The objective of this study was to investigate potential differences in the availability of medicines for chronic and acute conditions in low- and middle-income countries. Data on the availability of 30 commonly-surveyed medicines – 15 for acute and 15 for chronic conditions – were obtained from facility-based surveys conducted in 40 developing countries. The researchers found that availability of medicines for both acute and chronic conditions was suboptimal across countries, particularly in the public sector. Generic medicines for chronic conditions were significantly less available than generic medicines for acute conditions in both the public sector and the private sector. An inverse association was found between country income level and the availability gap between groups of medicines, particularly in the public sector. In low- and lower-middle income countries, drugs for acute conditions were 33.9% and 12.9% more available, respectively, in the public sector than medicines for chronic conditions. Differences in availability were smaller in the private sector than in the public sector in all country income groups. Current disease patterns do not explain the significant gaps observed in the availability of medicines for chronic and acute conditions. Measures are needed to better respond to the epidemiological transition towards chronic conditions in developing countries alongside current efforts to scale up treatment for communicable diseases.
Equitable health services
What is the best way to address the health care needs of an underserved population? Is it through disease prevention or is it through a more comprehensive and coordinated approach? According to a session of the August 2006 Geneva Health Forum integration of the two approaches is the key to a successful health care delivery system, providing wider access to a greater number of the population. The vertical approach is disease-centred, while the horizontal approach is patient-centred. The use of resources in a vertical approach is dictated by a centralized authority, while the horizontal approach encompasses area-wide planning at the centre with final decision-making devolved to the local or district level. Experiences reported from Uganda and Tanzania indicated limitations of the vertical approach and the better results provided by the adoption of a horizontal approach.
The objective of this study was to evaluate the impact of rapid diagnostic tests (RDTs) on prescribing behaviours, assess prescribers' and patients' perceptions, and identify operational issues during implementation. Baseline data was collected at six Tanzanian public dispensaries. RDTs were implemented for eight weeks and data collected on frequency of RDT use, results, malaria diagnoses and the prescription of antimalarials. The study found that overprescriptions decreased over the study period. There was a high degree of patient/caregiver and provider acceptance and satisfaction with RDTs. Implementation should include community education, sufficient levels of training and supervision and consideration of the need for additional staff.
Although qualitative studies have raised attention to humiliating treatment of women during labour and delivery, there are no reliable estimates of the prevalence of disrespectful and abusive treatment in health facilities. The authors measured the frequency of reported abusive experiences during facility childbirth in eight health facilities in Tanzania and examined associated factors. The study was conducted in rural northeastern Tanzania, using a structured questionnaire. A total of 1779 women participated in the exit survey and 593 were re-interviewed at home. Between 19% and 28% of women in eight facilities in northeastern Tanzania experienced disrespectful and/or abusive treatment from health providers during childbirth. This is argued by the author to be a health system crisis that requires urgent solutions both to ensure women’s right to dignity in health care and to improve effective utilization of facilities for childbirth in order to reduce maternal mortality.
Little is known about the prevalence of disrespectful treatment of patients in sub-Saharan Africa outside of maternity care. Data from a household survey of 2002 women living in rural Tanzania was used to describe the extent of disrespectful care during outpatient visits, who receives disrespectful care and the association with patient satisfaction, rating of quality and recommendation of the facility to others. Women were asked about their most recent outpatient visit to the local clinic, including if they were made to feel disrespected, if a provider shouted at or scolded them, and if providers made negative or disparaging comments about them. Women who answered yes to any of these questions were considered to have experienced disrespectful care. The most common reasons for seeking care were fever or malaria, vaccination and non-emergent check-up. Disrespectful care was reported by 14.3% of women and was more likely if the visit was for sickness compared to a routine check-up. Women who did not report disrespectful care were 2.1 times as likely to recommend the clinic. While there is currently a lot of attention on disrespectful maternity care, the authors suggest that this is a problem that goes beyond this single health issue and should be addressed by more horizontal health system interventions and policies.
