In this study, researchers assessed challenges and enablers for the Expanded Programme on Immunisation (EPI) in South Africa, in light of the approaching 2015 deadline for the Millennium Development Goals. Between September 2009 and September 2010 they requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. Systematic reviews on the effectiveness of the proposed solutions were added. Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes. The findings from reliable systematic reviews indicate that interactive educational meetings, audits and feedback, and supportive supervision improve healthcare worker performance. The authors conclude that numerous promising strategies for improving EPI performance in South Africa were found but their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation.
Equitable health services
In sub-Saharan Africa, shortages of trained health workers, limited diagnostic equipment, inadequate anti-epileptic drug supplies, cultural beliefs, and social stigma contribute to the large treatment gap for epilepsy. This paper examines the state of epilepsy care and treatment in sub-Saharan Africa and discusses priorities and approaches to scale up access to medications and services for people with epilepsy. In the last decade, the disproportionate majority of global health funding has been allocated to vertical programmes targeting HIV and AIDS, malaria, and tuberculosis. The renewed calls for action to raise the priority of chronic non-communicable diseases in global health planning and research are encouraging, however, the authors note. Funding commitments from domestic governments, international funders, nongovernmental organisations, industry, and private philanthropists will be critical, the authors argue, to scaling up access to anti-epileptic medications and building capacity in human resources for epilepsy care in sub-Saharan Africa. A Global Fund for Epilepsy should be established to accelerate support from external funders and coordinate programme development and implementation.
This study had two purposes: to evaluate the impact of a universal coverage campaign (UCC) of long-lasting insecticidal nets (LLINs) on LLIN ownership and usage, and to identify factors that may be associated with inadequate coverage. In 2011 two cross-sectional household surveys were conducted in 50 clusters in Muleba district, north-west Tanzania. Prior to the UCC 3,246 households were surveyed and 2,499 afterwards. The proportion of households with at least one ITN increased from 62.6% before the UCC to 90.8% afterwards. Eighty percent of households surveyed received LLINs from the campaign. ITN usage in all residents rose from 40.8% to 55.7%, and after the UCC, 58.4% of households had sufficient ITNs to cover all their sleeping places. Households with children under five years and small households were most likely to reach universal coverage, while poverty was not associated with net coverage. The authors conclude that UCC in Muleba district of Tanzania was equitable, greatly improving LLIN ownership and, more moderately, usage. However, the goal of universal coverage in terms of the adequate provision of nets was not achieved. Multiple, continuous delivery systems and education activities are required to maintain and improve bed net ownership and usage.
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.
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.