Health System Failures Research Articles

Representations of MDR and XDR-TB in South African newspapers

The emergence of drug-resistant tuberculosis has brought with it diverse perspectives concerning the way in which the disease should be managed. The media is an important source of these perspectives, as they perform the dual role of reflecting and shaping public discourse. In this study, we are interested in how the media presents multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in South Africa, where both variants are a growing public health concern. We examined newspaper content from 310 South African newspaper articles from February 2004 to July 2009 that discussed MDR-TB and XDR-TB. Newspaper articles were collected from the Dow Jones Factiva database and imported into QDA Miner v3.2.1 for analysis. Using Attride-Stirling’s thematic network analysis method, articles were analyzed according to themes, sub-themes, and thematic networks. This analysis identified two main dimensions: causes of MDR/XDR-TB and treatment approaches/solutions. Causes of MDR/XDR-TB revolved around three main global themes: i) patient-centred causes (32.6%); ii) lack of infection control procedures (18.7%); and iii) health systems failures (19.4%). Treatment approaches or solutions to tackling MDR/XDR-TB focused on i) patient targeted solutions (38.4%); ii) improving infection control (12.3%); iii) systems restructuring (10.6%); and iv) new diagnostic and therapeutic options (10%). Our analysis identifies a trend in the South African media to identify a broad range of causes of MDR/XDR-TB, while emphasizing that treatment approaches should be directed primarily at the individual. Of particular importance is the fact that such a perspective runs contrary to the World Health Organization's (WHO) recommendations for approaching the TB epidemic, in particular by insufficiently addressing systemic and social drivers of the epidemic. Due to the media's potential influence on policy formation, how the media presents issues – especially issues pertaining to emerging public health concerns – should warrant more attention.

"Workhood"-a useful concept for the analysis of health workers' resources? an evaluation from Tanzania

BackgroundInternational debates on improving health system performance and quality of care are strongly coined by systems thinking. There is a surprising lack of attention to the human (worker) elements. Although the central role of health workers within the health system has increasingly been acknowledged, there are hardly studies that analyze performance and quality of care from an individual perspective. Drawing on livelihood studies in health and sociological theory of capitals, this study develops and evaluates the new concept of workhood. As an analytical device the concept aims at understanding health workers' capacities to access resources (human, financial, physical, social, cultural and symbolic capital) and transfer them to the community from an individual perspective.MethodsCase studies were conducted in four Reproductive-and-Child-Health (RCH) clinics in the Kilombero Valley, south-eastern Tanzania, using different qualitative methods such as participant observation, informal discussions and in-depth interviews to explore the relevance of the different types of workhood resources for effective health service delivery. Health workers' ability to access these resources were investigated and factors facilitating or constraining access identified.ResultsThe study showed that lack of physical, human, cultural and financial capital constrained health workers' capacity to act. In particular, weak health infrastructure and health system failures led to the lack of sufficient drug and supply stocks and chronic staff shortages at the health facilities. However, health workers' capacity to mobilize social, cultural and symbolic capital played a significant role in their ability to overcome work related problems. Professional and non-professional social relationships were activated in order to access drug stocks and other supplies, transport and knowledge.ConclusionsBy evaluating the workhood concept this study highlights the importance of understanding health worker performance by looking at their resources and capacities. Rather than blaming health workers for health system failures, applying a strength-based approach offers new insights into health workers' capacities and identifies entry points for target actions.

Enhancing Leadership and Governance Competencies to Strengthen Health Systems in Nigeria: Assessment of Organizational Human Resources Development

The lack of effective leadership and governance in the health sector has remained a major challenge in Nigeria and contributes to the failure of health systems and poor development of human resources. In this cross-sectional intervention study, leadership and governance competencies of policy makers were enhanced through a training workshop, and an assessment was conducted of organizational activities designed to promote evidence-informed leadership and governance to improve human resources for health (HRH). The training workshop increased the understanding of policy makers with regard to leadership and governance factors that ensure the functionality of health systems and improve human resources development, including policy guidance, intelligence and oversight, collaboration and coalition building, regulation, system design and accountability. Findings indicated that systems for human resources development exist in all participants' organizations, but the functionality of these systems was suboptimal. More systematic and standardized processes are required to improve competencies of leadership and governance for better human resources development in low-income settings.

Do inquiries into health system failures lead to change in clinical governance systems?

