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.
Equitable health services
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.
Adherence to antiretroviral therapy (ART) is important to optimise treatment outcomes and prevent the development of drug resistance. It is however compromised under a number of situations in the countries most heavily affected by HIV and AIDS. The question this paper is concerned with is: ‘How do we keep people on treatment?’ It proposes that the answer to this question is an improved understanding of why adherence is important; what levels of adherence are needed to ensure that treatment remains effective; how different types of crisis affect access to treatment; and how patients and service providers respond to difficulties. The paper considers the longer-term impact of unplanned ART treatment interruptions and offers suggestions as to how they might be avoided and managed in future. It considers three case studies, by looking at the problems with health system functioning and ART delivery during the 2007 public sector strike in South Africa, the ongoing political and economic crisis in Zimbabwe and the 2008 floods in Mozambique. It is based on a literature review and a relatively small number of interviews with health managers and clinicians in each country.
Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. New research presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco has shown that cervical cancer screening among HIV-positive women prevented one death for every 32 women screened. The research originated from a pilot study of about 6,600 HIV-positive women examined as part of the Cervical Cancer Prevention Programme in Zambia (CCPPZ), an ongoing low-cost screening project. More than half the women had abnormal results, and about 20% were diagnosed as having lesions at varying stages from pre-cancerous to advanced cancer. Screening by the programme's service costs about US$1 as compared to pap smears that cost about $15 and remain prohibitively expensive even in richer countries like South Africa. To keep costs this low, the programme enables health workers and nurses to carry out screening and treatment, allowing doctors - already in short supply - to perform other tasks. The screening programme has also drawn interest from other countries, including Botswana, Tanzania and Cameroon, which have sent delegations for training.
This study took the form of a randomised, placebo-controlled, multicenter trial in South Africa and Malawi to evaluate the efficacy of a live, oral rotavirus vaccine in preventing severe rotavirus gastroenteritis. A total of 4,939 infants were enrolled and randomly assigned to one of the three groups: 1,647 infants received two doses of the vaccine, 1,651 infants received three doses of the vaccine, and 1,641 received placebo. Of the 4,417 infants included in the per-protocol efficacy analysis, severe rotavirus gastroenteritis occurred in 4.9% of the infants in the placebo group and in 1.9% of those in the pooled vaccine group. Vaccine efficacy was lower in Malawi than in South Africa (49.4% vs. 76.9%); however, the number of episodes of severe rotavirus gastroenteritis that were prevented was greater in Malawi than in South Africa (6.7 vs. 4.2 cases prevented per 100 infants vaccinated per year). Efficacy against all-cause severe gastroenteritis was 30.2%. In conclusion, human rotavirus vaccine significantly reduced the incidence of severe rotavirus gastroenteritis among African infants during the first year of life.
The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. This study investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country’s pharmaceutical businesses. The findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. Sound coordination is needed between public medicine wholesalers and their clients to harmonise procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.
This report is a short update to the WHO report on global tuberculosis (TB) control that was published in March 2009, based on data collected from July to September 2009. It is designed to fill an 18-month gap between the full reports of 2009 (in March) and 2010 (in October), following changes to the production cycle of the report in 2009 that have been made to ensure that future reports in the series contain more up-to-date data. In 2008, there were an estimated 8.9–9.9 million incident cases of TB, 9.6–13.3 million prevalent cases of TB, 1.1–1.7 million deaths from TB among HIV-negative people and an additional 0.45–0.62 million TB deaths among HIV-positive people (classified as HIV deaths in the International Statistical Classification of Diseases), with best estimates of 9.4 million, 11.1 million, 1.3 million and 0.52 million, respectively. The number of notified cases of TB in 2008 was 5.7 million, equivalent to 55–67% of all incident cases, with a best estimate of 61% (10% less than the Global Plan milestone of a case detection rate of 71% in 2008). Among patients in the 2007 cohort, 87% were successfully treated; this is the first time that the target of 85% (first set in 1991) has been exceeded at global level. Funding for TB control has increased since 2002, and is expected to reach US$ 4.1 billion in 2010. Funding gaps remain, however; compared with the Global Plan, funding gaps amount to at least US$ 2.1 billion in 2010.
This report offers a fresh and practical approach to strengthening health systems through ‘systems thinking’. It first decodes the complexity of a health system, and then applies that understanding to design better interventions to strengthen health systems, increase coverage, and improve health. The report suggests ways to more realistically forecast how health systems might respond to strengthening interventions, while also exploring potential synergies and dangers among those interventions. Additionally, it shows how better evaluations of health system strengthening initiatives can yield valuable lessons about what works, how it works and for whom. It is hoped that this report will deepen understanding and stimulate fresh thinking among stewards of health systems, health systems researchers, and development partners.