This study is a review of public health perspectives of preeclampsia in developing countries and implications for health system strengthening. Literature from Pubmed (MEDLINE), AJOL, Google Scholar, and Cochrane database were reviewed. Results showed that the prevalence of preeclampsia in developing countries ranges from 1.8% to 16.7%. Many challenges exist in the prediction, prevention, and management of preeclampsia. Promising prophylactic measures like low-dose aspirin and calcium supplementation need further evidence before recommendation for use in developing countries. Treatment remains prenatal care, timely diagnosis, proper management, and timely delivery. Overcoming the prevailing challenges in the control of preeclampsia in developing countries hinges on the ability of health care systems to identify and manage women at high risk, the authors conclude.
Equitable health services
Little conceptual or empirical work exists on the measurement of antenatal care (ANC) quality at health facilities in low-income countries. To address this gap, researchers in this study developed a classification tool and assessed the level of ANC service provision at health facilities in Zambia on a national scale and compared this to the quality of ANC received by expectant mothers. They included 1,299 antenatal facilities in the study and compared the quality of ANC received by 4,148 mothers between 2002 and 2007. Results showed that only 45 antenatal facilities (3%) fulfilled the study’s developed criteria for optimum ANC service, while 47% of facilities provided adequate service, and the remaining 50% offered inadequate service. Although 94% of mothers reported at least one ANC visit with a skilled health worker and 60% attended at least four visits, only 29% of mothers received good quality ANC, and only 8% of mothers received good quality ANC and attended in the first trimester. The authors argue that these results indicate missed opportunities at ANC for delivering effective interventions. Evaluating the level of ANC provision at health facilities is an efficient way to detect the “quality gap” where deficiencies are located in the system and could serve as a monitoring tool to evaluate country progress.
Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. This audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape Province. The usual steps in the quality improvement cycle were followed. Data was obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% a self-management plan. In conclusion, the availability of medication and prescription of inhaled steroids is reasonable and yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.
The objective of this study was to assess the quality of child health services provided at primary health care (PHC) facilities in Johannesburg, South Africa. Sixteen PHC clinics were surveyed, using a researcher-developed structured checklist based on national guidelines and protocols. Most facilities were found to be adequately equipped and well stocked with drugs. A total of 141 sick child and 149 well child visits were observed. Caregivers experienced long waiting times (mean length of 135 minutes). Many routine examination procedures were poorly performed, with an adequate diagnosis established in 108 of 141 consultations (77%), even though health professionals were experienced and well trained. Triage and attention to danger signs were poor. An antibiotic was prescribed in almost half of the consultations, but antibiotic use was unwarranted in one-third of these cases. Health promotion activities (such as growth monitoring) were consistently ignored during sick child visits. HIV status was seldom asked about or investigated, for the mother or for the child. Growth monitoring and nutritional counselling at well child visits was generally inadequate, with not one of 11 children who qualified for food supplementation receiving it. In conclusion, the findings indicate that PHC offered to children in Johannesburg is seriously inadequate. The study urges for a deliberate and radical restructuring of PHC for children, with clearly defined and monitored standard clinical practice routines and norms.
An estimated 55,000 people die of rabies in Africa and Asia every year, a viral disease passed from an infected animal to a human through biting or scratching. In both humans and animals it is deemed fatal once it enters the central nervous system, with only a handful of survivors. Already nine human cases that resulted in death have been confirmed in South Africa this year; three in the Eastern Cape, two in Kwa Zulu-Natal, one in Mpumalanga and three in Limpopo. Experts in the medical fraternity have described this as worrying, saying people need to be aware of rabies. Professor Lucille Blumberg of the National Institute for Communicable Diseases, says her institution deals with up to 20 cases of human rabies per year. She says that if a person is bitten by a stray animal, they should immediately wash the wound very well, to physically remove the virus, then visit a clinic immediately to get an injection to prevent infection and to go on a course of injections to develop antibodies to the disease.
Commonly available malaria maps are based on parasite rate, a poor metric for measuring malaria at extremely low prevalence. New approaches are required to provide case-based risk maps to countries seeking to identify remaining hotspots of transmission while managing the risk of transmission from imported cases. In this study, household locations and travel histories of confirmed malaria patients during 2011 were recorded for the higher transmission months of January to April and the lower transmission months of May to December. Data was gathered and used to generate maps predicting the probability of a locally acquired case at 100 m resolution across Swaziland for each season. Results indicated that case households during the high transmission season tended to be located in areas of lower elevation, closer to bodies of water, in more sparsely populated areas, with lower rainfall and warmer temperatures, and closer to imported cases. The high-resolution mapping approaches described here can help elimination programmes understand the epidemiology of a disappearing disease. The authors argue that generating case-based risk maps at high spatial and temporal resolution will allow control programmes to direct interventions proactively according to evidence-based measures of risk and ensure that the impact of limited resources is maximised to achieve and maintain malaria elimination.
