Equitable health services

Mixed-methods evaluation of mental healthcare integration into tuberculosis and maternal-child healthcare services of four South African districts
Lovero K; Lammie S; van Zyl A: BMC Health Services Research 19(83), doi: https://doi.org/10.1186/s12913-019-3912-9, 2019

The South African National Mental Health Policy Framework and Strategic Plan 2013–2020 was adopted to address the country’s substantial burden and inadequate treatment of mental illness. It outlines measures for full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, the authors conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of forty clinics in four districts in South Africa, interviewing district-level program managers (DPMs) and clinic nurses and mental health practitioners (MHPs). DPMs indicated that nurses should screen for mental illness at every patient visit, but only 73% of nurses reported conducting universal screening and 44% reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialised care. However, only 41% of MHPs indicated that they diagnose mental illness and 82% offer any treatment for mental illness. The challenges to current integration efforts include insufficient funding and material resources, poor coordination at the district administrative level, and low mental health awareness in district administration and the general population. Though some progress has been made toward integration of mental health services into primary care settings, the authors observe that implementation calls for improved district-level administrative coordination, mental health awareness, and financial and material resources.

The NeoTree application: developing an integrated mHealth solution to improve quality of newborn care and survival in a district hospital in Malawi
Crehan C, Kesler E, Nambiar B, Dube Q; et al: British Medical Journal of Global Health. 4(e000860) 1-12, 2019

An integrated mHealth solution was developed to improve quality of newborn care and survival in a district hospital in Malawi. The NeoTree application described in this paper focused on newborn care in low-income facilities, combining data collection by healthcare workers themselves, with interactive decision support and education for improving quality of care. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. Healthcare workers perceived the NeoTree to be acceptable, feasible and clinically usable. Healthcare workers reported high perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. The authors suggest that such an interactive co-development with healthcare workers can create a highly usable interactive admission platform, providing a teaching resource and improving the perceived quality of care delivered by healthcare workers involved in newborn care.

Integrating noncommunicable disease services into primary health care, Botswana
Tapela N; Tshisimogo G; Shatera B; et al: Bulletin of the World Health Organisation 97(2), 142-153, 2018

Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. The authors describe strategies that were employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of policy instruments and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multi-method training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country’s first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. Provision of primary health-care delivery of noncommunicable disease services was included in the country’s 11th national development plan (2017–2023). During the guideline development process, the authors learnt that strong interdisciplinary skills in communication, organisation, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. They found that delays and poor communication emerged from the misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and weak initial coordination of the processes outside the health ministry. The authors share this experience for its relevance to other countries interested in developing and implementing guidelines for evidence-based services for noncommunicable diseases.

Oral cholera vaccination in hard-to-reach communities, Lake Chilwa, Malawi
Grandesso F; Rafael F; Chipeta S; et al: Bulletin of the World Health Organization 96(12), doi: http://dx.doi.org/10.2471/BLT.17.206417, 2018

This study aimed to evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak. The authors performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras. Vaccination coverage with at least one dose was 79.5%, on the lake shores, 99.3% on the islands and 84.7% on zimboweras. Coverage with two doses was 53.0% 91.1% and 78.8% in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies. Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.

Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit
Fairall L; Cornick R; Bateman E: BMJ, doi: https://doi.org/10.1136/bmj.k4451, 2018

Global efforts to strengthen primary healthcare are observed by the authors to have generally not focused on the critical interface between provider and patient but rather on policy, financing and infrastructure. Over the past two decades the Knowledge Translation Unit at the University of Cape Town has worked with government, academic, and non-governmental organisation partners to develop and evaluate health systems innovations that empower frontline providers. The unit developed the Practical Approach to Care Kit (PACK), a programme that covers primary healthcare needs across the life course. At the centre of the programme are concise clinical decision support tools (guides) comprising standardised and user friendly algorithms and checklists that provide a comprehensive and integrated approach to screening, diagnosing, and treating common symptoms and chronic conditions in adults, adolescents, and children. The accompanying training programme uses case-based, short training sessions delivered by existing health staff to support frontline providers and their teams. PACK provides decision support tools and training to support frontline providers in low and middle income countries. It prompts primary care health workers to claim “system agency” based on an intervention that resonates with their primary identity as clinicians. The authors suggest that delivering on universal primary healthcare requires a change in investments to prioritise comprehensive approaches that can meet the changing burden of disease

Oral cholera vaccine coverage during a preventive door-to-door mass vaccination campaign in Nampula, Mozambique.
Sema Baltazar C; Rafael F; Langa J; Chicumbe S; et al: PLoS ONE 13(10) 1-13, 2018

In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two- dose regimen of the ShancholTM OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess oral cholera vaccine coverage, frequency of adverse events following immunization, vaccine acceptability and reasons for non-vaccination. In the absence of a household listing and clear administrative neighborhood delimitations, the authors used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose was 69.5% and the two-dose coverage was 51.2%. The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 reported minor and non-specific complaints, and 78 mentioned they did not receive any information before the campaign. In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. The authors’ results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks.

