This study sought to identify the leading causes of mortality and premature mortality in Cape Town, South Africa, and its subdistricts, and to compare levels of mortality between subdistricts. It analysed Cape Town mortality data for the period 2001–2006 by age, cause of death and sex. The study found that the pattern of mortality in Cape Town reflects the quadruple burden of disease observed in the national cause-of-death profile, with AIDS, other infectious diseases, injuries and non-communicable diseases all accounting for a significant proportion of deaths. AIDS has replaced homicide as the leading cause of death. AIDS, homicide, tuberculosis and road traffic injuries accounted for 44% of all premature mortality. Khayelitsha, the poorest subdistrict, had the highest levels of mortality for all main cause groups. The study emphasises how local mortality surveillance helps to map out the differential needs of the population of Cape Town. Data used in the study may provide a wealth of data to inform planning and implementation of targeted interventions. Multisectoral interventions will be required to reduce the burden of disease.
Equitable health services
The purpose of this declaration is to raise awareness of the magnitude of the cancer burden in Africa and to call for immediate action to bring comprehensive care to African countries. The establishment of cancer care programmes in African countries requires the integration of clinical and public health systems. A comprehensive cancer control strategy must bring together prevention, early detection and diagnosis, treatment and palliative care. More investment is needed to deliver these services in terms of trained staff, equipment, relevant drugs and information systems, as well as public education.
Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control programme. However, studies to understand patents’ perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. In this qualitative, phenomenological study, researchers conducted 26 in-depth interviews with tuberculosis patients. Results indicated that a lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments. The authors argue that decentralisation of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts, is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 people aged 15–30 years who had attended trial schools on sexual education during the first phase of the MEMA kwa Vijana sexual health intervention trial (1999–2002). Prevalences of the primary outcomes HIV and herpes simplex 2 (HSV-2) were 1.8% and 25.9% in males and 4% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV or HSV-2 but was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime and an increase in reported condom use at last sex with a non-regular partner among females. There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study concluded that knowledge of sexual and reproductive health can be improved and retained long-term, but this intervention had only a limited effect on sexual behaviour. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
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.
The study’s aim was to estimate rates of completion of CD4+ lymphocyte testing (CD4 testing) within 12 weeks of testing positive for human immunodeficiency virus (HIV) at a large HIV/AIDS clinic in South Africa, and to identify clinical and demographic predictors for completion. In the study, CD4 testing was considered complete once a patient had retrieved the test results. To determine the rate of CD4 testing completion, researchers reviewed the records of all clinic patients who tested positive for HIV between January 2008 and February 2009 to identify predictors for completion through multivariate logistic regression. Of the 416 patients who tested positive for HIV, 84.6% initiated CD4 testing within the study timeframe. Of these patients, 54.3% were immediately eligible for antiretroviral therapy (ART) because of a CD4 cell count ≤ 200/µl, but only 51.3% of the patients in this category completed CD4 testing within 12 weeks of HIV testing. Among those not immediately eligible for ART, only 14.9% completed CD4 testing within 12 weeks. Overall, of HIV+ patients who initiated CD4 testing, 65% did not complete it within 12 weeks of diagnosis. The higher the baseline CD4 cell count, the lower the odds of completing CD4 testing within 12 weeks. The study concluded that patient losses between HIV testing, baseline CD4 cell count and the start of care and ART are high. As a result, many patients receive ART too late. It recommends health information systems that link testing programmes with care and treatment programmes.
The authors of this study assessed barriers related with long-lasting insecticide treated net (LLIN) use at the household level in Ethiopia from October to November 2010. A total of 2,867 households were selected and data were collected by interviewing women, direct observation of LLINs conditions and use, and in-depth interviewing of key informants. Results indicated that only about one third of LLIN owned households are actually using at least one LLIN for protection against mosquito bite. Thus, most of the residents are at higher risk of mosquito bite and acquiring of malaria infection. Households living in fringe zone are not benefiting from the LLIN protection. Further progress in malaria prevention can be achieved by specifically targeting populations in fringe zones and conducting focused public education to increase LLIN use, the authors recommend.
In Tanzania, the prevention of mother to child transmission of HIV (PMTCT) is a health sector priority, but there is very little information on how well gender mainstreamed in relation to national PMTCT guidelines. In this paper the authors research assessed the gender content of key policy documents in order to better understand how this area could be strengthened, using a WHO Gender Responsive Assessment Scale (GRAS). The GRAS divides gender responsiveness into 5 levels. Level 1, gender unequal, contains content which perpetuates gender inequality by reinforcing unbalanced norms, roles and relations. Level 2, gender blind, contains content which ignores gender norms, roles and relations and differences in opportunities and resource allocation for women and men. Level 3, gender sensitive, contains content which indicates awareness of the impact of gender norms, roles, and relations, but no remedial actions are developed. Level 4, gender specific, contains content which goes beyond indicating how gender may hinder PMTCT to highlighting remedial measures, such as the promotion of couple counselling and testing for HIV. Level 5, gender transformative, contains content which includes ways to transform harmful gender norms, roles and relations. The findings showed that gender-related issues are mentioned in all of the guidelines, indicating some degree of gender responsiveness. The level of gender responsiveness of PMTCT policy documents, however, varies, with some graded at GRAS level 3 (gender sensitive), and others at GRAS level 4 (gender specific). None of the reviewed policy documents could be graded as gender transformative. While the policy documents indicate recognition of gender inequality in decision-making and access to resources as a barrier to accessing PMTCT services by women, no attempt is made to transform harmful gender norms, roles, or relations. Overall, gender was not mainstreamed into any of the documents in the sense that gender was not considered in all key sections. Overall, the study revealed limited integration of gender concerns (less or lack of attention on the disadvantageous position of women in terms of inequality in ownership of resources, power imbalance in decision making, asymmetrical division of roles, and masculine norms that distance men from maternal and child care) in PMTCT guidelines. The authors suggest that revision of guidelines to mainstream gender is greatly needed if PMTCT services are to effectively contribute towards a reduction of child and maternal morbidity and mortality in Tanzania
In 2009, as part of a strategic planning process, Makerere University College undertook a qualitative study to examine care and service provision at Mulago National Referral Hospital (MNRH), identify challenges, gaps, and solutions, and explore how the University could contribute to improving care and service delivery at MNRH. Twenty-three key informant interviews and seven focus group discussions were conducted with nurses, doctors, administrators, clinical officers and other key stakeholders. Participants identified a number of challenges to care and service delivery at MNRH, including resource constraints, staff inadequacies, overcrowding, a poorly functioning referral system, limited quality assurance, and a cumbersome procurement system. They also pointed to insufficiencies in the teaching of professionalism and communication skills to students, and patient care challenges that included lack of access to specialised services, risk of infections, and inappropriate medications. The authors recommend addressing these barriers by strengthening the relationship between the hospital and Makerere. Strategic partnerships and creative use of existing resources, both human and financial, could improve quality of care and service delivery.
This report addresses the critical choices of fairness and equity that arise on the path to UHC. Accordingly, the report is not primarily about why UHC ought to be a goal, but about the path to that goal. The report may differ from others in the direct way it addresses fundamental issues and difficult trade-offs. This approach was facilitated by the involvement of philosophers and ethicists in addition to economists, policy experts, and clinical doctors.