The South African National Mental Health Policy Framework and Strategic Plan 2013–2020 was adopted to address the country’s substantial burden and inadequate treatment of mental illness. It outlines measures for full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, the authors conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of forty clinics in four districts in South Africa, interviewing district-level program managers (DPMs) and clinic nurses and mental health practitioners (MHPs). DPMs indicated that nurses should screen for mental illness at every patient visit, but only 73% of nurses reported conducting universal screening and 44% reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialised care. However, only 41% of MHPs indicated that they diagnose mental illness and 82% offer any treatment for mental illness. The challenges to current integration efforts include insufficient funding and material resources, poor coordination at the district administrative level, and low mental health awareness in district administration and the general population. Though some progress has been made toward integration of mental health services into primary care settings, the authors observe that implementation calls for improved district-level administrative coordination, mental health awareness, and financial and material resources.
Equitable health services
Mobile health (mHealth) approaches for non-communicable disease (NCD) care seem particularly applicable to sub-Saharan Africa given the penetration of mobile phones in the region. The evidence to support its implementation has not been critically reviewed. The authors systematically searched databases and grey literature for studies reported between 1992 and 2012 published in English or with an English abstract available. mHealth for NCDs in sub-Saharan Africa appears feasible for follow-up and retention of patients, can support peer support networks, and uses a variety of mHealth modalities. Whether mHealth is associated with any adverse effect has not been systematically studied. Only a small number of mHealth strategies for NCDs have been studied in sub-Saharan Africa. There is insufficient evidence to support the effectiveness of mHealth for NCD care in sub-Saharan Africa. The authors present a framework for cataloging evidence on mHealth strategies that incorporates health system challenges and stages of NCD care. This framework can guide approaches to fill evidence gaps in this area.
Applying mobile phones in healthcare is increasingly prioritized to strengthen healthcare systems. Antenatal care has the potential to reduce maternal morbidity and improve newborns' survival but this benefit may not be realized in sub-Saharan Africa where the attendance and quality of care is declining. This study evaluated the association between a mobile phone intervention and antenatal care in a resource-limited setting. It aimed to assess antenatal care in a comprehensive way taking into consideration utilisation of antenatal care as well as content and timing of interventions during pregnancy. The wired mothers' mobile phone intervention significantly increased the proportion of women receiving the recommended four antenatal care visits during pregnancy and there was a trend towards improved quality of care with more women receiving preventive health services, more women attending antenatal care late in pregnancy and more women with antepartum complications identified and referred. Mobile phone applications may contribute towards improved maternal and newborn health and should be considered by policy makers in resource-limited settings.
A Kenyan initiative to use mobile phones to improve health systems indicates that the use of mobile phones to track patients may help relieve the burden of overworked health workers. 'Eighty percent of those [health workers] we talked to in Nairobi and Kajiado said they feel relieved - health workers need that kind of relief,' said Sarah Karanja, study coordinator of the Weltel Project. 'Patients, on the other hand, feel they are cared for which is good for their health and wellbeing.' Weltel uses a weekly text message to study mobile-phone effectiveness for health. The message to the patient reads 'Mambo', Swahili for 'How are you?' to which the patients can respond 'Sawa' ('OK') to show they are fine, or 'Shida', which means 'problem', to show they need attention. Patients who respond Shida and non-responders are followed up with a call from the clinic nurse to identify and handle any problems. Initial study findings reveal that 80% of patients are comfortable with the use of mobile phones to manage their HIV care and treatment. Mobile phone use in Kenya has risen rapidly from 200,000 users in 2000 to an estimated 17.5 million today, offering great potential for expanding the use of mobile phones for health services.
Antimicrobial resistance is a global problem that affects all countries. This year’s World Health Day on 7 April aims to make governments more aware of the problem and to encourage them to take measures to combat this global threat. According to this article, clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. Data is lacking, they say. The problem of microbial resistance is significant in middle- and low-income countries: for example, poor children in Africa, Asia and Latin America suffering from pneumonia, meningitis or blood stream infections are often given old drugs rendered ineffective by resistance since they are the only available treatment options. For some, simply restricting over-the-counter sales of antimicrobials does not go far enough, and they suggest that more is needed to curb the use of second-line antibiotics, which should be used to treat infections when first-line antibiotics fail and may be the last resort. They argue that the beneficial effect of restriction of first-line antibiotics sold over the counter will be evident in the long term, but what is needed most is restriction of higher-end antibiotics used in hospitals.
