This policy brief analyses the relationships between Universal Health Coverage (UHC) and Non-Communicable Diseases (NCDs). It covers the unique challenges the NCD epidemic poses to achieving UHC, and the role of UHC in strengthening the NCD response. It also explores the implications and possible position of health, NCDs and UHC in the post-2015 development agenda. The key messages from the report include: UHC is a goal that all governments should commit to. It can help focus greater attention on coverage of quality services, health equity, and guar-anteeing financial-risk protection. The NCD epidemic poses unique challenges to the three dimensions of UHC. Access and availability to essential NCD services remains unacceptably low in many LMICs; major inequalities exist in terms of NCD risk, access to services, and health outcomes; and the epidemic imposes a huge economic burden on national budgets and can push households into poverty. Attainment of UHC will be dependent on prioritising NCD prevention and control in UHC design and implementation. When achieved, UHC can provide a powerful vehicle to accelerate progress on NCD outcomes, inequalities, and socio-economic impact. Lessons learnt from the NCD response can help support pathways to UHC. These include a focus on health promotion and prevention, multi-sectoral approach-es, addressing the social determinants of health, and domestic innovative financing mechanisms (including taxation on unhealthy products). For the post-2015 development agenda to be truly transformative for health, NCDs must be recognised as a priority and UHC must be articulated as a means to achieve improved health outcomes.
Equitable health services
Developing countries with high maternal mortality need to invest in indicators that not only provide information about how many women are dying, but also where, and what can be done to prevent these deaths. The unmet Obstetric Needs (UONs) concept provides this information. This concept was applied at district level in Kenya to assess how many women had UONs and where the women with unmet needs were located. A facility based retrospective study was conducted in 2010 in Malindi District, Kenya. Data on pregnant women who underwent a major obstetric intervention (MOI) or died in facilities that provide comprehensive Emergency Obstetric Care (EmOC) services in 2008 and 2009 were collected. The difference between the number of women who experienced life threatening obstetric complications and those who received care was quantified. The most common MOI was caesarean section, commonly indicated by Cephalopelvic Disproportion (CPD)–narrow pelvis. In absolute terms, 22 (11%) women in 2008 and 12 (6%) in 2009, who required a life saving intervention failed to get it. Deficits in terms of unmet needs were identified in rural areas.
Cervical cancer is a serious public health problem in South Africa. Even though the screening is free in health facilities in South Africa, the Pap smear uptake is very low. The objective of the study is to investigate the knowledge and beliefs of female university students in South Africa. A cross sectional study was conducted among university women in South Africa to elicit information about knowledge and beliefs, and screening history. A total of 440 students completed the questionnaire. Regarding cervical cancer, 55.2% had ever heard about it. Results indicated that only 15% of the students who had ever had sex and had heard about cervical cancer had taken a Pap test. Pearson correlation analysis showed that cervical cancer knowledge had a significantly negative relationship with barriers to cervical cancer screening. Susceptibility and seriousness score were significantly moderately correlated with benefit and motivation score as well as barrier score. Self-efficacy score also had a moderate correlation with benefit and motivation score. Students who had had a Pap test showed a significantly lower score in barriers to being screened compared to students who had not had a Pap test. This study showed that educated women in South Africa lack complete information on cervical cancer. Students who had had a Pap test had significantly lower barriers to cervical cancer screening than those students who had not had a Pap test.
Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. The authors measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania, using a structured questionnaire. A total of 1779 women participated in the exit survey and 593 were re-interviewed at home. Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is argued by the author to be a health system crisis that requires urgent solutions both to ensure women’s right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.
Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here the authors share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff. The study aims to describe experiences implementing EQUIP’s QI approach at the community level. A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. The authors outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce. Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.
Research consistently shows that gaps in health and health care persist, and are even widening. While the strength of a country’s primary health care system and its primary care attributes significantly improves populations’ health and reduces inequity (differences in health and health care that are unfair and unjust), many areas, such as inequity reduction through the provision of health promotion and preventive services, are not explicitly addressed by general practice. Substantiating the role of primary care in reducing inequity as well as establishing educational training pro-grams geared towards health inequity reduction and improvement of the health and health care of underserved populations are needed. This paper summarizes the work performed at the World World Organization of National Colleges and Academies of Family Medicine 2013 Meetings’ Health Equity Workshop which aimed to explore how a better understanding of health inequities could enable primary care providers /general practitioners (GPs) to adopt strategies that could improve health outcomes through the delivery of primary health care. It explored the development of a health equity curriculum and opened a discussion on the future and potential impact of health equity training among GPs.
Low rates of adherence to artemisinin-based combination therapy (ACT) regimens increase the risk of treatment failure and may lead to drug resistance, threatening the sustainability of current anti-malarial efforts. The authors assessed the impact of text message reminders on adherence to ACT regimens. Health workers at hospitals, clinics, pharmacies, and other stationary ACT distributors in Tamale, Ghana provided flyers advertising free mobile health information to individuals receiving malaria treatment. The messaging system automatically randomized self-enrolled individuals to the control group or the treatment group with equal probability; those in the treatment group were further randomly assigned to receive a simple text message reminder or the simple reminder plus an additional statement about adherence in 12-hour intervals. The main outcome was self-reported adherence based on follow-up interviews occurring three days after treatment initiation. The authors estimated the impact of the messages on treatment completion using logistic regression. The results of this study suggest that a simple text message reminder can increase adherence to antimalarial treatment and that additional information included in messages does not have a significant impact on completion of ACT treatment. Further research is needed to develop the most effective text message content and frequency.
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.
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.