The authors of this article challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment in poor countries. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deploying primary and secondary caregivers, using off-patent drugs, and applying regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage, with a focus on people living in poverty. These strategies can reduce costs, increase access to health services and strengthen health systems to meet the challenge of cancer and other diseases, the authors argue. To promote cancer treatment in poor countries, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries was formed in 2009. It is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation and evaluation of strategies to advance this agenda.
Equitable health services
Eclampsia is the commonest direct cause of maternal death in South Africa. The latest Saving Mothers Report (2005-2007) indicates that there were 622 maternal deaths due to hypertensive disorders of pregnancy. Of these, 334 (55.3%) were due to eclampsia; of the eclamptic deaths, 50 were over the age of 35 years and 83 were under 20 years old. Avoidable factors involved patient related factors (mainly delay in seeking help), administrative factors (mainly delay in transport) and health personnel issues (mainly due to delay in referring patients). The major causes of death were cerebrovascular accidents and cardiac failure. The majority of deaths due to cardiac failure were due to pulmonary oedema. To reduce deaths from eclampsia, this study argues that more attention must be given to the detection of pre-eclampsia; the provision of information on the advantages of antenatal care to the population at large and training of health professions in the management of obstetric emergencies.
The United Nations Economic Commission for Africa (UNECA) and the World Health Organization (WHO) are joining forces to establish an African-owned and -governed initiative to promote innovation for the research and development of pharmaceuticals and other products to meet the health needs of the continent. The African Network for Drugs and Diagnostics Innovation (ANDI) will be based in Ethiopia and will help build research capacity on the continent and link biomedical innovation to development and public health. Overall, ANDI aims to mobilise Africa health research capability, uncapping African health innovation potential and expanding global partnerships and regional collaborations to accelerate the delivery of quality health care in Africa. Specific goals include increasing research and development collaboration among African institutions and countries, and fostering public-private partnerships within Africa to support the development and manufacture of new drugs and health products. It also aims to generate and manage intellectual property, explore innovative mechanisms to encourage and reward local innovation – including research drawing on traditional medicine – and promote long-term economic sustainability by supporting research and development.
Despite lack of resources, activities undertaken to mitigate the impact of neglected tropical diseases are so far producing unprecedented results, according to this report. It points to a number of successes: treatment with preventive chemotherapy reached 670 million people in 2008, while dracunculiasis, also called guinea worm disease, is on course to becoming first disease eradicated not by a vaccine, but by health education and behaviour change. Reported cases of sleeping sickness have also dropped to their lowest level in 50 years. The report notes opportunities for strengthening delivery systems, such as by targeting primary schools to treat millions of children for schistosomiasis and helminthiasis in Africa. In addition, better co-ordination is argued to be needed, such as with veterinary public health and to respond to changing disease patterns resulting from climate change and environmental factors.
This report provides highlights of the findings of the phase 1 Researching Equity in Access to Health Care (REACH) project, completed in 2009. REACH aims to document levels of and inequities in access, according to socio-economic status, gender, and urban/rural status, within the public health system for three services: maternal health (focusing on emergency and specialised needs at the time of delivery), tuberculosis (TB) care, and antiretroviral therapy. Detailed case studies were undertaken in various parts of South Africa. During 2008 and 2009, the REACH project undertook exit interviews with approximately 4,000 adult (+18 years) users of TB, HIV and maternal health services, carried out quality of care assessments in fifty health facilities, and analysed secondary data from a variety of sources to establish the socio-economic profile of facility catchment populations. The project found that considerably greater access barriers are experienced by rural compared to urban communities, with respect to distance, time, costs and staff attitudes. Rural women experience large health cost burdens during their pregnancy and at the time of delivery, and coverage by a minimum package of antenatal care is still inadequate. TB services were found to be more accessible than anti-retroviral therapy services in all dimensions of availability, affordability and acceptability. The report also notes there was considerable local variation in nature of services (e.g. home visits) and policies (e.g. birth companions).
