South Africa remains the country with the greatest burden of HIV-infected individuals and the second highest estimated tuberculosis (TB) incidence per capita worldwide. This study reviewed records of consecutive HIV-infected people initiated onto ART between 1 January 2005 and 31 March 2006. Patients were screened for TB at initiation and incident episodes recorded. CD4 counts, viral loads and follow-up status were recorded; data was censored on 5 August 2008. Geographic cluster analysis was performed using spatial scanning. Eight hundred and one patients were initiated. TB prevalence was 25.3%, associated with lower CD4 and prior TB. Prevalent and incident TB were significantly associated with mortality. Incident TB was associated with a non-significant trend towards viral load >25copies/ml. A low-risk cluster for incident TB was identified for patients living near the local hospital in the geospatial analysis. The study concluded that there is a large burden of TB in the population. Rate of incident TB stabilises at a rate higher than that of the overall population. This data highlights the need for greater research on strategies for active case finding in rural settings and the need to focus on strengthening primary health care.
Equitable health services
The incidence of cervical cancer in South Africa remains high, and the current screening programme has had limited success. New approaches to prevention and screening tactics are needed to investigate acceptance of school-based human papillomavirus (HPV) vaccination, as well as the information provided, methods of obtaining consent and assent, and completion rates achieved. Information on cervical cancer and HPV vaccination was provided to 19 primary schools in Western Cape and Gauteng provinces participating in the study. Girls with parental consent and child assent were vaccinated during school hours at their schools. A total of 3 465 girls were invited to receive HPV vaccine, of whom 2 046 provided written parental consent as well as child assent. Sufficient vaccination was achieved in 92% of the vaccinated cohort. The implementation project demonstrated that HPV vaccination is practical and safe in SA schools. Political and community acceptance was good, and positive attitudes towards vaccination were encountered. During the study, which mimicked a governmental vaccine roll-out programme, high completion rates were achieved in spite of several challenges encountered.
Despite widely acknowledged WHO guidelines for the integration of tuberculosis (TB) and HIV services, heavily burdened countries have been slow to implement these and thus significant missed opportunities have arisen. The individual-centred, rights-based paradigm of the national AIDS policy remains dissonant with the compelling public-health approach of TB control. The existence of independent and disconnected TB and HIV services wastes scarce health resources, increases burden on patients' time and finances, and ignores evidence of patients' preference for an integrated service, resulting in ongoing missed opportunities, such as failure to maximise collaborative disease surveillance, voluntary counselling and testing, adherence support, infection control, and positive prevention. The full potential of an integrated TB-HIV service has not been fully harvested. Missed opportunities discount existing efforts in both programmes, will perpetuate the burden of disease, and prevent major gains in future interventions. This paper outlines simple, readily implementable strategies to narrow the gap and reclaim existing missed opportunities.
Controlled medicines are medicines that are listed under the international conventions on narcotic and psychotropic drugs and their precursors. Global morphine consumption – an indicator of access to pain treatment – has increased over the past two decades, but mainly in a small number of developed countries. Developing countries, which represent about 80% of the world’s population, accounted for only about 6% of global morphine consumption.
Surveys of medicine prices and availability, conducted using a standard methodology, have shown that poor medicine availability, particularly in the public sector, is a key barrier to access to medicines. Public sector availability of generic medicines is less than 60% across WHO regions, ranging from 32% in the Eastern Mediterranean Region to 58% in the European Region. Private sector availability of generic medicines is higher that in the public sector in all regions. However, availability is still less than 60% in the Western Pacific, South-East Asia and Africa Regions. Due to low availability of medicines in the public sector, patients are often forced to purchase medicines in the private sector. When originator brands are prescribed and dispensed for products that are also available in generic form, patients are paying four times more, on average, to purchase the brand. High medicine prices increase the cost of treatment. Low public sector availability can be addressed through improved procurement efficiency, and adequate, equitable and sustainable financing. Medicine prices can be reduced by eliminating duties and taxes on medicines and promoting the use of quality-assured generic medicines. Mark-ups can also be regulated to avoid excessive add-on costs in the supply chain. The most appropriate actions to follow depend on a country’s individual survey results and their underlying determinants, as well as local factors including existing pharmaceutical policies and market situations.
Irrational use of medicines is an extremely serious global problem that is wasteful and harmful, according to the authors of this paper. In developing and transitional countries, in primary care less than 40% of patients in the public sector and 30% of patients in the private sector are treated in accordance with standard treatment guidelines. Antibiotics are misused and over-used in all regions. In developing and transitional countries, while only 70% of pneumonia cases receive an appropriate antibiotic, about half of all acute viral upper respiratory tract infection and viral diarrhoea cases receive antibiotics inappropriately. Patient adherence to treatment regimes is about 50% worldwide and lower in developing and transitional countries. Harmful consequences of irrational use of medicines include unnecessary adverse medicines events, rapidly increasing antimicrobial resistance (due to over-use of antibiotics) and the spread of blood-borne infections such as HIV and hepatitis B/C (due to unsterile injections) all of which cause serious morbidity and mortality and cost billions of dollars per year. Effective interventions to improve use of medicines are generally multi-faceted. They include provider and consumer education with supervision, group process strategies (such as peer review and self-monitoring), community case management (where community members are trained to treat childhood illness in their communities and provided with medicines and supervision to do it) and essential medicines programmes with an essential medicine supply element.