South Africa (SA) has the highest prevalence of HIV/AIDS of any country in the world, which adds complexity to a health system already overwhelmed by chronic kidney disease, particularly that due to hypertension, diabetes and chronic glomerulonephritis. Renal disease is common in HIV-infected individuals. Prior to availability of ART, HIV was a death sentence for individuals with chronic kidney disease (CKD). However, since ART roll-out there is growing evidence of little difference in survival between HIV-infected patients who are receiving efficacious ART compared with the general population on dialysis. In this issue of the SAMJ, Fabian et al. demonstrate that haemodialysis in black African HIV-positive patients in the private sector in SA imparts excellent overall survival. This study contributes to the growing data reflecting good outcomes for HIV-positive patients on dialysis. However, transplantation is regarded as the best treatment option for CKD in patients without HIV, and we ask whether we should not be striving for dialysis to be the bridge to transplantation in HIV-positive patients. Also, importantly, attention needs to be geared towards prevention of CKD and slowing progression towards end-stage renal disease (ESRD). Those who provide healthcare to HIV-positive patients need to be aware of the special renal issues relevant to HIV, and the potential for evolution to ESRD.
There is hope for people living with multi-drug resistant tuberculosis (MDR-TB) as the “gruelling” two-year treatment with “terrible side-effects” such as deafness can now be successfully shortened to just nine months. A team of TB experts at the International Union Against Tuberculosis and Lung Disease has announced the final results of the Francophone study which evaluated the efficacy of a shorter MDR-TB treatment regimen in nine African countries. Three quarters of people in the study were cured with the new nine-month regimen. Of the patients who successfully completed the treatment – the cure rate was almost 90 percent. Only half of patients taking the older regimen can expect to be cured even after taking drugs for over 20 months. Just completing this course, whether it cures one or not, is a feat of sheer determination, according to TB advocates speaking at the 47th Union World Conference on Lung Health. The study was conducted among 1006 people with MDR-TB in Benin, Burkina Faso, Burundi, Cameroon, Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Niger and Rwanda. Based on the preliminary results of this study, in May this year the World Health Organisation (WHO) officially recommended this regimen for MDR-TB patients who have not taken treatment before and who are not resistant to the drugs contained in this regimen. These final results are expected to give countries the data needed to start rolling out the regimen to all eligible patients.
This report presents for the first time the treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.
This report presents the global treatment outcomes from all sites providing complete data for new and previously treated multi-drug-resistant TB (MDR-TB) patients. Ten of the 27 high MDR-TB burden countries reported treatment outcomes. A total of 71 countries and territories provided complete data for treatment outcomes for 4,500 MDR-TB patients. In 48 sites documenting outcomes, patient management and drug quality were found to conform to international standards. Treatment success was documented in 60% of patients overall. The report found that treatment success in MDR-TB patients remains low, even in well-resourced settings because of a high frequency of death, treatment failure and default, as well as many cases reported without definitive outcomes. New findings presented in this report give reason to be cautiously optimistic that MDR-TB can be controlled. While information available is growing and more and more countries are taking measures to combat MDR-TB, urgent investments in infrastructure, diagnostics, and provision of care are essential if the target established for 2015 – the diagnosis and treatment of 80% of the estimated M/XDR-TB cases – is to be reached.
A descriptive, non-interventive, observational study design was used to audit all public and private sector ICUs and HCUs in South Africa to evaluate the distribution and functioning of South African intensive care units (ICUs) and high care units (HCUs), in particular the extent to which units were ‘closed units'. In the face of already limited resources (financial and human) and given the emphasis on primary care medicine (with consequent limited capacity for further ICU development), it is crucial that existing facilities are maximally utilised.