Laura Steinhardt

Sequelae due to bacterial meningitis among African children: a systematic literature review

BackgroundAfrican children have some of the highest rates of bacterial meningitis in the world. Bacterial meningitis in Africa is associated with high case fatality and frequent neuropsychological sequelae. The objective of this study is to present a comprehensive review of data on bacterial meningitis sequelae in children from the African continent.MethodsWe conducted a systematic literature search to identify studies from Africa focusing on children aged between 1 month to 15 years with laboratory-confirmed bacterial meningitis. We extracted data on neuropsychological sequelae (hearing loss, vision loss, cognitive delay, speech/language disorder, behavioural problems, motor delay/impairment, and seizures) and mortality, by pathogen.ResultsA total of 37 articles were included in the final analysis representing 21 African countries and 6,029 children with confirmed meningitis. In these studies, nearly one fifth of bacterial meningitis survivors experienced in-hospital sequelae (median = 18%, interquartile range (IQR) = 13% to 27%). About a quarter of children surviving pneumococcal meningitis and Haemophilus influenzae type b (Hib) meningitis had neuropsychological sequelae by the time of hospital discharge, a risk higher than in meningococcal meningitis cases (median = 7%). The highest in-hospital case fatality ratios observed were for pneumococcal meningitis (median = 35%) and Hib meningitis (median = 25%) compared to meningococcal meningitis (median = 4%). The 10 post-discharge studies of children surviving bacterial meningitis were of varying quality. In these studies, 10% of children followed-up post discharge died (range = 0% to 18%) and a quarter of survivors had neuropsychological sequelae (range = 3% to 47%) during an average follow-up period of 3 to 60 months.ConclusionBacterial meningitis in Africa is associated with high mortality and risk of neuropsychological sequelae. Pneumococcal and Hib meningitis kill approximately one third of affected children and cause clinically evident sequelae in a quarter of survivors prior to hospital discharge. The three leading causes of bacterial meningitis are vaccine preventable, and routine use of conjugate vaccines could provide substantial health and economic benefits through the prevention of childhood meningitis cases, deaths and disability.

Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan

BACKGROUND User fees for primary care tend to suppress utilization, and many countries are experimenting with fee removal. Studies show that additional inputs are needed after removing fees, although well-documented experiences are lacking. This study presents data on the effects of fee removal on facility quality and utilization in Afghanistan, based on a pilot experiment and subsequent nationwide ban on fees. METHODS Data on utilization and observed structural and perceived overall quality of health care were compared from before-and-after facility assessments, patient exit interviews and catchment area household surveys from eight facilities where fees were removed and 14 facilities where fee levels remained constant, as part of a larger health financing pilot study from 2005 to 2007. After a national user fee ban was instituted in 2008, health facility administrative data were analysed to assess subsequent changes in utilization and quality. RESULTS The pilot study analysis indicated that observed and perceived quality increased across facilities but did not differ by fee removal status. Difference-in-difference analysis showed that utilization at facilities previously charging both service and drug fees increased by 400% more after fee removal, prompting additional inputs from service providers, compared with facilities that previously only charged service fees or had no change in fees (P = 0.001). Following the national fee ban, visits for curative care increased significantly (P < 0.001), but institutional deliveries did not. Services typically free before the ban-immunization and antenatal care-had immediate increases in utilization but these were not sustained. CONCLUSION Both pilot and nationwide data indicated that curative care utilization increased following fee removal, without differential changes in quality. Concerns raised by non-governmental organizations, health workers and community leaders over the effects of lost revenue and increased utilization require continued effort to raise revenues, monitor health worker and patient perceptions, and carefully manage health facility performance.

Can community health workers increase coverage of reproductive health services

Background Health services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved, yet absolute levels of coverage remain very low, especially in rural areas. One strategy for increasing use of reproductive health services is deploying community health workers (CHWs) to promote the use of services within the community and at health facilities. Methods Using a multilevel model employing data from a cross-sectional survey of 8320 households in 29 provinces of Afghanistan conducted in 2006, this study determines whether presence of a CHW in the community leads to an increase in use of modern contraceptives, skilled antenatal care and skilled birth attendance. This study further examines whether the effect varies by the sex of the CHW. Results Results show that presence of a female CHW in the community is associated with higher use of modern contraception, antenatal care services and skilled birth attendants but presence of a male CHW is not. Community-level random effects were also significant. Conclusions This study provides evidence that indicates that CHWs can contribute to increased use of reproductive health services and that context and CHW sex are important factors that need to be addressed in programme design.

Contracting for health and curative care use in Afghanistan between 2004 and 2005

Afghanistan has used several approaches to contracting as part of its national strategy to increase access to basic health services. This study compares changes in the utilization of outpatient curative services from 2004 to 2005 between the different approaches for contracting-out services to non-governmental service providers, contracting-in technical assistance at public sector facilities, and public sector facilities that did not use contracting. We find that both contracting-in and contracting-out approaches are associated with substantial double difference increases in service use from 2004 to 2005 compared with non-contracted facilities. The double difference increase in contracting-out facilities for outpatient visits is 29% (P < 0.01), while outpatient visits from female patients increased 41% (P < 0.01), use by the poorest quintile increased 68% (P < 0.01) and use by children aged under 5 years increased 27% (P < 0.05). Comparing the individual contracting-out approaches, we find similar increases in outpatient visits when contracts are managed directly by the Ministry of Public Health compared with when contracts are managed by an experienced international non-profit organization. Finally, contracting-in facilities show even larger increases in all the measures of utilization other than visits from children under 5. Although there are minor differences in the results between contracting-out approaches, these differences cannot be attributed to a specific contracting-out approach because of factors limiting the comparability of the groups. It is nonetheless clear that the government was able to manage contracts effectively despite early concerns about their lack of experience, and that contracting has helped to improve utilization of basic health services.

An experiment with community health funds in Afghanistan

As Afghanistan rebuilds its health system, it faces key challenges in financing health services. To reduce dependence on donor funds, it is important to develop sustainable local financing mechanisms. A second challenge is to reduce high levels of out-of-pocket payments. Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF), which was piloted for the first time in five provinces of Afghanistan between June 2005 and October 2006. The performance of the CHF programme demonstrates that complex community-based health financing schemes can be implemented in post-conflict settings like Afghanistan, except in areas of high insecurity. The funds raised from the community, via premiums and user fees, enabled the pilot facilities to overcome temporary shortages of drugs and supplies, and to conduct outreach services via mobile clinics. However, enrolment and cost-recovery were modest. The median enrolment rate for premium-paying households was 6% of eligible households in the catchment areas of the clinics. Cost recovery rates ranged up to 16% of total operating costs and 32% of non-salary operating costs. No evidence of reduced out-of-pocket health expenditures was observed at the community level, though CHF members had markedly higher utilization of health services. The main reasons among non-members for not enrolling were being unaware of the programme; high premiums; and perceived low quality of services at the CHF clinics. The performance of Afghanistans CHF was similar to other CHF-type programmes operating at the primary care level internationally. The solution to building local capacity to finance health services lies in a combination of financing sources rather than any single mechanism. In this context, it is critical that international assistance for Afghanistans health sector continues.

Cognitive Functioning and the Probability of Falls among Seniors in Havana, Cuba

This article explores the connection between cognitive functioning and falls among seniors (> 60 years of age) in Havana, Cuba, after controlling for observable characteristics. Using the SABE (Salud, Bienestar, and Envejecimiento) cross-sectional database, we used an econometric strategy that takes advantage of available information to reduce the endogeneity problem of cognitive functioning and the individual probability of falling. Our findings suggest that memory scores and cognitive functioning impacts the probability of falling—even after controlling for demographics, socioeconomic status, existence of chronic non-communicable conditions, vision/hearing capacity, and baseline health. Monitoring elderly with low cognitive functioning may be a cost-effective way to reduce the economic burden of falls.