From Alma Ata to millennium development goals: to what extent has equity been achieved?

Equity was a core value in the Alma Ata declaration on PHC. However, the interpretation of equity varied and its application became difficult. Equity goals and objectives have often been rhetoric rather than practical. Policy reforms since Alma Ata have been dominated by the neo-liberal economic ideology, which does not include equity as its core value. After 25 years, reforms such as the essential health package, sector-wide approach, user-fees and decentralization have not achieved the key goals of PHC such as equity, and of health sector reforms such as cost recovery, efficiency and sustainability

Rapid diagnostic tests for malaria: effect on quality of care under experimental conditions and in routine practice

Introduction We know that translating new knowledge from research into change in health care delivery is not a simple process. This thesis examines this process for a new technology applied to primary health care in tropical countries: including RDTs in clinical guidelines for treating fever in children Method The thesis examines the question: ―does implementing policy of using RDTs to target treatment instead of presumptive treatment of fever result in better quality patient care under experimental conditions as well as in routine practice?‖ Three methodological approaches are used to delineate translation to change in the field. A Cochrane review of randomised trials examines effects on quality of care in a trial, where delivery conditions are usually optimal. An analysis of a dataset from an effectiveness trial from Uganda examines effects of the policy on quality of care delivered within the context of a trial through routine health services. And third, a survey of current practice assesses implementation of an RDT-based guideline when it is introduced into the health system for routine use in selected districts. Across all three components, the thesis examines implementation of the guideline. In addition, both the systematic review and the effectiveness trial measure effects of the intervention on prescribing of antimalarials and antibiotics, and clinical outcomes (primary outcomes).The effectiveness trial evaluates effects of the policy on incremental cost, and the survey of current practice also assesses adequacy of essential health systems inputs and support services. Results The systematic review showed that HWs prescribed antimalarials to as many as 40% to 80% of cases with negative RDTs under experimental conditions. Use of RDTs was associated with 29% decline in prescribing of antimalarial drugs. Prescribing of antibiotics did not change in one trial but increased by 19% in another. Data from the effectiveness trial show that HWs used RDTs and adhered to RDT results almost all the time. This reduced antimalarials usage by 60.2% (high), 48.9% (medium) and by 22.1% (low). The data show no significant change in usage of antibiotics. Both the review and the pragmatic trial detected no significant difference in clinical outcomes between RDT and clinical diagnosis arms. Data from the effectiveness trial shows that use of RDTs is associated with a cost-saving of US$0.50 per case of fever (24.5$ 0.33 per case of fever (17.7% decline) in medium transmission. Use of RDTs did not lead to a significant change in cost in high transmission settings: US$+0.02 (95$ -0.97 to US$+1.06). Cost-savings were accrued exclusively in older children and adults. The survey found inadequate implementation of all components of the guideline in both districts. Essential supplies, equipment and in-service training were inadequate in both districts. Discussion and conclusion Antimalarial use is lower when RDTs are used to guide treatment of fever instead of presumptive treatment. This results in savings from drugs costs in older children and adults with fever in low and medium transmission areas. This research does not confirm whether or not use of RDT-based guidelines has any effects on usage of antibiotics or clinical outcomes. A case study of Uganda shows that when delivered through routine services, none of the components of an RDT-based guideline is implemented to acceptable standards. There is insufficient evidence to suggest that the policy is superior to presumptive treatment of fever in terms of clinical outcomes. However, it can save money for medicines in low and medium transmission settings if its use is restricted to older children and adults

'I believe that the staff have reduced their closeness to patients': an exploratory study on the impact of HIV/AIDS on staff in four rural hospitals in Uganda

<p>Abstract</p> <p>Background</p> <p>Staff shortages could harm the provision and quality of health care in Uganda, so staff retention and motivation are crucial. Understanding the impact of HIV/AIDS on staff contributes to designing appropriate retention and motivation strategies. This research aimed 'to identify the influence of HIV/AIDS on staff working in general hospitals at district level in rural areas and to explore support required and offered to deal with HIV/AIDS in the workplace'. Its results were to inform strategies to mitigate the impact of HIV/AIDS on hospital staff.</p> <p>Methods</p> <p>A cross-sectional study with qualitative and quantitative components was implemented during two weeks in September 2005. Data were collected in two government and two faith-based private not-for-profit hospitals purposively selected in rural districts in Uganda's Central Region. Researchers interviewed 237 people using a structured questionnaire and held four focus group discussions and 44 in-depth interviews.</p> <p>Results</p> <p>HIV/AIDS places both physical and, to some extent, emotional demands on health workers. Eighty-six per cent of respondents reported an increased workload, with 48 per cent regularly working overtime, while 83 per cent feared infection at work, and 36 per cent reported suffering an injury in the previous year. HIV-positive staff remained in hiding, and most staff did not want to get tested as they feared stigmatization. Organizational responses were implemented haphazardly and were limited to providing protective materials and the HIV/AIDS-related services offered to patients. Although most staff felt motivated to work, not being motivated was associated with a lack of daily supervision, a lack of awareness on the availability of HIV/AIDS counselling, using antiretrovirals and working overtime. The specific hospital context influenced staff perceptions and experiences.</p> <p>Conclusion</p> <p>HIV/AIDS is a crucially important contextual factor, impacting on working conditions in various ways. Therefore, organizational responses should be integrated into responses to other problematic working conditions and adapted to the local context. Opportunities already exist, such as better use of supervision, educational sessions and staff meetings. However, exchanges on interventions to improve staff motivation and address HIV/AIDS in the health sector are urgently required, including information on results and details of the context and implementation process.</p

HEALTH INEQUITY IN UGANDA: THE ROLE OF FINANCIAL AND NON-FINANCIAL BARRIERS

Inequality in health is known to be rampant among different socio-economic groups, with the poor typically suffering more ill-health and facing greater economic cost of ill-health than the rich. Yet a number of other non-economic factors are also known to concurrently operate, in a complex way, to further ration healthcare in favour of the rich. Measuring, monitoring and understanding the influences these factors pose in determining health-seeking behaviour at district and sub district levels are necessary to guide policy. Policies based on intuition alone can be misleading. The household survey was an attempt to understand the level and direction of disparities in health by socio-economic differentials in Uganda; and the roles of both financial and non barriers to healthcare use. A total of 843 households were sampled (by probability proportionate to size technique) from four health sub districts. We found that the poorest quintiles were 2.4 times more likely to suffer ill-health than the richest quintiles, with a greater proportion of them lacking access to publicly-provided health services than the richest counter-parts. There were no rich-poor differences in the types of illnesses/injuries. Although the findings of this survey confirm the conventional wisdom, they also reveal healthcare use patterns that reflect, not only the importance of financial barriers, but also the opportunity costs in travel (and possibly waiting) time, and other important factors including the availability, affordability and the perceived quality of services

FROM ALMA ATA TO MILLENNIUM DEVELOPMENT GOALS: TO WHAT EXTENT HAS EQUITY BEEN ACHIEVED?

Equity was a core value in the Alma Ata declaration on PHC. However, the interpretation of equity varied and its application became difficult. Equity goals and objectives have often been rhetoric rather than practical. Policy reforms since Alma Ata have been dominated by the neo-liberal economic ideology, which does not include equity as its core value. After 25 years, reforms such as the essential health package, sector-wide approach, user-fees and decentralization have not achieved the key goals of PHC such as equity, and of health sector reforms such as cost recovery, efficiency and sustainability