Feasible universal health coverage in South Africa seems ever more remote, according to this article, as a dysfunctional Department of Public Works continues to stymie vital public hospital revitalisation projects, and five provinces have proved grossly incapable of spending their health budgets. Meanwhile, hospitals fall into disrepair and programmes are not expanded. Health Minister, Aaron Motsoaledi told parliament that the national ‘failure to spend’ was due to delays in the awarding of tenders, rolling over of budgets, poor performance of contractors (and the consequent termination of contracts and ensuing court challenges). Against this background, Dr Olive Shisana, Chairperson of the NHI ministerial advisory task team, argued that quality-based health facility accreditation is pivotal to the South African national health insurance (NHI) model. Dr Ravindra Rannan-Eliya, Director for Health Policy in Colombo, Sri Lanka, added that for an NHI to succeed in South Africa, public sector service quality and availability would need to ‘at least’ reach current medical scheme levels.
Equitable health services
Since 2002, an estimated 4.7 million long-lasting insecticide-treated nets (LLINs) have been distributed in the Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia among a population of approximately 10 million people at risk for contracting malaria. This study sought to determine the status of current net ownership, utilisation and rate of long-lasting insecticide-treated nets (LLIN) loss in the previous three years. A total of 750 household respondents were interviewed in SNNPR. Approximately 67.5% of households currently owned at least one net. An estimated 31% of all nets owned in the previous three years had been discarded by owners, most of whom considered the nets too torn, old or dirty. Households reported that one-third of nets (33.7%) were less than one year old when they were discarded. These results suggest that the life span of nets may be shorter than previously thought, with little maintenance by their owners. With the global move towards malaria elimination it makes sense to aim for sustained high coverage of LLINs, the authors argue. However, in the current economic climate, it also makes sense to use simple tools and messages on the importance of careful net maintenance, which could increase their lifespans.
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This retrospective study of the introduction of district-wide community-level malaria rapid diagnostic test (RDT) was conducted in Livingstone District, Zambia, to assess its impact on malaria reporting, incidence of mortality and on district anti-malarial consumption. Reported malaria declined from 12,186 cases in the quarter prior to RDT introduction in 2007 to an average of 12.25 confirmed and 294 unconfirmed malaria cases per quarter over the year to September 2009. Consumption of artemisinin-based combination therapy (ACT) dropped dramatically at all levels, but remained above reported malaria, declining from 12,550 courses dispensed by the district office in the quarter prior to RDT implementation to an average of 822 per quarter over the last year. From these results, it’s clear that RDT introduction led to a large decline in reported malaria cases and in ACT consumption in Livingstone district. Reported malaria mortality declined to zero, indicating safety of the new diagnostic regime, although adherence and/or use of RDTs was still incomplete. However, a deficiency is apparent in management of non-malarial fever, with inappropriate use of a lowc-ost single dose drug, SP, replacing ACT. While large gains have been achieved, the authors conclude that the full potential of RDTs will only be realised when strategies can be put in place to better manage RDT-negative cases.
In this study, the authors compare the health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. While both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system, the schemes have been more successful in Tanzania. The authors found that contextual factors that provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the ‘interference’ of competing delivery systems that occurred in Ghana.
A Health Policy Dialogue was held in Accra, Ghana, on 26 July 2012 to identify ways in which to help Kayayei (headload porters) better access health services, and to help integrate these workers into the Ghanaian National Health Insurance Scheme (NHIS). At the Dialogue, a case study of the Ghana NHIS was presented, which showed that the Kayayei were unable to easily use the health services in Accra. A large number of Kayayei were not registered with the NHIS. Most could not afford the premium, even though the minimum annual premium is set at US$5. In practice, $15-$20 is charged as a minimum in urban areas and many Kayayei earn $2-3 or less a day, making this unaffordable for them. Those few who could afford to join complained that they were mistreated or ignored when they went to use the health services. The Ministry of Health has indicated a willingness to enter into discussions with the Kayayei associations and WIEGO on the poor quality of care received by these workers when accessing health services. Ministry of Health officials proposed that clinics and hospitals in areas where Kayayei live and work should have doctors and nurses specially mandated to look after their needs.
Many patients present to an emergency centre (EC) with problems that could be managed at primary healthcare (PHC) level. This has been noted at George Provincial Hospital in the Western Cape province of South Africa. In order to improve service delivery, researchers in this study aimed to determine the patient-specific reasons for accessing the hospital EC with PHC problems. A descriptive study using a validated questionnaire to determine reasons for accessing the EC was conducted among 277 patients who were triaged as green (routine care), using the South African Triage Score. The duration of the complaint, referral source and appropriateness of referral were recorded. Of the cases 88.2% were self-referred and 30.2% had complaints persisting for more than a month. Only 4.7% of self-referred green cases were appropriate for the EC. The three most common reasons for attending the EC were that the clinic medicine was not helping (27.5%), a perception that the treatment at the hospital is superior (23.7%), and that there was no PHC service after-hours (22%). Increased acceptability of the PHC services is needed, the authors conclude. The current triage system must be adapted to allow channelling of PHC patients to the appropriate level of care. Strict referral guidelines are needed.
While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. The authors of this paper argue that a comprehensive systems perspective should guide health practice, education, research and policy. They propose key ‘systems thinking’ tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organisations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organisation within health systems, from families and communities to national Ministries of Health.
Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. This paper assesses the progress in scaling up mental health services worldwide, using a survey of key national stakeholders in mental health. The authors note that major barriers to scaling up of mental health services in countries with low and middle incomes include absence of financial resources and government commitment and over-centralisation. In addition, challenges of integration of mental health care into primary care settings, scarcity of trained mental health personnel and shortage of public health expertise among mental health leaders are tangible barriers as well. As a result, the authors argue that a systemic and strategic approach to scaling up is needed.
In this study, researchers evaluated the effect of a community health worker-based, interpersonal communication campaign for increasing insecticide-treated mosquito net (ITN) use among children in Luangwa District, Zambia, an area with near universal coverage of ITNs and moderate to low malaria parasite prevalence. Results indicated that ITN use among children younger than five years old in households with one ITN increased overall from 54 % in 2008 to 81 % in 2010. However, there was no difference in increase between the treatment and control arms in 2010. ITN use also increased among children five to 14 years old from 37 % in 2008 to 68 % in 2010. There was no indication that the community health worker-based intervention activities had a significant effect on increasing ITN use in this context, over and above what is already being done to disseminate information on the importance of using an ITN to prevent malaria infection. Contamination across control communities, coupled with linear settlement patterns and subsequent behavioural norms related to communication in the area, likely contributed to the observed increase in net use and null effect in this study, the authors conclude.