Equitable health services

In line with international developments in mental health legislation, the Mental Health Care Act (2002) was promulgated in South Africa. Its core principles – human rights for users; decentralisation and integration of mental health care at primary, secondary and tertiary levels of care; and a focus on care, treatment and rehabilitation – are progressive and laudable. However, the task of implementing the requirements of the Act at community and district hospital levels is fraught with problems. Lack of infrastructure, inadequate skills and poor support and training undermine its successful implementation. Health workers already burdened with enormous workloads and inadequate resources struggle to manage mentally ill patients at district hospitals. The 72-hour observation is a particular area of difficulty throughout the country. This paper outlines the rationale and sense behind this legislation, discusses the problems encountered at the ‘rock face', and offers solutions to the problem of translating principles into practice.

Inadequate patient tracking at one of South Africa's largest antiretroviral (ARV) distribution sites, has led to many patients disappearing from the clinic before treatment starts, a new report has found. The report by the Reproductive Health & HIV Research Unit (RHRU) of the University of the Witwatersrand, based on a 2006 review of patient files at the Tshepong Wellness Clinic, about 120km southwest of Johannesburg, shows that a standard percentage - about 14 percent - stop taking treatment, but more than 20 percent of patients never get to the treatment stage.

Malaria fever is a common medical presentation and diagnosis in Malawi. The national malaria policy supports self-diagnosis and self-medication for uncomplicated malaria with first line anti-malaria drugs. While a qualitative appreciation of the burden of malaria on the health system is recognised, there is limited quantitative estimation of the burden malaria exacts on the health system, especially with regard to human resources and financial burden on Malawi. The burden of malaria was assessed based on estimated incidence rates for a high endemic country of which Malawi is one. Data on the available human resources and financial resources committed towards malaria from official Malawi government documents and programme reports were obtained. Malaria exacts a heavy toll on the health system in Malawi. The national recommendation of self-medication with first-line drug for uncomplicated malaria is justified as there are not enough clinicians to provide clinical care for all cases. The Malawi Ministry of Healthas promotion of malaria drug prescription including other lower cadre health workers may be justified.

This World Health Organization study describes various activities aimed towards strengthening the management of health service delivery in three countries: South Africa, Togo and Uganda. The paper considers factors that affect management capacity: the number of managers at all levels; opportunities for building existing managers’ own competences; improving management support systems; and creating a more supportive work environment. It also identifies several ways to help managers do their jobs better. These include clarity about their responsibilities; practical reference handbooks; and a regular forum for managers to identify their needs, discuss problems and share ideas. On-the-job support is perceived by many managers as key to improving their performance – this can include technical assistance, mentoring, coaching and learning networks. In terms of management strengthening activities, the study reveals that a range of approaches have been used in recent years, but countries and external development agencies have concentrated mainly on training and some management systems (planning and monitoring) to the detriment of other key conditions for facilitating good management. Medium- to long-term sector-wide budgets and plans for management strengthening are required if good management is to play its appropriate role in scaling up health services.