This paper reports the first part of a case study investigation to examine the changes at King Edward Memorial Hospital (KEMH) following an inquiry established to review the quality of obstetric and gynaecological services. Common findings from a range of health inquiries in recent times include that there have been inadequate adverse event reporting systems, the absence of transparent systems for staff and patients to report concerns about quality of patient care, and an ineffective medical credentialing and performance review system. The similarity of findings from many health inquiries raises the question of whether an inquiry does lead to changes to improve patient care and safety. There has been very little reported in the literature about this. Using a case study strategy the areas of medical credentialing, performance review and involvement of consumers in care were chosen as the KEMH clinical governance processes to be examined for changes post inquiry. Documents, archives and interviews were used as data sources for this case study. Documents were examined using a normative analytic approach and the Miles and Huberman framework was used for data analysis of the interviews. There were significant changes in the area of credentialing and performance review evident in analysis of all sources of data. There were some improvements in the processes of involving consumers in care, but deficits were identified in regard to the provision of training and upskilling for clinicians to improve their communication skills and interactions with patients and families.

EVOLUÇÃO DOS ÓBITOS POR GRUPOS DE CAUSAS EM MENORES DE 1 ANO NO MUNICÍPIO DE MACEIÓ, ALAGOAS, 1997- 2007

Objective: To identify the main causes of death among children under one year in the city of Maceio, and compared with the Northeast and Brazil. Material and Methods: A descriptive study using secondary data to construct indicators of proportional mortality by causes of death in children under 1 year according to the ICD-10 chapters in the city of Maceio, in the Northeast and in Brazil in 1997 and 2007. Results: 391 deaths in 1997 were in Maceio and perinatal conditions (AP) were the leading causes of death followed by infectious and parasitic diseases. In 2007 there were 300 deaths registered with the AP as the main cause followed by birth defects. The Northeast and Brazil maintained the AP as the major causes of deaths in both periods. AP is the largest cause of deaths in the three contexts in the period studied, indicating the neonatal component as the major contributor to infant mortality. These deaths result from a combination of biological, social, cultural and health system failures. Conclusion: The study show the need for intersectoral policies that improve the living conditions of families and access to health services, in addition to offering quality services for the mother and newborn. DESCRIPTORS: Infant Mortality, Epidemiologic Studies, Maternal-Child Health Services

The Great Perhaps: A Novel

Back to table of contents Previous article Next article Book ReviewFull AccessThe Great Perhaps: A NovelRobert L. Oldham M.D., M.S.H.A.Robert L. Oldham M.D., M.S.H.A.Search for more papers by this authorPublished Online:1 Dec 2010https://doi.org/10.1176/ps.2010.61.12.1269AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail The book The Great Perhaps is Chicagoan Joe Meno's poignant yet funny story about the Caspers, a family in crisis after being plagued with "cowardice" for generations. This novel should entertain and engage almost any audience, with its humorous and honest depiction of the modern American family in all of its complexity and dysfunction. This book will appeal to the mental health professional, in particular, because it speaks to some of our most challenging problems, such as reductionism, stigma, health system failures, intergenerational transmission of psychological trauma, and our wish to understand and prevent manmade causes of suffering. In addition to telling the engaging story of the modern Casper family, Meno provides the reader with artful depictions of family members' suffering from various anxiety disorders and other identifiable mental illnesses in a wide variety of historical contexts. Each successive illustration of the Casper clan seems more tragically comical and reminds us that anxiety disorders and other mental illnesses are not new phenomena, that they don't tend to go away without intervention, and that they, indeed, may confer an evolutionary selective advantage that allows certain seemingly disabling traits to perpetuate themselves across generations, even if they can sometimes thwart our human desire to live lives of integrity and meaning.The mental health professional will notice that mental illness goes unnamed, undiagnosed, and untreated for generations of Caspers, including the contemporary generations that dominate the novel. Although psychiatric diagnoses are never mentioned, the Caspers and their medical professionals accept more reductionistic, and seemingly less accurate and useful, general medical diagnoses. The absence of mental health care for this family (and the inadequacy of other health care professionals) is an indictment of our society and health care system, especially given that this family with almost every imaginable social advantage is still unable to get appropriate help.The dust jacket asserts that this novel is about the need for complicated answers to complex questions. Whether this was actually Meno's intent is unclear. In fact, at times this story seems to argue that, while the questions that people face are often complicated, sometimes the best answers are pretty simple to understand, although the solutions are perhaps much more difficult to execute. In the case of the Caspers, the answer indeed seems to be fairly simple: be kind and truthful to yourself and others, be committed to reality, and get appropriate professional help! As the Caspers come together at the end of the novel, I found myself rooting for them but not really knowing whether this family would make it. The Great Perhaps calls on us as mental health professionals to help the Casper families of this world, for the sake of those suffering today and for future generations. Dr. Oldham is a psychiatrist with Fresno County Perinatal Mental Health Program, Fresno, California. FiguresReferencesCited byDetailsCited byNone Volume 61Issue 12 December, 2010Pages 1269-1269PSYCHIATRIC SERVICES December 2010 Volume 61 Number 12 Metrics PDF download History Published online 1 December 2010 Published in print 1 December 2010

