This study aimed to assess feasibility, uptake, yield, treatment outcomes and costs of adding an active tuberculosis case-finding programme to an existing mobile HIV testing service in South Africa. All HIV-negative individuals with symptoms suggestive of tuberculosis and all HIV-positive individuals, regardless of symptoms, were eligible for participation. Of the 6,309 adults who accessed the mobile clinic, 1,385 were eligible and 1,130 (81.6%) were enrolled. The prevalence of smear-positive tuberculosis was 2.2%, 3.3% and 0.4% in HIV-negative individuals, individuals newly diagnosed with HIV, and known HIV+ individuals, respectively. Of the 56 new tuberculosis cases detected, 42 started tuberculosis treatment and 34 (81%) completed treatment. The cost of the intervention was US$1,117 per tuberculosis case detected and US$2,458 per tuberculosis case cured. In conclusion, mobile active tuberculosis case finding in deprived populations with a high burden of HIV and tuberculosis was found to be feasible, and had high uptake, yield and treatment success. Further work is now required to examine cost-effectiveness and affordability, and to establish if the same results may be achieved after scaling up services.
Equitable health services
In this study, researchers compared vaccine coverage achieved by two different delivery strategies for the quadrivalent human papillomavirus (HPV) vaccine in Tanzanian schoolgirls. In a cluster-randomised trial, 134 primary schools were randomly assigned to class-based or age-based vaccine delivery. Of the 3,352 and 2,180 eligible girls included in the study, HPV vaccine coverage was 84.7% for dose 1, 81.4% for dose 2, and 76.1% for dose 3. For each dose, coverage was slightly higher in class-based schools than in age-based schools. Vaccine-related adverse events were rare. Reasons for not vaccinating included absenteeism (6.3%) and parent refusal (6.7%). In conclusions, the authors argue that HPV vaccine can be delivered with high coverage in schools in sub-Saharan Africa. Compared with age-based vaccination, class-based vaccination located more eligible pupils and achieved higher coverage. HPV vaccination did not increase absenteeism rates in selected schools. Innovative strategies will also be needed to reach out-of-school girls.
Current malaria control strategies rely heavily on repeated application of single neurotoxic insecticides that quickly kill adult mosquitoes, yet the effectiveness of insecticide-treated bed nets (ITNs) and indoor insecticide sprays to control adult mosquito vectors is being threatened by the spread of insecticide resistance. This narrow insecticide-based paradigm is beginning to fail, the authors of this paper argue, as it did in agriculture, as well as in previous malaria eradication campaigns of the '50s and '60s. They note that ITNs, indoor spraying programmes and other malaria control measures should be integrated in the same way as pest management is integrated in agriculture. Integrated approaches have the potential to provide more effective and durable pest management. To achieve the equivalent for malaria control requires additional tools to manage malaria vectors, as well as a better understanding of the impact of individual tools and their interactions, appropriate training for end users and strategies that maximise impact and fit the local ecological and socioeconomic context. Given the current lack of any clear alternative to the current insecticide paradigm, the authors urge researchers, policy makers, and funding agencies to act now to support this more diverse and adaptive approach.
The dominant approach used to promote sexual health relies on centralised public clinic service delivery, unisectoral implementation, and vertically organised support (national/state/local public health structures). But the authors of this study argue that these systems have failed to test, link and retain a large portion of most-at-risk populations. Instead, the authors favour a social entrepreneurship for sexual health (SESH) approach, which focuses on decentralised community delivery, multisectoral networks, and horizontal collaboration (business, technology, and academia). Although SESH approaches have yet to be widely implemented, they show great promise, according to this study. Social marketing and sales of point-of-care, community-based tests for HIV and other sexually transmitted diseases, conditional cash transfers to incentivise safe sex, and microenterprise among most-at-risk-populations are all SESH tools that can optimise the delivery of comprehensive sexual health interventions.
This study explored possible differences in health care seeking behaviour among a rural and urban African population. Four rural and urban SetTswana communities which represented different strata of urbanisation in the North West Province, South Africa, were selected. Structured interviews were held with 206 participants. Data on general demographic and socio-economic characteristics, health status, beliefs about health and (access to) health care was collected. The results illustrated differences in socio-economic characteristics, health status, beliefs about health, and health care utilisation. Inhabitants of urban communities rated their health significantly better than rural participants. Although most urban and rural participants consider their access to health care as sufficient, they still experienced difficulties in receiving the requested care. Rural participants had significantly lower employment and available weekly budget for health care and transport costs. Urban participants were more than 5 times more likely to prefer a medical doctor in private practice.
Maternal mental health is largely neglected in low- and middle-income countries. There is no routine screening or treatment of maternal mental disorders in primary care settings in South Africa. The Perinatal Mental Health Project (PMHP) developed an intervention to deliver mental health care to pregnant women in a collaborative, step-wise manner making use of existing resources in primary care. Over a 3-year period, 90% of all women attending antenatal care in the maternity clinic were offered mental health screening with 95% uptake. Of those screened, 32% qualified for referral to counselling. Through routine screening and referral, the PMHP model demonstrates the feasibility and acceptability of a stepped care approach to provision of mental health care at the primary care level.
Universal coverage by health services is one of the core obligations that any legitimate government should fulfil vis-à-vis its citizens. However, universal coverage may not in itself ensure universal access to health care. Among the many challenges to ensuring universal coverage as well as access to health care are structural inequalities by caste, race, ethnicity and gender. Based on a review of published literature and applying a gender-analysis framework, this paper highlights ways in which the policies aimed at promoting universal coverage may not benefit women to the same extent as men because of gender-based differentials and inequalities in societies. It also explores how ‘gender-blind’ organisation and delivery of health care services may deny universal access to women even when universal coverage has been nominally achieved.
Since 2002, an estimated 4.7 million long-lasting insecticide-treated nets (LLINs) have been distributed in the Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia among a population of approximately 10 million people at risk for contracting malaria. This study sought to determine the status of current net ownership, utilisation and rate of long-lasting insecticide-treated nets (LLIN) loss in the previous three years. A total of 750 household respondents were interviewed in SNNPR. Approximately 67.5% of households currently owned at least one net. An estimated 31% of all nets owned in the previous three years had been discarded by owners, most of whom considered the nets too torn, old or dirty. Households reported that one-third of nets (33.7%) were less than one year old when they were discarded. These results suggest that the life span of nets may be shorter than previously thought, with little maintenance by their owners. With the global move towards malaria elimination it makes sense to aim for sustained high coverage of LLINs, the authors argue. However, in the current economic climate, it also makes sense to use simple tools and messages on the importance of careful net maintenance, which could increase their lifespans.
The purpose of this study was to describe the results of eight human papillovirus (HPV) vaccination programmes conducted in seven lowest-income countries, including Lesotho, through the Gardasil Access Programme (GAP), which provides free HPV vaccines to organisations and institutions working in those countries. The eight programmes initially targeted a total of 87,580 girls, of which 76,983 received the full three-dose vaccine course, with mean programme vaccination coverage of 87.8%, while the mean adherence between the first and third doses of vaccine was 90.9%. Mixed models consisting of school-based and health facility-based vaccinations were found to record better overall performance compared with models using just one of the methods. Increased rates of programme coverage and adherence were positively correlated with the number of vaccination sites. Qualitative key insights from the school models showed a high level of coordination and logistics to facilitate vaccination administration, a lower risk of girls being lost to follow-up and vaccinations conducted within the academic year to limit the number of girls lost to follow-up. This study is intended to provide lessons for development of public health programmes and policies as countries go forward in national decision-making for HPV vaccination.
This report highlights the systemic problems that prevent women, men and young people from accessing reproductive health supplies, and provide recommendations on moving forward. The authors call for increased funding for reproductive health and argue that reproductive health must be incorporated into national health plans and budgeted for accordingly. Additionally, governments should create an enabling environment for sexual and reproductive health and rights. The authors make several recommendations for health service provision. Governments should ensure that a wide range of reproductive health supplies are included in the national essential drug list, while health system-strengthening initiatives and national health plans must include provisions for monitoring the distribution of reproductive health supplies. Capacity for quality of care should be built among all health professionals that deliver supplies, including health care providers, pharmacists and nurses, and there should be more investment in adequate storage facilities at national and municipal levels, and implementation of logistics management systems.