Traditional medicines, including herbal medicines, have been, and continue to be, used in every country around the world in some way. In much of the developing world, a large share of the population rely on these traditional medicines for primary care. The global market for traditional medicines was estimated at US$ 83 billion annually in 2008, with an exponential rate of increase. Traditional medicines are used as prescription or over-the-counter (OTC) medications, as self-medication or self-care, as home remedies, or as dietary supplements, health foods, functional foods, phytoprotectants, and under any of many other titles in different jurisdictions, with only minimal consistency between the definitions of these terms from country to country and significant communication issues as a result. It is difficult to control quality and to ensure safety and efficacy in production of traditional medicines. WHO, in cooperation with the WHO Regional Offices and Member States, has produced a series of technical documents in this field, including publications on Good Agricultural and Collection Practices (GACP) and Good Manufacturing Practices (GMP), along with other technical support, to assist with standardization and creation of high quality products. Regulation of traditional medicines is a complicated and challenging issue as it is highly dependent upon experience with use of these products. Model countries such as China, India, and South Africa present usable templates, as do the guidelines on regulation and registration of traditional or herbal medicines produced in the WHO African, Eastern Mediterranean, and South-East Asian regions and in the European Union.
This report, compiled annually by Human Rights Watch (HRW), is focused on human rights, but it makes a number of observations about the state of health services in several east, central and southern African countries. It notes that, partly due to health care system failures, tens of thousands of Kenyan women and girls die each year in childbirth and pregnancy, while more suffer preventable injuries, serious infections, and disabilities. Maternal deaths represent 15% of all deaths for women of reproductive age, while an estimated 300,000 women and girls are living with untreated fistula. Kenya’s restrictive abortion laws, which criminalise abortion generally, are argued to contribute to maternal death and disability, as unsafe abortions account for 30% of maternal deaths. HRW also alleges that the Kenyan government fails to provide adequate pain treatment and palliative care for hundreds of thousands of children with diseases such as cancer or HIV and AIDS. Oral morphine, an essential medicine for pain treatment, is currently out of stock. Kenya’s few palliative care services, which provide pain treatment but also counselling and support to families of chronically ill patients, lack programmes for children. In South Africa, millions of suffer from inadequate access to shelter, water, education, and health care, according to the report. South Africa is unlikely to meet the health-related Millennium Development Goals, and is one of only eight countries in the region where the rate of maternal deaths seems to be increasing. The South African government estimates that the maternal mortality ratio was 625 deaths per 100,000 live births in 2007, up from 150 deaths per 100,000 live births in 1998. In Uganda, women face numerous obstacles to reproductive health products and services such as contraception, voluntary sterilisation procedures, and abortion after rape. The most common barriers are long delays in obtaining services, unnecessary referrals to other clinics, demands for spousal permission contrary to law, financial barriers, and, in some cases, arbitrary denials. As a direct result of these barriers, women and girls may face unwanted or unhealthy pregnancies. Unsafe abortions have been a leading cause of maternal mortality for decades. HRW argues that government oversight of reproductive health care and accountability practices is seriously deficient.
In 2007, the World Health Organization (WHO) launched the ‘make medicines child size’ (MMCS) campaign by urging countries to prioritize procurement of medicines with appropriate strengths for children’s age and weight and, in child-friendly formulations of rectal and flexible oral solid formulations. This study examined policy provisions for MMCS recommendations in Uganda. This was an in-depth case study of the Ugandan health policy documents to assess provisions for MMCS recommendations in respect to oral and rectal medicine formulations for malaria, pneumonia and diarrhea, the major causes of morbidity and mortality among children in Uganda- diseases that were also emphasized in the MMCS campaign. Asthma and epilepsy were included as conditions that require long term care. Schistomiasis was included as a neglected tropical disease. Content analysis was used to assess evidence of policy provisions for the MMCS recommendations. For most medicines for the selected diseases, appropriate strength for children’s age and weight was addressed. However, policy documents neither referred to ‘child size medicines’ concept nor provided for flexible oral solid dosage formulations like dispersible tablets, pellets and granules- indicating limited adherence to MMCS recommendations. Some of the medicines recommended in the clinical guidelines as first line treatment for malaria and pneumonia among children were not evidence-based. The Ugandan health policy documents reflected limited adherence to the MMCS recommendations. This and failure to use evidence based medicines may result into treatment failure and or death. A revision of the current policies and guidelines to better reflect ‘child size’, child appropriate and evidence based medicines for children is recommended.
In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: strengthen public systems for medicines’ management, to improve inventory control and the reliability of procurement forecasts; reduce stress on central medical stores, through liberalisation and reimbursement schemes; strengthen the regulation of drug donations; explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; strengthen the enforcement of regulations on safe drug disposal; invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector.