Equity in health expenditure in low-income and middle-income countries is commonly analysed using benefit incidence analysis (BIA). In BIA, the monetary value of the subsidy associated with public sector health-care utilisation (approximated by the cost of the service) is attributed to each individual according to their frequency and type of health-care utilisation. The benefit distribution is measured according to socioeconomic status. Despite widespread within-country geographical inequalities in health status and public expenditure, BIA has rarely accounted for such differences. The authors investigate how results would differ if geographical inequalities were taken into account for outpatient public health-care expenditure in Manica Province, Mozambique using data from the Household Budget Survey 2008/09, Census 2007, Ministry of Health, and Ministry of Finance records. The analysis showed that the gap in benefit from public expenditure between highest and lowest quintiles widened substantially if differences in health status and expenditure across districts are taken into account, increasing from a ratio of 1.2 to 2.0. Results suggest that the methods currently used may underestimate inequities in public health expenditure in contexts where geographical inequalities exist. Refinement of BIA using disaggregated data available from local institutions may improve estimates, stimulate local information systems' strengthening, and ultimately provide insights for a more equitable and efficient allocation of resources.
Equitable health services
A consortium of AIDS organisations has given the South African government three months to deliver on promises to integrate tuberculosis (TB) and HIV services. A local AIDS lobby group, the Treatment Action Campaign (TAC), international medical charity Medicines Sans Frontiers (MSF) and the AIDS and Rights Alliance for Southern Africa (ARASA), a regional partnership of non-governmental organisations, were among civil society groups that issued the deadline at the South African TB Conference in Durban, which took place from 1–4 June 2010. MSF spokesperson Lesley Odendal called the three-month deadline 'generous' because TB and HIV care should have been integrated by 1 April 2010, according to newly adopted national antiretroviral (ARV) treatment guidelines, but the Department of Health has yet to issue an implemention plan. TAC Deputy Secretary General, Lihle Dlamini, noted that integrating TB and HIV care would lead to earlier diagnosis of TB, especially strains of the disease occurring outside the lungs, which are common in co-infected patients. It would also help health workers become more familiar with the potentially severe interactions between antiretroviral (ARV) and TB drugs.
This paper outlines the main findings on reasons for adherence to TB treatment in Ethiopia, including physical lack of access to the treatment centre as the main cause of failure to adherence to therapy.
This paper reports on a cross-sectional study conducted between May and August,2007 in Wakiso district. A total of 762 women (442 adolescents and 320 adult)were interviewed using a structured questionnaire. The study calculated odds ratios with their 95% CI for antenatal and postnatal health care seeking, stigmatisation and violence experienced from parents comparing adolescents to adult first time mothers. It found that adolescent mothers showed poorer health care seeking behaviour for themselves and their children, and experienced increased community stigmatisation and violence, suggesting bigger challenges to the adolescent mothers in terms of social support. The authors propose that adolescent-friendly interventions such as pregnancy groups targeting to empower pregnant adolescents providing information on pregnancy, delivery and early childhood care need to be introduced and implemented.
In this study, researchers assessed challenges and enablers for the Expanded Programme on Immunisation (EPI) in South Africa, in light of the approaching 2015 deadline for the Millennium Development Goals. Between September 2009 and September 2010 they requested national and provincial EPI managers in South Africa to identify key challenges facing EPI, and to propose appropriate solutions. Systematic reviews on the effectiveness of the proposed solutions were added. Challenges identified by EPI managers were linked to healthcare workers (insufficient knowledge of vaccines and immunisation), the public (anti-immunisation rumours and reluctance from parents), and health system (insufficient financial and human resources). Strategies proposed by managers to overcome the challenges include training, supervision, and audit and feedback; strengthening advocacy and social mobilisation; and sustainable EPI funding schemes. The findings from reliable systematic reviews indicate that interactive educational meetings, audits and feedback, and supportive supervision improve healthcare worker performance. The authors conclude that numerous promising strategies for improving EPI performance in South Africa were found but their implementation would need to be tailored to local circumstances and accompanied by high-quality monitoring and evaluation.
This paper illustrates unintended consequences of apparently rational allocations to curative and preventive services, using computer modelling. The model exhibits a “spend more get less” equilibrium in which higher revenue by the curative sector is used to influence government allocations away from prevention towards cure. Spending more on curing disease leads paradoxically to a higher overall disease burden of unprevented cases of other diseases. The authors suggest that this paradoxical behaviour of the model can be stopped by eliminating lobbying, eliminating fees for curative services and ring-fencing public health funding. The authors have created an artificial system as a laboratory to gain insights about the trade-offs between curative and preventive health allocations, and the effect of indicative policy interventions. The underlying dynamics of this artificial system resemble features of modern health systems where a self-perpetuating industry has grown up around disease-specific curative programs like HIV/AIDS or malaria. The model shows how the growth of curative care services can crowd both fiscal and policy space for the practice of population level prevention work, requiring dramatic interventions to overcome these trends.
National programmes for palliative care offer the most effective means of improving the quality of life for the greatest number of patients and families, even where resources are severely constrained. Palliative care, however, is low on the list of under-resourced governments' health care priorities. What part can advocacy play in raising its profile and promoting its value? According to the World Health Organisation, a public health approach to palliative care has three foundations: Governmental policy: adoption of a national palliative care strategy; Education: training of health care professionals and creating awareness among the general public; Drug availability: assuring the availability of drugs for pain control and symptom management.
Experts warn of impending crisis in health systems geared towards epidemics not chronic diseases such as cancer. Unless urgent attention is paid to decreasing the burden of cancer, there are going to be catastrophic results especially in Africa and parts of Asia, experts warned at a gathering in Cape Town in October 2007. Thirty countries in Africa and Asia had no access whatsoever to radiotherapy.
Parents and children will continue dying from malaria, until Europe rejects its colonialist past. But every year calls for action turn out to be mere bombast, as healthcare agencies refuse to go beyond bed nets and capacity building, radical greens continue to obstruct proven strategies, and disease and death rates climb. This year, however, things may be different. Archbishop Desmond Tutu, Greenpeace co-founder Patrick Moore, and hundreds of physicians, clergy and human rights advocates have joined in demanding that DDT be put back into the malaria control arsenal.
This interview was conducted with Dr John Seffrin, CEO of the American Cancer Society (ACS), who spoke about the cancer challenges facing Africa. By next year cancer is set to become the biggest killer in the world, killing more people than HIV/AIDS, TB and malaria combined. In Africa, people are dying of cancers that are curable in the developed world. Cancer is a growing problem in Africa but is given little attention as the continent is overwhelmed by many other problems. There are relatively low cancer prevalence rates in Africa, but a high growth of the cancer burden. This is argued to call for health promotion for people who don’t have cancer and palliative care for people who have late-stage disease.