Many patients present to an emergency centre (EC) with problems that could be managed at primary healthcare (PHC) level. This has been noted at George Provincial Hospital in the Western Cape province of South Africa. In order to improve service delivery, researchers in this study aimed to determine the patient-specific reasons for accessing the hospital EC with PHC problems. A descriptive study using a validated questionnaire to determine reasons for accessing the EC was conducted among 277 patients who were triaged as green (routine care), using the South African Triage Score. The duration of the complaint, referral source and appropriateness of referral were recorded. Of the cases 88.2% were self-referred and 30.2% had complaints persisting for more than a month. Only 4.7% of self-referred green cases were appropriate for the EC. The three most common reasons for attending the EC were that the clinic medicine was not helping (27.5%), a perception that the treatment at the hospital is superior (23.7%), and that there was no PHC service after-hours (22%). Increased acceptability of the PHC services is needed, the authors conclude. The current triage system must be adapted to allow channelling of PHC patients to the appropriate level of care. Strict referral guidelines are needed.
Equitable health services
Among all reproductive health indicators, the least progress has been made in reducing maternal mortality. This means that the fifth Millennium Development Goal to reduce by three quarters the maternal mortality ratio, given that over half a million women die every year during pregnancy or childbirth – will not be reached in many countries. Lack of funds and the slow progress to implement laws that protect maternal healthcare and reproductive health rights are undermining this goal.
Scale-up of vertical HIV transmission prevention has been too slow in sub-Saharan Africa. We describe approaches, challenges, and results obtained in Kinshasa. Staff members of 21 clinics managed by public servants or non-governmental organizations were trained in improved basic antenatal care (ANC) including nevirapine (NVP)-based HIV transmission prevention. Program initiation was supported on-site logistically and technically. Aggregate implementation data were collected and used for program monitoring. Contextual information was obtained through a survey. Among 45,262 women seeking ANC from June 2003 through July 2005, 90% accepted testing; 792 (1.9%) had HIV of whom 599 (76%) returned for their result. Among 414 HIV+ women who delivered in participating maternities, NVP coverage was 79%; 92% of newborns received NVP. Differences were noted by clinic management in program implementation and HIV prevalence (1.2 to 3.0%). Initiating vertical HIV transmission prevention embedded in improved antenatal services in a fragile, fragmented, severely resource-deprived health care system was possible and improved over time. Scope and quality of service coverage should further increase; strategies to decrease loss to follow-up of HIV+ women should be identified to improve program effectiveness. The observed differences in HIV prevalence highlight the importance of selecting representative sentinel surveillance centers.
In Zanzibar, the Ministry of Health and its partners accelerated malaria control from September 2003 onwards by scaling up provision of insecticide-treated nets, indoor-residual spraying and artemisinin-combination therapy. The authors of this study assessed the impact of the scale up on malaria burden at six out of seven in-patient health facilities in Zanzibar by comparing numbers of out-patient and in-patient cases and deaths between 2008 and the pre-intervention period 1999-2003. They found that, in 2008, for all age groups combined, malaria deaths had fallen by an estimated 90%, malaria in-patient cases by 78% and parasitologically confirmed malaria out-patient cases by 99.5%. Anaemia in-patient cases decreased by 87%, but declines in anaemia deaths and out-patient cases were statistically insignificant due to small numbers. Reductions were similar for children under-five and older ages. The authors conclude that the government’s scaling up effective malaria interventions reduced malaria-related burden at health facilities by over 75% over a period of five years. They argue that, in high-malaria settings, intensified malaria control can substantially contribute to reaching the Millennium Development Goal 4 target of reducing under-five mortality by two-thirds between 1990 and 2015.
The study aimed to examine the medical referral pattern of patients received at the Muhimbili National Hospital (MNH) in Tanzania to inform the process of strengthening the referral system. This prospective study was conducted at MNH during a 10-week study period from January to March 2004. The study sample consisted of patients referred to MNH. Of the 11,412 patients seen, 72.5% were self-referrals. More than 70% of the patients seen required admission, though not necessarily at tertiary level. Only 0.8% came from outside the Dar es Salaam region. More than 70% of the patients seen required admission. Surgical services were required by 66.8% of patients, with obstetric conditions being most prominent (24.6% of all patients). For those who were formally referred from other health services, lack of expertise and equipment were the most common reasons given for referral (96.3%). Efforts to improve referral systems in low-income countries require that the primary and secondary level hospitals services be strengthened and increased to limit inappropriate use of national referral hospitals.
