The fight against tuberculosis (TB) is argued to have failed children: the share of paediatric TB is increasing, and children have not escaped the rising tide of drug-resistant strains, according to new research presented at the South African TB Conference, which was held from 1–4 June 2010. Dr Ntombi Mhlongo-Sigwebela, TB programme director at the University Research Company, a public health consultancy, told the conference in Durban that TB in children under four years of age now accounted for about 9% of all national TB cases annually. Dr Kalpesh Rahevar, a World Health Organization (WHO) medical officer, said inconclusive conventional TB skin tests (to determine whether a patient has a latent TB infection) and the inability to get sputum samples from young children made paediatric TB more difficult to diagnose and treat than in adults. Paediatric drug formulations and international treatment guidance for children were also inadequate, said Dr Ben Marais of the University of Stellenbosch, in Western Cape Province.
Equitable health services
This study investigated knowledge of, perceptions of and access to tuberculosis (TB) treatment and adherence to treatment among an Eastern Cape population in South Africa. An area-stratified sampling design was applied. A total of 1,020 households were selected randomly in proportion to the total number of households in each neighbourhood. It found TB knowledge was fairly good among this community. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say and therefore may not seek treatment. Regression analyses revealed that in this population young and old, men and women and the lower and higher educated share the same attitudes and perceptions, suggesting that the findings are likely to reflect the actual situation of TB patients in the population. Future interventions should be directed at improving attitudes and perceptions to potentially reduce stigma. This requires a patient-centred approach to empower TB patients and their active involvement in the development and implementation of stigma reduction programmes.
The African Health Initiative (AHI) has yielded many lessons about how to support health systems within complex and changing geographic, social and political contexts. This has been organised into a series of essays from the field on “What We’re Learning". The first in this series is reported here, with information to support an understanding of the nuances of how health services that result in improvements in population health are delivered.
Growing international concern about the need for improved health systems in Africa has catalysed an expansion of the health systems literature. This review applies a bibliometric procedure to analyse the acceleration of scientific writing on this theme. The authors focus on research published during the Millennium Development Goal (MDG) era between 1990 and 2014, reporting findings from a systematic review of a database comprised of 17,655 articles about health systems themes from sub-Saharan African countries or subregions. Using bibliometric tools for co-word textual analysis, the authors analysed the incidence and associations of keywords and phrases to generate and visualise topical foci on health systems as clusters of themes. Results show that African health systems research is dominated by literature on diseases and categorical systems research topics, rather than on systems science that cuts across diseases or specific systemic themes. Systems research is highly developed in South Africa but relatively uncommon elsewhere in the region. Results identify several themes that are unexpectedly uncommon in the country-specific health systems literature. This includes research on the processes of achieving systems change, the health impact of systems strengthening, processes that explain the systems determinants of health outcomes, or systematic study of organisational dysfunction and ways to improve system performance. Research quantifying the relationship of governance indicators to health systems strengthening is nearly absent from the literature. Long-term experimental studies and statistically rigorous research on cross-cutting themes of health systems strengthening are rare. Studies of organisational malaise or corruption are virtually absent. Trend analysis shows the emergence of organisational research on specific priority diseases, such as on HIV/AIDS, malaria, and tuberculosis, but portrays a lack of focus on integrated systems research on the general burden of disease. If health systems in Africa are to be strengthened, then organisational change research must be a more concerted focus in the future than has been the case in the past.
The Algiers Declaration on Narrowing the Knowledge Gap to Improve Africa’s Health was adopted during a Conference held in Algiers, Algeria, in June 2008. The Conference, which brought Ministers from the African Region together with researchers, non-governmental organisations, donors and the private sector, renewed commitments to narrow the knowledge gap in order to improve health development and health equity in the Region. This paper describes the background to the Algiers Declaration and the Framework for its implementation and their significance in assisting efforts by countries in the Region to strengthen their health systems. The paper argues that countries should implement the series of steps in the Algiers Framework to strengthen their health systems. These steps will help them to develop the content, processes and use of technology aimed at improving: the availability of relevant and timely health information; the management of health information through better analysis and interpretation of data; the availability of relevant, ethical and timely research evidence; the use of evidence by policy-makers and decision-makers; improving dissemination and sharing of information, evidence and knowledge; access to global health information; and the use of information and communication technologies.
This study aimed to describe the burden of malaria in Gauteng Province, and to identify potential risk factors for severe disease. It conducted a prospective survey of malaria cases diagnosed in hospitals throughout Gauteng from December 2005 to end November 2006. It identified 1,701 malaria cases, of which 1,548 (91%) were seen at public sector hospitals and 153 (9%) at private hospitals, while 1,149 (68%) patients were male. Most (84%) infections were acquired in Mozambique. While most patients appropriately received quinine, only 9% of severe malaria cases received the recommended loading dose. The incidence of malaria in Gauteng was higher than previously reported, emphasising the need to prevent malaria in travellers by correct use of non-drug measures and, when indicated, malaria chemoprophylaxis. Disease severity was increased by delays between onset and treatment and lack of partial immunity. The study recommends that providers should consult the latest guidelines for treatment of malaria in South Africa, particularly about treatment of severe malaria. A change in drug policy to artemisinin combination therapy for imported uncomplicated malaria in non-malaria risk provinces should be strongly considered.
South Africa’s burden of non-communicable diseases will probably increase as the roll-out of antiretroviral therapy takes effect and reduces mortality from AIDS. The scale of the challenge posed by the combined and growing burden of HIV and AIDS and non-communicable diseases demands an extraordinary response that South Africa is well able to provide. Concerted action is needed to strengthen the district-based primary health-care system, to integrate the care of chronic diseases and management of risk factors, to develop a national surveillance system, and to apply interventions of proven cost-effectiveness in the primary and secondary prevention of such diseases within populations and health services. The researchers urge the launching of a national initiative to establish sites of service excellence in urban and rural settings throughout South Africa to trial, assess and implement integrated care interventions for chronic infectious and non-communicable diseases.
Despite more than half a century of advocacy for safe water, sanitation and hygiene, approximately 100,000 cholera cases and 5,000 deaths were reported in Zimbabwe between August 2008 and by July 2009. Safe and effective oral cholera vaccines have been licensed and used by affluent tourists for more than a decade to prevent cholera. The authors of this study investigated whether oral cholera vaccines could be used to protect high risk populations at a time of cholera. They calculated how many cholera cases could have been prevented if mass cholera vaccinations would have been implemented in reaction to past cholera outbreaks, estimating that determined, well-organised mass vaccination campaigns could have prevented 34,900 (40%) cholera cases and 1,695 deaths (40%) in Zimbabwe. They identify barriers to implementation of mass vaccinations, particularly the cost of the vaccine.
Coverage for the recommended two intermittent preventive treatment during pregnancy (IPTp) IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage. Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. Simplified IPTp guidelines for front-line health workers as recommended by the World Health Organisation (WHO) could lead to a 20% increase in IPTp coverage. Pregnant women also need to be educated about the risks of malaria during pregnancy and their right to receive health services.
The Director-General of the World Health Organisation in an opening address at the International Conference on Health for Development in Buenos Aires, Argentina on 16 June 2007 argued that to realize the great potential of health to drive human development, we must reach the poor with appropriate, high-quality care. The speech explores challenges in the role that primary health care can play in this and how to overcome major barriers, such as weak health systems, inadequate numbers of health care staff, and the challenge of financing care for impoverished people.