The South African parliament’s social services select committee has welcomed the investigation into the death of 36 psychiatric patients in Gauteng. This comes after Gauteng Health MEC Qedani Mahlangu revealed during an oral reply to questions in the legislature that 36 psychiatric patients, who had been transferred from Life Healthcare Esidimeni, had died while in the care of NGOs. The psychiatric patients were relocated to 122 NGOs after the department cancelled its contract with Life Healthcare, which looked after almost 2 000 patients. Health Minister Aaron Motsoaledi has called for the Office of the Health Ombudsman to investigate the allegations. The committee conveyed its condolences to the families of the patients. "While the Committee is cognisant of the need to find alternative measures to care for patients, these measures should have been made with the clear understanding and guarantees that the care of patients will not deteriorate. Every decision that is made must have as its central pillar the delivery of quality care for our people," committee chairperson Cathy Dlamini said in a statement. The committee called for the investigation to be sped up, in order to avoid further loss of life. They would engage with the health department at national and provincial levels to ensure quality care of all patients, the committee said.
Equitable health services
Malawi has been the only country in Sub-Saharan Africa to provide universal free health services throughout its public health system and never charge user fees – with the exception of some recent worrying user fee experiments. Conversely in Nigeria, which only spends 0.9% of its GDP in the form of public health financing and where user fees are charged at all levels, private out-of-pocket health financing accounts for 72% of total health expenditure – one of the highest rates in the world. Perhaps the most stark illustration of the difference in performance between these two countries at the opposite ends of this curve, is that whereas Nigeria is 8 times richer than Malawi, Nigeria’s child mortality rate (109 deaths per 1000 live births) is 70% higher than Malawi ’s (64 deaths). In reviewing these records, the obvious policy recommendation for Nigeria is that it too should increase its public health spending and abolish user fees in its public health system. And for Malawi, the authors argue that the lesson should be to build on this success and use further increases in public financing to improve the availability and quality of free services.
Cardiovascular diseases are the leading cause of death globally, killing 17.5 million people per year and 80% of deaths from these diseases occur in low- and middle-income countries. Evidence suggests that the main drivers of the global cardiovascular disease epidemic are urbanisation and industrialisation, which lead to an increase in sedentary lifestyles, unhealthy dietary patterns, tobacco consumption and increased alcohol consumption. Hypertension is a leading risk factor for cardiovascular diseases, and its prevalence is increasing worldwide – from 25% in 2000 to a projected 40% in 2025. The rising burden of hypertension in low- and middle-income countries is amplified by the public’s low levels of awareness, treatment and control of this condition, particularly among slum residents, who typically constitute a large portion of neglected urban populations in such settings. Studies in slum populations suggest that when people are made aware of having hypertension they do tend to seek care. However, the level of adherence to treatment for hypertension remains low for several reasons, including, but not limited to, the high costs of treatment and to patients’ perceptions of a low risk of cardiovascular diseases and belief in a one-time cure for disease rather than to lifelong preventive treatment and monitoring. In response to the rising burden of cardiovascular disease risk factors in slum populations in Kenya, a community-based intervention was developed and implemented in the capital city, Nairobi. This intervention, known as SCALE UP (the sustainable model for cardiovascular health by adjusting lifestyle and treatment with economic perspective in settings of urban poverty), has been described in detail elsewhere. The intervention had multiple components with the overall aim of reducing cardiovascular diseases risk through awareness campaigns, improvements in access to screening and standardised clinical management of hypertension. This paper shares experiences of implementing a comprehensive intervention for primary prevention of hypertension in a slum setting and to examine the processes, outcomes and costs of the intervention. It raises lessons for policy-makers and other stakeholders looking to implement similar interventions in highly resource-constrained settings.
Sub-Saharan Africa (SSA) communities suffer a disease burden that is aggravated by shortage of medical personnel and medical supplies such as medical devices. This paper outlines how for a long time, observation and practical experiences meant that people learned to use different plant species that led to the emergence of traditional medicine (TM) systems. The ancient Pharaonic Egyptian TM system is for example, said to be one of the oldest documented forms of TM practice in Africa and a pioneer of world’s medical science. These medical practices diffused to other continents and were accelerated by advancement of technologies while leaving Africa lagging behind in the integration of the practice in formal health-care system. The author raises issues that drag back integration, such as the lack of development of education curricula for training TM experts as the way of disseminating the traditional medical knowledge and practices. A few African countries such as Ghana have managed to integrate TM products in the National Essential Medicine List while South Africa, Sierra Leone, and Tanzania have TM products being sold over the counters due to the availability of education training programs. This paper analyses the contribution of TM practice and products in modern medicine and gives recommendations that Africa should take in the integration process to safeguard the SSA population from disease burdens.
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.
