Rebecca Surender

The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme.

Abstract Objectives: To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practices and to contrast these with changes occurring in similar nonfundholding practices. Design: Prospective observational study. Setting: Oxford region fundholding study. Subjects: Eight first wave fundholding practices and five practices that were not interested in fundholding in 1990-1, which were similar in terms of practice size, training status, locality, and urban rural mix. Three of the fundholding and none of the non-fundholding practices were dispensing practices. Main outcome measures: Changes in prescribing practice as measured by net cost per prescribing unit, cost per item, number of items prescribed, and substitution rates for generic drugs three years after the introduction of fundholding. Data for fundholding practices were analysed separately according to whether they were dispensing or non-dispensing practices. Results: Prescribing costs rose by a third or more in all types of practice. The patterns of change observed in this cohort after one year of fundholding were reversed. No evidence existed that fundholding had controlled prescribing costs among non-dispensing fundholders; costs among dispensing fundholders rose least, but the differences were small compared with the overall increase in costs. Conclusions: Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study.

A global call for action to include gender in research impact assessment

Global investment in biomedical research has grown significantly over the last decades, reaching approximately a quarter of a trillion US dollars in 2010. However, not all of this investment is distributed evenly by gender. It follows, arguably, that scarce research resources may not be optimally invested (by either not supporting the best science or by failing to investigate topics that benefit women and men equitably). Women across the world tend to be significantly underrepresented in research both as researchers and research participants, receive less research funding, and appear less frequently than men as authors on research publications. There is also some evidence that women are relatively disadvantaged as the beneficiaries of research, in terms of its health, societal and economic impacts. Historical gender biases may have created a path dependency that means that the research system and the impacts of research are biased towards male researchers and male beneficiaries, making it inherently difficult (though not impossible) to eliminate gender bias. In this commentary, we – a group of scholars and practitioners from Africa, America, Asia and Europe – argue that gender-sensitive research impact assessment could become a force for good in moving science policy and practice towards gender equity. Research impact assessment is the multidisciplinary field of scientific inquiry that examines the research process to maximise scientific, societal and economic returns on investment in research. It encompasses many theoretical and methodological approaches that can be used to investigate gender bias and recommend actions for change to maximise research impact. We offer a set of recommendations to research funders, research institutions and research evaluators who conduct impact assessment on how to include and strengthen analysis of gender equity in research impact assessment and issue a global call for action.

Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial.

BackgroundEffective use of proven treatments for high blood pressure, a preventable health risk, is challenging for many patients. Prompts via mobile phone SMS-text messaging may improve adherence to clinic visits and treatment, though more research is needed on impact and patient perceptions of such support interventions, especially in low-resource settings.MethodAn individually-randomised controlled trial in a primary care clinic in Cape Town (2012–14), tested the effect of an adherence support intervention delivered via SMS-texts, on blood pressure control and adherence to medication, for hypertensive patients. (Trial registration: ClinicalTrials.gov NCT02019823). We report on a qualitative evaluation that explored the trial participants’ experiences and responses to the SMS-text messages, and identified barriers and facilitators to delivering adherence support via patients’ own mobile phones. Two focus groups and fifteen individual interviews were conducted. We used comparative and thematic analysis approaches to identify themes and triangulated our analysis amongst three researchers.ResultsMost participants were comfortable with the technology of using SMS-text messages. Messages were experienced as acceptable, relevant and useful to a broad range of participants. The SMS-content, the respectful tone and the delivery (timing of reminders and frequency) and the relational aspect of trial participation (feeling cared for) were all highly valued. A subgroup who benefitted the most, were those who had been struggling with adherence due to high levels of personal stress. The intervention appeared to coincide with their readiness for change, and provided practical and emotional support for improving adherence behaviour. Change may have been facilitated through increased acknowledgement of their health status and attitudinal change towards greater self-responsibility. Complex interaction of psycho-social stressors and health service problems were reported as broader challenges to adherence behaviours.ConclusionAdherence support for treatment of raised blood pressure, delivered via SMS-text message on the patient’s own phone, was found to be acceptable, relevant and helpful, even for those who already had their own reminder systems in place. Our findings begin to identify for whom and what core elements of the SMS-text message intervention appear to work best in a low-resource operational setting, issues that future research should explore in greater depth.