Access to essential medicines in national constitutions

Access to essential medicines is well founded in international law as part of the right to the highest attainable standard of health (“the right to health”). The International Covenant on Economic, Social and Cultural Rights adopted in 1966 calls for States Parties to take steps to ensure access to medical services for all. General Comment 14, added in the year 2000, applies the principles of accessibility, availability, appropriateness and assured quality to goods and services, including essential medicines as defined by the World Health Organization’s (WHO’s) Action Programme on Essential Drugs. One important success factor for the legal enforcement of access to essential medicines is the incorporation of right-to-health principles into national constitutions. In one study, in 11 out of 12 middle-income countries in which successful court cases in support of access took place there was supportive constitutional language and, in the twelfth country, international treaties ratified by the State acquire the status of national law.1 Constitutional recognition of the right to access to medical products and technologies has therefore become a country progress indicator in WHO's Medium-term strategic plan for 2008–2013.2 WHO recently published a first baseline study for this indicator, including a database and analysis of all health-related texts in national constitutions.3 The study reports that 135 (73%) of 186 national constitutions include provisions on health or the right to health. Of these, 95 (51%) constitutions mention the right to access health facilities, goods and services, 62 (45%) include in-text reference to equity and non-discrimination and 111 (82%) include one or more article(s) mandating the right to be treated equally or freedom from discrimination. Four national constitutions (2%) specifically mention universal access to medicines. In Mexico, “(women) are entitled to medical and obstetrical attention, medicines, nursing aid and infant care services. Members of a worker's family shall be entitled to medical attention and medicines, in those cases and in the proportions specified by law”. In Panama, “the State is primarily obligated to (…) supply medicines to all the people”. In the Philippines, “the State shall (…) endeavour to make essential goods, health and other social services available to all people at affordable cost”. In the Syrian Arab Republic, “the State protects the citizens’ health and provides them with the means of protection, treatment and medication”. Some constitutions, such as those of Cuba, Nicaragua and South Africa, use very clear text to describe access to health care, goods and services in more general terms, using words like “without exclusions”, “everyone” and “all citizens regardless of …”. Some texts focus on poor and disadvantaged groups, e.g. those of Nicaragua, the Philippines and Viet Nam. The constitutions of Ecuador and Panama specify that national medicine policies shall be established and implemented to achieve the constitutional obligations. There are at least three different routes through which the right to health can be recognized in national legal frameworks. The strongest government commitment is created by including the right to essential goods and services in the national constitution. The second approach is constitutional recognition that international treaties ratified by the State override or acquire the status of national law. This option is available to 31 countries and was already used in a landmark court decision in Argentina.4 The third option, inclusion of health rights in other national legislation, is easier to create but also easier to change or cancel. This is the subject of another study currently under way. The full range of strategies to promote universal access to essential medicines through rational selection, affordable prices, sustainable financing and reliable health systems is described in many other documents.5,6 Constitutional recognition of the right to access essential medicines is an important sign of national values and commitment, but is neither a guarantee nor an essential step – as shown by those countries that have failing health systems despite good constitutional language, and those that have good access without it. Yet the many court cases in the Americas have shown that constitutional recognition creates an important supportive environment, especially in middle-income countries where health insurance systems are being created and patients are becoming more aware of their rights and are more vocal in demanding them.1 More recent constitutional texts seem to include stronger commitments, possibly reflecting the positive influence of the global development of the right to health in the past 50 years. Political opportunities to update a country’s constitution present a chance to align national values and aspirations with international human rights standards. The new constitutional texts should then consider key human rights principles, and specifically the right to health and equitable access to essential medical goods and services. Constitutional frameworks can thus become valuable aspirational statements on which to base other legislation and policies. The examples identified in the recent WHO study could serve as a model.

