In this study, researchers assessed knowledge of tuberculosis (TB) and HIV, and perceptions about provider-initiated testing and counselling (PITC) among TB patients attending health facilities in Harar town, Eastern Ethiopia. Using a semi-structured questionnaire, a total of 415 study participants were interviewed about their knowledge of TB and HIV as well as the impact of HIV testing on their treatment-seeking behaviour. Results showed that living more than 10 km from a health facility was associated with low knowledge of TB and low knowledge of HIV testing. Delay in treatment was more likely among female participants, single participants and those living more than 10 km from a health facility. Most of the study participants (70%) believed that there was no association between TB and HIV and AIDS, while most (81.6%) of the study participants who were 21 years old or younger believed that fear of PITC could cause delay in treatment seeking. The authors recommend that emphasis should be given to improving knowledge of TB and HIV among residents living far from a health facility, as well as to improving the negative perceptions of PITC among young adults.
Equitable health services
Little conceptual or empirical work exists on the measurement of antenatal care (ANC) quality at health facilities in low-income countries. To address this gap, researchers in this study developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers. They included 1,299 antenatal facilities in the study and compared the quality of ANC received by 4,148 mothers between 2002 and 2007. Results showed that only 45 antenatal facilities (3%) fulfilled the study’s developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. The authors argue that these results indicate missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect the “quality gap” where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.
Commonly available malaria maps are based on parasite rate, a poor metric for measuring malaria at extremely low prevalence. New approaches are required to provide case-based risk maps to countries seeking to identify remaining hotspots of transmission while managing the risk of transmission from imported cases. In this study, household locations and travel histories of confirmed malaria patients during 2011 were recorded for the higher transmission months of January to April and the lower transmission months of May to December. Data was gathered and used to generate maps predicting the probability of a locally acquired case at 100 m resolution across Swaziland for each season. Results indicated that case households during the high transmission season tended to be located in areas of lower elevation, closer to bodies of water, in more sparsely populated areas, with lower rainfall and warmer temperatures, and closer to imported cases. The high-resolution mapping approaches described here can help elimination programmes understand the epidemiology of a disappearing disease. The authors argue that generating case-based risk maps at high spatial and temporal resolution will allow control programmes to direct interventions proactively according to evidence-based measures of risk and ensure that the impact of limited resources is maximised to achieve and maintain malaria elimination.
The authors of this study synthesised the findings of all relevant qualitative studies reporting on the views and experiences of women in low- and middle-income countries (LMICs) who received inadequate antenatal care. The synthesis revealed that centralised, risk-focused antenatal care programmes may be at odds with the resources, beliefs, and experiences of pregnant women who underuse antenatal services. These findings suggest that there may be a misalignment between current antenatal care provision and the social and cultural context of some women in LMICs. Antenatal care provision that is theoretically and contextually at odds with local contextual beliefs and experiences is likely to be underused, especially when attendance generates increased personal risks of lost family resources or physical danger during travel, when the promised care is not delivered because of resource constraints, and when women experience covert or overt abuse in care settings.
Despite Malawi government’s policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care. This study explored the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. Results indicated that onset of labour at night, rainy season, rapid labour, socio-cultural factors and health workers’ attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbours. Most women went to the health facility the same day after delivery. This study reveals beliefs about labour and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. There is a need for further exploration of barriers that prevent women from accessing health care.
This review examined approaches for delivering child and newborn interventions to large populations and how research can help achieve universal coverage of essential maternal, newborn and child health interventions. The literature review included 87 articles, which described 79 discrete studies, mostly in developing countries. The authors found that interventions are available that can prevent serious illness and save the lives of millions of infants and children living in low- and middle-income countries but achieving universal coverage of these interventions depends on a functional health system, the delivery approach used by that system, and community or individual considerations such as access, demand for and acceptability of the intervention, and ability to comply. The authors found that little is known about the process of scaling up, namely, moving from delivery in one district to national coverage – more research is needed. They recommend that any intervention aimed at reducing financial or physical barriers should consider questions of affordability, equity and sustainability. Strategies taking health interventions directly to communities and individual homes can increase the uptake and improve the quality of local services, helping to reduce maternal, newborn and infant mortality, though findings were inconsistent. The authors call for knowledge and training to be linked with establishing conditions that encourage health workers to change their practices in terms of leadership, motivation, opportunity and accountability.
