Equitable health services

Oral cholera vaccination in hard-to-reach communities, Lake Chilwa, Malawi
Grandesso F; Rafael F; Chipeta S; et al: Bulletin of the World Health Organization 96(12), doi: http://dx.doi.org/10.2471/BLT.17.206417, 2018

This study aimed to evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak. The authors performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras. Vaccination coverage with at least one dose was 79.5%, on the lake shores, 99.3% on the islands and 84.7% on zimboweras. Coverage with two doses was 53.0% 91.1% and 78.8% in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies. Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.

Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit
Fairall L; Cornick R; Bateman E: BMJ, doi: https://doi.org/10.1136/bmj.k4451, 2018

Global efforts to strengthen primary healthcare are observed by the authors to have generally not focused on the critical interface between provider and patient but rather on policy, financing and infrastructure. Over the past two decades the Knowledge Translation Unit at the University of Cape Town has worked with government, academic, and non-governmental organisation partners to develop and evaluate health systems innovations that empower frontline providers. The unit developed the Practical Approach to Care Kit (PACK), a programme that covers primary healthcare needs across the life course. At the centre of the programme are concise clinical decision support tools (guides) comprising standardised and user friendly algorithms and checklists that provide a comprehensive and integrated approach to screening, diagnosing, and treating common symptoms and chronic conditions in adults, adolescents, and children. The accompanying training programme uses case-based, short training sessions delivered by existing health staff to support frontline providers and their teams. PACK provides decision support tools and training to support frontline providers in low and middle income countries. It prompts primary care health workers to claim “system agency” based on an intervention that resonates with their primary identity as clinicians. The authors suggest that delivering on universal primary healthcare requires a change in investments to prioritise comprehensive approaches that can meet the changing burden of disease

Oral cholera vaccine coverage during a preventive door-to-door mass vaccination campaign in Nampula, Mozambique.
Sema Baltazar C; Rafael F; Langa J; Chicumbe S; et al: PLoS ONE 13(10) 1-13, 2018

In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two- dose regimen of the ShancholTM OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess oral cholera vaccine coverage, frequency of adverse events following immunization, vaccine acceptability and reasons for non-vaccination. In the absence of a household listing and clear administrative neighborhood delimitations, the authors used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose was 69.5% and the two-dose coverage was 51.2%. The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 reported minor and non-specific complaints, and 78 mentioned they did not receive any information before the campaign. In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. The authors’ results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks.

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.