Affordable assisted reproductive technologies in developing countries: pros and cons

¹ Correspondence address. E-mail: akandewole{at}yahoo.com Infertility in developing countries is pervasive and a seriousconcern. In addition to the personal grief and suffering itcauses, the inability to have children especially in poor communitiescan create broader problems, particularly for the woman. Infertilityservices in developing countries span the spectrum from preventionto treatment. From a societal and public health standpoint,prevention is cost–effective and is considered by manygovernments and public health care providers to be a priorityfor service delivery. While prevention remains paramount, takenalone it ignores the plight of infertile couples, includingthose with non-infectious causes of infertility. Two key argumentsare frequently used to challenge the development of new reproductivetechnologies in developing countries: overpopulation and limitedresources. Evidence supports the conclusion that there is acompelling need for infertility treatment beyond prevention.In many instances, assisted reproductive technologies (ART)are the last hope or the only means to achieve a child for couples.In an effort to make much needed ART to developing countriesaccessible and affordable, developing countries should lookto public–private partnerships. Governments have a responsibilityto ensure safe and effective services including the controlof standards for clinical procedures and the regulation of professionalpractice.     

False perceptions and common misunderstandings surrounding the subject of infertility in developing countries

¹ Correspondence address. E-mail: willem.ombelet{at}telenet.be ^{Although the consequences of the problem of childlessness aremore pronounced in developing countries when compared with Westernsocieties, local health care providers and international organizationspay little attention on this issue. The limited budgets forreproductive health care are mostly restricted to family planningand mother care. The most common misunderstanding is the ‘overpopulation-issue’.It is generally believed that the expected growth of the worldpopulation puts a real burden on the issue of infertility treatmentin resource-poor countries, although recent UN reports clearlyshow that in most developing countries the fertility rate isdropping significantly and will fall below the threshold of2.0 by 2050. It seems that the expected population growth indeveloping countries in the next decades is rather due to populationageing and not to high fertility rates. Another important issuesurrounding infertility in developing countries is the so-called‘limited resources argument’. Because the problemof childlessness is a major health problem in most developingcountries, a re-arrangement of the global reproductive healthcare budget should be requested from local governments and internationalorganizations taking into account the urgent need for a go-togetherof more successful family-planning policies and affordable simplifiedART methods.}     

Is affordable and cost-effective assisted reproductive technology in low-income countries possible? What should we know to answer the question?

¹ Correspondence address. E-mail: j.d.f.habbema{at}erasmusmc.nl Decision making on infertility treatment in low-income countries(LIC) assumes answers to quite a few questions: how should theinfertility problem be defined? How often does infertility occur?What is the burden-of-disease of infertility? What is the incomein LIC, and what can be spend on health care? How cheap shouldIVF be in order to be accessible to a considerable part of thepopulation? With what alternative health interventions shouldinfertility treatment be compared? How cost-effective shouldIVF be in order to compete with those other interventions? Thesequestions will be discussed. The emphasis is on the situationin Sub-Saharan Africa (SSA). It is concluded that a place forART in a health care package is not straightforward. Many ofthe questions are not or only partially answered. Moreover,cheap and effective ART has yet to be developed and tested.From the limited evidence available for each of the questions,it could be calculated that an IVF cycle should cost between50 and 75 dollar in order to be a candidate for the inclusionin a health package in SSA. This estimate can easily changeconsiderably when in the future the calculations will be basedon thorough research. Thus, a targeted research programme foranswering the open questions, especially on quality-of-lifeimplications of infertility in different societies, is the preferredoption for facilitating the future evaluation of ART in LIC.     

Infertility in African countries: challenges created by the HIV epidemic

¹ Correspondence address. E-mail: silke.dyer{at}uct.ac.za HIV infection and infertility are two common reproductive healthdisorders in Africa. From the perspective of infertility-relatedreproductive health care, the HIV epidemic has created severalchallenges which include reduction of fecundity, depletion ofscarce health resources, creation of barriers to infertilitytreatment and increased suffering. Infertility in turn is arisk factor for HIV acquisition and a possible force in thespread of the HIV epidemic. Recognition of the reproductivehealth needs and desires of HIV-infected infertile men and womenis a prerequisite for addressing these challenges. Subsequentstrategies comprise the development of treatment guidelinesfor low-resource environments and a greater integration of HIVand sexual and reproductive health services. Where resourcesfor infertility treatment are not available, the consequencesmust be critically assessed.     

