Eye injuries that occur in the workplace are more common in developing countries like South Africa where appropriate eye protection might be lacking. The purpose of this paper is to assist the occupational health care provider to correctly assess damage to the eye and interpret the findings to make a diagnosis and appropriate decisions for primary care. The authors argue that examination of the eyes by health-care doctors and nurses should be systematic, assessing all the structures in order to determine appropriate treatment and referral. The most urgent condition is a chemical burn in which minutes matter and immediate irrigation can prevent long-term vision loss. Lid lacerations are usually easy to identify but penetrating globe injuries or intraocular foreign bodies may be missed and result in permanent loss of vision and disability. Many injuries can be adequately managed by primary care health workers, either medical doctors or nurses, and do not require referral, the authors conclude.
Equitable health services
Over 90% of the world’s severe and fatal Plasmodium falciparum malaria is estimated to affect young children in sub-Sahara Africa, where it remains a common cause of hospital admission and inpatient mortality. Few children will ever be managed on high dependency or intensive care units and, therefore, rely on simple supportive treatments and parenteral anti-malarials. There has been some progress on defining best practice for antimalarial treatment with the AQUAMAT trial in 2010 showing that in artesunate-treated children, the relative risk of death was 22.5% lower than in those receiving quinine. This review highlights the spectrum of complications in African children with severe malaria, the therapeutic challenges of managing these in resource-poor settings and examines in-depth the results from clinical trials with a view to identifying the treatment priorities and a future research agenda.
This paper was commissioned as a background paper for discussion at the First Global Symposium on Health Systems Research, held 16-19 November, 2010, in Montreux, Switzerland. It argues that, to advance towards universal coverage, decision-makers have to determine ways to incentivise providers and patients alike to increase access to good quality health services and promote efficient modes of delivery that can be sustainable. It found little rigorous evidence to guide policymakers on how the theoretical incentives created by different payment mechanisms for individual providers or facilities operate in practice. Available data indicates that fee-for-service systems (for individuals or facilities) result in higher rates of utilisation and resource use. Limited evidence on reimbursement mechanisms for facilities suggests that case-based payments are efficiency enhancing, but important questions remain about their impact on quality of care and the possibility of implementing them in systems or facilities where capacity is low. The evidence in support of pay-for-performance (P4P) mechanisms was found to be mixed and the paper advises policymakers seeking to implement P4P schemes to proceed with caution. Conditional cash transfers (CCT) were found to have been effective in increasing uptake of health services, but continued success is likely to be dependent on adequate infrastructure, reliable funding and technical capacity. Key questions remain about the desirability and cost-effectiveness of CCTs, in particular in low-income settings.
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.
A Chronic Disease Outreach Programme (CDOP), based on the chronic care model was used to follow patients with diabetes and hypertension, support primary health care nurses (PHCNs), and improve health systems for management in Soweto. A group of 257 diabetes patients and 186 PHCN were followed over two years, with the study including the evaluation of ‘functional’ and clinical outcomes, diary recordings outlining program challenges, and a questionnaire assessing PHCNs’ knowledge and education support, and the value of CDOP. CDOP was successful in supporting PHCNs, detecting patients with advanced disease, and ensuring early referral to a specialist centre. It improved early detection and referral of high risk, poorly controlled patients and had an impact on PHCNs’ knowledge. Its weaknesses include poor follow up due to poor existing health systems and the programme’s inability to integrate into existing chronic disease services. The study also revealed an overworked, poorly supported, poorly educated and frustrated primary health care team.
Rape survivors are not getting the healthcare they need. Teenage girls who are raped are often scolded or branded liars by healthworkers attending to them, while men, gays and lesbians and sex workers who have been raped are also discriminated against. Other problems facing rape survivors include the denial of healthcare to those who have not reported the rape to police, the lack of privacy for examinations and staff ignorance of basic treatment procedures. This is according to the South African National Working Group on Sexual Offences, a group of 25 organisations including Childline, the Teddy Bear Clinic, People Opposing Women Abuse and the Tshwaranang Legal Advocacy Centre.
Peripartum deaths remain significantly high in low- and middle-income countries, including Kenya. The authors outline how the COVID-19 pandemic has disrupted essential services, which could lead to an increase in maternal and neonatal mortality and morbidity. The lockdowns, curfews, and increased risk for contracting COVID-19 may affect how women access health facilities. They argue for a community-centred response, not just hospital-based interventions. In this prolonged health crisis, pregnant women deserve a safe and humanised birth that prioritises the physical and emotional safety of the mother and the baby. The authors propose strengthening community-based midwifery to avoid unnecessary movements, decrease the burden on hospitals, and minimise the risk of COVID-19 infection among women and their newborns.
Eclampsia is the commonest direct cause of maternal death in South Africa. The latest Saving Mothers Report (2005-2007) indicates that there were 622 maternal deaths due to hypertensive disorders of pregnancy. Of these, 334 (55.3%) were due to eclampsia; of the eclamptic deaths, 50 were over the age of 35 years and 83 were under 20 years old. Avoidable factors involved patient related factors (mainly delay in seeking help), administrative factors (mainly delay in transport) and health personnel issues (mainly due to delay in referring patients). The major causes of death were cerebrovascular accidents and cardiac failure. The majority of deaths due to cardiac failure were due to pulmonary oedema. To reduce deaths from eclampsia, this study argues that more attention must be given to the detection of pre-eclampsia; the provision of information on the advantages of antenatal care to the population at large and training of health professions in the management of obstetric emergencies.
The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care. The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness. Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3–50 %) and alcohol consumption during pregnancy (5–51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community. It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.
This paper investigated the association between maternal overweight and obesity and caesarean births in Malawi. The authors utilised cross-sectional population-based Demographic Health Surveys data collected from mothers aged 18–49 years in 2004/05, 2010, and 2015/16 in Malawi. The results showed that maternal overweight in 2015/16 and from 2004 to 2015 were risk factors for caesarean births in Malawi. Women who had one parity, and lived in the northern region were significantly more likely to have undergone caesarean birth. In order to reduce non-elective caesarean birth in Malawi, the authors propose that public health programs focus on reducing overweight and obesity among women of reproductive age.