Zoë M. McLaren

Distance decay and persistent health care disparities in South Africa

BackgroundAccess to health care is a particular concern given the important role of poor access in perpetuating poverty and inequality. South Africa’s apartheid history leaves large racial disparities in access despite post-apartheid health policy to increase the number of health facilities, even in remote rural areas. However, even when health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer health.MethodsUsing newly available health care utilization data from the first nationally representative panel survey in South Africa, together with administrative geographic data from the Department of Health, we use graphical and multivariate regression analysis to investigate the role of distance to the nearest facility on the likelihood of having a health consultation or an attended birth.ResultsNinety percent of South Africans live within 7 km of the nearest public clinic, and two-thirds live less than 2 km away. However, 14% of Black African adults live more than 5 km from the nearest facility, compared to only 4% of Whites, and they are 16 percentage points less likely to report a recent health consultation (p < 0.01) and 47 percentage points less likely to use private facilities (p < 0.01). Respondents in the poorest income quintiles live 0.5 to 0.75 km further from the nearest health facility (p < 0.01). Racial differentials in the likelihood of having a health consultation or an attended birth persist even after controlling for confounders.ConclusionsOur results have two policy implications: minimizing the distance that poor South Africans must travel to obtain health care and improving the quality of care provided in poorer areas will reduce inequality. Much has been done to redress disparities in South Africa since the end of apartheid but progress is still needed to achieve equity in health care access.

Understanding the relationship between access to care and facility-based delivery through analysis of the 2008 Ghana Demographic Health Survey

To determine the types of access to care most strongly associated with facility‐based delivery among women in Ghana.

Does directly observed therapy improve tuberculosis treatment? More evidence is needed to guide tuberculosis policy

BackgroundTuberculosis (TB) now ranks alongside HIV as the leading infectious disease cause of death worldwide and incurs a global economic burden of over

Gender patterns of tuberculosis testing and disease in South Africa.

12 billion annually. Directly observed therapy (DOT) recommends that TB patients complete the course of treatment under direct observation of a treatment supporter who is trained and overseen by health services to ensure that patients take their drugs as scheduled. Though the current WHO End TB Strategy does not mention DOT, only “supportive treatment supervision by treatment partners”, many TB programs still use it despite the fact that the has not been demonstrated to be statistically significantly superior to self-administered treatment in ensuring treatment success or cure.DiscussionDOT is designed to promote proper adherence to the full course of drug therapy in order to improve patient outcomes and prevent the development of drug resistance. Yet over 8 billion dollars is spent on TB treatment each year and thousands undergo DOT for all or part of their course of treatment, despite the absence of rigorous evidence supporting the superior effectiveness of DOT over self-administration for achieving drug susceptible TB (DS-TB) cure. Moreover, the DOT component burdens patients with financial and opportunity costs, and the potential for intensified stigma.To rigorously evaluate the effectiveness of DOT and identify the essential contributors to both successful treatment and minimized patient burden, we call for a pragmatic experimental trial conducted in real-world program settings, the gold standard for evidence-based health policy decisions. It is time to invest in the rigorous evaluation of DOT and reevaluate the DOT requirement for TB treatment worldwide.SummaryRigorously evaluating the choice of treatment supporter, the frequency of health care worker contact and the development of new educational materials in a real-world setting would build the evidence base to inform the optimal design of TB treatment protocol. Implementing a more patient-centered approach may be a wise reallocation of resources to raise TB cure rates, prevent relapse, and minimize the emergence of drug resistance. Maintaining the status quo in the absence of rigorous supportive evidence may diminish the effectiveness of TB control policies in the long run.

