland Hospital a model for TB treatment
Plus News: 9 October 2009

Three years ago, the Church of Scotland Hospital in the rural Umsinga area of South Africa's KwaZulu-Natal Province was the epicentre of a deadly outbreak of extremely drug-resistant tuberculosis (XDR-TB). It was reported that 52 of the 53 patients initially diagnosed died within a month of contracting this strain of TB, which is resistant to both of the first-line antibiotics used to treat the disease, as well as two classes of second-line drugs. At the peak of the epidemic in 2006, Umsinga was contributing more than two-thirds of the XDR-TB and multi-drug resistant TB (MDR-TB) cases in the province, but Dr Tony Moll, Principal Medical Officer at the Church of Scotland Hospital, is credited with leading efforts to turn the tide against the deadly new TB strains. Since then, 488 cases of XDR-TB and 356 cases of MDR-TB have been diagnosed. ‘The TB prevalence rate is still very high in the area,’ Moll said. ‘We get about 150 new TB cases every month.’ In 2008, the hospital achieved a TB cure rate of 83%, compared to the national cure rate of about 60%.

Clinical practice guidelines within the Southern African Development Community: a descriptive study of the quality of guideline development and concordance with best evidence for five priority diseases
Kredo T, Gerritsen A, van Heerden J, Conway S and Siegfried N: Health Research Policy and Systems 10(1), 5 January 2012

There is limited data on availability, quality and content of guidelines within the Southern African Development Community (SADC). This evaluation aimed to address this gap in knowledge and provide recommendations for regional guideline development. The authors prioritised five diseases: HIV in adults, malaria in children and adults, pre-eclampsia, diarrhoea in children and hypertension in primary care. A comprehensive electronic search to locate guidelines was conducted between June and October 2010 and augmented with email contact with SADC Ministries of Health. The authors identified 30 guidelines from 13 countries, publication dates ranging from 2003-2010. Overall the 'scope and purpose' and 'clarity and presentation' domains of the AGREE II instrument scored highest, with a median of 58% and 83% respectively. 'Stakeholder involvement' followed with median 39%. The authors recommend that future guideline development processes within SADC should better adhere to global reporting norms requiring broader consultation of stakeholders and transparency of process. A regional guideline support committee could harness local capacity to support context appropriate guideline development.

Closing the cancer divide: a blueprint to expand access in low and middle income countries
Knaul FM, Farmer P and Arreola-Ornelas H: Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries, Harvard University, 2011

This report aims to present the evidence that supports the case for expanded access to cancer care and control (CCC) in low and middle income countries (LMICs), and describe innovative models for achieving this goal. The document summarises information from 56 countries. The report emphasises that innovation in delivery systems, increased access to affordable vaccines and medications, innovative financing mechanisms to make care accessible and affordable are of great importance in terms of CCC. The authors call for promoting prevention policies that reduce cancer risk, mobilising all public and private stakeholders in the cancer arena, and expanding training opportunities for researchers in LMICs. They recommend that national cancer control programmes in LMICs must work systematically to adapt global guidelines for national cancer prevention, treatment, and palliation programmes. Also, they must strengthen procurement and distribution systems and ensure regulation of quality and safety. Cancer detection and treatment should be made more accessible and affordable through diagnostic tests and medications that are more easily delivered in remote settings. Governments must expand access across the cancer care control continuum through universal financial protection for health, and efficient use of all levels of care.

Closing the poor-rich gap in contraceptive use in urban Kenya: are family planning programs
Fotso JC, Speizer IS, Mukiira C, Kizito P, LumumbaV: International Journal for Equity in Health 12:71, 2013

Kenya is characterized by high unmet need for family planning (FP) and high unplanned pregnancy, in a context of urban population explosion and increased urban poverty. It witnessed an improvement of its FP and reproductive health (RH) indicators in the recent past, after a period of stalled progress. The paper describes inequities in modern contraceptive use, types of methods used, and the main sources of contraceptives in urban Kenya; examines the extent to which differences in contraceptive use between the poor and the rich widened or shrank over time; and attempts to relate these findings to the FP programming context, with a focus on whether the services are increasingly reaching the urban poor. It uses data from the 1993, 1998, 2003 and 2008/09 Kenya demographic and health survey. The authors found a dramatic change in contraceptive use between 2003 and 2008/09 that resulted in virtually no gap between the poor and the rich in 2008/09, by contrast to the period 1993–1998 during which the improvement in contraceptive use did not significantly benefit the urban poor.

Community perceptions of malaria and vaccines in South Coast and Busia regions of Kenya
Ojakaa DI, Ofware P, Machira YW, Yamo E, Collymore Y, Ba-Nguz A, Vansadia P and Bingham A: Malaria Journal 10(147), 30 May 2011

This qualitative study was conducted in two malaria-endemic regions of Kenya - South Coast and Busia. Participant selection was purposive and criterion based. A total of 20 focus group discussions, 22 in-depth interviews, and 18 exit interviews were conducted. While support for local child immunisation programmes exists, limited understanding about vaccines and what they do was evident among younger and older people, particularly men. In general, parents and caregivers weigh several factors - such as personal opportunity costs, resource constraints, and perceived benefits - when deciding whether or not to have their children vaccinated, and the decision often is influenced by a network of people, including community leaders and health workers. The study raises issues that should inform a communications strategy and guide policy decisions within Kenya on eventual malaria vaccine introduction. Unlike the current practice, where health education on child welfare and immunisation focuses on women, the communications strategy should equally target men and women in ways that are appropriate for each gender, the authors argue. It should involve influential community members and provide needed information and reassurances about immunisation. Efforts also should be made to address concerns about the quality of immunisation services, including health workers' interpersonal communication skills.

Community referral in home management of malaria in western Uganda: A case series study
Kallander K, Tomson G, Nsungwa-Sabiiti J, Senyonjo Y, Pariyo G, Peterson S: BioMed Central International Health and Human Rights 2006, 6:2

Home Based Management of fever (HBM) was introduced as a national policy in Uganda to increase access to prompt presumptive treatment of malaria. Pre-packed Chloroquine/Fansidar combination is distributed to febrile children under-five years in the community. Persisting fever or 'danger signs' are referred to the health centre. Functioning referral to health centres is a critical assumption in HBM. We assessed overall referral rate, causes of referral, referral completion and reasons for non-completion under the HBM strategy.

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