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The challenges in the health workforce are well known and clearly documented. What is not so clearly understood is how to address these issues in a comprehensive and integrated manner that will lead to solutions.

Despite the destruction of the National Tuberculosis Program (NTP) and basic health services by war and an uncertain security situation, the NTP, with assistance from many partners and REACH (the Rural Expansion of Afghanistan's Community-based Healthcare program), increased the number of patients receiving DOTS by 136% in 4 years (from 9261 cases in 2001 to 21851 in 2005), with an 86% treatment success rate. By focusing on rapidly expanding the number of facilities capable of providing tuberculosis (TB) diagnostic and treatment services and involving community health workers in case detection, referrals and home-based DOTS, REACH showed a 10-fold rise in the number of facilities providing TB services and a 380% increase in the number of sputum smear-positive pulmonary TB cases detected in 2 years (from 251/month in 2004 to 818/month in 2006) in 13 provinces. At the current rate of expansion, case detection and successful treatment of TB cases in Afghanistan will continue to expand rapidly. The NTP and REACH have demonstrated that expansion of TB services in Afghanistan is possible despite the challenges.

After the fall of the Taliban in 2001, the Afghan transitional government and international donors found the health system near collapse. Afghanistan had some of the worst health indicators ever recorded.

For the past few months we have been working with our colleagues to prepare Malawi’s antiretroviral treatment (ART) scale-up plan for 2006–0. This poor landlocked country is gripped by a serious HIV epidemic. With a population of almost 12 million, Malawi has an HIV/AIDS burden the same size as that of the USA; nearly 1 million people are infected with HIV.

The India Local Initiatives Program adapted a model used in Indonesia and Bangladesh to implement the government’s reproductive and child health strategy. From 1999 to 2003, three Indian nongovernmental organizations (NGOs) provided services for 784,000 people in four northern states.

As a recent international conference initiated and hosted by Afghanistan showed, there is no substitute for collaborative action fuelled by a common vision – and when it comes to eradicating the six deadliest diseases in the world today (HIV/AIDS, malaria, cholera, polio, tuberculosis and avian influenza), political boundaries and territorial conflicts become irrelevant.

In the fields of health and development, donors channel multiple resources into the design of new practices and technologies, as well as small-scale programmes to test them. But successful practices are rarely scaled up to the level where they beneficially impact large, impoverished populations.

The essential medicines concept has become an established approach in international public health – a vital component for combating HIV/AIDS, tuberculosis, malaria, respiratory infections, other communicable diseases and the vast majority of non-communicable diseases. But the survival and global dissemination of the essential medicines concept were by no means assured at the outset.  

The Problem: In developing countries, the most accessible source of treatment for common conditions is often an informal drug shop, where drug sellers are untrained and operations are unmonitored.

Although postconflict Afghanistan has some of the worst health indicators in the world, the government is working hard to rebuild the health infrastructure, extend services to underserved areas and improve the quality of health services.

A structured questionnaire was used to collect data from 500 respondents who were diagnosed clinically and/or parasitologically for malaria at Agogo Presbyterian Hospital and Suntreso Polyclinic, both in the Ashanti Region of Ghana. Collected information included previous use of anti-malarial drugs prior to attending the health facilities, types of drugs used, how the drugs were used, and the sources of the drugs. In addition, the anti-malarial therapy given and outcomes at the two health facilities were assessed. Of the 500 patients interviewed, 17% had severe malaria, 8% had moderate to severe malaria and 75% had uncomplicated malaria. Forty-three percent of the respondents had taken anti-malarial drugs within two weeks prior to hospital attendance. The most commonly used anti-malarials were chloroquine (76%), sulphadoxine-pyrimethamine (9%), herbal preparations (9%) and amodiaquine (6%). The sources of these medicines were licensed chemical sellers (50%), pharmacies (21%), neighbouring clinics (9%) or "other" sources (20%) including left-over medicines at home. One hundred and sixty three (77%) of the 213 patients who had used anti-malarial drugs prior to attending the health facilities, used the drugs inappropriately. At the health facilities, the anti-malarials were prescribed and used according to the national standard treatment guidelines with good outcomes. Conclusion: Prevalence of inappropriate use of anti-malarials in the community in Ghana is high. There is need for enhanced public health education on home-based management of malaria and training for workers in medicine supply outlets to ensure effective use of anti-malaria drugs in the country.

Background: HIV prevalence among pregnant women in Malawi is 12.6%, and mother-to-child transmission is a major route of transmission. As PMTCT services have expanded in Malawi in recent years, we sought to determine uptake of services, HIV-relevant infant feeding practices and mother-child health outcomes.

Objective  To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. Method  In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587 455) based on decentralization of care to health centres and community sites and task shifting.

