Nonhlanhla Nxumalo

Inequities in access to health care in South Africa

Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population without imposing an unaffordable burden on individuals or households. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n=4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.

Utilization of traditional healers in South Africa and costs to patients: Findings from a national household survey

The use of traditional medicine is widespread in developing countries. We report on the utilization of traditional healers, using data obtained in a 2008 national survey of 4762 households in South Africa. Only 1.2 per cent of survey participants reported utilization of traditional healers. Respondents’ reasons for visiting traditional healers included continuity of care and a belief in their effectiveness. Traditional healer utilization rates (0.02 visits per month) were considerably lower compared to utilization rates of public sector clinics (0.18 visits per month) or hospitals (0.09 visits per month). Almost three-quarters of the poorest quintile spent more than 10 per cent of their household expenditure in the previous month on traditional healers. Given the use of two parallel health-care systems, policy-makers should develop strategies to protect poor South Africans from out-of-pocket payments for health care. Simultaneous utilization of these systems evidently absorbs expenditure from low-income households significantly.

Outreach services to improve access to health care in South Africa: lessons from three community health worker programmes

INTRODUCTION In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care. METHODS The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care. RESULTS The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care. CONCLUSION Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.Introduction : In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care. Methods : The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care. Results : The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care. Conclusion : Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.

Assessment of capacity for Health Policy and Systems Research and Analysis in seven African universities: results from the CHEPSAA project

The importance of health policy and systems research and analysis (HPSR+A) is widely recognized. Universities are central to strengthening and sustaining the HPSR+A capacity as they teach the next generation of decision-makers and health professionals. However, little is known about the capacity of universities, specifically, to develop the field. In this article, we report results of capacity self- assessments by seven universities within five African countries, conducted through the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA). The capacity assessments focused on both capacity ‘assets’ and ‘needs’, and covered the wider context, as well as organizational and individual capacity levels. Six thematic areas of capacity were examined: leadership and governance, organizations’ resources, scope of HPSR+A teaching and research, communication, networking and getting research into policy and practice (GRIPP), demand for HPRS+A and resource environment. The self-assessments by each university used combinations of document reviews, semi-structured interviews and staff surveys, followed by comparative analysis. A framework approach, guided by the six thematic areas, was used to analyse data. We found that HPSR+A is an international priority, and an existing activity in Africa, though still neglected field with challenges including its reliance on unpredictable international funding. All universities have capacity assets, such as ongoing HPSR+A teaching and research. There are, however, varying levels of assets (such as differences in staff numbers, group sizes and amount of HPSR+A teaching and research), which, combined with different capacity needs at all three levels (such as individual training, improvement in systems for quality assurance and fostering demand for HPSR+A work), can shape a future agenda for HPSR+A capacity strengthening. Capacity assets and needs at different levels appear related. Possible integrated strategies for strengthening universities’ capacity include: refining HPSR+A vision, mainstreaming the subject into under- and post-graduate teaching, developing emerging leaders and aligning HPSR+A capacity strengthening within the wider organizational development.

Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa.

Recent global crises have brought into sharp relief the absolute necessity of resilient health systems that can recognise and react to societal crises. While such crises focus the global mind, the real work lies, however, in being resilient in the face of routine, multiple challenges. But what are these challenges and what is the work of nurturing everyday resilience in health systems? This paper considers these questions, drawing on long-term, primarily qualitative research conducted in three different district health system settings in Kenya and South Africa, and adopting principles from case study research methodology and meta-synthesis in its analytic approach. The paper presents evidence of the instability and daily disruptions managed at the front lines of the district health system. These include patient complaints, unpredictable staff, compliance demands, organisational instability linked to decentralisation processes and frequently changing, and sometimes unclear, policy imperatives. The paper also identifies managerial responses to these challenges and assesses whether or not they indicate everyday resilience, using two conceptual lenses. From this analysis, we suggest that such resilience seems to arise from the leadership offered by multiple managers, through a combination of strategies that become embedded in relationships and managerial routines, drawing on wider organisational capacities and resources. While stable governance structures and adequate resources do influence everyday resilience, they are not enough to sustain it. Instead, it appears important to nurture the power of leaders across every system to reframe challenges, strengthen their routine practices in ways that encourage mindful staff engagement, and develop social networks within and outside organisations. Further research can build on these insights to deepen understanding.

Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme

Background : In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives : This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods : Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africas nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results : Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion : Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.BACKGROUND In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. OBJECTIVES This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. METHODS Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africas nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. RESULTS Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. CONCLUSION Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.