Infertility in developing countries: funding the project

³ Correspondence address. E-mail: hnsallam{at}link.net Assisting developing countries in establishing infertility servicesis not a uniform exercise and depends on the stage of developmentof each country. Three levels of assistance are suggested: providingbasic (level 1), advanced (level 2) or tertiary referral infertilityservices (level 3). At each of these levels, four activitiesare needed: equipping the clinics, training the staff, educatingthe public and running the services. Basic (level 1) clinicscan be equipped by international donors, whereas level 2 and3 clinics can be funded through a partnership between an internationalscientific body (WHO, ESHRE, etc.) and an international bank(World Bank, African Development Bank, etc.). Training of themedical and paramedical staff should be the responsibility ofthe non-profit organizations (NPOs) preferably in regional trainingcenters. An awareness campaign is necessary to educate the publicand inform them of the range of treatment available in theircommunity and can also be funded by NPOs. Finally, the runningcost of the services including the staff salaries, the costof the investigations and medication should be the responsibilityof the local government, although in many countries, this hasto come from out of pocket payments.     

Beyond the Biomedical: Community Resources for Mental Health Care in Rural Ethiopia

BackgroundThe focus of discussion in addressing the treatment gap is often on biomedical services. However, community resources can benefit health service scale-up in resource-constrained settings. These assets can be captured systematically through resource mapping, a method used in social action research. Resource mapping can be informative in developing complex mental health interventions, particularly in settings with limited formal mental health resources.MethodWe employed resource mapping within the Programme for Improving Mental Health Care (PRIME), to systematically gather information on community assets that can support integration of mental healthcare into primary care in rural Ethiopia. A semi-structured instrument was administered to key informants. Community resources were identified for all 58 sub-districts of the study district. The potential utility of these resources for the provision of mental healthcare in the district was considered.ResultsThe district is rich in community resources: There are over 150 traditional healers, 164 churches and mosques, and 401 religious groups. There were on average 5 eddir groups (traditional funeral associations) per sub-district. Social associations and 51 micro-finance institutions were also identified. On average, two traditional bars were found in each sub-district. The eight health centres and 58 satellite clinics staffed by Health Extension Workers (HEWs) represented all the biomedical health services in the district. In addition the Health Development Army (HDA) are community volunteers who support health promotion and prevention activities.DiscussionThe plan for mental healthcare integration in this district was informed by the resource mapping. Community and religious leaders, HEWs, and HDA may have roles in awareness-raising, detection and referral of people with mental illness, improving access to medical care, supporting treatment adherence, and protecting human rights. The diversity of community structures will be used to support rehabilitation and social reintegration. Alcohol use was identified as a target disorder for community-level intervention.     

Community-based mental health care in Africa: mental health workers’ views

The World Health Organization (WHO) has for long proposed the development of community-based mental health services worldwide. However, the progress toward community mental health care in most African countries is still hampered by a lack of resources, with specialist psychiatric care essentially based in large, centrally located mental hospitals. It is again time to reconsider the direction of mental health care in Africa. Based on a small inquiry to a number of experienced mental health professionals in sub-Saharan Africa, we discuss what a community concept of mental health care might mean in Africa. There is a general agreement that mental health services should be integrated in primary health care. A critical issue for success of this model is perceived to be provision of appropriate supervision and continuing education for primary care workers. The importance of collaboration between modern medicine and traditional healers is stressed and the paper ends in a plea for WHO to take the initiative and develop mental health services according to the special needs and the socio-cultural conditions prevailing in sub-Saharan Africa.     

COVID-19 and indirect health implications in Africa: Impact,mitigation measures,and lessons learned for improved disease control

Seth Inzaule and co-authors discuss implications of the COVID-19 pandemic for health in African countries.

