Equitable health services

Associations in the continuum of care for maternal, newborn and child health: a population-based study of 12 sub-Saharan Africa countries
Owili P; Muga M; Chou YJ; Elsa Hau YH; Huang N; Chien LY: BMC Public Health 16(414), 2016

Despite the progress in the Millennium Development Goals (MDGs) 4 and 5, inequity in the utilization of maternal, newborn and child health (MNCH) care services still remain high in sub-Saharan Africa (SSA). In this study, the authors explored the distributions in the utilisation MNCH services in 12 SSA countries and further investigated the associations in the continuum of care for MNCH as key for health equity, using Demographic and Health Surveys data of 12 countries in SSA. Some countries have a consistently low (Mali, Nigeria, DR Congo and Rwanda) or high (Namibia, Senegal, Gambia and Liberia) utilisation in at least two levels of MNCH care. The path relationships in the continuum of care for MNCH from ‘adequate antenatal care’ to ‘adequate delivery care’ (0.32) and to ‘adequate child’s immunisation’ (0.36); from ‘adequate delivery care’ to ‘adequate postnatal care’ (0.78) and to ‘adequate child’s immunisation’ (0.15) were positively associated and statistically significant. Only the path relationship from ‘adequate postnatal care’ to ‘adequate child’s immunisation’ (−0.02) was negatively associated and significant. In conclusion, utilisation of each level of MNCH care is related to the next level of care, that is – antenatal care is associated with delivery care which is then associated with postnatal and subsequently with child’s immunisation. At the national level, identification of communities which are greatly contributing to overall disparity in health and a well laid out follow-up mechanism from pregnancy through to child’s immunisation program could serve towards improving maternal and infant health outcomes and equity.

Asthma still a big killer
Thom A: Health-e, 6 May 2008

Under-treatment, inappropriate treatment and lack of education for asthma patients in South Africa are contributing to still unacceptably high morbidity rates. The most recent figures reveal that at least 10 percent of South Africans have asthma with many still dying unnecessarily, especially people in poorer households. Asthma deaths are almost all preventable and a 2004 report by the Global Initiative for Asthma found that South Africa has the world's fourth highest asthma death rate among five- to 35-year-olds. Out of every 100 000 South Africans with asthma, 18,5 die of the illness. Asthma therapy is freely available in the government health service. The most effective means of controlling asthma is to use a preventer pump containing an anti-inflammatory. The most cost-effective way of relieving an attack is a pump with a bronchodilator. A study by the University of Pretoria to understand the impact (including the impact on health-related quality of life) of asthma on South African asthmatics found that patients were not accessing treatment or were being inappropriately treated.

Attitudes towards African traditional medicine and Christian spiritual healing regarding treatment of epilepsy in a rural community of northern Tanzania
Winkler AS, Mayer M, Ombay M, Mathias B, Schmutzhard E and Jilek-Aall L: African Journal of Traditional, Complementary and Alternative Medicines 7(2): 2010

In this study, 167 people (59 people with epilepsy [PWE], 62 relatives of PWEs and 46 villagers) were interviewed at a local hospital and in the community with a semi-structured validated questionnaire regarding the prevailing attitude towards traditional medicine for treatment of epilepsy in a rural area of northern Tanzania. Various traditional healing methods (THM) could be ascertained, namely traditional herbal medicine, spiritual healing, scarifications and spitting. In total, 44.3% the interviewed people were convinced that epilepsy could be treated successfully with THM. Interestingly, 34.1% thought that Christian prayers could cure the cause and/or treat symptoms of epilepsy. Significantly more PWE and their relatives were in favour of THM compared to villagers not knowing about or not immediately affected by epilepsy. Further factors influencing people’s attitudes towards THM were gender, tribe, religion and urbanity of people’s dwellings. This study demonstrates that not only THM but also prayers in the Christian sense seem to play an important role in people’s beliefs regarding successful treatment of epilepsy. Factors influencing this belief system have been identified and are discussed.

Back to basics: HIV/AIDS belongs with sexual and reproductive health
Germain A, Dixon-Mueller R and Sen G: Bulletin of the World Health Organization 87(11): 840–845, November 2009

The Programme of Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994 offers a comprehensive framework for achieving sexual and reproductive health and rights, including the prevention and treatment of HIV and AIDS, and for advancing other development goals. However, combating HIV remains a separate project with malaria and tuberculosis. This paper presents a brief history of key decisions made by major international donors that have led to the separation of HIV and AIDS from its logical programmatic base in sexual and reproductive health and rights. In urging a return to the original ICPD construct as a framework for action, the paper calls for renewed leadership commitment, investment in health systems to deliver comprehensive sexual and reproductive health services, including HIV prevention and treatment, comprehensive youth programmes, streamlined country strategies and donor support. All investments in research, policies and programmes should build systematically on the natural synergies inherent in the ICPD model.

