Disease control and health systems in low‐ and middle‐income countries: enhancing positive interrelation

There is a growing interest in improving the relationship between disease control programmes and the rest of the health system in low‐ and middle‐income countries. This short study seeks to contribute to this movement by providing a multi‐dimensional approach for policy‐makers and researchers. It recognizes the different and often conflicting perspectives in health systems held by stakeholders. Two such perspectives are those of disease control programmes and health systems. Both are based on perceived health needs and put forward requirements on each other through resource demands and organizational needs. Failure to reconcile these perspectives can lead to health system fragmentation. This study proposes a framework to address the importance of mutual support across stakeholder perspectives, striving to understand and analyse the consequences of their reciprocal views. In doing this, the study stresses the importance of common understanding around health system values, the political interplay between stakeholders, the contextual setting and the need to integrate research and capacity development in this area.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.     

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co‐operative Medical System)

Objective To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Methods Data from cross‐sectional household‐based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log‐linear model. Results Between 2002 and 2007, having no any pre‐natal visit decreased from 25% to 12% (difference 13%, 95% CI 10–17%); facility‐based delivery increased from 45% to 80% (difference 35%, 95% CI 29–37%); and differences in using pre‐natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre‐natal and delivery care in 2007. The expenditure for facility‐based delivery increased over the period, but the out‐of‐pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low‐income group. NCMS participation was found positively correlated with lower out‐of‐pocket expenditure for facility‐based delivery (coefficient ?1.14 P < 0.05) in 2007. Conclusions Facility‐based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility‐based delivery, although NCMS participation reduced the out‐of‐pocket expenditure on average.     

Prevention of mother to child transmission of HIV (PMTCT) programme in KwaZulu‐Natal,South Africa: an evaluation of PMTCT implementation and integration into routine maternal,child and women’s health services

Objectives To evaluate prevention of mother to child transmission of HIV (PMTCT) implementation and integration of PMTCT with routine maternal and child health services in two districts of KwaZulu‐Natal; to report PMTCT coverage, to compare recorded and reported information, and to describe responsibilities of nurses and lay counsellors. Methods Interviews were conducted with mothers in post‐natal wards (PNW) and immunisation clinics; antenatal and child health records were reviewed. Interviews were conducted with nurses and lay counsellors in primary health care clinics. Results Eight hundred and eighty‐two interviews were conducted with mothers: 398 in PNWs and 484 immunisation clinics. During their recent pregnancy, 98.6% women attended antenatal care (ANC); 60.8% attended their first ANC in the third trimester, and 97.3% were tested for HIV. Of 312 mothers reporting themselves HIV positive during ANC, 91.3% received nevirapine, 78.2% had a CD4 count carried out, and 33.1% had a CD4 result recorded. In the immunisation clinic, 47.6% HIV‐exposed babies had a PCR test, and 47.0% received co‐trimoxazole. Of HIV‐positive mothers, 42.1% received follow‐up care, mainly from lay counsellors. In 12/26 clinics, there was a dedicated PMTCT nurse, PCR testing was not offered in 14/26 clinics, and co‐trimoxazole was unavailable in 13/26 immunisation clinics. Nurses and lay counsellors disagreed about their roles and responsibilities, particularly in the post‐natal period. Conclusions There is high coverage of PMTCT interventions during pregnancy and delivery, but follow‐up of mothers and infants is poor. Poor integration of PMTCT services into routine care, lack of clarity about health worker roles and poor record keeping create barriers to accessing services post‐delivery.