Summary points

• Coronavirus Disease 2019 (COVID-19) and the mitigation measures taken to limit its spread have significantly disrupted other essential health services in Africa. This disruption has threatened the control of major high-burden diseases such as HIV, tuberculosis (TB), and malaria as well as the prevention of maternal and child mortality.
• While the 2020 WHO global reports for HIV, TB, and malaria show progress in control of these diseases in African countries, there are still significant gaps in meeting the global targets. Similarly, modeling studies predict that most African countries are unlikely to meet the Sustainable Development Goals (SDGs) 2030 targets for reductions in maternal and child mortality under the current rate of progress.
• Prediction models and emerging empirical data indicate that the implemented mitigation measures against COVID-19 such as travel restrictions and lockdowns as well as the repurposing of health resources and suspension of prevention programs such as immunizations will lead to an increase in new infections and deaths, significantly reversing the gains achieved in the control of these health challenges.
• A more comprehensive COVID-19 response that minimizes indirect deaths is therefore warranted in Africa. These include implementing WHO recommendations that limit contact with the clinic where possible, such as multimonths drug dispensing, self-testing, virtual platforms for case management, community- and home-based prevention, and care services such as home distribution of test kits, vaccines, treatment, and mosquito nets.
• This is in addition to ensuring effective implementation of COVID-19 infection prevention and control measures in healthcare facilities including providing healthcare workers with personal protective equipment and prioritizing them for COVID-19 immunization.
• There is also a need to incorporate aggressive recovery plans to reverse the lost gains in disease control efforts and put African countries back on course toward achieving the global targets. This includes leveraging on the wider COVID-19 response enablements such as the increased political will and global solidarity funding efforts to support a more comprehensive response that accounts for the indirect public health effects of the pandemic.

     

Traditional zootherapeutic studies in India: a review

Background

The objective of the present study was to reveal patterns in the treatment of health conditions in a Quechua-speaking community in the Bolivian Andes based on plant use data from traditional healers and patient data from a primary health care (PHC) service, and to demonstrate similarities and differences between the type of illnesses treated with traditional and biomedical health care, respectively.

Methods

A secondary analysis of plant use data from semi-structured interviews with eight healers was conducted and diagnostic data was collected from 324 patients in the community PHC service. Health conditions were ranked according to: (A) the percentage of patients in the PHC service diagnosed with these conditions; and (B) the citation frequency of plant use reports to treat these conditions by healers. Healers were also queried about the payment modalities they offer to their patients.

Results

Plant use reports from healers yielded 1166 responses about 181 medicinal plant species, which are used to treat 67 different health conditions, ranging from general symptoms (e.g. fever and body pain), to more specific ailments, such as arthritis, biliary colic and pneumonia. The results show that treatment offered by traditional medicine overlaps with biomedical health care in the case of respiratory infections, wounds and bruises, fever and biliary colic/cholecystitis. Furthermore, traditional health care appears to be complementary to biomedical health care for chronic illnesses, especially arthritis, and for folk illnesses that are particularly relevant within the local cultural context. Payment from patients to healers included flexible, outcome contingent and non-monetary options.

Conclusion

Traditional medicine in the study area is adaptive because it corresponds well with local patterns of morbidity, health care needs in relation to chronic illnesses, cultural perceptions of health conditions and socio-economic aspects of health care. The quantitative analysis of plant use reports and patient data represents a novel approach to compare the contribution of traditional and biomedical health care to treatment of particular health conditions.     

Task-shifting in HIV care: a case study of nurse-centered community-based care in Rural Haiti

Introduction

At least 36 countries are suffering from severe shortages of healthcare workers and this crisis of human resources in developing countries is a major obstacle to scale-up of HIV care. We performed a case study to evaluate a health service delivery model where a task-shifting approach to HIV care had been undertaken with tasks shifted from doctors to nurses and community health workers in rural Haiti.

