This report highlights the systemic problems that prevent women, men and young people from accessing reproductive health supplies, and provide recommendations on moving forward. The authors call for increased funding for reproductive health and argue that reproductive health must be incorporated into national health plans and budgeted for accordingly. Additionally, governments should create an enabling environment for sexual and reproductive health and rights. The authors make several recommendations for health service provision. Governments should ensure that a wide range of reproductive health supplies are included in the national essential drug list, while health system-strengthening initiatives and national health plans must include provisions for monitoring the distribution of reproductive health supplies. Capacity for quality of care should be built among all health professionals that deliver supplies, including health care providers, pharmacists and nurses, and there should be more investment in adequate storage facilities at national and municipal levels, and implementation of logistics management systems.
Equitable health services
Each year in Sub-Saharan Africa, South Central Asia and Southeast Asia, 49 million women have unintended pregnancies, leading to 21 million unplanned births, 21 million induced abortions (15 million of which are unsafe), 116,000 maternal deaths and the loss of 15 million healthy years of women’s lives. Seven in 10 women with unmet need for modern contraception in the three regions cite reasons for non-use that could be rectified with appropriate methods. In these three regions, the typical woman with reasons for unmet need that could be addressed with appropriate methods is married, is 25 or older, has at least one child and lives in a rural area. In the short term, women and couples need more information about pregnancy risk and contraceptive methods, as well as better access to high-quality contraceptive services and supplies. In the medium term, adaptations of current methods can make these contraceptives more acceptable and easier to use. Investment in longer-term work is needed to discover and develop new modes of contraceptive action that do not cause systemic side effects, that can be used on demand, and that do not require partner participation or knowledge. Overcoming method-related reasons for non-use of modern contraceptives is projected to reduce unintended pregnancy and its consequences by as much as 59% in these regions.
Inequities in both health status and coverage of health services are considered important barriers to achieving Millennium Development Goal 4. Community-based health promotion is a strategy that is believed to reduce inequities in rural low-income settings. This paper examines the contributions of community-based programming to improving the equity of newborn health in three districts in Malawi. This study is a before-and-after evaluation of Malawi's Community-Based Maternal and Newborn Care (CBMNC) program, a package of facility and community-based interventions to improve newborn health. Health Surveillance Assistants (HSAs) within the catchment area of 14 health facilities were trained to make pregnancy and postnatal home visits to promote healthy behaviours and assess women and newborns for danger signs requiring referral to a facility. Core groups of community volunteers were also trained to raise awareness about recommended newborn care practices. Baseline and endline household surveys measured the coverage of the intervention and targeted health behaviours for this before-and-after evaluation. Wealth indices were constructed using household asset data and concentration indices were compared between baseline and endline for each indicator. Despite modest coverage levels for the intervention, health equity improved significantly over the study period for several indicators. Greater improvements in inequities were observed for knowledge indicators than for coverage of routine health services. Although these results indicate promising improvements for newborn health in Malawi, the extent to which the programme contributed to these improvements in coverage and equity are not known. The strategies through which community-based programs are implemented likely play an important role in their ability to improve equity, and further research and monitoring are needed to ensure that the poorest households are reached by community-based health programs.
The authors describe the nature of geriatric medical admissions to teaching hospitals in three countries in Africa (Nigeria, Sudan, Tanzania) and compare them with data from the United Kingdom. They included all people aged 60 and older urgently medically admitted from March 1 to August 31, 2012. Data were collected regarding age, sex, date of admission, length of stay, diagnoses, medication, date of discharge or death, and discharge. In Africa, noncommunicable diseases (NCDs) accounted for 81.0% (n = 708) of admissions (n = 874), and tuberculosis, malaria, and the human immunodeficiency virus and acquired immunodeficiency syndrome accounted for 4.6% (n = 40). Cerebrovascular accident (n = 224, 25.6%) was the most common reason for admission, followed by cardiac or circulatory dysfunction (n = 150, 17.2%). Rates of hypertension were remarkably similar in the United Kingdom (45.8%) and Africa (40.2%).In the elderly population, the predicted increased burden of NCDs on health services in Africa appears to have occurred. Greater awareness and some reallocation of resources toward NCDs may be required if the burden of such diseases is to be reduced.
