Equitable health services

Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries
Rwabukwisi F; Bawah A; Gimbel S; et al.: BMC Health Services Research 17 (Suppl 3), doi: 10.1186/s12913-017-2662-9, 2017

This paper captures common implementation experiences and lessons learned to understand core elements of successful health systems interventions. Qualitative data was used rom key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through African Health Initiative in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. First, a variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels, with a learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Also identified was inclusion of strong implementation science tools and strategies that allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was seen to be the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the PHIT partnership projects. The authors conclude that the African Health Initiative experience has raised remaining, if not overlooked, challenges and potential solutions to address complex health systems strengthening intervention designs and implementation issues, while aiming to measurably accomplish sustainable positive change in dynamic, learning, and varied contexts.

Healthy Lives for Vulnerable Women and Children: Applying Health Systems Research
Godt S; Agyepong I; Flores W; et al: in_focus, IDRC, October 2017

Tremendous challenges remain for the most vulnerable populations, including women, children, and adolescents, to enjoy the healthy lives and well-being. Much of their poor health is caused by poverty, gender, lack of education, and social marginalization as well as inaccessible healthcare services. Strong, equitable, and well-governed health systems can contribute to sustainably improving their lives. But building strong health systems is challenging. This book draws on 15 years of IDRC-funded health systems research undertaken by researchers working closely with communities and decision-makers. They have generated contextually relevant evidence at local, national, regional, and global levels to tackle these entrenched health systems challenges. Six lessons have been distilled to inform and inspire a new generation of health leaders and researchers while some critical reflections on the remaining challenges are shared with others in the global health community, including funding organizations.

Integrating family planning services into HIV care: use of a point-of-care electronic medical record system in Lilongwe, Malawi
Tweya H; Feldacker C; Haddad L; et al: Global Health Action 10(1), doi: http://dx.doi.org/10.1080/16549716.2017.1383724, 2017

Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers’ ability to counsel women about pregnancy risks and contraceptive options. This study assessed trends in the use of contraceptive methods after implementing an electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15–49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. The authors conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. Between February 2012 and December 2016, in HIV clinics, the proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016. Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence and never thought about it. Incorporating the FP EMR module into HIV clinical care was found to prompt healthcare workers to encourage the use of contraceptives.

Uptake and correlates of cervical cancer screening among HIV-infected women attending HIV care in Uganda
Wanyenze R; Bwanika J; Beyeza-Kashesya J; et al: Global Health Action 10(1), doi: http://dx.doi.org/10.1080/16549716.2017.1380361, 2017

This study assessed uptake and correlates of cervical screening among HIV-infected women in care in Uganda. A nationally representative cross-sectional survey of HIV-infected women in care was conducted from August to November 2016. Structured interviews were conducted with 5198 women aged 15–49 years, from 245 HIV clinics. Knowledge and uptake of cervical screening and human papillomavirus (HPV) vaccination were determined. Overall, 94% had ever heard of cervical screening and 66% knew a screening site. However, 47% did not know the schedule for screening and 50% did not know the symptoms of cervical cancer. One-third rated their risk of cervical cancer as low. Uptake of screening was 30%. Women who had never been screened cited lack of information and no time as the main reasons. Increased likelihood of screening was associated with receipt of HIV care at a level II health center and private facilities, knowledge of cervical screening, where to go for screening, and low perception of risk. HPV vaccination was 2%. Cervical screening and HPV vaccination uptake were very low among HIV-infected women in care in Uganda. Improved knowledge of cervical screening schedules and sites, and addressing fears and risk perception are thus seen to potentially increase uptake of cervical screening in this vulnerable population.

Early antenatal care visit: a systematic analysis of regional and global levels and trends of coverage from 1990 to 2013
Moller A; Petzold M; Chou D; et al: The Lancet Global Health 5(10) e977-e983, 2017

The timing of the first antenatal care visit is paramount for ensuring optimal health outcomes for women and children, and it is recommended that all pregnant women initiate antenatal care in the first trimester of pregnancy (early antenatal care visit). Systematic global analysis of early antenatal care visits has not been done previously. This study reports on regional and global estimates of the coverage of early antenatal care visits from 1990 to 2013. Data were obtained from nationally representative surveys and national health information systems. Estimates of coverage of early antenatal care visits were generated with linear regression analysis and based on 516 logit-transformed observations from 132 countries. The model accounted for differences by data sources in reporting the cutoff for the early antenatal care visit. The estimated worldwide coverage of early antenatal care visits increased from 40.9% in 1990 to 58.6% in 2013, corresponding to a 43.3% increase. Overall coverage in the developing regions was 48.1% in 2013 compared with 84.8% in the developed regions. In 2013, the estimated coverage of early antenatal care visits was 24% in low-income countries compared with 81.9% in high-income countries. Progress in the coverage of early antenatal care visits has been achieved but coverage is still far from universal. Substantial inequity exists in coverage both within regions and between income groups. The absence of data in many countries is of concern and the authors argue that efforts should be made to collect and report coverage of early antenatal care visits to enable better monitoring and evaluation.

Global infection prevention and control priorities 2018–22: a call for action
Allegranzi B; Allegranzi B; Kilpatrick C; et al: The Lancet Global Health 5(12) e1178-e1180, 2017

The Ebola virus disease outbreak in west Africa and the rapid spread of other emerging viruses, such as the severe acute respiratory syndrome or the Middle East respiratory syndrome coronaviruses, showed how limited or non-existent infection prevention and control (IPC) programmes, combined with an inadequate water supply, poor sanitation, and a weak hygiene infrastructure in health facilities, can threaten global health security. In such outbreaks, instead of serving as points where disease was controlled, health-care facilities became dangerous places for outbreak amplification among staff and patients and transmission back to communities. The authors argue that it is now urgent to consider IPC capacity building and actual implementation as global health priorities. Among its efforts in this field, WHO coordinates the Global IPC (GIPC) Network. There are strong economic and ethical reasons to enhance IPC within the national and global health security agendas and efforts should capitalise upon evidence-based recommendations, proven and feasible implementation strategies, and awareness raised by AMR and epidemic-prone disease threats.

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.