Methods

Data were collected using mixed quantitative and qualitative methods at three clinics in rural Haiti. Distribution of tasks for HIV services delivery; types of tasks performed by different cadres of healthcare workers; HIV program outcomes; access to HIV care and acceptability of the model to staff were measured.

Results

A shift of tasks occurred from doctors to nurses and to community health workers compared to a traditional doctor-based model of care. Nurses performed most HIV-related tasks except initiation of TB therapy for smear-negative suspects with HIV. Community health workers were involved in over half of HIV-related tasks. HIV services were rapidly scaled-up in the areas served; loss to follow-up of patients living with HIV was less than 5% at 24 months and staff were satisfied with the model of care.

Conclusion

Task-shifting using a community-based, nurse-centered model of HIV care in rural Haiti is an effective model for scale-up of HIV services with good clinical and program outcomes. Community health workers can provide essential health services that are otherwise unavailable particularly in rural, poor areas.     

Ethical issues of infertility treatment in developing countries

¹ Correspondence address. Tel/Fax: +32-16-620767; E-mail: guido.pennings{at}ugent.be The provision of infertility treatment in developing countriesis controversial. Reports over the last decades have inculcatedin people from Western countries the belief that overpopulationis the major problem of developing countries. This paper willanalyse the different arguments advanced for and against providinginfertility treatment to resource-poor countries. There aretwo arguments in favour: reproductive autonomy and the hugeburden of infertility in these countries. Pronatalism, whichreigns in almost all developing countries, is to a great extentresponsible for the devastating effects of infertility. Thefive arguments against the application of infertility treatmentare overpopulation, prioritization of limited resources, preventionrather than cure, justice and equal access and risk of abuse.The importance of a person's reproductive autonomy demands thatefforts should be made to enable people to determine how manychildren to have. This is equally true in developing countries.However, given the enormous difficulties of resource-poor countriesto provide even the most basic goods, the contribution by societyshould be directed mostly at prevention and should depend ona strong cost reduction for assisted reproductive technology.     

Schistosomiasis-related perceptions, attitudes and treatment-seeking practices in Magu district, Tanzania: public health implications

A study on perceptions, attitudes and treatment-seeking practices related to schistosomiasis was conducted among the Wasukuma in the rural Magu district of Tanzania at the shore of Lake Victoria where Schistosoma haematobium and mansoni infections are endemic. The study applied in-depth interviews, focus group discussions and a questionnaire survey among adults and primary school children. The perceived symptoms and causes were incongruous with the biomedical perspective and a number of respondents found schistosomiasis to be a shameful disease. Lack of diagnostic and curative services at the government health care facilities was common, but there was a willingness from the biomedical health care services to collaborate with the traditional healers. Recommendations to the District Health Management Team were: that collaboration between biomedical and traditional health care providers should be strengthened and that the government facilities' diagnostic and curative capacity with regard to schistosomiasis should be upgraded. Culturally compatible health education programmes should be developed in collaboration with the local community.     

Community mental health care in the Asia‐Pacific region: using current best‐practice models to inform future policy

