Equitable health services

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.

Healthcare service delivery to refugee children from the Democratic Republic of Congo living in Durban, South Africa: a caregivers’ perspective
Meyer-Weitz A; Oppong Asante K; Lukobeka B: BMC Medicine 16(163), doi: https://doi.org/10.1186/s12916-018-1153-0, 2018

This study explored refugee caregivers’ perceptions of their children’s access to quality health service delivery to their young children in Durban, South Africa. This study used an explanatory mixed methods design, purposively sampling 120 and 10 participants for the quantitative and qualitative phases, respectively. The majority (89%) of caregivers were women, with over 70% of them aged between 30 and 35 years. Over 74% of caregivers visited public clinics for their children’s healthcare needs. The majority of caregivers (95%) were not satisfied with healthcare services delivery to their children due to the long waiting hours and the negative attitudes and discriminatory behaviours of healthcare workers, particularly in public healthcare facilities. These findings underscore the need to address health professionals’ attitudes when providing healthcare for refugees. The authors suggest that attitudinal change may improve the relationship between service providers and caregivers of refugee children in South Africa, which may improve the health-related outcomes in refugee children.

Is healthcare really equal for all? Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians
Dei V; Sebastian M: International Journal for Equity in Health 17(86)1-12, 2018

This paper aimed to assess whether horizontal and vertical equity were being met in the healthcare utilisation among adults aged 50 years and above. The paper was based on a secondary cross-sectional data from the World Health Organization’s Study on global AGEing and adult health wave 1 conducted from 2007 to 2008 in Ghana. Data on 4304 older adults aged 50 years-plus were analysed. Horizontal and vertical inequities were found in the use of outpatient services. Inpatient healthcare utilisation was both horizontally and vertically equitable. Women were found to be more likely to use outpatient services than men but had reduced odds of using inpatient services. Possessing a health insurance was also significantly associated with the use of both inpatient and outpatient services. Whilst equity exists in inpatient care utilisation, more needs to be done to achieve equity in the access to outpatient services. The paper reaffirms the need to evaluate both the horizontal and vertical dimensions in the assessment of equity in healthcare access.

Contact tracing performance during the Ebola epidemic in Liberia, 2014-2015
Swanson K; Altare C; Wesseh C; et al: PLOS Neglected Tropical Diseases, doi: https://doi.org/10.1371/journal.pntd.0006762, 2018

During the Ebola virus disease (EVD) epidemic in Liberia, contact tracing was implemented to rapidly detect new cases and prevent further transmission. The authors describe the scope and characteristics of this contact tracing and assess its performance during the 2014–2015 epidemic in six counties. Positive predictive value (PPV) was defined as the proportion of traced contacts who were identified as potential cases. Contact tracing was initiated for 26.7% of total EVD cases and detected 3.6% of all new cases during the period covered, with a PPV of 1.4%. Potential cases were more likely to be detected early in the outbreak; to hail from rural areas; report multiple exposures and symptoms; have household contact or direct bodily or fluid contact; and report nausea, fever, or weakness, as compared to contacts who completed monitoring. Contact tracing was identified to be a critical intervention in Liberia and represented one of the largest contact tracing efforts during an epidemic in history. While there were notable improvements in implementation over time, the study data suggest there were limitations to its performance—particularly in urban districts and during peak transmission. Recommendations for improving performance include integrated surveillance, decentralized management of multidisciplinary teams, comprehensive protocols, and community-led strategies.

Ebola Attacked Congo Again. But Now Congo Seems to Be Winning
McNeil D: New York Times, 2 September 2018

The month-old Ebola outbreak in the Democratic Republic of Congo, which rose quickly to over 100 cases appears to be fading. More than 3,500 contacts of known cases are being followed, more than 4,000 doses of vaccine have been given and officials reported feeling hopeful enough to allow schools in the area — North Kivu Province, on the eastern border with Uganda — to open as usual. Although five experimental treatments for infected patients recently won approval for emergency use, the author reports that so far too few patients have received them to draw conclusions about how well they may work. One reason experts are reluctant to declare the outbreak contained is that some remote towns have not been visited because of armed groups in the area. Ebola experts also said they would not let down their guard because they remembered a brief, deceptive lull in the early days of the 2014 West African outbreak before it reached three capital cities and exploded, killing more than 11,000 people. Medically, the most exciting prospect on the horizon is that, as of Aug. 22, DRC has approved the emergency use of five potential treatments: two antiviral drugs, remdesivir and favipiravir; and three cocktails of antibodies originally found in recovered patients, including ZMapp, mAb114 and Regn3450-3471-3479. Previously, only about half of Ebola patients were saved if they got supportive treatment, including fluid replacement and fever control, in time. Being consistently able to cure most patients is reported to be an important advance.

Health systems readiness for adopting mhealth interventions for addressing non-communicable diseases in low- and middle-income countries: a current debate
Feroz A; Kadir M; Saleem S: Global Health Action 11(1496887) 1-7, 2018

In low-and-middle-income countries (LMICs), epidemiologic transition is taking place very rapidly from communicable diseases to non-communicable diseases (NCDs). NCD mortality rates are increasing faster and nearly 80% of NCDs deaths occur in LMICs, with human and economic costs, increasing treatment costs and losses to productivity. At the same time, the increasing penetration of mobile phone technology and the spread of cellular network and infrastructure have led to the introduction of the mHealth. While mHealth offers a promising approach in prevention and control of NCDs, it is unclear how ready health systems are to adopt it for this. The authors raise a number of factors which determine health systems readiness and response for adoption of mHealth technology including preparedness of healthcare institutions, availability of the resources, willingness of healthcare providers and communities. They discuss these factors and suggest that they be dealt up-front through constant effort to improve health systems response for NCDs.

Maternity waiting facilities for improving maternal and neonatal outcome in low- resource countries
van Lonkhuijzen L; Stekelenburg J; van Roosmalen J: University of Groningen, 2011

A Maternity Waiting Home (MWH) is a facility, within easy reach of a hospital or health centre which provides Emergency Obstetric Care (EmOC). The aim of the MWH is to improve accessibility and thus reduce morbidity and mortality for mother and neonate should complications arise. This study assessed the effects of a maternity waiting facility on maternal and perinatal health. The authors searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009), CENTRAL (The Cochrane Library 2009, Issue 1), MEDLINE (1966 to April 2009), EMBASE (1980 to April 2009), CINAHL (1982 to April 2009), African Journals Online (AJOL) (April 2009), POPLINE (April 2009), Dissertation Abstracts (April 2009) and the National Research Register archive (March 2008) for conducted randomised controlled trials that compared perinatal and maternal outcome in women using a MWH and women who did not. There were no randomised controlled trials or cluster-randomised trials identified from the search. They found from this evidence that there is insufficient evidence to determine the effectiveness of Maternity Waiting Facilities for improving maternal and neonatal outcomes.

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