In southern coastal Kenya, insecticide-treated bed net use was negligible in 1997-1998 but since 2001, bed net use has increased progressively and reached high levels by 2009-2010 with corresponding decline in malaria transmission. In this study, researchers evaluated the impact of the substantial increase in household bed net use in this area. Compared to 1997-1998, and following more than five years of 60-86% coverage with bed nets, the density, human biting rate and entomological inoculation rate of indoor-resting mosquitoes were reduced by more than 92% for Anopheles funestus and by 75% for An. gambiae. In addition, the host feeding choice of both vectors shifted more toward non-human vertebrates. Besides bed net use, malaria vector abundance was also influenced by type of house construction and according to whether one sleeps on a bed or a mat (both of these are associated with household wealth). Mosquito density was positively associated with presence of domestic animals. The researcher conclude that, while increasing bed net coverage beyond the current levels may not significantly reduce the transmission potential of An. arabiensis, they anticipate that increasing or at least sustaining high bed net coverage will result in a diminished role for An. funestus in malaria transmission.
Equitable health services
In December 2011, having identified inter-facility transport as a problem in the maternity service, the Free State Department of Health procured and issued 48 vehicles including 18 dedicated to maternity care. Subsequently, a sustained reduction in mortality was observed. The author of this paper probed the role of inter-facility transport in effecting this reduction in mortality. The author conducted a before-after analysis of data from two separate databases, including the district health information system and the emergency medical and rescue services call-centre database. Results showed that the maternal mortality decreased from 279/100 000 live births during 2011 to 152/100 000 live births during 2012. The mean dispatch interval decreased from 32.01 to 22.47 minutes. The number of vehicles dispatched within 1 hour increased from 84.2% to 90.7%. Monthly mean dispatch interval curves closely mirrored the maternal mortality curve. The author concludes that effective and prompt inter-facility transport of patients with pregnancy complications to an appropriate facility resulted in a reduction of maternal mortality. Health authorities should prioritise funding for inter-facility vehicles for maternity services to ensure prompt access of pregnant women to centres with skills available to manage obstetric emergencies.
This paper explores telemonitoring/mhealth approaches as a promising real time and contextual strategy in HIV and TB interventions access and uptake, retention, adherence and coverage impact in endemic and prone-epidemic prevention and control in sub-Sahara Africa. A scoping review was applied to identify relevant articles on the theme. The authors found tele monitoring/mhealth approach as a more efficient and sustained proxy in HIV and TB risk reduction strategies for early diagnosis and prompt quality clinical outcomes. It was found to significantly contribute to decreasing health systems/patients cost, long waiting time in clinics, hospital visits, travels and time off/on from work. Improved integrated HIV and TB telemonitoring systems sustainability are thus argued to hold promise in health systems strengthening, including patient-centred early diagnosis and care delivery systems, uptake and retention to medications/services and improving patients’ survival and quality of life. Tele monitoring/mhealth (electronic phone text/video/materials messaging) acceptability, access and uptake are reported to be crucial in monitoring and improving uptake, retention, adherence and coverage in both local and national integrated HIV and TB programs and interventions. Telemonitoring is also argued to be crucial in patient-providers-health professional partnership, real-time quality care and service delivery, antiretroviral and anti-tuberculous drugs improvement, susceptibility monitoring and prescription choice, reinforcing cost effective HIV and TB integrated therapy model and survival rate.
This paper describes the immediate impact of conflict following Kenya’s presidential elections on 27 December 2007 with regard to clinic attendance and medication adherence for HIV-infected children cared for within the USAID-Academic Model Providing Access to Healthcare (AMPATH) in western Kenya. The researchers conducted a mixed methods analysis that included a retrospective cohort analysis, as well as key informant interviews with pediatric healthcare providers. They found that, during this period of humanitarian crisis, the vulnerable, HIV-infected paediatric population had disruptions in clinical care and in medication adherence, putting children at risk for viral resistance and increased morbidity. However, unique programme strengths may have minimised these disruptions.
The South African Mental Health Care Act (the Act) No. 17 of 2002 stipulated that regional and district hospitals be designated to admit, observe and treat mental health care users (MHCUs) for 72 hours before they are transferred to a psychiatric hospital. This study surveyed medical managers in 49 ‘designated’ hospitals in KwaZulu-Natal (KZN) on infrastructure, staffing, administrative requirements and mental health care user case load pertaining to the Act for the month of July 2009. Thirty-six (73.4%) hospitals responded to the survey: 83.3% stated that the Act improved mental health care for MHCUs through the protection of their rights, provision of least restrictive care, and reduction of discrimination; 27.8% had a psychiatric unit and, of the remaining 26 hospitals, 30.6% had general ward beds dedicated for psychiatric admissions; 44.4% had some form of seclusion facility; and 66.7% provided an outpatient psychiatric service. Seventy-six per cent of admissions were involuntary or assisted. Thirteen of the 32 state psychiatrists in KZN were employed at eight of these hospitals. Designated hospitals expressed dissatisfaction with the substantial administrative load required by the Act. The Review Board had not visited 29 (80.6 %) hospitals in the preceding 6 months. Although ‘designated’ hospitals admit and treat assisted and involuntary MHCUs, they do so against a backdrop of inadequate infrastructure and staff, a high administrative load, and a low level of contact with Review Boards.
