As the sustainable development goals (SDGs) require country-level tracking of indicators related to contraception, including met need, a key question is “What can be done to support adolescents to prevent unintended pregnancy? To answer this question, the authors developed country-specific fact sheets describing adolescent contraceptive use and non-use in 58 low- and middle-income countries spanning all six World Health Organisation Regions. The authors report the top three reasons adolescent girls give for why they are not currently using contraception, even though they do not want to become pregnant in the next two years. The data are based on responses from 15–19 year old adolescent girls, and are presented separately for those unmarried and sexually active and those in a union. Reasons for non-use vary considerably but among the most common reported are, being “not married” and infrequent sexual relations for unmarried, sexually active adolescents. In contrast, currently breastfeeding or postpartum abstinence are among the most common reasons for non-use reported by adolescents in a union. Fear of side-effects or health concerns was commonly reported by both groups of adolescent girls.The authors report on the two most common sources from which adolescents who are currently using a modern method most recently obtained that contraceptive method. The sources are driven by the types of contraceptive methods available, as well as those that are easy for adolescents to access. In some settings most sources are in the formal sector, including government facilities, private facilities and pharmacies. In other settings most adolescents obtain contraceptive commodities in the informal sector, such as shops, kiosks or roadside stands, or from friends. The data from the fact sheets indicate where best to target investments to improve access to – and quality of – contraceptive services for adolescents. The data provided in these fact sheets are disaggregated by age and marital status to address the calls for ensuring that no one is left behind. These data can help policy-makers and programme planners reduce inequities in service provision and access, and to make evidence-based decisions about how to better address adolescents’ contraceptive needs.
Equitable health services
African countries have mounted different response strategies to COVID-19, eliciting varied outcomes. In this paper the authors compare these response strategies in Rwanda, South Africa and Zimbabwe and discuss lessons that could be shared. In particular, Rwanda has a robust and coordinated national health system that has effectively contained the epidemic. South Africa has considerable testing capacity, which has been used productively in a national response largely funded by local resources, while Zimbabwe has an effective point-of-entry approach that utilizes strategic information. The authors propose meetings between countries to share experiences and lessons learned during the COVD-19 pandemic.
Hospitals have always played a pivotal role in the global healthcare system. They have power, authority and professional competences in both the rich and poor worlds. But what if we all begin to re-think the mission of hospital care and re-design the way we deliver it in order to increase access to health? The moment has arrived for reform in order to achieve optimal care, to learn from examples of real innovation and disseminate this knowledge, sharing ideas as well as best practices. For example one speaker at this session of the August 2006 Geneva Health Forum noted that the mission of hospitals has shifted from delivering specialized care to our patients; to responsibility for the care in our region; to promoting health to all our citizens.
The 2014/2015 West Africa Ebola epidemic has caused the global public health community to engage in difficult self-reflection. First, it must consider the part it played in relation to an important public health question: why did this epidemic take hold and spread in this unprecedented manner? Second, it must use the lessons learnt to answer the subsequent question: what can be done now to prevent further such outbreaks in the future? The authors contribute to the current self-reflection by presenting an analysis using a Primary Health Care (PHC) approach. This approach is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in authorities and mobile populations, a broader approach is required to engage affected communities. In the medium-term health system development with attention to primary level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local management and an investment in human resources for health. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD.
Despite extensive scientific and policy innovations in quality of care, the authors raise a gap in quality in resource-limited areas that undermine effective access to healthcare for poor people. In this perspective piece, the authors propose six actions to address this: revise global health investment mechanisms to value quality; enhance investment in the role of health persinnel for improving quality; scale up data capacity; deepen community accountability and engagement initiatives; implement evidence-based quality improvement programmes; and develop an implementation science research agenda.
The objective of this study was to assess the current integration of TB and HIV services in South Africa, using data from 2011. Forty-nine randomly selected health facilities were included, at which interviewers administered a standardised questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to TB clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centres.
This paper interrogated the relationship between data collection and the delivery of patient care in Kayunga, Uganda in five public health centres. The authors undertook ethnographic research from July 2015 to September 2016 in health centres, at project workshops, meetings and training sessions. This included three months of observations by three fieldworkers, in-depth interviews with health workers and stakeholders and six focus group discussions with health workers. The authors observed that the attempt to improve data collection within health facilities transferred data-value into health centres with little consideration among project staff for its impact on care, and noted both acquiescence and resistance to data-value by health workers. The authors also described the rare moments when senior health workers reconciled these two forms of value, where care-value and data-value were enacted simultaneously. The authors suggest that those seeking to make changes in health systems must take into account local forms of value and devise health systems interventions that reinforce and enrich existing ethically driven practice.
This study assessed the feasibility and impact of decentralised care for non-communicable diseases (NCDs) within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings. In collaboration with the Eswatini Ministry of Health, the authors developed and implemented a package of interventions to support nurse-led delivery of care, including clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. One thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean blood pressure among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic, and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l. Key components of non-communicable disease care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines. The findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.
The main objective of this study was to decompose wealth-related inequalities in skilled birth attendance (SBA) and measles immunisation into their contributing factors. Researchers used data from the Kenyan Demographic and Health Survey 2008/09 to investigate the effects of socio-economic determinants on coverage and wealth-related inequalities of the two health services. Results indicated that SBA utilisation and measles immunisation coverage differed according to household wealth, parent’s education, skilled antenatal care visits, birth order and father’s occupation. SBA utilisation further differed across provinces and ethnic groups. The overall C for SBA was 0.14 and was mostly explained by wealth (40%), parent’s education (28%), antenatal care (9%), and province (6%). The overall C for measles immunisation was 0.08 and was mostly explained by wealth (60%), birth order (33%), and parent’s education (28%). Rural residence (−19%) reduced this inequality. The authors conclude that both health care indicators require a broad strengthening of health systems with a special focus on disadvantaged sub-groups.
In Malawi essential drugs are provided free of charge to patients at all public health facilities in order to ensure equitable access to health care. The country thereby spends about 30% of the national health budget on drugs. In order to investigate the level of drug shortages and eventually find the reasons for the drugs shortages in Malawi, we studied the management of the drug supplies for common and life threatening diseases such as pneumonia and malaria in a random selection of health centres.