The scale-up of antiretroviral therapy (ART) for HIV-infected people in sub-Saharan Africa (SSA) over the past 15 years is one of the most remarkable achievements in public health. With approximately 12 million people on treatment in 2015, life expectancy on the subcontinent has vastly improved. Nevertheless, ART coverage in SSA is still suboptimal, HIV incidence remains high, and improved survival due to ART implies ever increasing numbers of people on treatment. Substantial additional resources are needed to further scale up ART, yet funding has recently levelled off, increasing the need to optimise the allocation of limited resources. This presents local policy makers with complex dilemmas. The authors argue that the current evidence base for prioritising ART scale-up strategies leads to recommendations that are theoretically optimal but practically infeasible to implement. They argue that cost-effectiveness analyses of scaling up ART in SSA take into account the local health system by integrating supply- and demand-side constraints in mathematical models and improving the dialogue between researchers and policy makers.
Equitable health services
Although recent survey data make it possible to examine inequalities in maternal and newborn health care in developing countries, analyses have not tended to take into consideration the special nature of urban poverty. Using improved methods to measure urban poverty in 30 countries, this study found substantial inequalities in maternal and newborn health, and in access to health care. The ‘urban advantage’ is, for some, non-existent. The urban poor do not necessarily have better access to services than the rural poor, despite their proximity to services. There are two main patterns of urban inequality in developing countries: massive exclusion, in which most of the population do not have access to services, and urban marginalisation, in which only the poor are excluded. At a country level, these two types of inequality can be further subdivided on the basis of rural access levels. Inequity is not mandatory. Patterns of health inequality differ with context, and there are examples of countries with relatively small degrees of urban inequity. Women and their babies need to have access to care, especially around the time of birth. Different strategies to achieve universal coverage in urban areas are needed according to urban inequality typology, but the evidence for what works is restricted to a few case studies.
Despite the Zambian Government’s effort to expand services to district level, this study reports that it is still hard for people living with HIV to access antiretroviral treatment (ART) in rural Zambia. Strong demands for expanding ART services at the rural health centre level face challenges of resource shortages. The Mumbwa district health management team introduced mobile ART services using human resources and technical support from district hospitals, and community involvement at four rural health centres in the first quarter of 2007. This paper discusses the uptake of the mobile ART services in rural Mumbwa. Before the introduction of mobile services, ART services were provided only at Mumbwa District Hospital. The study found that mobile services improved accessibility to ART, especially for clients in better functional status, i.e. still able to work. In addition, these mobile services may reduce the number of cases ‘lost to follow-up’. This might be due to the closer involvement of the community and the better support offered by these services to rural clients. These services helped expand services to rural health facilities where resources are limited, bringing them as close as possible to where clients live.
The authors of this article challenge the public health community's assumption that cancers will remain untreated in poor countries, and note the analogy to similarly unfounded arguments from more than a decade ago against provision of HIV treatment in poor countries. In resource-constrained countries without specialised services, experience has shown that much can be done to prevent and treat cancer by deploying primary and secondary caregivers, using off-patent drugs, and applying regional and global mechanisms for financing and procurement. Furthermore, several middle-income countries have included cancer treatment in national health insurance coverage, with a focus on people living in poverty. These strategies can reduce costs, increase access to health services and strengthen health systems to meet the challenge of cancer and other diseases, the authors argue. To promote cancer treatment in poor countries, the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries was formed in 2009. It is composed of leaders from the global health and cancer care communities, and is dedicated to proposal, implementation and evaluation of strategies to advance this agenda.
In response to requests for the funding of new drugs, reimbursement agencies are re-evaluating some of the methods used in assessing these products. Many trials submitted for the regulatory review of new drugs do not provide adequate data for subsidy decisions. The authors argue that all involved in bringing medicines to market need to be explicit about the additional information required, decide how these data should be collected and assessed and the methods that should be used to set a fair price for a new drug.
The expiry of medicines in the supply chain is a serious threat to the already constrained access to medicines in developing countries. This study investigated the extent of, and the main contributing factors to, expiry of medicines in medicine supply outlets in Kampala and Entebbe, Uganda. A cross-sectional survey of six public and 32 private medicine outlets was done using semi-structured questionnaires. The study area has 19 public medicine outlets (three non-profit wholesalers, 16 hospital stores/pharmacies), 123 private wholesale pharmacies and 173 retail pharmacies, equivalent to about 70% of the country’s pharmaceutical businesses. The findings indicate that medicines prone to expiry include those used for vertical programmes, donated medicines and those with a slow turnover. Sound coordination is needed between public medicine wholesalers and their clients to harmonise procurement and consumption as well as with vertical programmes to prevent duplicate procurement. Additionally, national medicine regulatory authorities should enforce existing international guidelines to prevent dumping of donated medicine. Medicine selection and quantification should be matched with consumer tastes and prescribing habits. Lean supply and stock rotation should be considered.
Malaria rapid diagnostic tests (RDTs) are relatively simple to perform and provide results quickly for making treatment decisions. However, the accuracy and application of RDT results depends on several factors such as quality of the RDT, storage, transport and end user performance. A cross sectional survey to explore factors that affect the performance and use of RDTs was conducted in the primary care facilities in South Africa.
This paper explored barriers to care seeking in public health facilities in Kenya among Somali women after complications related to female genital mutilation/cutting (FGM/C). The authors used interviews and focus group discussions to collect data from women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Barriers to care-seeking included the high cost of care, distance from health facilities, lack of a referral system and concerns on quality and privacy of care. Women faced cultural taboos in discussing sexual health with male clinicians, while fear of legal sanctions given the anti-FGM/C laws deterred women with complications from seeking healthcare. The authors suggest that the health system consider integrating FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care, address health-related financial, physical and communication barriers, and ensure culturally-sensitive and confidential care.
In this paper, the authors explore affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Between June 2008 and September 2009, they conducted a mixed-method study combining 1,231 quantitative exit interviews with 16 qualitative in-depth interviews with women in two urban and two rural health sub-districts in South Africa. Barriers were found to be unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability. Negative provider-patient interactions also inhibited access and compromised quality of care, including staff inattentiveness, turning away women in early labour, shouting at patients and insensitivity towards those who had experienced stillbirths. To move towards achieving its Millennium Development Goals, the authors argue that South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery.
This qualitative study explored in detail the ability of output-based aid (OBA) voucher programmes to increase access to gender-based violence recovery (GBVR) services. It was conducted in 2010 and data was gathered through in-depth interviews (IDIs) with health managers, service providers, voucher management agency (VMA) managers and focus group discussions (FGDs) with voucher users, voucher non-users, voucher distributors and opinion leaders drawn from five programme sites in Kenya. The findings showed promising prospects for the uptake of OBA GBVR services among target population. However, a number of factors affect the uptake of the services, such as lack of general awareness of the GBVR services vouchers, lack of understanding of the benefit package, immediate financial needs of survivors, as well as stigma and cultural beliefs that undermine reporting of cases or seeking essential medical services. The researchers also found that accreditation of only hospitals to offer GBVR services undermined access to the services in rural areas, and low provider knowledge on GBVR services and lack of supplies undermined effective provision and management of GBVR services. They argue that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA programme to promote the GBVR services voucher, and conduct widespread community education programmes aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.