This paper presents discussion on impact of training traditional birth attendants (TBAs) on overall improvement of reproductive health care with focus on reducing the high rate of maternal and new-born mortality in rural settings in sub-Saharan Africa. The author argues that trained TBAs in sub-Sahara Africa can have positive impact on reducing maternal and new-born mortality if the programme is well implemented with systematic follow-up after training. This could be done through joint meeting between health workers and TBAs as feed and learning experience from problem encountered in process of providing child delivery services. TBAs can help to break socio-cultural barriers on intervention on reproductive health programmes. However projects targeting TBAs should not be of hit and run; but gradually familiarize with the target group, build trust, transparency, and tolerance, willing to learn and creating a better relationship with them. In this paper, some case studies are described on how trained TBAs can be fully utilized in reducing maternal and new-born mortality rate in rural areas. The author suggests that what is needed is to identify TBAs, map their distribution and train them on basic primary healthcare related to child deliveries and complications which need to be referred to conventional health facilities immediately.
Genetic testing for BRCA mutations has been available in the Western Cape of South Africa since 2005, but practical implementation of genetic counselling and testing has been challenging. The authors of this paper describe an approach to breast cancer genetic counselling and testing developed in a resource-constrained environment at Tygerberg Hospital in Cape Town, Western Cape. Genetic counselling was offered in a stepwise manner to our diverse patient population, with a focus on affected probands, and subsequent cascade testing. A record review of BRCA testing between 2005 and 2011 was performed. During this period 302 probands received genetic testing, with increasing numbers tested over time. Of 1,520 women treated for breast cancer since 2008, 226 (14.9%) accepted BRCA testing, and 39 tested positive (17.3% of those tested, and 2.6% of all women). Common founder mutations were detected in 11.9% of women, and comprised 73% of mutations detected. Cascade testing increased after 2010: 16 female and 4 male family members of 19 probands accepted testing, with 6 positives being detected. In conclusion, this protocol-driven approach focusing on probands, with initial pre-test counselling by primary care staff was proven effective in establishing the service.
The aim of this study was to describe the implementation process of a national anti-tuberculosis drug resistance survey in Tanzania, in relation to the study protocol and standard operating procedures. Factors contributing positively to the implementation of the survey were a continuous commitment of the key stakeholders, the existence of a well-organised National Tuberculosis Programme, and a detailed design of cluster-specific arrangements for rapid sputum transportation. Factors contributing negatively to the implementation were a long delay between training and actual survey activities, limited monitoring of activities, and an unclear design of the data capture forms leading to difficulties in form-filling. Careful preparation of the survey, timing of planned activities, a strong emphasis on data capture tools and data management, and timely supervision are essential.
This research report analyses the Integrated Management of Childhood Illness (IMCI) policy in Tanzania. Two districts in North-Western Tanzania, Bunda and Tarime, in Mara region, were picked to examine the issues around introduction, planning and implementation by district health managers and at facility levels. The authors found that the percentage in health workers trained in IMCI case management varies between districts, probably due to differing levels of early sensitisation of key actors, a higher health budget per capita, local facilitators and strong external support. However, the cost of case management training is high and it is difficult for districts to finance more than one training session per year. IMCI suffers from poor visibility and challenges of monitoring impact compared to vertical programmes, reducing the potential for attracting donor investment. Therefore, the status of IMCI vs other health programmes at district and national levels needs to be enhanced and key managers need to be equipped with better resources to monitor overall implementation. Strengthening health systems remains a pillar for success of IMCI. Without required drugs, effective supervision, sufficient numbers of health workers with appropriate skill-mix and geographical distribution, it will be difficult to effectively deliver IMCI. Communities need to participate to enable them to know what to expect from facilities and their role in completing IMCI.
This research report analyses the integrated management of childhood illness (IMCI) policy in Tanzania. Two districts in North-Western Tanzania, Bunda and Tarime, in Mara region, were picked to examine the issues around introduction, planning and implementation by district health managers and at facility levels. The paper found that the percentage in health workers that are trained in IMCI case management varies between districts – Bunda at 44% and Tarime at only 5%. The relatively high levels of training in Bunda might be due to early sensitisation of key actors, a higher health budget per capita, local facilitators and strong external support. However, funding is low and IMCI suffers from poor visibility and challenges of monitoring impact compared to vertical programmes, reducing the potential for attracting donor investment.