Improving the food environment in UK schools: Policy opportunities and challenges

AbstractChildhood obesity and nutrition are high on the UK policy agenda because of their association with chronic illnesses and related costs. In 2007, to improve childrens nutrition, the Government introduced new standards for all school food sources, including products sold from vending machines. Our research explores the factors influencing schools’ decisions and childrens food choices in relation to vending machines. We conducted in-depth interviews with staff and pupils in one English Local Education Authority. We found that pupils made food decisions based on cost considerations, and convenience, and they strongly valued individual choice. Schools’ decisions to provide vending were influenced predominantly by fiscal and structural constraints. Although unhappy with the current quality of school food, staff and pupils criticised initiatives to restrict unhealthy foods. It appears that achieving a healthier school environment is a long-term project involving multiple strategies of education and incentives, as well as regulation. These must involve parents as well as pupils and schools.

Social policy in a developing world

Contents: PART I: CONTEXTS AND CONCEPTUAL FRAMEWORKS 1. Introduction Rebecca Surender 2. The Role of Historical Contexts in Shaping Social Policy in the Global South Rebecca Surender PART II: INSTITUTIONS AND ACTORS 3. The Role of the World Bank and the International Monetary Fund in Poverty Reduction: Limits of Policy Change Antje Vetterlein 4. Building the Welfare Mix or Sidelining the State? Non-Governmental Organisations in Developing Countries as Social l Policy Actors David Lewis 5. The Informal Economy: Dilemmas and Policy Responses Sony Pellissery 6. Addressing the Failings of Public Health Systems: Should the Private Sector be an Instrument of Choice? Jane Doherty and Di McIntyre PART III: INSTRUMENTS AND MECHANISMS 7. Social Security: Risks, Needs and Protection Robert Walker 8. The Implications of Conditionality in Social Assistance Programmes Paul Dornan and Catherine Porter 9. Work and Welfare in the Global South: Public Works Programmes as an Instrument of Social Policy Anna McCord and Charles Meth 10. The Social Entrepreneurship-Social Policy Nexus in Developing Countries Alex Nicholls PART IV: SCENARIOS AND TRAJECTORIES 11. Globalisation and Social Policy in Developing Countries Bob Deacon 12. South - South Cooperation: A New Paradigm for Global Social Policy? Rebecca Surender and Marian Urbina 13. Conclusion: Towards the Analysis of Social Policy in a Developing World Robert Walker Index

Why do families still not receive the child support grant in South Africa? A longitudinal analysis of a cohort of families across South Africa

BackgroundChild cash transfers are increasingly recognised for their potential to reduce poverty and improve health outcomes. South Africa‘s child support grant (CSG) constitutes the largest cash transfer in the continent. No studies have been conducted to look at factors associated with successful receipt of the CSG. This paper reports findings on factors associated with CSG receipt in three settings in South Africa (Paarl in the Western Cape Province, and Umlazi and Rietvlei in KwaZulu-Natal).MethodsThis study used longitudinal data from a community-based cluster-randomized trial (PROMISE EBF) promoting exclusive breastfeeding by peer-counsellors in South Africa (ClinicalTrials.gov: NCT00397150). 1148 mother-infant pairs were enrolled in the study and data on the CSG were collected at infant age 6, 12, 24 weeks and 18–24 months. A stratified cox proportional hazards regression model was fitted to the data to investigate factors associated with CSG receipt.ResultsUptake of the CSG amongst eligible children at a median age of 22 months was 62% in Paarl, 64% in Rietvlei and 60% in Umlazi. Possessing a birth certificate was found to be the strongest predictor of CSG receipt (HR 3.1, 95% CI: 2.4 -4.1). Other factors also found to be independently associated with CSG receipt were an HIV-positive mother (HR 1.2, 95% CI: 1.0-1.4) and a household income below R1100 (HR1.7, 95% CI: 1.1 -2.6).ConclusionReceipt of the CSG was sub optimal amongst eligible children showing administrative requirements such as possessing a birth certificate to be a serious barrier to access. In the spirit of promoting and protecting children’s rights, more efforts are needed to improve and ease access to this cash transfer program.

