Equitable health services

A Wake-up Call - Lessons from Ebola for the world's health systems
Wright S; Hanna L; Mailfert M; Gushulvili D; Kite G: Save the Children 2015

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.

Acceptability of evidence-based neonatal care practices in rural Uganda: Implications for programming
Waiswa P, Kemigisa M, Kiguli J, Naikoba S, Pariyo GW and Peterson S: BMC Pregnancy and Childbirth 8(21), 21 June 2008

Although evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. The researchers explored the acceptability of these interventions in two rural districts of Uganda; conducted ten focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children); and ten key informant interviews with health workers and traditional birth attendants. Most maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritise postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.

Access challenges in TB, ART and maternal health services: Phase 1 results: Researching Equity in Access to Health Care Project
University of the Witwatersrand Centre for Health Policy: August 2009

This report provides highlights of the findings of the phase 1 Researching Equity in Access to Health Care (REACH) project, completed in 2009. REACH aims to document levels of and inequities in access, according to socio-economic status, gender, and urban/rural status, within the public health system for three services: maternal health (focusing on emergency and specialised needs at the time of delivery), tuberculosis (TB) care, and antiretroviral therapy. Detailed case studies were undertaken in various parts of South Africa. During 2008 and 2009, the REACH project undertook exit interviews with approximately 4,000 adult (+18 years) users of TB, HIV and maternal health services, carried out quality of care assessments in fifty health facilities, and analysed secondary data from a variety of sources to establish the socio-economic profile of facility catchment populations. The project found that considerably greater access barriers are experienced by rural compared to urban communities, with respect to distance, time, costs and staff attitudes. Rural women experience large health cost burdens during their pregnancy and at the time of delivery, and coverage by a minimum package of antenatal care is still inadequate. TB services were found to be more accessible than anti-retroviral therapy services in all dimensions of availability, affordability and acceptability. The report also notes there was considerable local variation in nature of services (e.g. home visits) and policies (e.g. birth companions).

Access to and rational use of medicine
Health Action International and Ecumenical Pharmaceutical Network, 14 November 2007

The Pan African meeting on access to essential medicines (AEM) and rational use of medicines (RUM) was convened by Health Action International (HAI) Africa and the Ecumenical Pharmaceutical Network (EPN)2 on 14th and 15th November 2007 in Nairobi, Kenya. The meeting brought together African experts and stakeholders from the pharmaceutical sector, including civil society organizations (CSOs) and faith-based organizations (FBOs), to discuss issues around AEM and RUM.

Access to artemisinin-based anti-malarial treatment and its related factors in rural Tanzania
Khatib RA, Selemani M, Mrisho GA, Masanja IM, Amuri M, Njozi MH et al: Malaria Journal 12(155), 7 May 2013

Timely access within 24 hours to an authorised artemisinin-based combination treatment (ACT) outlet is one of the determinants of effective malaria treatment coverage. In this study, timely access was assessed in two district health systems in rural Tanzania: Kilombero-Ulanga and Rufiji. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data was collected on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. In Kilombero-Ulanga 41.8% and in Rufiji 36.8% of fever cases had access to an authorised ACT provider within 24 hours of fever onset. In neither site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. The poor results fly in the face of government interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. The authors call for more innovative interventions to raise effective coverage of malaria treatment in Tanzania.

Access to Cancer Treatment: A study of medicine pricing issues with recommendations for improving access to cancer medication
t Hoen E: Oxfam International, 4 February 2015

According to the World Health Organization, cancer is one of the leading causes of death around the world, with 8.2 million deaths in 2012. More than 60 percent of the world’s new cases of cancer occur in Africa, Asia, and Central and South America and these regions account for 70 percent of the world’s cancer deaths. In low- and middle-income countries, expensive treatments for cancer are not widely available. Unsustainable cancer medication pricing has increasingly become a global issue, creating access challenges in low-and middle-income but also high-income countries. This report describes recent developments within the pricing of medicines for the treatment of cancer, discusses what lessons can be drawn from HIV/AIDS treatment scale-up and makes recommendations to help increase access to treatment for people with cancer.

Access to health care in Mozambique
Ravenscroft J: Global Health Check, 4 February 2013

This film examines the barriers that people face in accessing healthcare in rural Mozambique, specifically the rural area of Tsangano in the province of Tete, a huge region in the centre of the country. In the film, you can see how the examples of Tsangano and Tete clearly show that all parts of a health system need to come together in order for the system as a whole to function. The film advocates for an end to out-of-pocket payments by health service users. To ensure this, the ‘key ingredients’ that will make user fee removal a success must also be addressed – the financing for the system as a whole and ensuring increased investment in transport and infrastructure – particularly in rural areas – a bigger, stronger health workforce, universal access to medicines and better information for the population to demand their right to health.

Access to institutional delivery care and reasons for home delivery in three districts of Tanzania
Exavery A, Kanté AM, Njozi M, Tani K, Doctor HV, Hingora A and Phillips JF: International Journal for Equity in Health (13) 48, 2014

This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Data was drawn from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area.

Access to vaccines: Obstacles and solutions
Arnodei I: Geneva Health Forum, 31 August 2006

More than 2,600,000 deaths have been prevented in 2003 thanks to the Hepatitis B vaccine currently available. This is only one impressive example of the benefits of good vaccination and immunisation programmes. Although vaccination programmes are very cost-efficient, costing as less than 1,000 USD per life saved, the world still faces over 100,000 neonatal tetanus deaths and over 400,000 deaths from measles per year. The international community has a very ambitious plan: to completely eradicate diseases which are preventable by global vaccine coverage. How can such a goal be accomplished?

Accounting for geographical inequalities in the assessment of equity in health care: a benefit incidence analysis
Anselmi L, Fernandes Q, Hanson K, Lagarde M: The Lancet, 381, S9, 17 June 2013

Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefit incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefit distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such differences. The authors investigate how results would differ if geographical inequalities were taken into account for outpatient public health-care expenditure in Manica Province, Mozambique using data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records. The analysis showed that the gap in benefit from public expenditure between highest and lowest quintiles widened substantially if differences in health status and expenditure across districts are taken into account, increasing from a ratio of 1.2 to 2.0. Results suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refinement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems' strengthening, and ultimately provide insights for a more equitable and efficient allocation of resources.