In this study, limited autopsies were conducted on young adults dying in a single public hospital in the province of KwaZulu-Natal between October 2008 and August 2009 in order to estimate the magnitude of deaths attributable to tuberculosis. A representative sample was taken of 240 adult inpatients (aged 20–45 years) who died after admission to Edendale Hospital. Ninety-four% of the study cohort was HIV seropositive and 50% of decedents had culture-positive tuberculosis at the time of death. Fifty percent of the participants were on treatment for tuberculosis at the time of death and 58% of these treated individuals remained culture positive at the time of death. Of the 50% not receiving tuberculosis treatment, 42% were culture positive. Seventeen percent of all positive cultures were multidrug resistant and 16% of patients dying during the initiation phase of their first ever course of tuberculosis treatment were infected with multidrug-resistant bacilli. The findings reveal the immense toll of tuberculosis among HIV-positive individuals in KwaZulu-Natal, as well as suggesting that the diagnosis of tuberculosis was made too late to alter the fatal course of the infection for many of the individuals. The study also revealed a significant burden of undetected multidrug-resistant tuberculosis among HIV-co-infected individuals dying in this setting. It recommends new public health approaches that improve early diagnosis of tuberculosis and accelerate the initiation of treatment.
Equitable health services
The objective of the study was to determine the prevalence of musculoskeletal conditions (MSC) and the functional implications in a sample of people attending community health centres in Cape Town, South Africa. It was conducted in clinics in two resource poor communities. A total of 1,005 people were screened. Of these, 362 (36%) reported MSC not due to injury in the past three months. Those with MSC had higher rates of co-morbidities in every category than those without. The mean Disability Index for those with MSC was mild to moderate, and moderate to severe in those aged over 55 years. In conclusion, although the sample may not be representative of the general community, the prevalence is considerably greater than those reported elsewhere, even when the population of the catchment area is used as a denominator. The common presentation of MSC with co-morbid diabetes and hypertension requires holistic management by appropriately trained health care practitioners. Any new determination of burden of disease due to MSC should recognise that these disorders may be more prevalent in developing countries than previously estimated.
Primary care internationally is approaching a new paradigm. The change agenda implicit in this threatens to destabilise and challenge established general practice and primary care. The Primary Care Amplification Model offers a means to harness the change agenda by 'amplifying' the strengths of established general practices around a 'beacon' practice. This 'beacon' practices can provide a mustering point for an expanded scope of practice for primary care, by offering integrated primary/secondary service delivery, interprofessional learning, relevant local clinical research and a focus on local service innovation, enhancing rather than fragmenting the collective capacity of existing primary care.
When considering the declining quality of emergency obstetrical surgery in Tanzania, lack of access to facilities, not a shortage of qualified staff, is the issue, argues this paper. Five countries in sub-Saharan Africa use non-physicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers (AMOs) – secondary school graduates with several years of medical training – perform most of this type of surgery outside the cities. The researchers compared obstetrical surgery performed by Tanzanian AMOs with surgery performed by medical officers (MOs) – medical school graduates with at least one year of internship and a licence to practice medicine and surgery. They found no significant differences between AMOs and MOs in outcomes, risk indicators or quality of care indicators. With 1,300 AMOs now trained for this kind of surgery, there are enough surgeons to meet the need in Tanzania. But hospitals are widely spaced and transport is difficult, so that fewer than one-third of Tanzanian women in need of major obstetrical surgery make it to a hospital that can do the job.
Malawi has been the only country in Sub-Saharan Africa to provide universal free health services throughout its public health system and never charge user fees – with the exception of some recent worrying user fee experiments. Conversely in Nigeria, which only spends 0.9% of its GDP in the form of public health financing and where user fees are charged at all levels, private out-of-pocket health financing accounts for 72% of total health expenditure – one of the highest rates in the world. Perhaps the most stark illustration of the difference in performance between these two countries at the opposite ends of this curve, is that whereas Nigeria is 8 times richer than Malawi, Nigeria’s child mortality rate (109 deaths per 1000 live births) is 70% higher than Malawi ’s (64 deaths). In reviewing these records, the obvious policy recommendation for Nigeria is that it too should increase its public health spending and abolish user fees in its public health system. And for Malawi, the authors argue that the lesson should be to build on this success and use further increases in public financing to improve the availability and quality of free services.