The reporting of child sexual abuse (CSA) and physician-patient sexual relationships (PPSR) are currently the focus of professional, legal and media attention in several countries. This paper briefly reviews mental health policies on these issues and reports on a WPA survey of them. While the WPA Madrid Declaration permits breaching confidentiality for mandatory reporting of CSA and clearly prohibits PPSR, it is not known how or to what extent these policies are implemented in WPA Member Societies’ countries. It is also not known whether policies or laws exist on these topics nationally or to what extent psychiatrists and the public are aware of them. Representatives of WPA Member Societies were e-mailed a survey about issues pertaining to CSA and PPSR. Fifty-one percent of 109 countries replied. All reporting countries had laws or policies regarding the reporting of CSA, but this was often voluntary (63%) and without protection for reporting psychiatrists either by law (29%) or by Member Societies (27%). A substantial number of psychiatric leaders did not know the law (27%) or their Society’s policy (11%) on these matters. With respect to PPSR, some reporting countries lacked laws or policies about PPSR with current (17%) or past (56%) patients. Fewer than half of responding representatives believed that their Society’s members or the public were well informed about the laws and policies pertaining to CSA or PPSR. There is clearly a wide range of laws, policies and practices about CSA and PPSR in WPA Member Societies’ countries. There is a need in some countries for laws or supplemental policies to facilitate the protection of vulnerable child and adult patients through clear, mandatory reporting policies for CSA and PPSR. Mechanisms to protect and support reporting psychiatrists should also be developed where they do not already exist. There is also a need in some countries to develop strategies to improve the education of psychiatrists, trainees, and the public on these issues.The Asia-Pacific region has close to half of the estimated 450 million people affected by mental illness globally 1.Based on international mental health care benchmarks, many Western health systems have established contemporary health policy and guidelines which include the provision of mental health care in the community. However, the delivery of quality and appropriate community mental health care remains an ongoing challenge for countries of both high and low socio-economic level. Difficulties and obstacles in implementation of comprehensive community service models include inadequate funding, availability of trained mental health workforce, integration with primary care services and community agencies, and collaboration between public and private health systems 2 - 3. As community mental health service system depends on sufficient workforce for service delivery, the critical shortage of adequately trained mental health staff continues to impede the progress of mental health reform.In response to such global trends, many countries in the Asia-Pacific region have begun to establish mental health policy and guidelines to move from institutional care to community mental health services. While these reforms are supported by recommendations from the World Health Organization (WHO) governing bodies, such as the Western Pacific Regional Mental Health Strategy 4, social, economic and cultural factors in Asia-Pacific countries often do not allow ready translation of Western community mental health models of care. Governments and service providers commonly face challenges in the development and implementation of locally appropriate community mental health care and services. Additionally, it would be unrealistic or undesirable to produce rigid recommendations for a singular community mental health care model, due to the diversity across the Asia-Pacific region. Hence, for constructive change to occur in the region, innovative, culturally appropriate and economically sustainable pathways for community treatment models need to be explored, developed and shared. Community mental health service reform appears to be gaining momentum in this region, despite the obstacles. Valuable lessons and inspiration for further development can be gained from both the successes and difficulties in reforming mental health systems and practices in the region.An emerging network of representatives from governments, peak bodies and key organizations is emerging in the Asia-Pacific region to build supportive relationships in order to facilitate the implementation of locally appropriate policy frameworks for community mental health service reform. The network is supported by the Asia-Pacific Community Mental Health Development (APCMHD) project, which involves 14 countries/regions in the Asia-Pacific region. Initiated in collaboration with the WHO Western Pacific Regional Office, the APCMHD project is led by Asia-Australia Mental Health, a consortium of the University of Melbourne Department of Psychiatry and Asialink, and St. Vincent’s Health, which is a part of the WHO Collaborating Centre for Mental Health (Melbourne). The project, which brought many key mental health organizations to work collaboratively, is consistent with the WHO Global Action Programme for Mental Health 5.The project aims are to promote best practice in community mental health care through exchange of knowledge and practical experience in the Asia-Pacific region. The key outcome is the documentation of the current status, strengths and needs of community mental health services in the region, in the hope to translate current understanding into practical changes in the future.     

Healthy firms: constraints to growth among private health sector facilities in Ghana and Kenya

Background

Health outcomes in developing countries continue to lag the developed world, and many countries are not on target to meet the Millennium Development Goals. The private health sector provides much of the care in many developing countries (e.g., approximately 50 percent in Sub-Saharan Africa), but private providers are often poorly integrated into the health system. Efforts to improve health systems performance will need to include the private sector and increase its contributions to national health goals. However, the literature on constraints private health care providers face is limited.

