Inadequate illness recognition and access to antibiotics contribute to high case fatality from infections in young infants (<2 months) in low- and middle-income countries (LMICs). The authors aimed to address three questions regarding access to treatment for young infant infections in LMICs: (1) Can frontline health workers accurately diagnose possible bacterial infection (pBI)?; (2) How available and affordable are antibiotics?; (3) How often are antibiotics procured without a prescription? Data were identified from 37 published studies, 46 WHO/Health Action International national surveys, and eight service provision assessments. Availability of first-line injectable antibiotics appears low in many health facilities in Africa and Asia. Improved data and advocacy are needed to increase the availability and appropriate utilization of antibiotics for young infant infections in LMICs.
Equitable health services
The 67th World Health Assembly (WHA) in May 2014 mandated the WHO Secretariat “to develop a draft global action plan to combat antimicrobial resistance, including antibiotic resistance, which addresses the need to ensure that all countries, especially low and middle income countries. The Global Action Plan (GAP) is to be submitted to the 68th WHA through the 136th Session of the Executive Board meeting which will take place on 26 January to 3 February 2015 in Geneva. The author argues that the draft GAP fails to provide bold solutions especially where the pharmaceutical transnational corporations (TNCs) and their home countries have vested interests. The areas where the plan is argued to raise concern are: on the mechanism to ensure access to antimicrobial medicines at affordable prices, including local production capabilities of antimicrobial medicines and diagnostics, technology transfer and public procurement. Another major area of strategic silence is the research and development (R&D) of new AMR medicines including antibiotics and diagnostics. Other important omissions are the explicit mention of promotion of rational use of antimicrobial medicines and the management of conflict of interests.
This study assesses facilitators and barriers to institutional delivery in three districts of Tanzania. Data was drawn from a cross-sectional survey of random households on health behaviours and service utilization patterns among women and children aged less than 5 years. The survey was conducted in 2011 in Rufiji, Kilombero, and Ulanga districts of Tanzania, using a closed-ended questionnaire. This analysis focuses on 915 women of reproductive age who had given birth in the two years prior to the survey. Chi-square test was used to test for associations in the bivariate analysis and multivariate logistic regression was used to examine factors that influence institutional delivery. Overall, 74.5% of the 915 women delivered at health facilities in the two years prior to the survey. Multivariate analysis showed that the better the quality of antenatal care (ANC) the higher the odds of institutional delivery. Similarly, better socioeconomic status was associated with an increase in the odds of institutional delivery. Women of Sukuma ethnic background were less likely to deliver at health facilities than others. Presence of couple discussion on family planning matters was associated with higher odds of institutional delivery. Institutional delivery in Rufiji, Kilombero, and Ulanga district of Tanzania is relatively high and significantly dependent on the quality of ANC, better socioeconomic status as well as between-partner communication about family planning. Therefore, improving the quality of ANC, socioeconomic empowerment as well as promoting and supporting inter-spousal discussion on family planning matters is likely to enhance institutional delivery. Programs should also target women from the Sukuma ethnic group towards universal access to institutional delivery care in the study area.
Mobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed. The authors systematically searched databases and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa. There is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa. The authors present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care. This framework can guide approaches to fill evidence gaps in this area.
The green paper for the national health insurance scheme in South Africa has identified private community pharmacies as potential access points for medicines, in combination with public clinics. This study examined changes in the ownership and geographical distribution of community pharmacies between 1994 and 2012 using routine national data. The authors summed community pharmacies and public clinics to assess their combined provincial distribution patterns against a South African benchmark of one clinic per 10000 residents. The study shows that monitoring trends in the distribution of community pharmacies is feasible. It shows that the increase in the number of community pharmacies has not kept pace with population growth and there are differences between urban and rural provinces and between the most and least deprived districts. Although corporations have seen substantial growth, this has not resulted in improved density ratios or equity in distribution.