The control of sexually transmitted infections (STIs) is a public health outcome measured by reduced incidence and prevalence. The means to achieve this include: targeting and outreach to populations at greatest risk; promoting and providing condoms and other means of prevention; effective clinical interventions; an enabling environment; and reliable data. Clinical services alone are insufficient for control since many people with STIs do not attend clinics. Outreach and peer education have been effectively used to reach such populations. STI control requires effective interventions with core populations whose rates of partner change are high enough to sustain transmission. Effective, appropriate targeting is thus necessary and often sufficient to reduce prevalence in the general population. Such efforts are most effective when combined with structural interventions to ensure an enabling environment for prevention. Reliable surveillance and related data are critical for designing and evaluating interventions and for assessing control efforts.
Global efforts focusing on eliminating malaria are counterproductive to the fight against the disease in Africa, experts have warned. They emphasise the importance of maintaining, and building on, control strategies rather than aiming for a target that may not be met. Buoyed by a reduction in malaria mortality in Africa, health leaders in 2007 switched their primary goal from control to elimination. But researchers from the Kenya Medical Research Institute-Wellcome Trust Research Programme in Nairobi now say that the emphasis on elimination or eradication in strategic plans for the next 10 to 20 years in Africa is 'at best irrelevant and at worst counterproductive', raising expectations that cannot be met. Increased use of insecticide-treated bed nets, improved rapid diagnostic tests and the replacement of failing drugs with artemisinin-based combination therapy are among the interventions that have helped to reduce malaria transmission and incidence substantially across the continent. On the coast of Kenya, for example, the incidence of severe malaria has fallen by more than 90% in the last five years. However, the researchers warn that positive results are not universal throughout Africa. A substantial funding gap remains to meet the estimated US$4 per head needed to treat malaria, which currently stands at less than US$1 per head.
This paper discusses the burden of cancer in developing countries and examines which types of cancers can be prevented and treated affordably in low-resource settings and which interventions can be used to control them. The paper concludes that to guide policymakers on the most effective cancer control strategies in developing countries, more work is needed in: clinical evaluations of cancer control interventions, health services research, and country specific economic evaluations. It recommends that since current knowledge about cancer control is incomplete, developing countries should start in small areas and gain knowledge from well-documented pilot programmes. Starting small might entail focusing on individuals with certain high-risk characteristics or in a limited geographic area, and scaling up should occur only after pilot programmes have been shown to perform well.
The objective of this study was to assess the cost–effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Incremental cost–effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective. Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. The authors suggest that community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.
The tools presented in this publication assess mother and child health (RMNCH) change over time and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, results are presented from Tanzania and Peru. The Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. All lifesaving RMNCH commodities were included on their essential medicines lists, but the health worker density (7.1/10,000 population), is below the 22.8 WHO minimum threshold.
This statement was delivered at the World Conference on Social Determinants of Health, held from 19-21 October 2011 in Rio de Janeiro, Brazil. According to Kenya’s Minister for Public Health and Sanitation, there are a number of steps that the Kenyan government has taken to reduce inequities in health. In 201 out of the country’s 210 constituencies, a model health facility is being constructed, with an additional 50 health workers employed per constituency, totaling 12,000 additional health workers. The Community-led Total Sanitation (CLTS) project for urban areas is also being rolled out, with government aiming at attaining full coverage by 2013. The Health Sector Service Fund has also been established, through which funds are being disbursed directly to health facilities that are run by local committees, and intersectoral co-ordinating mechanisms for thematic areas like child health, sanitation and malaria have been created. However, the Minister identified challenges in providing universal access to health services, including inadequate funding to the health sector, the influx of refugees from neighbouring countries with weak health systems, high levels of rural-urban migration, the emerging threat of non-communicable diseases, and hard-to-reach terrains which hinder access to health facilities. With regards to the medical brain drain, the Minister urged the developed countries that are the major beneficiaries of health worker migration to support training of health workers in developing countries.