The debate on the interaction between disease-specific programmes and health system strengthening in the last few years has intensified as experts seek to tease out common ground and find solutions and synergies to bridge the divide. Unfortunately, the debate continues to be largely academic and devoid of specificity, resulting in the issues being irrelevant to health care workers on the ground.

In Tanzania, many people seek malaria treatment from retail drug sellers. The National Malaria Control Program identified the accredited drug dispensing outlet (ADDO) program as a private sector mechanism to supplement the distribution of subsidized artemisinin-based combination therapies (ACTs) from public facilities and increase access to the first-line antimalarial in rural and underserved areas. The ADDO program strengthens private sector pharmaceutical services by improving regulatory and supervisory support, dispenser training, and record keeping practices. The government's pilot program made subsidized ACTs available through ADDOs in 10 districts in the Morogoro and Ruvuma regions, covering about 2.9 million people. As part of the evaluation, 448 ADDO dispensers brought their records to central locations for analysis, representing nearly 70% of ADDOs operating in the two regions. ADDO drug register data were available from July 2007-June 2008 for Morogoro and from July 2007-September 2008 for Ruvuma. During the pilot, over 300,000 people received treatment for malaria at the 448 ADDOs. The percentage of ADDOs that dispensed at least one course of ACT rose from 26.2% during July-September 2007 to 72.6% during April-June 2008. The number of malaria patients treated with ACTs gradually increased, while the use of non-ACT antimalarials declined; ACTs went from 3% of all antimalarials sold in July 2007 to 26% in June 2008.

The WHO 2010 guidelines specify that a CD4 cell count is crucial to decisions about the eligibility of HIV-infected pregnant women for lifelong antiretroviral treatment (ART). In Malawi, however, access to CD4 cell count analysis is minimal.

In Bangladesh, fertility was high in the 1950s and declined to fewer than five births per woman in the early or mid-1990s like other developing countries. After that the level of fertility is stalled. The aim of this study is to assess the extent of unmet need for family planning among married women of reproductive age group in Bangladesh and to study the factors related to it.

In the CIPRA-SA trial (July 3, p. 33), Ian Sanne and colleagues compared the outcomes of nurse-monitored patients with those of doctor-monitored patients in an antiretroviral treatment (ART) program in South Africa and concluded that the outcomes of ART services provided by nurses were non-inferior to those provided by doctors.

Background:Increased availability and accessibility of antiretroviral therapy (ART) has improved the length and quality of life amongst people living with HIV/AIDS. This has changed the landscape for care from episodic to long-term care that requires more monitoring of adherence. This has led to increased demand on human resources, a major problem for most ART programs.

Namibia had the fourth highest incidence of TB in the world and is among the countries most affected by HIV & AIDS. The country also faces a huge challenge in its pursuit of malaria eradication. In the face of these challenges, Namibia has an acute shortage of health care personnel, including in pharmaceutical care.

Objective: To assess whether linking the Global Alliance for Vaccine and Immunization (GAVI) service support with performance-based interventions has influenced the quality of reporting and of immunization systems. GAVI Service Support (ISS) combines performance assessment, recommendations and implementation support with financial reward.

To explore the process, major players and procedural success factors for recent public sector TB regimen changes, we conducted 166 interviews of country stakeholders in 21 of the 22 TB high-burden countries (HBCs).Stakeholders described 40 distinct regimen changes for drug-susceptible TB. Once countries committed to considering a change, the average timing was ∼1 year for decision-making and ∼2 years for roll-out. Stakeholders more often cited concerns that were program-based (e.g., logistics and cost) rather than patient-focused (e.g., side effects), and patient representatives were seldom part of decision making. Decision-making bodies in higher-income HBCs had more formalized procedures and fewer international participants. Pilot studies focused on logistics were more common than effectiveness studies, and the evidence base was often felt to be insufficient. Once implementation started, weaknesses in drug management were often exposed, with additional complications if local manufacturing was required. Best practices for regimen change included early engagement of budgeting staff, procurement staff, regulators and manufacturers. Future decision makers will benefit from strengthened decision-making bodies, patient input, early and comprehensive planning, and regimens and evidence that address local, practical implementation issues.

In this paper, we discuss the reasons why we urgently need a point-of-care (POC) CD4 test, elaborate the problems we have experienced with the current technology which hampers CD4-count coverage and highlight the ideal characteristics of a universal CD4 POC test.

Following over 30 years of conflict in Afghanistan, the Ministry of Public Health and its partners are rebuilding the pharmaceutical system to provide safe, affordable, and equitable access to medicines. Pharmaceutical system structures and processes are being strengthened; however, developing the pharmacy workforce is critical to ensuring the sustainability of these efforts.

This review article discusses the sustainability and robust advantages of planar chromatography that are critical to the successful performance of product quality assessments in resource limited areas including field applications.

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