In this study, the authors compare the health system and other contexts between Tanzania and Ghana that are relevant to the scaling up of continuous delivery of insecticide treated nets (ITNs) for malaria prevention. While both countries have made major efforts and investments to address this intervention through integrating consumer discount vouchers into the health system, the schemes have been more successful in Tanzania. The authors found that contextual factors that provided an enabling environment for the voucher scheme in Tanzania did not do so in Ghana. The voucher scheme was never seen as an appropriate national strategy, other delivery systems were not complementary and the private sector was under-developed. The extensive time devoted to engagement and consensus building among all stakeholders in Tanzania was an important and clearly enabling difference, as was public sector support of the private sector. This contributed to the alignment of partner action behind a single co-ordinated strategy at service delivery level which in turn gave confidence to the business sector and avoided the ‘interference’ of competing delivery systems that occurred in Ghana.
Equitable health services
A Health Policy Dialogue was held in Accra, Ghana, on 26 July 2012 to identify ways in which to help Kayayei (headload porters) better access health services, and to help integrate these workers into the Ghanaian National Health Insurance Scheme (NHIS). At the Dialogue, a case study of the Ghana NHIS was presented, which showed that the Kayayei were unable to easily use the health services in Accra. A large number of Kayayei were not registered with the NHIS. Most could not afford the premium, even though the minimum annual premium is set at US$5. In practice, $15-$20 is charged as a minimum in urban areas and many Kayayei earn $2-3 or less a day, making this unaffordable for them. Those few who could afford to join complained that they were mistreated or ignored when they went to use the health services. The Ministry of Health has indicated a willingness to enter into discussions with the Kayayei associations and WIEGO on the poor quality of care received by these workers when accessing health services. Ministry of Health officials proposed that clinics and hospitals in areas where Kayayei live and work should have doctors and nurses specially mandated to look after their needs.
Many patients present to an emergency centre (EC) with problems that could be managed at primary healthcare (PHC) level. This has been noted at George Provincial Hospital in the Western Cape province of South Africa. In order to improve service delivery, researchers in this study aimed to determine the patient-specific reasons for accessing the hospital EC with PHC problems. A descriptive study using a validated questionnaire to determine reasons for accessing the EC was conducted among 277 patients who were triaged as green (routine care), using the South African Triage Score. The duration of the complaint, referral source and appropriateness of referral were recorded. Of the cases 88.2% were self-referred and 30.2% had complaints persisting for more than a month. Only 4.7% of self-referred green cases were appropriate for the EC. The three most common reasons for attending the EC were that the clinic medicine was not helping (27.5%), a perception that the treatment at the hospital is superior (23.7%), and that there was no PHC service after-hours (22%). Increased acceptability of the PHC services is needed, the authors conclude. The current triage system must be adapted to allow channelling of PHC patients to the appropriate level of care. Strict referral guidelines are needed.
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.
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.