Equity in the national rollout of public AIDS treatment in South Africa 2004–08

SETTING In South Africa, tuberculosis (TB) has been the leading cause of death for over a decade. The TB incidence rate is the second highest in the world, and continues to rise. OBJECTIVE To examine gender patterns in South Africas TB epidemic. This is one of the first studies to use National Health Laboratory Service (NHLS) data to evaluate the epidemic at the national level. DESIGN Observational study using NHLS retrospective data for every TB test performed in public health facilities between 2009 and 2011. RESULTS Despite an increase in the number of TB tests performed, the number of TB cases remained relatively constant. Although prevalence rates differ between health districts, we find a similar female-to-male ratio (0.70) in each district. The age profile for TB resembles that of human immunodeficiency virus (HIV), with peak TB prevalence in women occurring 7 years earlier than in men. The female-to-male ratio of TB cases and 3+ positive (severe) cases decreases rapidly between ages 25 and 35 years. CONCLUSION These age and gender patterns are driven by the HIV epidemic and risks associated with pregnancy and childbearing. Increasing the quality and quantity of active TB case finding at existing points of care would be a sustainable and cost-effective intervention for both treatment and prevention.

Assessing healthcare quality using routine data: evaluating the performance of the national tuberculosis programme in South Africa

Low- and middle-income country governments face the challenge of ensuring an equitable distribution of public resources, based on need rather than socioeconomic status, race or political affiliation. This study examines factors that may influence public service provision in developing countries by analysing the 2004-08 implementation of government-provided AIDS treatment in South Africa, the largest programme of its kind in the world. Despite assurances from the National Department of Health, some have raised concerns about whether the rollout was in fact conducted equitably. This study addresses these concerns. This is the first study to assemble high-quality national data on a broad set of census main place (CMP) characteristics that the public health, economic and political science literature have found influence public service provision. Multivariate logistic regression and duration (survival) analysis were used to identify characteristics associated with a more rapid public provision of anti-retroviral therapy (ART) in South Africa. Overall, no clear pattern emerges of the rollout systematically favouring better-off CMPs, and in general the magnitude of statistically significant associations is small. The centralization of the early phases of the rollout to maximize ART enrolment led to higher ART coverage rates in areas where district and regional hospitals were located. Ultimately, these results demonstrate that the provision of life-saving AIDS treatment was not disproportionately delayed in disadvantaged areas. The combination of a clear policy objective, limited bureaucratic discretion and monitoring by civil society ensured equitable access to AIDS treatment. This work highlights the potential for future public investment in South Africa and other developing countries to reduce health and economic disparities.

A Data-Driven Evaluation of the Stop TB Global Partnership Strategy of Targeting Key Populations at Greater Risk for Tuberculosis

To assess the performance of healthcare facilities by means of indicators based on guidelines for clinical care of TB, which is likely a good measure of overall facility quality.

Do Incarcerated Populations Serve as a Reservoir for Tuberculosis in South Africa

Objective Identifying those infected with tuberculosis (TB) is an important component of any strategy for reducing TB transmission and population prevalence. The Stop TB Global Partnership recently launched an initiative with a focus on key populations at greater risk for TB infection or poor clinical outcomes, due to housing and working conditions, incarceration, low household income, malnutrition, co-morbidities, exposure to tobacco and silica dust, or barriers to accessing medical care. To achieve operational targets, the global health community needs effective, low cost, and large-scale strategies for identifying key populations. Using South Africa as a test case, we assess the feasibility and effectiveness of targeting active case finding to populations with TB risk factors identified from regularly collected sources of data. Our approach is applicable to all countries with TB testing and census data. It allows countries to tailor their outreach activities to the particular risk factors of greatest significance in their national context. Methods We use a national database of TB test results to estimate municipality-level TB infection prevalence, and link it to Census data to measure population risk factors for TB including rates of urban households, informal settlements, household income, unemployment, and mobile phone ownership. To examine the relationship between TB prevalence and risk factors, we perform linear regression analysis and plot the set of population characteristics against TB prevalence and TB testing rate by municipality. We overlay lines of best fit and smoothed curves of best fit from locally weighted scatter plot smoothing. Findings Higher TB prevalence is statistically significantly associated with more urban municipalities (slope coefficient β1 = 0.129, p < 0.0001, R2 = 0.133), lower mobile phone access (β1 = -0.053, p < 0.001, R2 = 0.089), lower unemployment rates (β1 = -0.020, p = 0.003, R2 = 0.048), and a lower proportion of low-income households (β1 = -0.048, p < 0.0001, R2 = 0.084). Municipalities with more low-income households also have marginally higher TB testing rates, however, this association is not statistically significant (β1 = -0.025, p = 0.676, R2 = 0.001). There is no relationship between TB prevalence and the proportion of informal settlement households (β1 = 0.021, p = 0.136, R2 = 0.014). Conclusions These analyses reveal that the set of characteristics identified by the Global Plan as defining key populations do not adequately predict populations with high TB burden. For example, we find that higher TB prevalence is correlated with more urbanized municipalities but not with informal settlements. We highlight several factors that are counter-intuitively those most associated with high TB burdens and which should therefore play a large role in any effective targeting strategy. Targeting active case finding to key populations at higher risk of infection or poor clinical outcomes may prove more cost effective than broad efforts. However, these results should increase caution in current targeting of active case finding interventions.