Childbirth experiences of women with obstetric fistula in Tanzania and Uganda and their implications for fistula program development

authors sought evidence from the testimonies of women living with fistula regarding local risk factors for fistula and the impact of fistula on women's lives. one hundred thirty-seven women recruited from health facilities and at the community level in Tanzania and Uganda were interviewed using quantitative and qualitative methods, including participatory approaches. women of all ages and parities endured fistula. The testimonies illustrated that physical, socio-economic and cultural constraints, as well as health system failures, led to fistula, and the condition imposed harsh consequences on women's lives. Constraints included deficient maternal health services and personnel, delays in seeking and accessing care, and limited fistula repair services. Women endured severe social stigma and severe economic hardships. participants' testimonies expand current understanding of women's experience of fistula and point to recommendations that could improve maternal health care, reduce women's risk of fistula, and improve the lives of women living with the condition.

Establishing pharmacovigilance programs in resource-limited settings: the example of treating malaria

The unprecedented levels of political, technical and financial support for improved malaria control, and particularly for changes in the malaria treatment policy, have heralded a renewed appreciation of the role of pharmacovigilance, its relationship with other areas of public health and the development of novel approaches to addressing the pharmacovigilance priorities in malaria-endemic countries. In order to become a valuable public health activity in these resource-limited settings, pharmacovigilance needs to be viewed within its broadest definition of detecting, understanding and preventing adverse drug reactions and drug-related problems. Pharmacovigilance in resource-limited settings provides an opportunity to identify and address health system failures that significantly impact on patient morbidity and mortality, particularly those that are drug related. Countries need to establish a national strategy that identifies realistic and relevant objectives that meet the most pressing pharmacovigilance needs, taking into consideration the conditions under which these systems are likely to develop.

A solution might be within people with diabetes themselves

In 10 minutes, by the time you finish reading this editorial, 60 people with diabetes will die and 120 people will be diagnosed with diabetes worldwide. As tragic as the death of so many people is, the doubling of people with the same illness, an illness we have not learned how to manage and one that can be prevented in the first place, represents a failure of the world health system of apocalyptic proportions. Two hundred and fifty million people diagnosed with diabetes today will grow to nearly 400 million by 2025. As dramatic as this quantitative analysis is, qualitative considerations make this global suffering unsustainable and unacceptable. The burden of diabetes is the greatest in the developing world, where some 80% of people with diabetes live. Unfortunately, more than 80% of expenditures for medical care for diabetes are made in the world’s economically richest countries. The world spends about USD 250 billion to treat and prevent diabetes and its complications. One country alone, the US, spends more than half of this amount (www. IDF.org). In spite of this robust expenditure, only 7.3% of people with diabetes in the US achieve recommended levels of glucose, cholesterol and blood pressure control simultaneously (www.cdc.gov). This cannot be explained only by health disparities, since far more than 7.3% of US adults with diabetes enjoy access to quality health care. Rather it is a reflection of the complexity of managing diabetes as well as other chronic diseases, of which diabetes is an important example. There is no doubt that more resources are needed in countries of the developing world for the care of people with diabetes, but it is also clear that expenditures and investments do not guarantee satisfactory outcomes. Alternative hypotheses for the care of people with diabetes must be put forward and tested if we are to modify the course or predicted prevalence, morbidity and burden of diabetes. One such hypothesis is the focus of this supplement of Family Medicine. A World Health Organization (WHO) consultation on peer support programmes in diabetes was convened in November 2007 and published in July 2008 at www.who.int/diabetes/publications/en/. Participants were experts in peer support frommore than 25 countries, representing all regions of the world. The proceedings of this conference and the original scholarly background papers supporting the conference are published herein. As background to all of these, this editorial answers three questions: Why was the WHO consultation convened? What were the conclusions and recommendations? and How will implementation of these recommendations provide part of a solution (not necessarily the solution) to the global burden of diabetes? The premise of the WHO consultation and the projects that will follow from it is that people living with diabetes have a great deal to offer one another in terms of behavioural and emotional support. People with diabetes need more thanmedical treatment from their health-care providers: they also need support in mastering and sustaining complex self-care behaviour that enables them to live healthy and satisfying lives while managing their diabetes 365 days a year for the rest of their lives. That people living with diabetes have much to offer each other is reflected in a wide range of research. A recent study of the determinants of medical outcomes in Type 2 diabetes demonstrated that patient-level factors accounted for the majority of variability in haemoglobin A1c (98%) while physician-related factors accounted for a very small portion of metabolic control. An earlier review of self-management programmes found that the only characteristic predictive of metabolic control was the amount of time spent between the health-care professional and the patient. These two findings suggest development of patientlevel interventions that entail ongoing support and follow-up for those with diabetes to support their efforts at disease management. Peer mentors may be identified and trained to provide this kind of patientlevel support to assist others in need. If effective, the peer support model would be a promising addition to public health systems that face severe resource constraints and increasing needs among patients living with diabetes and/or other chronic diseases. Reflecting the hope that peer support might be part of the solution to worldwide diabetes, the Lilly

