With at least 67,000 refugees in southwest Uganda, the government and aid workers are still battling inadequate resources in what a United Nations (UN) official described as a ‘silent emergency’. ‘We can hardly meet international standards of indicators such as water, health and food,’ reported Nemia Temporal, deputy representative of the UN Refugee Agency (UNHCR) in Uganda. ‘For instance, we are delivering fifteen litres [of water] per person per day instead of the standard twenty litres.’ After years of protracted conflict in eastern Democratic Republic of Congo (DRC), with large influxes to neighbouring countries, the situation of the majority Congolese refugees is no longer considered that urgent by the wider aid community, Temporal said. At least 45,000 Congolese live in the 217sqkm Nakivale settlement in Isingiro District and Kyaka II in Kyegegwa District, where, thanks to the Ugandan government's refugee-friendly policy, they cultivate small pieces of land. Among the aid delivery gaps were the provision of shelter (plastic sheeting), water, health and sanitation, infrastructure and refugee protection. She urged a shift in humanitarian assistance so that relief aid goes hand-in-hand with livelihood support ‘right from day one'.
Equitable health services
Chronic Myeloid Leukemia (CML), a rare disease, can be treated effectively, but the pharmaceutical treatment available (imatinib) is costly and unaffordable by most patients. 'GIPAP' is a programme set up between a manufacturer and a non-governmental organisation to provide free treatment to eligible CML patients in 80 countries worldwide. This study discusses the socio-economic and demographic characteristics of patients participating in GIPAP. It researches the impact GIPAP is having on health outcomes (survival) of assistance-eligible CML patients and discusses the determinants of such outcomes and whether there are any variations according to socio-economic, demographic, or geographical criteria. Data for 13,568 patients across 15 countries, available quarterly, was analysed over the 2005-2007 period. GIPAP was found to have a significant positive effect on patient access to medicines for CML and on survival rates.
Malawi's government has set itself a major challenge this year, announcing plans to more than double the number of people receiving antiretroviral (ARV) drugs to half a million by the end of 2010. The country recently adopted new World Health Organization (WHO) guidelines that raise the threshold for ARV therapy from a CD4 count (a measure of immune system strength) of less than 200, to a CD4 count of 350, regardless of whether the patient is displaying symptoms. Some experts argue that starting patients on ARVs earlier could save the government money in the long term by reducing opportunistic infections such as tuberculosis. UNAIDS Country Coordinator, Patrick Brenny, said the targets were reachable, provided the country could mobilise the resources, including money, drugs and manpower. He noted that the Global Fund to Fight AIDS, Tuberculosis and Malaria had expressed willingness to fund implementation of new WHO treatment guidelines. Malawi has just had its funding extended by the Fund for a further six years and is now looking at how to make best use of the money in relation to the new guidelines. Brenny said Malawi was also researching ways to reduce its high dependence on foreign aid, including the possibility of building a local ARV manufacturing plant in partnership with Indian drug companies.
Adequate ventilation can reduce the transmission of infection in health-care settings. Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections in health care. This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings.
Alcohol use disorders (AUDs) – conditions that range from hazardous and harmful alcohol use to alcohol dependence – are a low priority in low- and middle-income countries (LMICs), despite causing a large health burden. Most alcohol-related harm is attributable to hazardous/harmful drinkers who make disproportionate use of primary health care systems, but often go undetected and untreated for long periods, even though brief, easily delivered interventions are effective in this group of people. Health care systems in LMICs currently focus on providing tertiary care services for the treatment of dependence (where there is often a poor outcome). This study indicates that the focus needs to shift towards the cost-effective strategy of providing brief interventions for early AUDs. Effective evidence-based combinations of psychosocial and pharmacological treatments for AUDs are available in LMICs but are costly to implement. Policy makers need to ensure that people with AUDs are offered the most appropriate services using stepped-care solutions that start with simple, structured advice for risky drinkers and progress to specialist treatment services for more serious AUDs. LMICs also need to improve their implementation of proven population-level preventive measures to reduce the health burden due to AUDs. An international Framework Convention on Alcohol Control may help them do this.
Two-thirds of people with dementia live in low- and middle-income countries (LMICs), where there are few services available and levels of awareness and help-seeking are low. After early diagnosis, the principal goals for management of dementia are optimising physical health, cognition, activity, and wellbeing; detecting and treating behavioural and psychological symptoms (BPSD); and providing information and long-term support to carers. This study recommends that routine packages of continuing care should comprise diagnosis coupled with information, regular needs assessments, physical health checks, and carer support, and where necessary carer training, respite care, and assessment and treatment of BPSD. Care can be delivered by trained primary care teams working in a collaborative care framework. Continuing care with practice-based care coordination, and community outreach are essential components of this model. Efficient care delivery in LMICs involves integrating dementia care with that of other chronic diseases and community-support programmes for the elderly and disabled.
Depression is clearly a global health priority. Improving the recognition of this disorder in clinical populations in LMICs is aided by the successful adaption of depression-screening instruments from HIC settings into settings with few resources and weaker health systems. This review suggests that evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression; it is important, however, that such treatments are adapted when used in LMICs to increase their acceptability, accessibility, and manage their costs. The review proposes two packages of care on the basis of the availability of mental health specialist resources. The delivery of these treatments should ideally be carried out through an integration of depression programmes into existing health services or community settings with task-shifting to non-specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers.
It is estimated that about 41.7 million people need treatment for schizophrenia and related disorders in low- and middle-income countries (LMICs). The majority of these cases are concentrated in Asia (70%) and Africa (16%). In countries with low resources, general physicians and primary health care workers can be trained to recognise and treat people with psychotic disorders in the community. This study found that health systems can scale up such interventions across all routine-care settings by training general physicians and primary health care workers to recognise and treat clients with schizophrenia with effective, evidence-based interventions. In addition, first- and second-generation antipsychotics (FGAs and SGAs) are similarly effective in the acute treatment of psychotic symptoms. In addition, a number of trials have shown the efficacy of psycho-educational strategies to improve adherence to antipsychotics, to decrease relapse and readmission rates, and to have a positive impact in social functioning of family members and patients. The study recommends a package of care combining low doses of conventional antipsychotics along with brief and simple psycho-educational interventions as an important strategy to decrease the treatment gap for schizophrenia in LMICs. The combination of FGAs and psycho-educational interventions are more cost-effective than the use of drugs alone.
South Africa’s health minister, Dr Aaron Motsoaledi, is reported as having called for South Africa’s health system to make a 180 turn away from the dominant curative health system, which is unsustainable and unaffordable, to a health system where prevention is the cornerstone. This and the primary health care approach is argued by the Minister to make the national health insurance system an affordable option and to improve equity and universal coverage.
This study investigated knowledge of, perceptions of and access to tuberculosis (TB) treatment and adherence to treatment among an Eastern Cape population in South Africa. An area-stratified sampling design was applied. A total of 1,020 households were selected randomly in proportion to the total number of households in each neighbourhood. It found TB knowledge was fairly good among this community. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say and therefore may not seek treatment. Regression analyses revealed that in this population young and old, men and women and the lower and higher educated share the same attitudes and perceptions, suggesting that the findings are likely to reflect the actual situation of TB patients in the population. Future interventions should be directed at improving attitudes and perceptions to potentially reduce stigma. This requires a patient-centred approach to empower TB patients and their active involvement in the development and implementation of stigma reduction programmes.