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.
Equitable health services
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.
Governments at the recent World Health Assembly have committed to a higher level of action to combat antibiotic resistance that is an increasing public health threat across the world. On 24 May, a resolution was approved by health ministers on “Combating antimicrobial resistance, including antibiotic resistance” after an important exchange of country positions and one amendment put forward by Mexico with regard to conflict of interests. India supported the antimicrobial resistance (AMR) resolution subject to the understanding that its concerns would be included in the proposed global plan of action. These included financial access of developing countries patients to new antibiotics, news ways of funding research and development based on the delinkage principle in the context of developing countries, and the special needs of developing countries and their capacity building to take on relevant activities. India’s proposal was in lieu of making changes in the resolution text itself which was its first preference. The United Kingdom in its statement also acknowledged the legitimate concern of developing countries on access to antibiotics, and the importance of support for technical capacities and affordable drugs. All Member States agreed on the importance and magnitude of antimicrobial resistance and broad support was heard in the statements made by all delegations on the paramount need to take action. Both developing and developed countries agreed that this is of global magnitude and urged the WHO to develop the action plan and for Member States to build up their own national plans. Developing countries stressed on the urgency of the problem but also on the importance of ensuring access to new antibiotics for developing countries and the mobilization of resources so that they can implement action plans and surveillance.
The African Health Initiative (AHI) has yielded many lessons about how to support health systems within complex and changing geographic, social and political contexts. This has been organised into a series of essays from the field on “What We’re Learning". The first in this series is reported here, with information to support an understanding of the nuances of how health services that result in improvements in population health are delivered.
Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda. Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents. This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3–6 hours before receipt of services although this was more common at public facilities. Only 33% of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% of the survey respondents used these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities. Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, the authors find that governments should strengthen health systems to cater for increasing urban populations.