The Impact of Acquired Immune Deficiency Syndrome Treatment on Tuberculosis Detection at the National Level in South Africa

Tuberculosis (TB) prevalence among incarcerated populations is as much as 1,000 times higher than in the general population. This study evaluates whether correctional facilities serve as a reservoir through which TB is transmitted to surrounding communities. Tuberculosis test data were extracted from the South African National Health Laboratory Service database for patients tested for TB between 2005 and 2011. We conducted graphical analysis to assess the relationship of TB rates between incarcerated and non-incarcerated populations over time. We performed generalized linear modeling with a log link function to assess TB risk in communities surrounding correctional facilities, net of confounders. We assessed linkages between incarcerated and non-incarcerated populations over time using Granger causality analysis. Tuberculosis prevalence among incarcerated populations was four times higher than in the general population. Tuberculosis incidence rates in incarcerated and non-incarcerated populations followed similar trends over time. The presence of a correctional facility in a municipality was associated with 34.9% more detected TB cases (confidence interval: 11.6-63.2; P < 0.01), controlling for potential confounders. Detected TB in incarcerated populations did not have predictive power in explaining detected TB rates in the non-incarcerated population after controlling for serial correlation in the time series data. Despite high TB prevalence, trends in correctional facilities do not appear to be driving temporal trends in the general population. However, correctional facilities still act as a TB reservoir that raises the overall TB risk in the vicinity. Intensified TB control policies for correctional facilities, formerly incarcerated individuals, and surrounding communities will reduce TB prevalence overall.

Does Family Planning Increase Children’s Opportunities? Evidence from the War on Poverty and the Early Years of Title X

Human immunodeficiency virus/tuberculosis (HIV/TB) coinfection is particularly prevalent in South Africa, where TB has been the leading cause of death for more than a decade. The 2004-2008 national rollout of antiretroviral therapy (ART) provides a unique opportunity to examine the population-level impact of ART on the TB epidemic. We performed longitudinal regression analysis to follow the evolution of TB outcomes before and after the introduction of ART using a large data set from the National Health Laboratory Service. This is the first study to produce estimates of the impact of the ART rollout by exploiting staggered timing and geographic variation in the rollout. After ART became available in a health facility, 3.7% (P < 0.0001) more patients were tested for TB and 3.2% (P < 0.0001) more received repeat testing; however, there was a steep rise in testing before the introduction of ART. Although the number of TB-positive patients increased by 4.3% (P = 0.0002) in the first year post-ART, the TB rate among tested patients fell by 2 percentage points (8%, P = 0.001) after 2 years. Sputum smear testing declined relative to more technologically advanced diagnostics post-ART. Antiretroviral therapy availability increased the attention to TB screening and drew new patients into the health-care system. Small increases in the numbers of repeat patients are indicative of retention in care. The decline in TB rates post-ART suggests that the reduction in TB risk due to improved immune functioning and health-care contact likely outweighed the increased TB risk because of the longer lifespan of ART initiators.