Bacteraemia in Kenyan children with sickle-cell anaemia: A retrospective cohort and case-control study
Williams T, Uyoga S, Macharia A, Ndila C, McAuley CF, Opi DH, Mwarumba S, Makani J, Komba A, Ndiritu MN, Sharif SK, Marsh K, Berkley JA and Scott JAG: The Lancet 374(9698): 1364–1370, 17 October 2009

In sub-Saharan Africa, more than 90% of children with sickle-cell anaemia die before the diagnosis can be made. The causes of death are poorly documented, but bacterial sepsis is probably important. This study examined the risk of invasive bacterial diseases in children with sickle-cell anaemia. It was undertaken in a rural area on the coast of Kenya, with a case-control approach. Blood cultures were undertaken on all children younger than 14 years who were admitted from within a defined study area to Kilifi District Hospital between 1 August 1998 and 31 March 2008 – those with bacteraemia were defined as cases. The study detected 2,157 episodes of bacteraemia in 38,441 admissions (6%). 1,749 of these children with bacteraemia (81%) were typed for sickle-cell anaemia, of whom 108 (6%) were positive as were 89 of 13,492 controls (1%). The study concludes that the organisms causing bacteraemia in African children with sickle-cell anaemia are the same as those in developed countries. Introduction of conjugate vaccines against S pneumoniae and H influenzae into the childhood immunisation schedules of African countries could substantially affect survival of children with sickle-cell anaemia.

Barriers to Accessing Safe Motherhood and Reproductive Health Services: The Situation of Women with Disabilities in Lusaka, Zambia

Researchers examined how well Lusakan health services met the safe motherhood and reproductive health care needs of women with disabilities, using in-depth tape-recorded interviews with 24 women with disabilities and 25 safe motherhood service providers. Social, attitudinal, and physical barriers to accessing safe motherhood and reproductive health services in this particular setting were experienced by the women, such as assumption among reproductive health service providers that women with disabilities will not be sexually active and will not require reproductive health services. Beliefs about transmission of disabilities were also experienced, and nurse-midwives' feared delivery complications in women with physical impairments.

Barriers to prompt and effective malaria treatment among the poorest population in Kenya
Chuma J, Okungu V and Molyneux C: Malaria Journal 9(144), 27 May 2010

This paper explores access barriers to effective malaria treatment among the poorest population in four malaria endemic districts in Kenya. The study was conducted in the poorest areas of four malaria endemic districts in Kenya. Multiple data collection methods were applied including: a cross-sectional survey of 708 households; 24 focus group discussions; semi-structured interviews with 34 health workers; and 359 patient exit interviews. The paper found that multiple factors related to affordability, acceptability and availability interact to influence access to prompt and effective treatment. Regarding affordability, about 40% of individuals who self-treated using shop-bought drugs and 42% who visited a formal health facility reported not having enough money to pay for treatment and other factors influencing affordability included seasonality of illness and income sources, transport costs, and unofficial payments. Regarding acceptability, the major interrelated factors identified were provider patient relationship, patient expectations, beliefs on illness causation, perceived effectiveness of treatment, distrust in the quality of care and poor adherence to treatment regimes. Availability barriers identified were related to facility opening hours, organisation of health care services, drug and staff shortages.

Bed net ownership in Kenya: The impact of 3.4 million free bed nets
Hightower A, Kiptui R, Manya A, Wolkon A, Vanden Eng J, Hamel M, Noor A, Sharif SK, Buluma R, Vulule J et al: Malaria Journal 9(183), 24 June 2010

In July and September 2006, 3.4 million long-lasting insecticide-treated bed nets (LLINs) were distributed free in a campaign targeting children 0-59 months old (CU5s) in the 46 districts with malaria in Kenya. A survey was conducted one month after the distribution to evaluate who received campaign LLINs, who owned insecticide-treated bed nets and other bed nets received through other channels, and how these nets were being used. In targeted areas, 67.5% of all households with CU5s received campaign LLINs. Including previously owned nets, 74.4 % of all households with CU5s had an ITN. Over half of CU5s (51.7%) slept under an ITN during the previous evening. Nearly 40% of all households received a campaign net, elevating overall household ownership of ITNs to 50.7%. The campaign was successful in reaching the target population, families with CU5s, the risk group most vulnerable to malaria. Targeted distribution strategies will help Kenya approach indicator targets, but will need to be combined with other strategies to achieve desired population coverage levels.

Bed net usage increases, but 90 million African children still exposed to malaria
Kenya Medical Research Institute, Wellcome Trust (UK) and Oxford University: 18 November 2008

The use of insecticide-treated bed nets (ITNs) to protect children from malaria has risen six-fold in the past seven years, but 90 million children still do not have access to this simple protective tool, and remain at risk from the life-threatening disease. When African heads of state met in 2000, the Abuja Declaration stated that they would work towards protecting 60% of their vulnerable populations with insecticide treated nets. This study examines what has been achieved since. Data from 40 African countries which shows that at the time of the Abuja meeting in 2000 just over 3% of Africa’s young children were protected by a treated mosquito net. Seven years later this increased to only 18.5%. The authors report that bed net use increases faster in countries that distribute them free of charge by an average of 25% compared to 4% when people have to pay for them.

Bed/population ratios in South African public sector mental health services
Crick Lund, Alan J. Flisher, Kim Porteus, Tennyson Lee Social Psychiatry and Psychiatric Epidemiology Volume 37, Number 7 July, 2002

Mental health service planners face critical decisions regarding appropriate and affordable inpatient care. Before a fashion of deinstitutionalisation is followed, effective community services should be in place and sufficient psychiatric beds should remain in hospitals for those who cannot be catered for in the community. In order to maintain the delicate balance between hospital and community-based services, it is essential that useful indicators of inpatient care are established. This study documents current bed/population ratios per 100 000 population in public sector mental health services in South Africa. It found low levels of inpatient service provision in South Africa, and considerable variability between provinces. This study gives further support to the need to develop acute inpatient psychiatric services, reduce levels of chronic care where appropriate, and redirect resources towards the development of community-level residential and day-care services. It is crucial to develop accurate indicators to monitor this process.