The authors of this paper drew upon local-level research to examine the roll out of treatment for two neglected tropical diseases (NTDs) – schistosomiasis and soil-transmitted helminthes – in Uganda. Ethnographic research was undertaken over a period of four years between 2005-2009 in north-west and south-east Uganda to determine the effectiveness of mass drug administration (MDA) for the two NTDs. In addition to participant observation, survey data recording self-reported take-up of drugs was collected from a random sample of at least 10% of households at study locations. The comparative analysis of take-up among adults revealed that, although most long-term residents have been offered treatment at least once since 2004, the actual take-up of drugs varies considerably from one district to another and often also within districts. The authors argue that this is due to local dynamics and highlight the need to adapt MDA to local circumstances. They call for improvements in health education, drug distribution and more effective use of existing public health legislation. Current standard practices of monitoring, evaluation and delivery of MDA for NTDs were found to be inconsistent and inadequate.
The aim of this study was to synthesise recent evidence on how to scale up the delivery of malaria interventions in endemic regions through a systematic review of the available literature. The researchers included 39 papers, including 19 African countries, related to scaling up the delivery of intermittent preventive treatment in pregnancy (IPTp), artemisinin combination therapy (ACT) or insecticide-treated nets (ITNs). They found that relatively few strategies for scaling up have been reported in published literature and acute knowledge gaps exist for scale up of diagnostics and treatment. In terms of coverage and equity, the evidence to link changes in coverage to any specific strategy was found to be weak. IPTp coverage was low, while a 15% increase in ACT among children was reported with delivery through accredited drug dispensing outlets and health facilities in Tanzania. For ITN programmes, reaching programme targets was associated with free delivery through campaigns. There was a shortage of information on facilitators and barriers to scale up and what little was available was setting-specific. The researchers conclude that, to prioritise strengthening of health system elements for scale up, additional research methods and new studies are needed to fill the knowledge gap.
The aim of this study was to synthesise knowledge concerning various models for the integrated delivery of TB/HIV services at health facility level in low- and middle-income countries. The authors conducted a systematic review of literature, selecting 63 papers and 70 abstracts for inclusion, which described 136 examples of models of integration. Strengths and weaknesses of different models of integration are identified. Models based on referral only are easiest to implement, requiring as little as additional staff training and supervision, if a functional referral system exists, but optimal communication is necessary. Models with closer integration are more efficient but require more staff training and may also require additional infrastructure, e.g. private space for HIV counselling. The authors conclude that their comparison of different models of integration of tuberculosis and HIV services was undermined by a lack of rigorous studies. More research is needed to investigate potential efficiencies of integrated care from the perspective of both provider and service user.
Médecins Sans Frontières welcomes the World Health Organization’s (WHO) proposed Global Immunization Vision and Strategy, which encourages a rebalancing of the global vaccine strategy so that support for the introduction of the newer vaccines does not mean momentum is lost as regards the need to ensure basic immunisation. New vaccines such as pneumococcal vaccines have the potential to avert millions of deaths worldwide, but MSF argues that the need for their medical teams to intervene in several measles outbreak responses illustrates the weak coverage of traditional vaccines, and is a clear indication of the failure of routine basic immunisation, despite the global decrease in measles morbidity and mortality. National immunisation programmes should be supported to leverage every interaction with young children to provide ‘catch-up’ vaccinations. The report lacks strategies and concrete actions to bring vaccine prices down, according to MSF, despite the fact that the WHO admits that vaccine prices continue to be a major obstacle. MSF notes that the current funding crisis at the GAVI Alliance is partly due to overpriced vaccines. Too much emphasis has been put on incentivising multinational pharmaceutical companies, at the expense of investing in support to emerging producers that can produce quality vaccines at dramatically reduced prices.