Community health workers, recipients’ experiences and constraints to care in South Africa – a pathway to trust

ABSTRACT Community health workers (CHWs) affiliated with community-based organisations are central to the implementation of primary health care in district health services in South Africa. Here, we explore factors that affect the provision of and access to care in two provinces – Gauteng and Eastern Cape. Drawing on narratives of care recipients and the CHWs who support them, we illustrate the complex issues surrounding health maintenance and primary care outreach in poor communities, and describe how the intimate interactions between providers and recipients work to build trust. In the study we report here, householders in Gauteng Province had poor access to health care and other services, complicating the impoverished circumstances of their everyday lives. The limited resources available to CHWs hindered their ability to meet householders’ needs and for householders to benefit from existing services. CHWs in the Eastern Cape were better able to address the needs of poor householders because of the organisational support available to them. Based on an ethos of integrated and holistic care, this enabled the CHWs to address the recipients’ context-related needs, and health and medical needs, while building greater levels of trust with their clients.

Social solidarity and civil servants’ willingness for financial cross-subsidization in South Africa: Implications for health financing reform

In South Africa, anticipated health sector reforms aim to achieve universal health coverage for all citizens. Success will depend on social solidarity and willingness to pay for health care according to means, while benefitting on the basis of their need. In this study, we interviewed 1330 health and education sector civil servants in four South African provinces, about potential income cross-subsidies and financing mechanisms for a National Health Insurance. One third was willing to cross-subsidize others and half favored a progressive financing system, with senior managers, black Africans, or those with tertiary education more likely to choose these options than lower-skilled staff, white, Indian or Asian respondents, or those with primary or less education. Insurance- and health-status were not associated with willingness to pay or preferred type of financing system. Understanding social relationships, identities, and shared meanings is important for any reform striving toward universal coverage.

Strengthening post-graduate educational capacity for health policy and systems research and analysis: the strategy of the Consortium for Health Policy and Systems Analysis in Africa.

BackgroundThe last 5–10 years have seen significant international momentum build around the field of health policy and systems research and analysis (HPSR + A). Strengthening post-graduate teaching is seen as central to the further development of this field in low- and middle-income countries. However, thus far, there has been little reflection on and documentation of what is taught in this field, how teaching is carried out, educators’ challenges and what future teaching might look like.MethodsContributing to such reflection and documentation, this paper reports on a situation analysis and inventory of HPSR + A post-graduate teaching conducted among the 11 African and European partners of the Consortium for Health Policy and Systems Analysis in Africa (CHEPSAA), a capacity development collaboration. A first questionnaire completed by the partners collected information on organisational teaching contexts, while a second collected information on 104 individual courses (more in-depth information was subsequently collected on 17 of the courses). The questionnaires yielded a mix of qualitative and quantitative data, which were analysed through counts, cross-tabulations, and the inductive grouping of material into themes. In addition, this paper draws information from internal reports on CHEPSAA’s activities, as well as its external evaluation.ResultsThe analysis highlighted the fluid boundaries of HPSR + A and the range and variability of the courses addressing the field, the important, though not exclusive, role of schools of public health in teaching relevant material, large variations in the time investments required to complete courses, the diversity of student target audiences, the limited availability of distance and non-classroom learning activities, and the continued importance of old-fashioned teaching styles and activities.ConclusionsThis paper argues that in order to improve post-graduate teaching and continue to build the field of HPSR + A, key questions need to be addressed around educational practice issues such as the time allocated for HPSR + A courses, teaching activities, and assessments, whether HPSR + A should be taught as a cross-cutting theme in post-graduate degrees or an area of specialisation, and the organisation of teaching given the multi-disciplinary nature of the field. It ends by describing some of CHEPSAA’s key post-graduate teaching development activities and how these activities have addressed the key questions.

Leadership and governance of community health worker programmes at scale: a cross case analysis of provincial implementation in South Africa

BackgroundNational community health worker (CHW) programmes are returning to favour as an integral part of primary health care systems, often on the back of pre-existing community based initiatives. There are significant challenges to the integration and support of such programmes, and they require coordination and stewardship at all levels of the health system. This paper explores the leadership and governance tasks of large-scale CHW programmes at sub-national level, through the case of national reforms to South Africa’s community based sector, referred to as the Ward Based Outreach Team (WBOT) strategy.MethodsA cross case analysis of leadership and governance roles, drawing on three case studies of adoption and implementation of the WBOTs strategy at provincial level (Western Cape, North West and Gauteng) was conducted. The primary case studies mapped system components and assessed implementation processes and contexts. They involved teams of researchers and over 200 interviews with stakeholders from senior to frontline, document reviews and analyses of routine data. The secondary, cross case analysis specifically focused on the issues and challenges facing, and strategies adopted by provincial and district policy makers and managers, as they engaged with the new national mandate. From this key sub-national leadership and governance roles were formulated.ResultsFour key roles are identified and discussed:1.Negotiating a fit between national mandates and provincial and district histories and strategies of community based services2.Defining new organisational and accountability relationships between CHWs, local health services, communities and NGOs3.Revising and developing new aligned and integrated planning, human resource, financing and information systems4.Leading change by building new collective visions, mobilising political, including budgetary, support and designing implementation strategies.ConclusionsThis analysis, from real-life systems, adds to understanding of the processes involved in developing CHW programmes at scale, and specifically the negotiated and multilevel nature of leadership and governance in such programmes, spanning analytic, managerial, technical and political roles.