The needs of caregivers of children with disability may not be recognized despite evidence to suggest that they experience increased strain because of their care-giving role. This strain may be exacerbated if they live in under-resourced areas. The authors set out to establish the well-being of caregivers of children with Cerebral Palsy (CP) living in high-density areas of Harare, Zimbabwe. In addition, the authors wished to identify factors that might be predictive of caregivers’ well-being. Finally, they examined the psychometric properties of the Caregiver Strain Index (CSI) within the context of the study. Caregivers of 46 children with CP were assessed twice, at baseline, and after three months, for perceived burden of care and health-related quality of life. The psychometric properties of the CSI were assessed post hoc. The caregivers reported considerable caregiver burden with half of the caregivers reporting CSI scores in the ‘clinical distress’ range. Many of the caregivers experienced some form of pain, depression and expressed that they were overwhelmed by the care-giving role. No variable was found to be associated with clinical distress. The authors propose that caregivers be monitored routinely for their level of distress and that there is an urgent need to provide them with support. The CSI is likely to be a valid measure of distress in this population.
Globally challenges regarding healthcare provision are sometimes related to a failure to estimate client numbers in peri-urban areas due to rapid population growth. About one-sixth of the world's population live in informal settlements which are mostly characterised by poor healthcare service provision. Poor access to primary healthcare may expose residents of informal settlement more to the human immunodeficiency virus (HIV) and to acquired immunodeficiency syndrome (AIDS) than their rural and urban counterparts due to a lack of access to information on prevention, early diagnosis and treatment. This study explored and described the experiences of both the reproductive health services' clients and the healthcare providers with regard to the provision of reproductive health services including the prevention of HIV and AIDS in a primary healthcare setting in Tshwane. A qualitative, exploratory and contextual design using a phenomenological approach to enquire about the participants' experiences was implemented. Purposive sampling resulted in the selection of 23 clients who used the reproductive healthcare services and ten healthcare providers who were interviewed during individual and focus group interviews respectively. The findings revealed that females who lived in informal settlements were aware of the inability of the PHC setting to provide adequate reproductive healthcare to meet their needs, as were providers. The authors argue that inputs from people at grass roots level be integrated during policy development to ensure that informal settlement residents are provided with accessible reproductive health services. It was further found that the community members could be taught how to coach teenagers and support each other in order to bridge staff shortages and increase health outcomes including HIV/AIDS prevention.
This study assesses universal health coverage for adults aged 50 years or older with chronic illness in China, Ghana, India, Mexico, the Russian Federation and South Africa. The authors obtained data on 16 631 participants aged 50 years or older who had at least one diagnosed chronic condition from the World Health Organization Study on Global Ageing and Adult Health. Access to basic chronic care and financial hardship were assessed and the influence of health insurance and rural or urban residence was determined by logistic regression analysis. The weighted proportion of participants with access to basic chronic care ranged from 21% in Mexico to 48% in South Africa. Access rates were unequally distributed and disadvantaged poor people, except in South Africa where primary health care is free to all. Rural residence did not affect access. The proportion with catastrophic out-of-pocket expenditure for the last outpatient visit ranged from 15% in China to 55% in Ghana. Financial hardship was more common among poor people in most countries but affected all income groups. Health insurance generally increased access to care but gave insufficient protection against financial hardship. No country provided access to basic chronic care for more than half of the participants with chronic illness. Poor people were less likely to receive care and more likely to face financial hardship in most countries. However, inequity of access was not fully determined by the level of economic development or insurance coverage. The authors argue that future health reforms should aim to improve service quality and increase democratic oversight of health care.
The 2014/2015 West Africa Ebola epidemic has caused the global public health community to engage in difficult self-reflection. First, it must consider the part it played in relation to an important public health question: why did this epidemic take hold and spread in this unprecedented manner? Second, it must use the lessons learnt to answer the subsequent question: what can be done now to prevent further such outbreaks in the future? The authors contribute to the current self-reflection by presenting an analysis using a Primary Health Care (PHC) approach. This approach is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in authorities and mobile populations, a broader approach is required to engage affected communities. In the medium-term health system development with attention to primary level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local management and an investment in human resources for health. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD.
MamaYe is a campaign initiated by Evidence for Action, a multi-year programme which aims to improve maternal and newborn survival in sub-Saharan Africa. It is led by African experts in the six countries, Nigeria, Ghana, Sierra Leone, Ethiopia, Malawi and Tanzania and supported by experts in academic and other institutions specialising in maternal and newborn health. MamaYe has produced a factsheet to summarise the evidence on Malawi’s blood services, including how much blood is collected and how much is needed. Just over one third of blood needed in Malawi is being collected. The factsheet covers the importance of blood for preventing maternal deaths, the 4 key components of World Health Organization’s strategy for safe and effective use of blood and achievements in Malawi in blood donation and availability. The factsheet also reviews continued challenges for availability of blood in Malawi and an overview of Malawi’s blood transfusion services, including: the organisation of the blood transfusion services; blood supply; donor population; blood use towards maternal, newborn and child health; and blood safety and screening.