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    • Ashuntantang and colleagues should have also highlighted oth

    2019-05-28

    Ashuntantang and colleagues should have also highlighted other prominent factors in the region that contribute to such poor outcomes, including a dearth of workforce (<1 nephrologist per 1 million population in many countries) and the absence of early disease and risk factor detection and screening programmes. In view of the burden associated with the cost of ESKD care, perhaps efforts in sub-Saharan Africa should be devoted to early disease detection and prevention. Awareness of ESKD and its risk factors (eg, diabetes mellitus and hypertension) is low, and few countries in sub-Saharan Africa have early detection programmes; even fewer have a national maintenance dialysis programme for those with advanced disease. Early risk factor identification and initiation of treatment can delay onset of disease or slow progression to ESKD. Like for HIV/AIDS, countries in sub-Saharan Africa should stop burying their heads in the sand and realise that the burden of ESKD will worsen and every small step taken in the right direction now will help to save lives in future.
    In a study in , Adam Bennet and colleagues have applied innovative methods to do an analysis of household survey data providing evidence that artemisinin combination therapy (ACT) treatment coverage for children younger than 5 years with malaria remains very low despite huge efforts at increasing ACT availability across the continent. Although the authors bemoan the low ACT treatment coverage, particularly in the private sector, it is important to scrutinise treatment coverage further to identify possible solutions to the problem. Examination of table 2 of the tyrosine kinase receptor shows several instances in which the proportion of children with fever and infection who received treatment with any antimalarial was considerably higher than the proportion of children with fever and infection who received an ACT. For instance, in Uganda, which has the highest ACT treatment coverage, the proportion of children with fever and infection who received an ACT was 10 percentage points lower than the proportion of children with fever and infection who received treatment with any antimalarial, according to survey UG20141. Therefore, increasing the availability of ACTs as emphasised by the authors is unlikely to achieve the desired effect on ACT treatment coverage as long as non-policy-recommended antimalarial therapies remain available, particularly in the private sector. Emphasis is being placed on the private sector because procurement is largely driven by anticipated sales volumes and profit margins. Unlike the public sector, where the centralised nature of commodity procurement and service delivery mechanisms makes ureter simpler to achieve adherence to antimalarial policy with respect to not stocking artemisinin monotherapies and non-artemisinin therapies. Although increasing availability of ACTs has been shown to outcompete inappropriate therapies, deliberate actions need to be taken to reduce the availability of undesirable antimalarial treatments. Examples include imposing outright importation bans or other severe penalties on importation of non-policy-recommended antimalarial treatments and vigorous negative campaigns against their use. Negative campaigning has the potential to modify demand and supply patterns and has been effective in a number of health interventions. Important differences in factors influencing commodity procurement and service delivery among healthcare providers, and health seeking behaviour, exist between the public and private health sectors in countries. The authors show that even though ACT treatment coverage was generally low, those who sought treatment in the public sector were twice as likely to receive an ACT than those in the private sector. Thus, in analysing malaria treatment survey data to inform policy action, two issues require careful consideration. First, the way a malaria treatment facility operates should inform its classification into either a public or a private treatment source. For example, it is well known that non-governmental, or so-called mission, facilities function largely as quasi-public in several malaria endemic countries. In fact, in some countries, mission hospitals double as the main district secondary health facility. In such cases, it becomes relevant whether or not they are classified along with governmental sources as public sector, even though they are really not owned by the government. Second, policy interventions often include elements aimed at modifying factors that influence outcomes differently between public and private sectors. As such, there is better policy-actionable information to be derived, when results for survey analysis are presented stratified by public and private sectors at country level.