Equitable health services

Service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania
Leslie H; Spiegelman D; Zhoub X; et al: Bulletin World Health Organisation 95(11)738–748, 2017

This study evaluates the service readiness of health facilities in Bangladesh, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Uganda and the United Republic of Tanzania. Using existing data from service provision assessments of the health systems of the 10 study countries, the authors calculated a service readiness index for each of 8443 health facilities. This index represents the percentage availability of 50 items that the World Health Organization considers essential for providing health care. For the analysis, the authors used 37–49 of the items on the list. The mean values for the service readiness index were 77% for the 636 hospitals and 52% for the 7807 health centres/clinics. Deficiencies in medications and diagnostic capacity were particularly common. The readiness index varied more between hospitals and health centres/clinics in the same country than between countries. There was weak correlation between national factors related to health financing and the readiness index. Most health facilities in the study countries were insufficiently equipped to provide basic clinical care. The authors argue that if countries are to bolster health-system capacity towards achieving universal coverage, more attention needs to be given to within-country inequities.

Antimicrobial resistance among children in sub-Saharan Africa
Williams P; Isaacs D; Berkley J: The Lancet Infectious Diseases, doi: http://dx.doi.org/10.1016/S1473-3099(17)30467-X, 2017

Antimicrobial resistance is an important threat to international health. Therapeutic guidelines for empirical treatment of common life-threatening infections depend on available information regarding microbial aetiology and antimicrobial susceptibility, but sub-Saharan Africa lacks diagnostic capacity and antimicrobial resistance surveillance. The authors systematically reviewed studies of antimicrobial resistance among children in sub-Saharan Africa since 2005. Among neonates, gram-positive bacteria were responsible for a high proportion of infections among children beyond the neonatal period, with high reported prevalence of non-susceptibility to treatment advocated by the WHO therapeutic guidelines. There are few up-to-date or representative studies given the magnitude of the problem of antimicrobial resistance, especially regarding community-acquired infections. Research should focus on differentiating resistance in community-acquired versus hospital-acquired infections, implementation of standardised reporting systems, and pragmatic clinical trials to assess the efficacy of alternative treatment regimens.

Development of a Hypertension Health Literacy Assessment Tool for use in primary healthcare clinics in South Africa, Gauteng
Mafutha N; Mogotlane S; De Swardt H: African Journal of Primary Health Care and Family Medicine 9(1)1-8, 2017

This study investigated the development of a hypertension heath literacy assessment tool to establish patients’ comprehension of the health education they receive in primary healthcare clinics in Tshwane, Gauteng, South Africa. The design was quantitative, descriptive and contextual. The study population comprised health promoters who were experts in the field of health, documents containing hypertension health education content and individuals with hypertension. The tool was administered to 195 participants concurrently with a learning ability battery. The health literacy assessment tool was found to be a valid tool that can be used in busy primary healthcare clinics as it takes less than two minutes to administer. This tool can inform the healthcare worker on the depth of hypertension health education to be given to the patient, empowering the patient and saving time in primary healthcare facilities.

Diabetes in sub-Saharan Africa: from clinical care to health policy
Atun R; Davies J; Gale E; et al: The Lancet Diabetes & Endocrinology Commission 5(8), doi: http://dx.doi.org/10.1016/S2213-8587(17)30181-X, 2017

This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. The authors assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% of eight recommended antenatal care actions and 54.5% of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care.

Health systems in low income countries - four new overviews
Cochrane: Cochrane EPOC, October 2017

Four new Cochrane EPOC overviews of reviews show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries and identify important evidence gaps. Strengthening health systems in low-income countries is key to achieving universal health coverage and achieving the health-related Sustainable Development Goals. Achieving these goals requires informed decisions about health systems. A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.

Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda.
Niyitegeka J; Nshimirimana G; Silverstein A; et al.: Biological Medicine Central Pregnancy Childbirth 17(1), doi: 10.1186/s12884-017-1426-1, 2017

In low-resource settings, access to emergency caesarean section is associated with various delays leading to poor neonatal outcomes. In this study, the authors described the delays a mother faces when needing emergency caesarean delivery and assessed the effect of these delays on neonatal outcomes in Rwanda. It included 441 neonates and their mothers who underwent emergency cesarean section in 2015 at three district hospitals in Rwanda. Four delays were measured: duration of labour prior to hospital admission, travel time from health centre to district hospital, time from admission to surgical incision, and time from decision for emergency caesarean section to surgical incision. Neonatal outcomes were categorised as unfavourable and favourable. The authors assessed the relationship between each type of delay and neonatal outcomes using multivariate logistic regression. In their study, 9.1% of neonates had an unfavourable outcome, 38.7% of neonates' mothers laboured for 12-24 h before hospital admission, and 44.7% of mothers were transferred from health centres that required 30-60 min of travel time to reach the district hospital. Furthermore, 48.1% of caesarean sections started within 5 h after hospital admission and 85.2% started more than 30 min after the decision for caesarean section was made. Neonatal outcomes were significantly worse among mothers with more than 90 min of travel time from the health centre to the district hospital compared to mothers referred from health centres located on the same compound as the hospital. Neonates with caesarean deliveries starting more than 30 min after decision for caesarean section had better outcomes than those starting immediately. Longer travel time between health centre and district hospital was associated with poor neonatal outcomes, highlighting a need to decrease barriers to accessing emergency maternal services. However, longer decision to incision interval posed less risk for adverse neonatal outcome. While this could indicate thorough pre-operative interventions including triage and resuscitation, this relationship should be studied prospectively in the future.

An assessment of equity in the distribution of non-financial health care inputs across public primary health care facilities in Tanzania
Kuwawenaruwa A; Borghi J; Remme M; Mtei G: International Journal for Equity in Health 16(124) 2017

This paper assesses equity in the distribution of health care inputs across public primary health facilities at the district level in Tanzania. It reports a quantitative assessment of equity in the distribution of health care inputs (staff, drugs, medical supplies and equipment) from district to facility level. The study was carried out in three districts (Kinondoni, Singida Rural and Manyoni district) in Tanzania. These districts were selected because they were implementing primary care reforms. The authors administered 729 exit surveys with patients seeking out-patient care; and health facility surveys at 69 facilities in early 2014. The authors found a significant pro-rich distribution of clinical staff and nurses per 1000 population. Facilities with the poorest patients (most remote facilities) have fewer staff per 1000 population than those with the least poor patients (least remote facilities): 0.6 staff per 1000 among the poorest, compared to 0.9 among the least poor; 0.7 staff per 1000 among the most remote facilities compared to 0.9 among the least remote. The negative concentration index for support staff suggests a pro-poor distribution of this cadre but the 45 degree dominated the concentration curve. The distribution of vaccines, antibiotics, anti-diarrhoeal, anti-malarials and medical supplies was approximately proportional (non dominance), whereas the distribution of oxytocics, anti-retroviral therapy (ART) and anti-hypertensive drugs was pro-rich, with the 45 degree line dominating the concentration curve for ART. This study has shown there are inequities in the distribution of health care inputs across public primary care facilities. This highlights the need to ensure a better coordinated and equitable distribution of inputs through regular monitoring of the availability of health care inputs and strengthening of reporting systems.

Threats posed by stockpiles of expired pharmaceuticals in low- and middle-income countries: a Ugandan perspective
Kamba P; Ireeta M; Balikuna S; Kaggwa B: Bulletin World Health Organisation; 95(8)594–598, 2017

In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: strengthen public systems for medicines’ management, to improve inventory control and the reliability of procurement forecasts; reduce stress on central medical stores, through liberalisation and reimbursement schemes; strengthen the regulation of drug donations; explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; strengthen the enforcement of regulations on safe drug disposal; invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector.

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania
Kruk ME; Chukwuma A; Mbaruku G; Leslie H: Bull World Health Organ 95:408–418, 2017

This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. They assessed national, facility, provider and patient factors that might explain variations in quality of care, using separate multilevel regression models of quality for each service. Data were available for 2594 and 11 402 observations of clinical consultations for antenatal care and sick children, respectively. Overall, health-care providers performed a mean of 62.2% of eight recommended antenatal care actions and 54.5% of nine sick-child care actions at observed visits. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. Analysis of reasons for variations in quality could identify strategies for improving care

Variation in quality of primary-care services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania.
Kruk M; Chukwuma A; Mbaruku G; Leslie H: Bulletin World Health Organisation 95(6), 408-418, 2017

This study analysed factors affecting variations in the observed quality of antenatal and sick-child care in primary-care facilities in seven African countries. The authors pooled nationally representative data from service provision assessment surveys of health facilities in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of Tanzania (survey year range: 2006-2014). Based on World Health Organisation protocols, the authors created indices of process quality for antenatal care (first visits) and for sick-child visits. The authors assessed national, facility, provider and patient factors that might explain variations in quality of care. Quality of antenatal care was higher in better-staffed and -equipped facilities and lower for physicians and clinical officers than nurses. Experienced providers and those in better-managed facilities provided higher quality sick-child care, with no differences between physicians and nurses or between better- and less-equipped clinics. Private facilities outperformed public facilities. Country differences were more influential in explaining variance in quality than all other factors combined. The quality of two essential primary-care services for women and children was weak and varied across and within the countries. The authors propose that analysis of reasons for these variations in quality could identify strategies for improving care.

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