Access to health care is a particular concern given the centrality of poor access in perpetuating poverty and inequality. Even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health. Using new data from the first nationally representative panel survey in South Africa together with administrative geographic data from the Department of Health, the authors investigate the role of distance to the nearest facility on patterns of health care utilization. Ninety percent of South Africans live within 7km of the nearest public clinic, and two-thirds live less than 2km away. However, 15% of Black African adults live more than 5km from the nearest facility, in contrast to only 7% of coloureds and 4% of whites. There is a clear income gradient in proximity to public clinics. The poorest people tend to reside furthest from the nearest clinic and an inability to bear travel costs constrains them to lower quality health care facilities. Within this general picture, men and women have different patterns of health care utilization, with the reduction in utilization of health care associated with distance being larger for men than it is for women.
There is a high disparity in access to perinatal care services between urban and rural areas in Tanzania. This study analysed repeated cross-sectional data from Tanzania to explore the relationship between antenatal care (ANC) visits, facility-based delivery and the reasons for home births in women who had made ANC visits. The relationship between the number of ANC visits (up to four) and facility delivery in the latest pregnancy was explored. For rural women, there was no significant relationship between the number of ANC visits and facility delivery rate. The most frequent reason for home delivery was ‘physical distance to facility’, and a significant proportion of rural women reported that they were ‘not allowed to deliver in facility’. The disconnect between ANC visits and facility delivery in rural areas may be attributable to physical, cultural or familial barriers, and quality of care in health facilities. This suggests that improving access to ANC may not be enough to motivate facility-based delivery, especially in rural areas.
Due to growing antimalarial drug resistance, Tanzania changed malaria treatment policies twice within a decade – in 2001 and again in 2006. The authors of this study assessed health workers‟ attitudes and personal practices following the first treatment policy change, at six months post-change and two years later. Two cross-sectional surveys were conducted in 2002 and 2004 among healthcare workers in three districts in South-East Tanzania using semi-structured questionnaires. Attitudes were assessed by enquiring which antimalarial was considered most suitable for the management of uncomplicated malaria for the three patient categories: children below 5; older children and adults; and pregnant women. A total of 400 health workers were interviewed; 254 and 146 in the first and second surveys, respectively. Results showed that following changes in malaria treatment recommendations, most health workers did not prefer the new antimalarial drug, and their preferences worsened over time. However, many of them still used the newly recommended drug for management of their own or family members’ malaria episode. This indicates that factors other than providers’ attitude may have more influence in their personal treatment practices.
The authors of this paper drew upon local-level research to examine the roll out of treatment for two neglected tropical diseases (NTDs) – schistosomiasis and soil-transmitted helminthes – in Uganda. Ethnographic research was undertaken over a period of four years between 2005-2009 in north-west and south-east Uganda to determine the effectiveness of mass drug administration (MDA) for the two NTDs. In addition to participant observation, survey data recording self-reported take-up of drugs was collected from a random sample of at least 10% of households at study locations. The comparative analysis of take-up among adults revealed that, although most long-term residents have been offered treatment at least once since 2004, the actual take-up of drugs varies considerably from one district to another and often also within districts. The authors argue that this is due to local dynamics and highlight the need to adapt MDA to local circumstances. They call for improvements in health education, drug distribution and more effective use of existing public health legislation. Current standard practices of monitoring, evaluation and delivery of MDA for NTDs were found to be inconsistent and inadequate.
In this presentation given at the Second Global Symposium on Health Systems Research in November 2012, researchers presented the results of a study in which they evaluated the effectiveness of daily observation of drug consumption at tuberculosis (TB) clinics in South Africa. They conducted 1,200 patient exit interviews with patients in 30 different TB facilities, as well as 17 in-depth interviews to understand patient access barriers. Findings indicated that the requirement for daily observation of drug consumption at clinics imposes substantial costs on patients, and this may impact adversely on adherence. In multivariate regressions, patients that visited the facility on a daily basis (versus other) were more than twice as likely to report missing their TB medication (after controlling for other factors). Qualitative findings suggest that long travel distances to facilities, the cost of transport, and the opportunity cost of clinic attendance were some of the factors influencing adherence. Less frequent clinic visits may be a win-win for TB treatment because of: improved efficiency through reduced provider costs; higher adherence; and lower patient access barriers to care.