Methodology/Principal Findings

We analyze data from a survey of private health facilities in Kenya and Ghana to evaluate growth constraints facing private providers. A significant portion of facilities (Ghana: 62 percent; Kenya: 40 percent) report limited access to finance as the most significant barrier they face; only a small minority of facilities report using formal credit institutions to finance day to day operations (Ghana: 6 percent; Kenya: 11 percent). Other important barriers include corruption, crime, limited demand for goods and services, and poor public infrastructure. Most facilities have paper-based rather than electronic systems for patient records (Ghana: 30 percent; Kenya: 22 percent), accounting (Ghana: 45 percent; Kenya: 27 percent), and inventory control (Ghana: 41 percent; Kenya: 24 percent). A majority of clinics in both countries report undertaking activities to improve provider skills and to monitor the level and quality of care they provide. However, only a minority of pharmacies report undertaking such activities.

Conclusions/Significance

The results suggest that improved access to finance and improving business processes especially among pharmacies would support improved contributions by private health facilities. These strategies might be complementary if providers are more able to take advantage of increased access to finance when they have the business processes in place for operating a successful business and health facility.     

Human Resource and Funding Constraints for Essential Surgery in District Hospitals in Africa: A Retrospective Cross-Sectional Survey

Background

There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries.

Methods and Findings

We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals.

Conclusion

African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors'' Summary     

The use of zootherapeutics in folk veterinary medicine in the district of Cubati, Paraíba State, Brazil

Background

Viewed through the micro focus of an interpretive lens, medical anthropology remains mystified because interpretivist explanations seriously downplay the given context in which individual health seeking-behaviours occur. This paper draws upon both the interpretivist and political economy perspectives to reflect on the ethno medical practices within the Korean-Australian community in Sydney.

Methods

We draw on research data collected between 1995 and 1997 for an earlier study of the use of biomedical and traditional medicine by Korean-Australians in Sydney. A total of 120 interviews were conducted with a range of participants, including biomedical doctors, traditional health professionals, Korean community leaders and Korean migrants representing a range of socio-economic backgrounds and migration patterns.

Results and Discussion

First, the paper highlights the extent to which the social location of migrants in a host society alters or restructures their initial cultural practices they bring with them. Second, taking hanbang medicine in the Korean-Australian community as an illustrative case, the paper explores the transformation of the dominant biomedicine in Australia as a result of the influx of ethnomedicine in the era of global capitalism and global movement.

Conclusion

In seeking to explain the popularity and supply of alternative health care, it is important to go beyond the culture of each kind of health care itself and to take into consideration the changes occurring at societal, national and global levels as well as consequential individual response to the changes. New social conditions influence the choice of health care methods, including herbal/alternative medicine, health foods and what are often called New Age therapies.     

Assessing Coverage,Equity and Quality Gaps in Maternal and Neonatal Care in Sub-Saharan Africa: An Integrated Approach

BackgroundGaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.MethodsData were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.ResultsAll the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.ConclusionOur findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.     

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap­proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision‐making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low‐ and middle‐income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low‐resource settings may lead to wider learning from locally embedded strategies.     

Examining inequities in incidence of catastrophic health expenditures on different healthcare services and health facilities in Nigeria

Objective

There is limited evidence about levels of socio-economic and other differences in catastrophic health spending in Nigeria and in many sub-Saharan African countries. The study estimated the level of catastrophic healthcare expenditures for different healthcare services and facilities and their distribution across socioeconomic status (SES) groups.

Methods

The study took place in four Local Government Areas in southeast Nigeria. Data were collected using interviewer-administered questionnaires administered to 4873 households. Catastrophic health expenditures (CHE) were measured using a threshold of 40% of monthly non-food expenditure. We examined both total monthly health expenditure and disaggregated expenditure by source and type of care.

Results

The average total household health expenditure per month was 2354 Naira ($19.6). For outpatient services, average monthly expenditure was 1809 Naira ($15.1), whilst for inpatient services it was 610 Naira ($5.1). Higher health expenditures were incurred by urban residents and the better-off SES groups. Overall, 27% of households incurred CHE, higher for poorer socioeconomic groups and for rural residents. Only 1.0% of households had a member that was enrolled in a health insurance scheme.

Conclusion

The worse-off households (the poorest SES and rural dwellers) experienced the highest burden of health expenditure. There was almost a complete lack of financial risk protection. Health reform mechanisms are needed to ensure universal coverage with financial risk protection mechanisms.