Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition

Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels—ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions’ deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions— and, in some cases, health outcomes in children—including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources

Understanding the determinants of the complex interplay between cost-effectiveness and equitable impact in maternal and child mortality reduction

One of the most unexpected outcomes arising from the efforts towards maternal and child mortality reduction is that all too often the objective success has been coupled with increased inequity in the population. The aim of this study is to analyze the determinants of the complex interplay between cost-effectiveness and equity and suggest strategies that will promote an impact on mortality that reduce population child health inequities

Risk factors for undernutrition of young children in a rural area of South Africa

To identify the factors associated with childhood undernutrition. Cross-sectional survey. Hlabisa health district in KwaZulu/Natal, South Africa. Eight hundred and sixty-eight children aged 3–59 months. Questionnaire survey and anthropometric survey of 516 random households with children in the health district. Multivariate analysis took into account the hierarchical relationships between the proposed risk factors. This conceptual model was built up during qualitative studies and with reference to international research in this area. The mean Z-scores for weight-for-age and height-for-age were 20.52 (95% confidence interval (CI) 20.44 to 20.60) and 21.25 (95% CI 21.15 to 21.35), respectively. Of the children, 26.3% (95% CI 23.3–29.3%) were stunted, 12.0% (95% CI 9.8–4.2%) were underweight-for-age (UWFA) and only 1.3% were wasted

"Nothing new": responses to the introduction of antiretroviral drugs in South Africa.

Interviews conducted in South Africa found that awareness of antiretroviral therapy was generally poor. Antiretroviral drugs were not perceived as new, but one of many alternative therapies for HIV/AIDS. Respondents had more detailed knowledge of indications, effects and how to access alternative treatments, which is bolstered by the active promotion and legitimization of alternative treatments. Many expressed a lack of excitement about the introduction of antiretroviral therapy, and little change in their attitudes concerning the epidemic

How equitable is the scaling up of HIV service provision in South Africa?

OBJECTIVES. To assess the extent of inequalities in availability and utilisation of HIV services across South Africa. DESIGN. Cross-sectional descriptive study. Setting. Three districts reflecting different socio-economic conditions, but with similar levels of HIV infection, were purposively sampled. Outcome measures. Availability and utilisation of HIV services and management and support structures for programmes were assessed through the collection of secondary data supplemented by site visits. RESULTS. There were marked inequalities in service delivery between the three sites. Compared with two poorer sites, clinics at the urban site had greater availability of HIV services, including voluntary counselling and testing (100% v. 52% and 24% respectively), better uptake of this service (59 v. 9 and 5.5 clients per 1 000 adults respectively) and greater distribution of condoms (15.6 v. 8.2 condoms per adult male per year). Extra counsellors had also been employed at the urban site in contrast to the other 2 sites. The urban site also had far more intensive management support and monitoring, with 1 manager per 12 health facilities compared with 1 manager per more than 90 health facilities at the other 2 sites. CONCLUSION. The process of scaling up of HIV services seems to be accentuating inequalities. The urban site in this study was better able to utilise the extra resources. In contrast, the poorer sites have thus far been unable to scale up the response to HIV even with the availability of extra resources. Unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness

Implementation of primary health care - package or process?

After establishing the commitment of the government to comprehensive primary health care (PHC), the Department of Health and provinces are now faced with the challenge of implementation. An important response has come with the recent proposed'core package of primary health care services'.' After consultation with national, provincial, district and facility health managers, various 'core packages' of services to be delivered at community, clinic/mobile and community health centre levels have been proposed. For example, undernutrition, which affects more than 1 in 4 young South African children,' is to be dealt with through treatment protocols, clinic-based growth monitoring and marketing messages about breastfeeding. The core package initiative seems to offer a pragmatic approach with its outlines of tasks and timetables and has been justified as a 'planning tool to move towards comprehensive services'.' In contrast, we believe there is a danger that it may have the opposite effect

Achieving the Millennium Development Goals through mainstreaming nutrition: speaking with one voice.

At the most recent meeting of the Standing Committee on Nutrition of the UN system in Geneva in March of this year (2006) there was a dramatic shift in the tenor of the opening plenary session. Three very high-ranking officials of three of the largest implementing UN agencies (WHO UNICEF World Bank) along with WFP and FAO produced -- independently of one another -- a clear consistent message focusing on the importance of nutrition for development. In each case this was couched within the comparative advantage of each agency. It was also striking that none of the speakers came from a background of nutrition training -- one economist one public health physician one health economist and one development expert. All had been converted by enthusiastic nutrition colleagues within their particular agency and by long experience in many countries and an expanding evidence base. All referred to the same evidence base -- the Bellagio Child Survival Study Group and subsequent papers published not in nutrition or even public health journals but in medical journals (the Lancet and the British Medical Journal in particular) although the significance of this will not be discussed here. But all were somewhat perplexed as to why nutrition issues were not an automatic component of all national health and development programmes including within each agency. They had clearly used their considerable experience in the public sector to think this through especially the importance of having a common and consistent message. (excerpt

Scaling up health promotion interventions in the era of HIV/AIDS: Challenges for a rights based approach

A sustained scaled up response to global public health challenges such as HIV/AIDS will require a functioning and efficient health system, based on the foundation of strong primary healthcare. Whilst this is necessary, it is not sufficient. Health promotion strategies need to be put into place to better engage and support families and communities in preventing disease, optimize caring, creating the demand for services and holding service providers to account. There will have to be a move away from the traditional model whereby the problem of HIV/TB/malaria is to be solved by merely increasing resources to a centralized bureaucracy that tries to increase the supply of services including health promotion messages

How equitable is the scaling up of HIV service provision in South Africa?

Objectives. To assess the extent of inequalities in availability and utilisation of HIV services across  South Africa.Design. Cross-sectional descriptive study.Setting. Three districts reflecting different socio-economic conditions, but with similar levels of HIV  infection, were purposively sampled.Outcome measures. Availability and utilisation of HIV services and management and support  structures for programmes were assessed through the collection of secondary data supplemented by site visits.Results. There were marked inequalities in service delivery between the three sites. Compared with  two poorer sites, clinics at the urban site had greater availability of HIV services, including voluntary counselling and testing (100% v. 52% and 24% respectively), better uptake of this service (59 v.9  and 5.5 clients per 1 000 adults respectively) and greater distribution of condoms (15.6 v. 8.2 condoms per adult male per year). Extra counsellors had also been employed at the urban site in contrast to the other 2 sites. The urban site also had far more intensive management support and monitoring, with 1 manager per 12 health facilities compared with 1 manager per more than 90 health facilities at the  other 2 sites.Conclusion. The process of scaling up of HIV services seems to be accentuating inequalities. The  urban site in this study was better able to utilise the extra resources. In contrast, the poorer sites have thus far been u':lable to scale up the response to HIV even with the availability of extra resources. Unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness