How far do we still need to go to provide health solutions for the poor?

In this issue of Public Health Action, we revisit the matter of knowing how to provide health solutions for the poor. To our previous list of publications¹ we add three more countries, India, Kenya and Zimbabwe, and evaluate issues related to tuberculosis and HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome). And, once again, we discover what is actually going on in health services rather than what is meant to be going on.

Sadly, a résumé of the findings of this first series of manuscripts does not make happy reading—all of them demonstrate serious challenges in the most basic aspects of health services delivery. A study on the management of a series of 141 patients admitted to hospital with chest symptoms reported that less than half of them had sputum smears examined, and only half of those with negative smears had chest radiographs.² And yet, 42% of those having full investigations had tuberculosis. It makes little sense to spend resources on active case finding when we don’t even examine those admitted to hospital with symptoms consistent with tuberculosis. A paper on 2463 tuberculosis patients living with HIV reported that only one in six were commenced at an early stage on antiretroviral treatment but that, more importantly, one-third of all these patients had an unfavourable treatment outcome.³ A third study of 2922 deaths among patients on antiretroviral treatment for HIV reported that more than one out of eight were omitted when being transcribed from one register to another, calling into serious question the quality of even the most basic health statistics we use to monitor our activities.⁴ A study from Pakistan of 1698 consecutive sputum smear-positive tuberculosis patients reported that one in every sixteen was never registered on treatment, most of them having been diagnosed in tertiary care hospitals.⁵

If we fail to provide comprehensive care for our patients in the very locations where we are training the next generation of physicians, it does not bode well for our ability to stop tuberculosis. A study of 19 200 malnourished children in Ethiopia found 179 with malaria, most of them without a record of fever, even though the presence of fever is the indication for undertaking tests for malaria.⁶ A study of 267 children with tuberculosis diagnosed in a large teaching hospital reported that 38% were not registered in the health statistics, including 73% of those with an unfavourable treatment outcome, indicating the unreliability of the routine statistics that we depend upon.⁷ A study from Zimbabwe of 1800 tuberculosis patients reported that 39% of them were never tested for HIV, even though most of those tested were found to be positive.⁸ Moreover, less than one in ten were started on antiretroviral treatment. A study from India on 3000 pulmonary tuberculosis patients who completed treatment reported that one in three new patients and more than one half of retreatment patients did not have complete follow-up examinations.⁹ Comprehensive follow-up is one of the means by which we identify those most likely to have drug-resistant disease, which requires more complex and prolonged treatment. Finally, a study from Kenya on 187 pregnant women living with HIV reported that seven of the ten tuberculosis cases detected had no symptoms and were identified by chest radiograph, indicating that current advice on screening for tuberculosis in this setting is not relevant.¹⁰

What is our conclusion? Should this journal be re-labelled the ‘Journal of Bad News’? These overall depressing results do not stem from the fact that we selected only those reports with bad news for publication —and certainly we have much bad news to face and to come to terms with. These two first issues of PHA also indicate the important role played by operational research in finding health solutions for the poor. However, these solutions will only be found when we address the issues raised and when we determine that the actions resulting from this research actually change policy, practice and health outcomes.