A working model for the extraordinary review of clinical privileges for doctors and dentists in the Australian Capital Territory

The extraordinary (unplanned) review of clinical privileges is the means by which an organisation can manage specific complaints about individual practitioners' clinical competence that require immediate investigation. To date, the extraordinary review of clinical privileges for doctors and dentists has not been the subject of much research and there is a pressing need for the evaluation and review of how different legislated and non-legislated administrative processes work and what they achieve. Although it seems a fair proposition that comprehensive processes for the evaluation of the clinical competence of doctors and dentists may improve the overall delivery of an organisation's clinical services, in fact, little is known about the relationship between the safety and quality of specific clinical services, procedures and interventions and the efficiency or effectiveness of established methodologies for the routine or the extraordinary review of clinical privileges. The authors present a model of a structured approach to the extraordinary review of clinical privileges within a clinical governance framework in the Australian Capital Territory. The assessment framework uses a primarily qualitative methodology, underpinned by a process of systematic review of clinical competence against the agreed standards of the CanMEDS Physician Competency Framework. The model is a practical, working framework that could be implemented on a hospital-, area health service- or state- and territory-wide basis in any other Australian jurisdiction.

Help-seeking for Mental Health Problems in Young Refugees: A Review of the Literature with Implications for Policy, Practice, and Research

The large and diverse bodies of literature on refugee child and adolescent mental health have not been matched by a commensurate interest in help-seeking. Most help-seeking research has centred on Western and, to a lesser extent, non-refugee ethnic minority adult populations. An emerging child and adolescent help-seeking literature consistently reports widespread underutilization of mental health services by children in the general population. Current research and opinion suggest a similar trend for refugee and other ethnic minority children. While service underutilization appears to be an issue for all children, those from refugee backgrounds may be at increased risk of mental health problems and have greater difficulty accessing mental health care. From a policy and practice perspective, the most important explanation for low uptake of services by refugee families concerns an overall failure of Western mental health systems to accommodate the needs of ethnically diverse populations in general and refugees in particular. In order to effectively plan for the mental health needs of refugee children and adolescents, Western host country governments need a clear understanding of help-seeking behaviour.

Qualitative and Mixed Methods Research in Cross-Cultural Psychology

Qualitative and Mixed Methods Research in Cross-Cultural Psychology

Caring for people with HIV: state policies and their dependence on women's unpaid work

This article explores the issue of women providing unpaid care for family members living with HIV in South Africa and Zimbabwe. State policies rely on women providing home-based care, in the context of failing health systems. This has the effect of impoverishing women, and reinforcing gender stereotypes. Recommendations will be given on how to make policies more gender-sensitive.

Recall of News Stories About Mental Illness by Australian Youth: Associations with Help-Seeking Attitudes and Stigma

The aim of the present study was to investigate what news stories about mental illness are recalled by Australian youth and whether these are associated with stigma and help-seeking beliefs. A random sample of 3746 Australian youth aged 12-25 years were interviewed about mental health literacy in 2006. As part of the interview, they were asked whether they could recall any news stories about mental health problems during the past 12 months. Stigma was assessed, as well as willingness to seek help for a mental illness described in a vignette. Common news story themes were entered as predictors of stigma components and willingness to seek help in a series of logistic regressions. Only a minority of youth could recall a news story about mental illness. The most common stories recalled were those involving crime or violence; mental health system failures; or disclosures of mental illness by prominent individuals. Recall of a disclosure by a prominent individual was associated with beliefs that people with mental illness are sick rather than weak, while recall of a story involving crime or violence was associated with greater reluctance to tell anyone about a mental health problem. There were no types of stories that predicted willingness to seek help. There is some evidence that recall of positive or negative news stories is associated with specific components of stigma. Overall, however, recall of news stories about mental illness added little explanatory power to differences in stigma or help-seeking intentions.

