Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage. Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 21 randomly selected districts. National IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 and 38% for second dose in 2005 but 30% in 2007. There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit.
Equitable health services
The objective of this study is to measure socio-economic inequalities in access to maternal health services in Namibia and propose recommendations relevant for policy and planning. Data from the Namibia Demographic and Health Survey 2006-07 was analysed for inequities in the utilisation of maternal health. Regions with relatively high human development index were found to have the highest rates of delivery by skilled health service providers. The rate of caesarean section in women with post secondary education is about seven times that of women with no education. Women in urban areas are delivered by skilled providers 30% more than their rural counterparts. High-income households use the public health facilities 30% more than poor households for child delivery. The paper concludes that, in the presence of inequities, it is difficult to achieve a significant reduction in the maternal mortality ratio needed to realise the Millennium Development Goal 5 targets. This is not achievable if a large segment of society has inadequate access to essential maternal health services and other basic social services.
Severe anemia in children is a leading indication for blood transfusion worldwide. Severe anemia, defined by the World Health Organization as a hemoglobin level <5 g/dL, is particularly common throughout sub-Saharan Africa. Analysis of data from the Fluid Expansion as Supportive Therapy trial offers new insights into the importance of blood transfusion for children with severe anemia. This analysis found that life-threatening anemia in children is a frequent presenting condition in East Africa; that delays in transfusion therapy are lethal; and that inadequate transfusion is probably more common than currently recognized. The findings of this study highlight the need for changes in blood inventory management in sub-Saharan hospitals and the need for more research on transfusion therapy for children in peril.
The authors of this paper hypothesised that just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. They present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. Between April 2009 and September 2010, we conducted their study in six rural public primary healthcare facilities and found that one-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. They observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing) but despite these improvements, no progress attributable to one-stop, integrated MCH services was observed. Structural healthcare system limitations, such as staff absences and an irregular supply of essential commodities, appear to have a larger effect. Regular technical support and adequate basic working conditions form valuable motivators and are of critical importance for improved staff performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.
Integrating family planning (FP) services into human immunodeficiency virus (HIV) clinical care helps improve access to contraceptives for women living with HIV. However, high patient volumes may limit providers’ ability to counsel women about pregnancy risks and contraceptive options. This study assessed trends in the use of contraceptive methods after implementing an electronic medical record (EMR) system with FP questions and determine the reasons for non-use of contraceptives among women of reproductive age (15–49 years) receiving antiretroviral therapy (ART) at the Martin Preuss Center clinic in Malawi. The authors conducted a retrospective, longitudinal cohort study using the EMR routinely collected data. Between February 2012 and December 2016, in HIV clinics, the proportion of women using contraceptives increased significantly from 18% to 39% between February 2012 and June 2013, and from 39% to 67% between July 2013 and December 2016. Common reasons reported for the non-use of contraceptives among those at risk of unintended pregnancy were: pregnancy ambivalence and never thought about it. Incorporating the FP EMR module into HIV clinical care was found to prompt healthcare workers to encourage the use of contraceptives.
Integrating mental health services into primary care is the most viable way of ensuring that people get the mental health care they need and primary care workers need adequate training and support for this. Integration is most successful when mental health is incorporated into health policy and legislative frameworks and supported by senior leadership, adequate resources and ongoing governance. To be fully effective and efficient, primary care for mental health must be coordinated with a network of services at different levels of care and complemented by broader health system development. Numerous low- and middle-income countries have successfully made the transition to integrated primary care for mental health. Mental health is central to the values and principles of the Alma Ata Declaration; holistic care will never be achieved until mental health is integrated into primary care.
Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. The authors describe strategies that were employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of policy instruments and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multi-method training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country’s first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. Provision of primary health-care delivery of noncommunicable disease services was included in the country’s 11th national development plan (2017–2023). During the guideline development process, the authors learnt that strong interdisciplinary skills in communication, organisation, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. They found that delays and poor communication emerged from the misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and weak initial coordination of the processes outside the health ministry. The authors share this experience for its relevance to other countries interested in developing and implementing guidelines for evidence-based services for noncommunicable diseases.
Pneumonia is a leading cause of morbidity and mortality worldwide. Effective vaccine and non-vaccine interventions to prevent and control pneumonia are urgently needed to reduce the global burden of the disease. In this paper, researchers explore practical strategies and policies for integrating interventions to prevent and treat pneumonia with routine immunisation services, and investigate the challenges involved in such integration. They identify three primary pneumonia prevention and treatment strategies that should be implemented during routine childhood immunisation visits: vaccination of children against the disease, caretaker education and referral of children to medical services when necessary.
The aim of this study was to synthesise knowledge concerning various models for the integrated delivery of TB/HIV services at health facility level in low- and middle-income countries. The authors conducted a systematic review of literature, selecting 63 papers and 70 abstracts for inclusion, which described 136 examples of models of integration. Strengths and weaknesses of different models of integration are identified. Models based on referral only are easiest to implement, requiring as little as additional staff training and supervision, if a functional referral system exists, but optimal communication is necessary. Models with closer integration are more efficient but require more staff training and may also require additional infrastructure, e.g. private space for HIV counselling. The authors conclude that their comparison of different models of integration of tuberculosis and HIV services was undermined by a lack of rigorous studies. More research is needed to investigate potential efficiencies of integrated care from the perspective of both provider and service user.
The aim of this study was to synthesise knowledge concerning various models for the integrated delivery of TB/HIV services at health facility level in low- and middle-income countries. The authors conducted a systematic review of literature, selecting 63 papers and 70 abstracts for inclusion, which described 136 examples of models of integration. Strengths and weaknesses of different models of integration are identified. Models based on referral only are easiest to implement, requiring as little as additional staff training and supervision, if a functional referral system exists, but optimal communication is necessary. Models with closer integration are more efficient but require more staff training and may also require additional infrastructure, e.g. private space for HIV counselling. The authors conclude that their comparison of different models of integration of tuberculosis and HIV services was undermined by a lack of rigorous studies. More research is needed to investigate potential efficiencies of integrated care from the perspective of both provider and service user.