TB control is hampered by the dual HIV epidemic, and is one of the main reasons for the rapid increase in TB in South Africa, compounded by escalating rates of multidrug resistance (MDR) and the emergence of extensively drug-resistant TB (XDR-TB) in all nine provinces. Rapid diagnosis of drug-resistant TB has been identified as one of the key efforts to find a solution to the control of MDR-TB. A demonstration study under field conditions involving 20,000 TB patients at risk of MDR-TB was conducted in four provinces in South Africa, evaluating the effectiveness of a new molecular test for rapid diagnosis of MDR-TB. Outcomes of this study showed that the test has the potential to revolutionise the control of MDR-TB and its use in TB control programmes has been endorsed by the World Health Organisation. The study showed that the test is highly effective in diagnosing MDR-TB and can be used in laboratory settings in developing countries. Although specialised laboratory facilities and specially trained personnel are required, the test is easy to perform in the laboratory and results are accurate and reproducible. This is very likely one of few instances that global policy for poverty-related disease is driven by evidence generated by scientists and institutions from high-burden countries, such as South Africa, with full credit for the results. The test will be rolled out to all provinces in South Africa, following the acceptance of a new diagnostic algorithm by the National TB Control Programme.
Amid fears that huge quantities of counterfeit medicines and pesticides are pouring into Africa, the international law enforcement agency INTERPOL is leading the way to invest more effort and money to bring authorities up to speed on the threat faced by those who depend on the imports, from hospital patients to pharmacists to farmers. Among the first of the OASIS anti-counterfeiting moves was Operation Mamba, a police action in Uganda and Tanzania in September and October that led to the seizure of more than 100 kinds of medical products, including anti-malarial pills, multivitamins, skin medicines and heart drugs. Four pharmacies in Tanzania were shut down; in Uganda, police are investigating 38 shops on suspicion that they are working illegally. INTERPOL is investing more effort and attention to Africa as the staggering extent of the counterfeiting problem on the continent becomes clearer. While precise numbers are difficult to come by, the World Health Organization believes that 30 percent of drugs sold in developing countries are counterfeit; in some parts of Africa, that number could be as high as 90%.
This study assessed whether home-based HIV care was as effective as was facility-based care. It undertook a cluster-randomised equivalence trial in Jinja, Uganda. Forty-four geographical areas in nine strata, defined according to ratio of urban and rural participants and distance from the clinic, were randomised to home-based or facility-based care by drawing sealed cards from a box. The trial was integrated into normal service delivery. Of the total patients, 859 patients (22 clusters) were randomly assigned to home and 594 (22 clusters) to facility care. During the first year, 93 (11%) receiving home care and 66 (11%) receiving facility care died, 29 (3%) receiving home and 36 (6%) receiving facility care withdrew, and 8 (1%) receiving home and 9 (2%) receiving facility care were lost to follow-up. Mortality rates were similar between groups, and 97 of 857 (11%) patients in home and 75 of 592 (13%) in facility care were admitted at least once. In conclusion, this home-based HIV-care strategy is as effective as is a clinic-based strategy, and therefore could enable improved and equitable access to HIV treatment, especially in areas with poor infrastructure and access to clinic care.
The aim of this paper is to reconsider established practices and policies for HIV and tuberculosis epidemic control, aiming at delivering better results and value for money. This may be achieved by promoting greater integration of HIV and tuberculosis control programme activities within a strengthened health system. The current health system approach to HIV and tuberculosis control often involves separate specialised services. Despite some recent progress, collaboration between the programmes remains inadequate, progress in obtaining synergies has been slow, and results remain far below those needed to achieve universal access to key interventions. A fundamental re-think of the current strategic approach involves promoting integrated delivery of HIV and tuberculosis programme activities as part of strengthened general health services: epidemiological surveillance, programme monitoring and evaluation, community awareness of health-seeking behavior, risk behaviour modification, infection control, treatment scale-up (first-line treatment regimens), drug-resistance surveillance, containing and countering drug-resistance (second-line treatment regimens), research and development, global advocacy and global partnership. Health agencies should review policies and progress in HIV and tuberculosis epidemic control, learn mutual lessons for policy development and scaling up interventions, and identify ways of joint planning and joint funding of integrated delivery as part of strengthened health systems.