REALITIES OF HEALTH POLICY IN NORTH AMERICA: GOVERNMENT IS THE PROBLEM, NOT THE SOLUTION

Healthcare systems in North America are sometimes criticised as being expensive or socially irresponsible relative to comparable systems in OECD (Organisation for Economic Co‐operation and Development) countries or regions. These perceived health system failures are often mistakenly attributed to greater private sector involvement in the delivery of medical care or the provision of medical insurance in Canada and the USA. However, the exact nature and scope of state involvement in the healthcare sector in Canada and the USA is also often misunderstood and underestimated. This paper presents a fact‐based context for evaluating health policy in North America.

Can the right to health inform public health planning in developing counties? A case study for maternal healthcare from Indonesia

Background: Maternal mortality remains unacceptably high in developing countries despite international advocacy, health and development targets, and simple, affordable and effective interventions. In recent years, regard for maternal mortality as a human rights issue as well as one that pertains to health, has emerged.Objective: We study a case of maternal death using a theoretical framework derived from the right to health to examine access to and quality of maternal health care. Our objective is to explore the potential of rights-based frameworks to inform public health planning from a human rights perspective.Design: Information was elicited as part of a verbal autopsy survey investigating maternal deaths in rural settings in Indonesia. The deceased's relatives were interviewed to collect information on medical signs, symptoms and the social, cultural and health systems circumstances surrounding the death.Results: In this case, a prolonged, severe fever and a complicated series of referrals culminated in the death of a 19-year-old primagravida at 7 months gestation. The cause of death was acute infection. The woman encountered a range of barriers to access; behavioural, socio-cultural, geographic and economic. Several serious health system failures were also apparent, reflecting her exclusion from access to healthcare. The theoretical framework derived from the right to health identified that none of the essential elements of the right were upheld.Conclusion: There are fundamental and inherent conflicts between the public health tradition (collective and preventative) and the right to health (individualistic and curative). As a result, and in practice, the right to health is likely to be ineffective for public health planning from a human rights perspective. Collective rights such as the right to development may provide a more suitable means to achieve equity and social justice in health planning.

Taking XDR TB seriously in South Africa

“The global emergence of extensively drug-resistant tuberculosis (XDR-TB) is a stark reminder of the failure of public health systems to control TB, an infectious disease that is easily diagnosed and treated.”

Equity Impacts of Neoliberal Reforms: What Should the Policy Responses Be?

The final article in this special section draws together the lessons learned from the ALPS analyses and considers a range of potential policy responses. The country case studies highlight that health systems in many low- and middle-income countries are failing not only the poor but also other income groups, who are faced with wide-ranging barriers to accessing the health care they need. A key policy intervention to address these health system failures is that of challenging the status quo in relation to the public-private health care mix. There is an urgent need to strengthen public health services that have been systematically neglected over the past few decades while also regulating the worst excesses of the private health sector. Promoting a greater reliance on financing mechanisms that are progressive and that strengthen cross-subsidies in the overall health system is critical, as is ensuring that available financial and human resources are equitably allocated among geographic areas and groups. Finally, health system interventions of this nature should be supported by broader poverty-reduction strategies. Such interventions to fundamentally change ailing health systems are essential to break the vicious cycle of poverty, ill-health, and (further) impoverishment.

Treatment adherence

<p>Patients with psychiatric illnesses show a greater degree of non-adherence than those with physical disorders. Adherence to treatment may be assessed using biological measurements, clinician ratings, patient self-report, pill count, caregiver reports and side-effects of medication. Reasons cited for non-adherence include factors related to the treatment, patient-related factors, health care, and socio-economic circumstances. It is important not to make prejudicial predictions of non-adherence based on these factors, or the use non-adherence as an excuse to blame the patient for an unfavourable outcome. Rather, non-adherence should be seen not only as the patient’s inability to follow treatment recommendations but also as the health system's failure to provide adequate care and to meet the patient’s needs.</p>