Effective and simple interventions and tools exist that can be used to either prevent, treat or rehabilitate patients suffering from infectious diseases of poverty (IDoP). The delivery of these interventions and tools to the affected populations, however, has proven difficult due to weak public health systems in many disease-endemic countries. Disease control and public health programmes are increasingly advocating community-based delivery strategies and interventions. These depend, to a large degree, on trained community health workers whose performance in various areas of health care such as maternal and child health has been the subject of rigorous recent systematic reviews. Community-based delivery platforms are increasingly being proposed not only to ensure sustainability and combat co-infections, but also to build capacity for integration of NTDs with existing malaria, tuberculosis, and HIV/AIDS programs for which more sophisticated healthcare delivery systems already exist. This thematic series of eight papers provides an overview on infectious diseases of poverty and integrated community-based interventions, describes the analytical framework and the methodology used to guide the systematic reviews, reports findings for the effectiveness of community-based interventions for the prevention and control of helminthic NTDs, non-helminthic NTDs, malaria, HIV/AIDS and tuberculosis and proposes a way forward. While previous reviews focus on process and effectiveness of integrated community-based interventions under real life field conditions, this series of papers evaluates the efficacy of such interventions with respect to disease or prevention outcomes.
Disparities in use of healthcare services between rural and urban areas have been empirically attributed to several factors. This study explores the existence of this disparity and its implication for planning and managing healthcare delivery systems. The objectives determine the relative importance of the various predisposing, enabling, need and health services factors on utilisation of health services; similarity between rural and urban areas; and major explanatory variables for utilisation. A four-stage model of service utilisation was constructed with 31 variables under appropriate model components. Data is collected using cross-sectional sample survey of 1086 potential health services consumers in selected health facilities and resident milieu via questionnaire. Data is analysed using factor analysis and cross tabulation. The 4-stage model is validated for the aggregate data and data for the rural areas with 3-stage model for urban areas. The order of importance of the factors is need, enabling, predisposing and health services. 11 variables are found to be powerful predictors of utilisation. Planning of different categories of health care facilities in different locations should be based on utilisation rates while proper management of established facilities should aim to improve health seeking behaviour of people.
The authors describe the nature of geriatric medical admissions to teaching hospitals in three countries in Africa (Nigeria, Sudan, Tanzania) and compare them with data from the United Kingdom. They included all people aged 60 and older urgently medically admitted from March 1 to August 31, 2012. Data were collected regarding age, sex, date of admission, length of stay, diagnoses, medication, date of discharge or death, and discharge. In Africa, noncommunicable diseases (NCDs) accounted for 81.0% (n = 708) of admissions (n = 874), and tuberculosis, malaria, and the human immunodeficiency virus and acquired immunodeficiency syndrome accounted for 4.6% (n = 40). Cerebrovascular accident (n = 224, 25.6%) was the most common reason for admission, followed by cardiac or circulatory dysfunction (n = 150, 17.2%). Rates of hypertension were remarkably similar in the United Kingdom (45.8%) and Africa (40.2%).In the elderly population, the predicted increased burden of NCDs on health services in Africa appears to have occurred. Greater awareness and some reallocation of resources toward NCDs may be required if the burden of such diseases is to be reduced.
There are many roads to ‘universal health’, and many different outcomes. This paper compares the experiences of Chile and Costa Rica, countries that have come to epitomize opposite approaches to health policy in Latin America. Chile represents the Universal Health Coverage (UHC) model promoted by global health agencies, which focus on public-private insurance schemes covering a limited package of services. Costa Rica represents a Universal Health System (UHS) approach that provides and funds all medical and preventive services to citizens through a single public entity. The authors demonstrate how the insurance-based health system in Chile has underperformed on most accounts when compared to the publicly financed and operated model in Costa Rica. Although both countries have seen major advances in primary care, Chile’s health ‘market’ has led to inefficient use of resources, with higher administrative costs and more irrational medical procedures resulting from oligopolies and collusion among private providers. In terms of affordability, Chileans incur significant out-of-pocket health payments and are more likely to face catastrophic health expenditures. Both countries have good scores on access to basic care, but people in Chile generally face more access barriers, including distance to facilities, wait times and cost. Finally, Costa Ricans continue to be largely satisfied with the quality of their healthcare services, more so than Chileans.
This report addresses the critical choices of fairness and equity that arise on the path to UHC. Accordingly, the report is not primarily about why UHC ought to be a goal, but about the path to that goal. The report may differ from others in the direct way it addresses fundamental issues and difficult trade-offs. This approach was facilitated by the involvement of philosophers and ethicists in addition to economists, policy experts, and clinical doctors.