Vera Scott

Scaling up integration: development and results of a participatory assessment of HIV/TB services, South Africa

BackgroundIn South Africa the need to integrate HIV, TB and STI programmes has been recognised at a policy and organisation level; the challenge is now one of translating policies into relevant actions and monitoring implementation to ensure that the anticipated benefits of integration are achieved. In this research, set in public primary care services in Cape Town, South Africa, we set out to determine how middle level managers could be empowered to monitor the implementation of an effective, integrated HIV/TB/STI service.MethodsA team of managers and researchers designed an evaluation tool to measure implementation of key components of an integrated HIV/TB/STI package with a focus on integration. They used a comprehensive health systems framework based on conditions for programme effectiveness and then identified and collected tracer indicators. The tool was extensively piloted in two rounds involving 49 clinics in 2003 and 2004 to identify data necessary for effective facility-level management. A subsequent evaluation of 16 clinics (2 per health sub district, 12% of all public primary care facilities) was done in February 2006.Results16 clinics were reviewed and 635 records sampled. Client access to HIV/TB/STI programmes was limited in that 50% of facilities routinely deferred clients. Whilst the physical infrastructure and staff were available, there was problem with capacity in that there was insufficient staff training (for example, only 40% of clinical staff trained in HIV care). Weaknesses were identified in quality of care (for example, only 57% of HIV clients were staged in accordance with protocols) and continuity of care (for example, only 24% of VCT clients diagnosed with HIV were followed up for medical assessment). Facility and programme managers felt that the evaluation tool generated information that was useful to manage the programmes at facility and district level. On the basis of the results facility managers drew up action plans to address three areas of weakness within their own facility.ConclusionsThis use of the tool which is designed to empower programme and facility managers demonstrates how engaging middle managers is crucial in translating policies into relevant actions.

Between HIV diagnosis and initiation of antiretroviral therapy: assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa

Objective  To assess the quality of pre‐antiretroviral therapy (ART) care in Cape Town and its continuity with HIV counselling and testing (HCT) and ART.

Critiquing the response to the Ebola epidemic through a Primary Health Care Approach

BackgroundThe 2014/2015 West Africa Ebola epidemic has caused the global public health community to engage in difficult self-reflection. First, it must consider the part it played in relation to an important public health question: why did this epidemic take hold and spread in this unprecedented manner? Second, it must use the lessons learnt to answer the subsequent question: what can be done now to prevent further such outbreaks in the future? These questions remain relevant, even as scientists announce that the Guinea Phase III efficacy vaccine trial shows that rVSV-EBOV (Merck, Sharp & Dohme) is highly efficacious in individuals. This is a major breakthrough in the fight against Ebola virus disease (EVD). It does not replace but may be a powerful adjunct to current strategies of EVD management and control.DiscussionWe contribute to the current self-reflection by presenting an analysis using a Primary Health Care (PHC) approach. This approach is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in authorities and mobile populations, a broader approach is required to engage affected communities. In the medium-term health system development with attention to primary level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local management and an investment in human resources for health. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD.ConclusionThe PHC approach offers an insightful critique of the global and regional factors which have compromised the response of health systems in Guinea, Liberia and Sierra Leone as well as suggesting what a strengthened EVD response might involve in the short, medium and long-term.

Ebola epidemic exposes the pathology of the global economic and political system.

While the current Ebola epidemic spiraled out of control to become the biggest in history, the global public health response has been criticized as “too little, too late.” Many, like the World Health Organization, are asking what lessons have been learned from this epidemic. We present an analysis of the political economy of this Ebola outbreak that reveals the importance of addressing the social determinants that facilitated the exposure of populations, previously unaffected by Ebola Virus Disease, to infection and restricted the capacity for an effective medical response. To prevent further such crises, the global public health community has a responsibility to advocate for health system investment and development and for fundamental pro-poor changes to economic and power relations in the region.

Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal

SETTING Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate. Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal. METHODS A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. RESULTS We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days. CONCLUSION Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.

Integration of HIV prevention into sexual and reproductive health services in an urban setting in South Africa

Abstract Background The United Nations Political Declaration on HIV and AIDS of 2006 stressed the need to strengthen policy and programme linkages between HIV and Sexual and Reproductive Health (SRH). However, the effectiveness and best practices for strengthening SRH and HIV linkages are poorly researched in the context of family-planning services. In Cape Town, HIV-prevention services have been integrated into family-planning services. There are two models of service configuration: dedicated stand-alone reproductive health clinics and family-planning services located in comprehensive primary-care facilities. Objective To describe how reproductive health services are integrating HIV prevention and care strategies and to measure the coverage and quality of these integrated services. Methods A cross-sectional study was conducted using structured interviews with facility managers; a facility-based checklist; and a patient record review to assess the availability of resources, training, access, quality and integration. Results Facilities in Cape Town are equipped adequately to offer integrated HIV-prevention and SRH services. Overall there was poor coverage of integrated services with 54% of family-planning clients having a known HIV status; 47% being screened for a sexually transmitted infection and 55% being offered HIV counselling and testing and receiving condoms. Quality and continuity of care seemed better at the dedicated clinics than at the comprehensive facilities, supported by better training coverage. Conclusion Engaging middle-level management is crucial with regard to improving integration within a well-resourced setting.

Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers’ use of information in decision-making: experience from Cape Town, South Africa

BackgroundGovernance, which includes decision-making at all levels of the health system, and information have been identified as key, interacting levers of health system strengthening. However there is an extensive literature detailing the challenges of supporting health managers to use formal information from health information systems (HISs) in their decision-making. While health information needs differ across levels of the health system there has been surprisingly little empirical work considering what information is actually used by primary healthcare facility managers in managing, and making decisions about, service delivery. This paper, therefore, specifically examines experience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers’ use of information for decision-making influenced by governance across levels of the health system? The research is novel in that it both explores what information these facility managers actually use in decision-making, and considers how wider governance processes influence this information use.MethodsAn academic researcher and four facility managers worked as co-researchers in a multi-case study in which three areas of management were served as the cases. There were iterative cycles of data collection and collaborative analysis with individual and peer reflective learning over a period of three years.ResultsCentral governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based HIS which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the subdistrict level had influence over what information was valued, generated and used locally.ConclusionsStrengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.

Knowledge, attitude and practice study of HIV in female adolescents presenting for contraceptive services in a rural health district in the north-east of Namibia

Abstract Background Namibia bears a large burden of Human Immunodeficiency Virus (HIV), and the youth are disproportionately affected. Objectives To explore the current knowledge, attitudes and behaviour of female adolescents attending family planning to HIV prevention. Methods A cross-sectional study design was used on a sample 251 unmarried female adolescents aged from 13 years to 19 years accessing primary care services for contraception using an interviewer-administered questionnaire. Data were analysed using Epi Info 2002. Crude associations were assessed using cross-tabulations of knowledge, attitude and behaviour scores against demographic variables. Chi-square tests and odds ratios were used to assess associations from the cross-tabulations. All p-values < 0.05 were considered statistically significant. Results A quarter of sexually active teenagers attending the family-planning services did not have adequate knowledge of HIV prevention strategies. Less than a quarter (23.9%) always used a condom. Most respondents (83.3%) started sexual intercourse when older than 16 years, but only 38.6% used a condom at their sexual debut. The older the girls were at sexual debut, the more likely they were to use a condom for the event (8% did so at age 13 years and 100% at age 19 years). Conclusions Knowledge of condom use as an HIV prevention strategy did not translate into consistent condom use. One alternate approach in family-planning facilities may be to encourage condom use as a dual protection method. Delayed onset of sexual activity and consistent use of condoms should be encouraged amongst schoolchildren, in the school setting.

Enabling relational leadership in primary healthcare settings: lessons from the DIALHS collaboration

Abstract Strong management and leadership competencies have been identified as critical in enhancing health system performance. While the need for strong health system leadership has been raised, an important undertaking for health policy and systems researchers is to generate lessons about how to support leadership development (LD), particularly within the crisis-prone, resource poor contexts that are characteristic of Low- and Middle-Income health systems. As part of the broader DIALHS (District Innovation and Action Learning for Health Systems Development) collaboration, this article reflects on 5 years of action learning and engagement around leadership and LD within primary healthcare (PHC) services. Working in one sub-district in Cape Town, we co-created LD processes with managers from nine PHC facilities and with the six members of the sub-district management team. Within this article, we seek to provide insights into how leadership is currently practiced and to highlight lessons about whether and how our approach to LD enabled a strengthening of leadership within this setting. Findings suggest that the sub-district is located within a hierarchical governance context, with performance monitored through the use of multiple accountability mechanisms including standard operating procedures, facility audits and target setting processes. This context presents an important constraint to the development of a more distributed, relational leadership. While our data suggest that gains in leadership were emerging, our experience is of a system struggling to shift from a hierarchical to a more relational understanding of how to enable improvements in performance, and to implement these changes in practice.

You can treat my HIV – But can you treat my blood pressure? Availability of integrated HIV and non-communicable disease care in northern Malawi

Background Many patients on antiretroviral therapy (ART) in Malawi have or will develop non-communicable diseases (NCDs). The current capacity of ART sites to provide care for NCDs is not known. Aim This study aimed to assess the capacity of ART sites to provide care for hypertension and diabetes in rural Malawi. Setting Twenty-five health centres and five hospitals in two rural districts in northern Malawi. Methods A cross-sectional survey was performed between March and May 2014 at all facilities. Qualitative interviews were held with three NCD coordinators. Results Treatment of hypertension and diabetes was predominantly hospital-based. Sixty percent of hospitals had at least one clinician and one nurse trained in NCD care, whereas 5% of health centres had a clinician and 8% had a nurse trained in NCD care. Hundred percent of hospitals and 92% of health centres had uninterrupted supply of hydrochlorothiazide in the previous 6 months, but only 40% of hospitals and no health centres had uninterrupted supply of metformin. Hundred percent of hospitals and 80% of health centres had at least one blood pressure machine, and 80% of hospitals and 32% of health centres had one glucometer. Screening for hypertension amongst ART patients was only conducted at one hospital and no health centres. At health centres, integrated NCD and ART care was more common, with 48% (12/25) providing ART and NCD treatment in the same consultation. Conclusions The results reflect the status of the initial stages of the Malawi NCD programme at sites currently providing ART care.