A participatory assessment has revealed the strengths and gaps of health services in Tanzania – from the perspectives of Burundian and Rwandan refugees. Refugees benefit from employment in hospitals, feeding programmes, drugs, HIV and AIDS education and so on. But lack of food, fear of rape and ‘voluntary repatriation’, and preferential treatment by health staff are a problem.
There is some evidence from refugees that health care services in South Africa are not responsive to their perceived needs. Using quantitative and qualitative approaches to evaluate the perceptions and opinions of refugees about health care services in South Africa, the authors find that major issues affecting refugees include: discrimination and xenophobic attitudes of health service providers; language barriers leading to inappropriate treatments due to misunderstanding; exclusion from public hospitals due to lack of valid permits or delay in the delivery of such permits. Based on these findings, the authors suggest that refugees should have at least a baseline health related interview and check-up preferably done in a primary health care (PHC) centre dedicated to refugees. Refugee support systems should be established and health care workers should be informed about issues such as refugee permits and policies regarding referral systems. Also, public hospitals should employ qualified translators to help in cases that are referred from PHC centres for refugees.
This report provides an update of the cholera situation in the region from the United Nations Office for the Coordination of Humanitarian Concerns (OCHA). According to OCHA, cholera and acute watery diarrhea cases (AWD) increased by 23,485 cases and there have been 649 deaths (CFR 2.7%) reported since 23 January 2009. Zimbabwe and South Africa remain the most affected with more than 67,500 and 6,000 cases respectively. Concerns remain on under-reporting. An additional 24,202 cholera cases and 683 deaths (CFR 2.8%) were reported from 23 January to 5 February 2009. Of the nine countries affected by cholera, Malawi (49 additional cases), South Africa (1,343 additional cases) and Zimbabwe (19,322 additional cases) have reported a significant increase compared to the last OCHA report issued on 23 January 2009. Three countries reported an increase in the number of cholera related deaths; these include Botswana, Namibia and Zimbabwe. The total numbers of people affected by cholera in Botswana and Namibia are reported to be low.
The researchers analysed the experiences of different countries affected by conflict, including Afghanistan, Cambodia, East Timor, Kosovo, Uganda and Mozambique. They began by looking at the impacts of conflict on public health. They then presented a framework for understanding how programmes for rehabilitating health systems might work in post-conflict countries. The authors suggest three interrelated approaches to health sector rehabilitation: an initial response to immediate health needs (through humanitarian assistance and relief); restoration or establishment of a package of essential health services including immunisation and obstetric care; and restoration of the health system itself. The authors highlight the lack of co-ordination between donor organisations, whose competing needs and projects distract health officials. Non-governmental organisations (NGOs) may also delay progress by continuing to focus on relief when the country has moved on to the next stage.
In this study, researchers prospectively assessed the functional impairments and rehabilitation needs of Africans admitted to a regional trauma centre in Ghana. It also acts as a pilot study to demonstrate the practical use of the Language Independent Functional Evaluation (L.I.F.E.) software in an acute hospital setting. A five-page questionnaire was used to gather demographic data, cause of disability/injury, severity of disability or functional impairment, and rehabilitation treatment received. Functional status on discharge was evaluated with the L.I.F.E. scale. A total of 84 consecutive consenting subjects were recorded. The predominant disability/injury of respondents involved the lower extremities (70%), followed by upper extremities (23%). The mechanisms of injury were largely related to auto accidents (69%). Falls made up 17% of these injuries and 14% were related to violence. Eleven subjects had disability measured using L.I.F.E and all were classified as having major disabilities. Only 14 patients (17%) received any rehabilitation therapy which consisted of only physical therapy provided at a frequency of once a day for less than one week duration. The researchers found that most persons admitted to a sophisticated trauma unit in Ghana are discharged without adequate rehabilitation services, and that the level of disability experienced by these people can be measured, even while they are still sick and in the hospital, using L.I.F.E. The researchers call on African trauma units to measure the long-term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world.