This study examined 'stigmatising' ideas and the view that TB patients should queue with other chronically ill patients at health facilities. Data was gathered through a survey administered to respondents from 1,020 households in Grahamstown, South Africa. The survey measured stigmatisation surrounding TB and HIV and AIDS, and determined perceptions of respondents whether TB patients should queue with other chronically ill patients. Results showed that respondents with TB-stigmatising ideas held positive attitudes toward volunteer support, special TB queues, and treatment at clinics, but held negative attitudes toward temporary disability grants, provision of information at work or school, and treatment at the TB hospital. Respondents who felt it beneficial for TB patients to queue with other chronically ill patients conversely held positive attitudes toward provision of porridge and disability grants, and treatment at the TB hospital, while they held negative attitudes toward volunteer support, special TB queues, information provision at work or school, and treatment at clinics. The authors conclude that TB stigma and the view that TB patients should queue with other chronically ill patients are associated with opposing attitudes and preferences towards TB treatment. These opposing attitudes complicate treatment outcomes, and the authors suggest that complex behaviours must be taken into account when designing health policy.
This publication pulls together available information on how health sector reform (HSR) has impacted on sexual and reproductive health services (SRH), and identifies information gaps and advocacy issues. The findings comes from the work of three research teams from Africa, Asia and Latin America who carried out systematic research on six elements on HSR. These elements include: financing, public-private interaction, priority-setting, decentralisation, integration of services and accountability.
Lesotho has one of the highest maternal mortality rates in the world, Partners In Health (PIH) has included maternity waiting homes since 2009 as part of a comprehensive effort to increase facility-based deliveries and reduce maternal mortality. The maternity waiting homes are located at seven PIH-supported health centres in some of the most remote, underserved areas of rural Lesotho. The homes provide food and shelter for women who live far away from the health centre or have risk factors for potential obstetric complications, and are well-regarded by both health centre staff and pregnant women. Since the implementation of the Maternal Mortality Reduction Project, PIH has seen waiting home admissions and the number of monthly deliveries at health centres increase dramatically. The authors suggest that failure of previous studies to demonstrate a positive impact of maternity waiting homes may reflect the failure to successfully implement other supporting components of a larger, comprehensive strategy to increase access to maternal health services.
In recent years, the importance of social differences in the physician-patient relationship has frequently been the subject of research. In this literature review, researchers conducted a systematic search of literature published between 1965 and 2011 on the social gradient in doctor-patient communication. Social class was determined by patient's income, education or occupation. Twenty original research papers and meta-analyses were included. Social differences in doctor-patient communication were described according to the following classification: verbal behaviour including instrumental and affective behaviour, non-verbal behaviour and patient-centred behaviour. The researchers found that the literature on the social gradient in doctor-patient communication that was published in the last decade addresses new issues and themes. Firstly, most of the found studies emphasise the importance of the reciprocity of communication. Secondly, there seems to be a growing interest in patient's perception of doctor-patient communication. By increasing the doctors' awareness of differences in communication and by empowering patients to express concerns and preferences, a more effective communication could be established, the researchers conclude.
The State of the World’s Antibiotics summarises the status of antibiotic use and resistance around the globe. The report challenges the prevailing argument that the biggest obstacle facing antibiotic resistance is a lack of new drugs in the “antibiotic pipeline.” New antibiotics are part of the solution, but only when coupled with conservation: strong antibiotic stewardship in its broadest sense, which involves limiting overuse of antibiotics in humans and livestock. CDDEP’s Global Antibiotic Resistance Partnership (GARP) of low- and middle-income countries provided both data and insight into the challenges in those countries and how they can be met successfully. Chapters cover human antibiotic resistance and use, resistance and use in agriculture and the environmental consequences of all use, maintaining the supply of antibiotic effectiveness and what works at the country level to minimise the spread of antibiotic resistance and maximise the positive impact of antibiotics.