Universal Health Coverage (UHC) is normally understood as ‘people being able to access curative, preventive and palliative health services without incurring financial hardship’. Yet this interpretation is only one part of the overall picture of health. To mitigate and prepare for such environmental and societal changes and the subsequent impact on health the authors suggest that there are at least three major ways in which health systems need to radically transform. Firstly, health systems across the world continue to be predominantly ‘sick care’ systems. Despite the success of immunization campaigns, the availability of contraceptive services and other preventive interventions, most investment is in healthcare facilities that provide primarily personal, curative health services. The World Health Organization estimates that low- and middle-income countries direct only 11-12 per cent of their total health spending towards preventive services. Secondly, animal and wildlife information systems vary enormously across countries in their objectives and structure but rarely interact with systems for tracking human health. This means that opportunities to identify dangerous viruses and diseases in the animal population before they crossover into humans are frequently missed. Thirdly, at the UN General Assembly (UNGA) the community of academics and activists concerned with non-communicable diseases were vocal, and rightly so. Such diseases now account for 41 out of the world’s 57 million deaths each year. The authors suggest that there is a need to move away from a narrow view of ‘sick care’ to one that prepares for and acknowledges present day complexities and challenges to achieve UHC.
Equitable health services
screening programme for preschool children in the Western Cape, South Africa, supported by mobile health technology and delivered by community health workers. The authors trained four community health workers to provide dual sensory screening in preschool centres of Khayelitsha and Mitchells Plain during September 2017–December 2018. Community health workers screened children aged 4–7 years using mobile health technology software applications on smart-phones. Community health workers screened 94.4% of eligible children at 271 centres at a cost of US$5.63 per child. The number of children who failed an initial hearing and visual test was 435 and 170, respectively. Of the total screened, 111 children were diagnosed with a hearing and/or visual impairment. Mobile health technology supported community health worker delivered hearing and vision screening in preschool centres provided a low-cost, acceptable and accessible service, contributing to lower referral numbers to resource-constrained public health institutions.
The third sustainable development goal (SDG), ensuring healthy lives and well-being for all at all ages, although comprising multiple components, is often strongly linked with the concept of universal health coverage (UHC) and its underlying principles of equity, quality and financial protection. While addressing the upstream determinants of health is seen as a vital accelerator of progress in achieving the SDGs, in practice, UHC has often been focused on a disease-fighting, healthcare-centric approach. African countries are not on track to achieve global targets for non-communicable disease (NCD) prevention, driven by an insufficient focus on ecological drivers of NCD risk factors, including poor urban development and the unbridled proliferation of the commercial determinants of health. As the risk factors for NCDs are largely shaped outside the healthcare sector, an emphasis on downstream healthcare service provision to the exclusion of upstream population-level prevention limits the goals of UHC and its potential for optimal improvements in (achieving) health and well-being outcomes in Africa. The author argues for a systems for health rather than a solely healthcare-centric approach, that proactively incorporates wider health determinants (sectors)—housing, planning, waste management, education, governance and finance, among others—in strategies to improve health. This includes aligning governance and accountability mechanisms and strategic objectives of all ‘health determinant’ sectors for health creation and long-term cost savings. Researchers are seen to have a vital role to play, collaborating with policy makers to provide evidence to support implementation and to facilitate knowledge sharing between African countries.
The authors applied Tanahashi’s equity model to review perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. A qualitative study was implemented between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. The findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, and limited efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors suggest that if Kenya is to achieve universal health coverage, then county governments must address all aspects of equity, including quality, including through community health services.
This paper applied Tanahashi’s equity model to identify the perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. The authors carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Their findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors observe that achieving universal health coverage means that all aspects of equity need to be addressed, including quality, and that community health services can play a crucial role in this.
The author questions whether Uganda national referral hospitals are performing their function. The author asks why a section of persons should be given special treatment by government in the names of being ‘Very Important Persons’ to access the best medical services in referral facilities for first line care or in ‘uptown’ private medical facilities and abroad. The author proposes that government perform its core minimum obligation and ensure that its public health care facilities function effectively.
Clinic and hospitals in the public sector in South Africa are stretched, but the author argues that this is not because of immigrants as is being proposed in some quarters, but because of understaffing, poor planning and other problems. A 2018 World Bank study showed that between 1996 and 2011, every immigrant worker generated two jobs for South Africans, mostly because their diverse skill sets led to productivity gains and multiplier effects. Immigrants also contribute to the national fiscus through payment of VAT and purchase goods and services, such as rent, from South Africans. The author calls for xenophobic blaming of foreigners to be resisted and for South Africans to see this for what it is: scapegoating of immigrants to hide domestic failures
This paper addresses the relationship between knowledge about cervical cancer, attitudes, self-reported behavior, and immediate support system, towards screening and vaccination of cervical cancer of Zambian women and men, as a basis for improving and adjusting existing prevention programs. A cross-sectional mixed methods study was conducted with women and men residing in Chilenje and Kanyama, Zambia. Less than half of the respondents had heard of cervical cancer, 20.7% of women had attended screening and 6.7% of the total sample had vaccinated their daughter. Knowledge of causes and prevention was very low. There was a strong association between having awareness of cervical cancer and practicing screening and vaccination. Social interactions were also found to greatly influence screening and vaccination behaviors. The low level of knowledge of causes and prevention of cervical cancer suggests a need to increase knowledge and awareness among both women and men. The authors note that interpersonal interactions have great impact on practicing prevention behaviors.
This paper investigated the association between maternal overweight and obesity and caesarean births in Malawi. The authors utilised cross-sectional population-based Demographic Health Surveys data collected from mothers aged 18–49 years in 2004/05, 2010, and 2015/16 in Malawi. The results showed that maternal overweight in 2015/16 and from 2004 to 2015 were risk factors for caesarean births in Malawi. Women who had one parity, and lived in the northern region were significantly more likely to have undergone caesarean birth. In order to reduce non-elective caesarean birth in Malawi, the authors propose that public health programs focus on reducing overweight and obesity among women of reproductive age.
This paper investigated socio-demographic inequities in cervical cancer screening and utilization of treatment among women in Harare, Zimbabwe. Two cross sectional surveys were conducted in Harare with a total sample of 277 women aged at least 25 years from high, medium, low density suburbs and rural areas. Only 29% of women reported ever screening for cervical cancer. Cervical cancer screening was less likely in women affiliated to major religions and those who never visited health facilities or doctors or visited once in previous 6 months. Ninety-two of selected patients were on treatment. Women with cervical cancer affiliated to protestant churches were 68 times more likely to utilize treatment and care services compared to those in other religions. Province of residence, education, occupation, marital status, income, wealth, medical aid status, having a regular doctor, frequency of visiting health facilities, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with cervical cancer screening and treatment respectively. The authors recommend strengthening health education in communities, including in churches, to improve uptake of screening and treatment of cervical cancer.