The scale-up of antiretroviral therapy (ART) for HIV-infected people in sub-Saharan Africa (SSA) over the past 15 years is one of the most remarkable achievements in public health. With approximately 12 million people on treatment in 2015, life expectancy on the subcontinent has vastly improved. Nevertheless, ART coverage in SSA is still suboptimal, HIV incidence remains high, and improved survival due to ART implies ever increasing numbers of people on treatment. Substantial additional resources are needed to further scale up ART, yet funding has recently levelled off, increasing the need to optimise the allocation of limited resources. This presents local policy makers with complex dilemmas. The authors argue that the current evidence base for prioritising ART scale-up strategies leads to recommendations that are theoretically optimal but practically infeasible to implement. They argue that cost-effectiveness analyses of scaling up ART in SSA take into account the local health system by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.
Equitable health services
The District Health Barometer (DHB) 2015/16, in its 11th edition, seeks to highlight, health system performance, inequities in health outcomes, and health-resource allocation and delivery, and to track the efficiency of healthcare delivery processes across all provinces and districts in South Africa. It has become a planning and management resource for health service providers, managers, researchers and policy-makers. This DHB contains 44 indicators, with trend illustrations and health profiles across South Africa’s nine provinces and 52 health districts. It includes a chapter on the burden of disease, as well as seven additional indicators, including: inpatient under 5 years death rate, percentage of ideal clinics, percentage of assessed PHC facilities with patients who have access to a medical practitioner and the MDR-TB treatment success rate.
The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework. The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. The authors propose that policy makers and program managers consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. They argue that researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.
On Jan 31, 2017, heads of states and governments of the African Union and the leadership of the African Union Commission officially launched the Africa Centres for Disease Control and Prevention (Africa CDC) in Addis Ababa, Ethiopia. As detailed in the African Union's Africa Agenda 2063—a roadmap for the development of the continent—some of the concerns that justified the establishment and initiation of an Africa-wide public health agency include rapid population growth; increasing and intensive population movement across Africa, with increased potential for new or re-emerging pathogens to turn into pandemics; existing endemic and emerging infectious diseases, including Ebola; antimicrobial resistance; increasing incidence of non-communicable diseases and injuries; high maternal mortality rates; and threats posed by environmental toxins.
Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, this paper identified gaps in service utilization in four different. A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 ‘seeds’ identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs’ sociodemographic characteristics. The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. The authors advise that intervention packages to improve use of contraceptives and SRH services be tailored to gaps in each city.
mHealth is a promising means of supporting adherence to treatment. The Start TB patients on ART and Retain on Treatment (START) study included real-time adherence support using short-text messaging service (SMS) text messaging and trained village health workers (VHWs). The authors describe the use and acceptability of mHealth by patients with HIV/tuberculosis and health care providers. Patients and treatment supporters received automated, coded medication and appointment reminders at their preferred time and frequency, using their own phones, and $3.70 in monthly airtime. Facility-based VHWs were trained to log patient information and text message preferences into a mobile application and were given a password-protected mobile phone and airtime to communicate with community-based VHWs. The use of mHealth tools was analysed from process data over the study course. Acceptability was evaluated during monthly follow-up interviews with all participants and during qualitative interviews with a subset of 30 patients and 30 health care providers at intervention sites. Use and acceptability were contextualised by monthly adherence data. From April 2013 to August 2015, the automated SMS system successfully delivered 39,528 messages to 835 individuals, including 633 patients and 202 treatment supporters. Uptake of the SMS intervention was high, with 92.1% of 713 eligible patients choosing to receive SMS messages. Patient and provider interviews yielded insight into barriers and facilitators to mHealth utilisation. The intervention improved the quality of health communication between patients, treatment supporters, and providers. HIV-related stigma and technical challenges were identified as potential barriers. The mHealth intervention for HIV/tuberculosis treatment support in Lesotho was found to be a low-tech, user-friendly intervention, which was acceptable to patients and health care providers.
There is international evidence that people with disabilities face barriers when accessing primary healthcare services and that there is inadequate information about effective interventions that work to improve the lives of people with disabilities, especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities. This study explored the challenges faced by people with disabilities in accessing healthcare in Madwaleni, a poor rural Xhosa community in South Africa. Purposive sampling was done with 26 participants, using semi-structured interviews and content analysis to identify major themes. The study showed a number of barriers to healthcare for people with disabilities. These included practical barriers, including geographical and staffing issues, and attitudinal barriers.
Mental, neurological and substance use disorders contribute to a significant proportion of the world’s disease burden, including in low and middle income countries. In this study, the authors focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. A checklist guided by the World Health Organisation Assessment Instrument for Mental Health Systems was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analysed using thematic content analysis. Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilisation for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be inadequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate. Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services.
In a double move hailed as a milestone for public health, African leaders have launched an agency to tackle global threats such as Ebola and pledged to make immunisation available throughout the continent by 2020. Under the twin commitments, African heads of state will establish regional health centres around the continent, increase funding for immunisation, improve supply chains and delivery, and prioritise vaccines as part of broader efforts to strengthen health systems. At the heart of the new health push will be the Africa Centres for Disease Control and Prevention, which will help countries across the continent to deal with major health emergencies by establishing systems for early warning and response surveillance. Based in Addis Ababa, the new organisation will liaise with regional centres in Zambia, Gabon, Kenya, Nigeria and Egypt. Dr Matshidiso Moeti, the World Health Organization’s (WHO) regional director for Africa, said the announcements, made on Tuesday at the African Union summit in Addis Ababa, demonstrated a strong commitment by African leaders to “save lives across the continent”. “This is a very important milestone,” said Moeti. “We are extremely excited to have got here with the immunisation declaration. It’s something we worked on for quite a few months with a range of partners, and it includes commitments with heads of state and partners in mobilising finances for the vaccines.
“It shows leaders reiterating their commitments to saving the lives of children across the continent, and contributing their own funding, as they transition into middle-income states.”
There are few reports of the effect of socioeconomic and potentially modifiable factors on the control of hypertension in South Africa (SA). This study investigated associations between patients’ socioeconomic status and characteristics of primary healthcare facilities, and control and treatment of blood pressure in hypertensive patients. The authors enrolled hypertensive patients attending 38 public sector primary care clinics in the Western Cape, SA, in 2011, and followed them up 14 months later as part of a randomised controlled trial. Blood pressure was measured and prescriptions for antihypertension medications were recorded at baseline and follow-up. Blood pressure was uncontrolled in 60% of patients at baseline, less likely in patients with a higher level of education or in English compared with Afrikaans respondents. Treatment was intensified in 48% of patients with uncontrolled blood pressure at baseline, more likely in patients with higher blood pressure at baseline, concurrent diabetes, more education and those who attended clinics offering off-site drug supply, with a doctor every day or with more nurses. Patient and clinic factors influence blood pressure control and treatment in primary care clinics in SA. Potential modifiable factors include ensuring effective communication of health messages, providing convenient access to medications, and addressing staff shortages in primary care clinics.