Social policy in the context of new global actors: How far is China’s developmental model in Africa impacting traditional donors?

China’s role as an emerging donor and its conceptualization of social policy in Africa has generated polarized reactions in the West. Many argue its ‘productivist’ approach is driven less by notions of citizenship and social rights, and more in terms of accumulation functions. Social investment is justified for broader economic development goals in contrast to current safety-net or ‘welfarist’ models of Western donors. While some international organizations perceive the Chinese approach as antithetical to Western goals and practice, others welcome it as an opportunity to develop new ideas about social development.This qualitative research explores to what extent and in which direction Chinese aid to Africa is influencing Western ideas about welfare policy in developing countries. The study comprises a systematic review of Sino-African and Western policy documents and in-depth interviews with senior Chinese, Western and African stakeholders. It investigates how social policy is conceptualized by those involved in Chinese aid to Africa, to what extent this differs from traditional Western approaches, and what it means for Western social development policy. The implications for understanding the drivers of global policy development and links between the economic and social dimensions of welfare are explored.

The Drivers of Universal Health Care in South Africa: The Role of Ideas, Actors and Institutions

This chapter examines the opportunities and challenges entailed by the recently proposed National Health Insurance (NHI) reforms in South Africa. It discusses what NHI is trying to achieve within the context of the country’s current two-tiered health system and how it hopes to address existing problems, before examining the political, institutional and implementation challenges the reforms will face. While most attention has been thus far devoted to the structural requirements and fiscal affordability of universal coverage, this chapter highlights attention on wider challenges—in particular the important role played by key stakeholders tasked with implementing the reforms.

The experience of cash transfers in alleviating childhood poverty in South Africa: Mothers' experiences of the Child Support Grant

Cash transfer (CT) programmes are increasingly being used as policy instruments to address child poverty and child health outcomes in developing countries. As the largest cash-transfer programme in Africa, the South African Child Support Grant (CSG) provides an important opportunity to further understand how a CT of its kind works in a developing country context. We explored the experiences and views of CSG recipients and non-recipients from four diverse settings in South Africa. Four major themes emerged from the data: barriers to accessing the CSG; how the CSG is utilised and the ways in which it makes a difference; the mechanisms for supplementing the CSG; and the impact of not receiving the grant. Findings show that administrative factors continue to be the greatest barrier to CSG receipt, pointing to the need for further improvements in managing queues, waiting times and coordination between departments for applicants trying to submit their applications. Many recipients, especially those where the grant was the only source of income, acknowledged the importance of the CSG, while also emphasising its inadequacy. To maximise their impact, CT programmes such as the CSG need to be fully funded and form part of a broader basket of poverty alleviation strategies.

‘To be a woman is to make a plan’: a qualitative study exploring mothers’ experiences of the Child Support Grant in supporting children’s diets and nutrition in South Africa

Food security and good nutrition are key determinants of child well-being. There is strong evidence that cash transfers such as South Africa’s Child Support Grant (CSG) have the potential to help address some of the underlying drivers of food insecurity and malnutrition by providing income to caregivers in poor households, but it is unclear how precisely they work to affect child well-being and nutrition. We present results from a qualitative study conducted to explore the role of the CSG in food security and child well-being in poor households in an urban and a rural setting in South Africa. Setting Mt Frere, Eastern Cape (rural area); Langa, Western Cape (urban township). Participants CSG recipient caregivers and community members in the two sites . We conducted a total of 40 in-depth interviews with mothers or primary caregivers in receipt of the CSG for children under the age of 5 years. In addition, five focus group discussions with approximately eight members per group were conducted. Data were analysed using manifest and latent thematic content analysis methods. Results The CSG is too small on its own to improve child nutrition and well-being. Providing for children’s diets and nutrition competes with other priorities that are equally important for child well-being and nutrition. Conclusions In addition to raising the value of the CSG so that it is linked to the cost of a nutritious basket of food, more emphasis should be placed on parallel structural solutions that are vital for good child nutrition outcomes and well-being, such as access to free quality early child development services that provide adequate nutritious meals, access to adequate basic services and the promotion of appropriate feeding, hygiene and care practices.