Data value and care value in the practice of health systems: A case study in Uganda
Hutchinson E; Nayiga S; Nabirye C; et al: Social Science & Medicine (211) 123-130, 2018

This paper interrogated the relationship between data collection and the delivery of patient care in Kayunga, Uganda in five public health centres. The authors undertook ethnographic research from July 2015 to September 2016 in health centres, at project workshops, meetings and training sessions. This included three months of observations by three fieldworkers, in-depth interviews with health workers and stakeholders and six focus group discussions with health workers. The authors observed that the attempt to improve data collection within health facilities transferred data-value into health centres with little consideration among project staff for its impact on care, and noted both acquiescence and resistance to data-value by health workers. The authors also described the rare moments when senior health workers reconciled these two forms of value, where care-value and data-value were enacted simultaneously. The authors suggest that those seeking to make changes in health systems must take into account local forms of value and devise health systems interventions that reinforce and enrich existing ethically driven practice.

Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990–2015: a literature review
Chol C; Negin J; Garcia-Basteiro; et al: Global Health Action 11(1), doi: https://doi.org/10.1080/16549716.2018.1517931, 2018

Sub-Saharan Africa (SSA) has had more major armed conflicts (wars) in the past two decades – including 13 wars during 1990–2015 – than any other part of the world, and this has had an adverse effect on health systems in the region. This study aimed to understand the best health system practices in five SSA countries that experienced wars during 1990–2015, and yet managed to achieve a maternal mortality reduction – equal to or greater than 50% during the same period – according to the Maternal Mortality Estimation Inter-Agency Group (MMEIG). The study showed three general health system reforms across all five countries that could explain MMR reduction: health systems decentralisation, the innovation related to the WHO workforce health system building block such as training of community healthcare workers, and governments-financing reforms. Restoring health systems after disasters is an urgent concern, especially in countries that have experienced wars.

Role of maternity waiting homes in the reduction of maternal death and stillbirth in developing countries and its contribution for maternal death reduction in Ethiopia: a systematic review and meta-analysis
Dadi T; Bekele B; Kasaye H; et al: BMC Health Services Research 18(748)1-10, 2018

This study synthesised the best available evidence on effectiveness of maternity waiting homes on the reduction of maternal mortality and stillbirth in developing countries. In developing countries, maternity waiting homes users were 80% less likely to die than non-users and there was 73% less occurrence of stillbirth among users. In Ethiopia, there was a 91% reduction of maternal death among maternity waiting homes users unlike non-users and it contributes to the reduction of 83% stillbirth unlike non-users. Maternity waiting home contributes more than 80% to the reduction of maternal death among users in developing countries and Ethiopia. Its contribution for reduction of stillbirth is good. More than 70% of stillbirth is reduced among the users of maternity waiting homes. In Ethiopia maternity waiting homes contributes to the reduction of more than two third of stillbirths.

Feasibility, acceptability and potential sustainability of a ‘diagonal’ approach to health services for female sex workers in Mozambique
Lafort Y; de Melo M; Lessitala F; et al: BMC Health Services Research 18(752) 1-11, 2018

Female sex workers in many settings have restricted access to sexual and reproductive health services. This paper tested a diagonal intervention which combined strengthening of female sex workers targeted services with making public health facilities more female sex worker-friendly. It was piloted over 18 months and then its performance assessed. The intervention, as designed, was considered theoretically feasible by all informants, but in practice the expansion of some of the targeted services was hampered by insufficient financial resources, institutional capacity and buy-in from local government and private partners, and could not be fully actualised. In terms of acceptability, there was broad consensus on the need to ensure that female sex workers have access to sexual reproductive health services, but not on how this might be achieved. Targeted clinical services were no longer endorsed by the national government, which now prefers a strategy of making public services more friendly for key populations. Stakeholders judged that the piloted model was not fully sustainable, nor replicable elsewhere in the country, given its dependency on short-term project-based funding, lack of government endorsement for targeted clinical services, and viewing the provision of community activities as a responsibility of civil society. In the current Mozambican context, a ‘diagonal’ approach to ensure adequate access to sexual and reproductive health care for female sex workers is not fully feasible, acceptable or sustainable, because of insufficient resources and lack of endorsement by national policy makers for the targeted, vertical component.