While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. The authors of this paper argue that a comprehensive systems perspective should guide health practice, education, research and policy. They propose key ‘systems thinking’ tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organisations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organisation within health systems, from families and communities to national Ministries of Health.
Equitable health services
Mental disorders constitute a huge global burden of disease, and there is a large treatment gap, particularly in low-income and middle-income countries. This paper assesses the progress in scaling up mental health services worldwide, using a survey of key national stakeholders in mental health. The authors note that major barriers to scaling up of mental health services in countries with low and middle incomes include absence of financial resources and government commitment and over-centralisation. In addition, challenges of integration of mental health care into primary care settings, scarcity of trained mental health personnel and shortage of public health expertise among mental health leaders are tangible barriers as well. As a result, the authors argue that a systemic and strategic approach to scaling up is needed.
In this study, researchers evaluated the effect of a community health worker-based, interpersonal communication campaign for increasing insecticide-treated mosquito net (ITN) use among children in Luangwa District, Zambia, an area with near universal coverage of ITNs and moderate to low malaria parasite prevalence. Results indicated that ITN use among children younger than five years old in households with one ITN increased overall from 54 % in 2008 to 81 % in 2010. However, there was no difference in increase between the treatment and control arms in 2010. ITN use also increased among children five to 14 years old from 37 % in 2008 to 68 % in 2010. There was no indication that the community health worker-based intervention activities had a significant effect on increasing ITN use in this context, over and above what is already being done to disseminate information on the importance of using an ITN to prevent malaria infection. Contamination across control communities, coupled with linear settlement patterns and subsequent behavioural norms related to communication in the area, likely contributed to the observed increase in net use and null effect in this study, the authors conclude.
The authors of this study prospectively assessed resistance to second-line anti-tuberculosis drugs in eight countries, including South Africa. From 1 January 2005 to 31 December 2008, they enrolled consecutive adults with locally confirmed pulmonary multi-drug-resistant (MDR) tuberculosis at the start of second-line treatment. Among 1,278 patients, 43.7% showed resistance to at least one second-line drug, 20% to at least one second-line injectable drug and 12.9% to at least one fluoroquinolone. A total of 6.7% of patients had extremely drug-resistant (XDR) tuberculosis. Previous treatment with second-line drugs was consistently the strongest risk factor for resistance to these drugs, which increased the risk of XDR tuberculosis by more than four times. Fluoroquinolone resistance and XDR tuberculosis were more frequent in women than in men. Unemployment, alcohol abuse and smoking were associated with resistance to second-line injectable drugs across countries. Other risk factors differed between drugs and countries. The authors recommend that representative drug-susceptibility results should guide in-country policies for laboratory capacity and diagnostic strategies.
This study was initiated to establish if any South African ethnomedicinal plants (indigenous or exotic) that have been reported to be used traditionally to repel or kill mosquitoes may exhibit effective mosquito larvicidal properties. Researchers tested extracts of a selection of plant taxa sourced in South Africa for larvicidal properties. Preliminary screening of crude extracts revealed substantial variation in toxicity with 24 of the 381 samples displaying 100% larval mortality within the seven-day exposure period. The researchers then selected four of the high-activity plants and subjected them to bioassay guided fractionation. The results of the testing of the fractions generated identified one fraction of the plant Toddalia asiatica as being very potent against the An. arabiensis larvae. These results have initiated further research into isolating the active compound and developing a malaria vector control tool.
Induction of labour is being increasingly used to prevent adverse outcomes in the mother and the newborn. In this study, researchers assessed the prevalence of induction of labour and determinants of its use in Africa. They performed secondary analysis of the WHO Global Survey of Maternal and Newborn Health of 2004 and 2005 and assessed unmet needs for specific obstetric indications at country level. A total of 83,437 deliveries were recorded in the seven participating countries, including Angola, the Democratic Republic of Congo, Kenya and Uganda. The average rate of induction was 4.4% and the researchers found that induction was associated with reduction of stillbirths and perinatal deaths. Unmet need for induction ranged between 66% and 80.2% across countries. Determinants of having an induction were place of residence, duration of schooling, type of health facility and level of antenatal care. As utilisation of induction of labour in health facilities in Africa is very low and unmet need very high, the authors call for improvements in social and health infrastructure.
To explore perceptions of malaria and utilisation of insecticide-treated bed-nets after a noticeable reduction in malaria incidence in Zanzibar, the authors of this study conducted 19 in-depth interviews with caretakers of children under five in North A district on the island. They found that awareness of malaria among caretakers was high but the illness was now seen as easily curable and uncommon. The discomfort of sleeping under a net during the hot season was identified as the main barrier to consistent bed-net usage. The main cue to using a bed-net was high mosquito density, and children were prioritised when it came to bed-net usage. Caretakers had high perceived self-efficacy and did not find it difficult to use bed-nets. Indoor Residual Spraying (IRS), which was recognised as an additional means of mosquito prevention, was not identified as an alternative for bed-nets. A barrier to net ownership was the increasingly high cost of bed-nets. The authors call on the government to continue providing bed nets through sustainable and affordable delivery mechanisms.
In this study, researchers assessed challenges and enablers for the Expanded Programme on Immunisation (EPI) in South Africa, in light of the approaching 2015 deadline for the Millennium Development Goals. Between September 2009 and September 2010 they requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. Systematic reviews on the effectiveness of the proposed solutions were added. Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes. The findings from reliable systematic reviews indicate that interactive educational meetings, audits and feedback, and supportive supervision improve healthcare worker performance. The authors conclude that numerous promising strategies for improving EPI performance in South Africa were found but their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation.
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This study had two purposes: to evaluate the impact of a universal coverage campaign (UCC) of long-lasting insecticidal nets (LLINs) on LLIN ownership and usage, and to identify factors that may be associated with inadequate coverage. In 2011 two cross-sectional household surveys were conducted in 50 clusters in Muleba district, north-west Tanzania. Prior to the UCC 3,246 households were surveyed and 2,499 afterwards. The proportion of households with at least one ITN increased from 62.6% before the UCC to 90.8% afterwards. Eighty percent of households surveyed received LLINs from the campaign. ITN usage in all residents rose from 40.8% to 55.7%, and after the UCC, 58.4% of households had sufficient ITNs to cover all their sleeping places. Households with children under five years and small households were most likely to reach universal coverage, while poverty was not associated with net coverage. The authors conclude that UCC in Muleba district of Tanzania was equitable, greatly improving LLIN ownership and, more moderately, usage. However, the goal of universal coverage in terms of the adequate provision of nets was not achieved. Multiple, continuous delivery systems and education activities are required to maintain and improve bed net ownership and usage.