Although recent survey data make it possible to examine inequalities in maternal and newborn health care in developing countries, analyses have not tended to take into consideration the special nature of urban poverty. Using improved methods to measure urban poverty in 30 countries, this study found substantial inequalities in maternal and newborn health, and in access to health care. The ‘urban advantage’ is, for some, non-existent. The urban poor do not necessarily have better access to services than the rural poor, despite their proximity to services. There are two main patterns of urban inequality in developing countries: massive exclusion, in which most of the population do not have access to services, and urban marginalisation, in which only the poor are excluded. At a country level, these two types of inequality can be further subdivided on the basis of rural access levels. Inequity is not mandatory. Patterns of health inequality differ with context, and there are examples of countries with relatively small degrees of urban inequity. Women and their babies need to have access to care, especially around the time of birth. Different strategies to achieve universal coverage in urban areas are needed according to urban inequality typology, but the evidence for what works is restricted to a few case studies.
Despite the Zambian Government’s effort to expand services to district level, this study reports that it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages. The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital. The study found that mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases ‘lost to follow-up’. This might be due to the closer involvement of the community and the better support offered by these services to rural clients. These services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.
The South African Mental Health Care Act (the Act) No. 17 of 2002 stipulated that regional and district hospitals be designated to admit, observe and treat mental health care users (MHCUs) for 72 hours before they are transferred to a psychiatric hospital. This study surveyed medical managers in 49 ‘designated’ hospitals in KwaZulu-Natal (KZN) on infrastructure, staffing, administrative requirements and mental health care user case load pertaining to the Act for the month of July 2009. Thirty-six (73.4%) hospitals responded to the survey: 83.3% stated that the Act improved mental health care for MHCUs through the protection of their rights, provision of least restrictive care, and reduction of discrimination; 27.8% had a psychiatric unit and, of the remaining 26 hospitals, 30.6% had general ward beds dedicated for psychiatric admissions; 44.4% had some form of seclusion facility; and 66.7% provided an outpatient psychiatric service. Seventy-six per cent of admissions were involuntary or assisted. Thirteen of the 32 state psychiatrists in KZN were employed at eight of these hospitals. Designated hospitals expressed dissatisfaction with the substantial administrative load required by the Act. The Review Board had not visited 29 (80.6 %) hospitals in the preceding 6 months. Although ‘designated’ hospitals admit and treat assisted and involuntary MHCUs, they do so against a backdrop of inadequate infrastructure and staff, a high administrative load, and a low level of contact with Review Boards.
As a signatory to the UN Convention on the Rights of Persons with Disabilities, South Africa has committed itself to transformation aimed at ending the inequities that characterise mental health service provision and ‘closing the gap’. To measure South Africa’s progress, this study compared budget allocations over a five-year period to six psychiatric and six general hospitals in KwaZulu-Natal (KZN) and contrasted current numbers of psychiatric beds and psychiatric personnel in that province with the numbers required to comply with national norms. It found that the mean increase in budget allocations to public psychiatric hospitals was 3.8% per annum, while that to general hospitals over the same period was 10.2% per annum. The median cumulative budget increase for psychiatric hospitals was significantly lower than that of general hospitals. No psychiatric hospitals received specific funding for tertiary services development. KZN has 25% of the acute psychiatric beds and 25% of the psychiatrists required to comply with national norms, with the most serious shortages experienced in northern KZN. There are 0.38 psychiatrists per 100 000 population in KZN. In conclusion, the author argues that inequitable funding, inadequate facilities and significant shortages of mental health professionals pervade the mental health and psychiatric services in KZN; and that there is little evidence of government abiding by its public commitments to redress the inequities that characterise mental health services.
This presentation investigates the barriers to access that couples face when deciding to use family planning. It identifies a number of key barriers in Africa, including limited method choice, prohibitive financial costs, psychosocial factors relating to the status of women, medical and legal restrictions, provider bias and misinformation. The author of the presentation has two recommendations. Firstly, Governments should prioritise family planning and have line items in their budgets for family planning training and services, and for commodities. Secondly, they should make available the fullest possible range of contraceptive choices, including voluntary sterilisation, through the widest range of distribution channels, backed up by access to safe abortion.