... Also, given the centrality of PHC services to the health system, the possibility of ringfenci... more ... Also, given the centrality of PHC services to the health system, the possibility of ringfencing PHC funding in each province should be urgently considered. Read this article. For subscription and additional information please contact us on: ...
Background. An essential part of providing high-quality patient care and a means of efficiently c... more Background. An essential part of providing high-quality patient care and a means of efficiently conducting research studies relies upon high-quality routinely collected medical information. Objectives. To describe the registers, paper records and databases used in a sample of primary healthcare clinics in South Africa (SA) with the view to conduct an impact evaluation using routine data. Methods. Between October 2015 and December 2015, we collected information on the presence, quality and completeness of registers, clinical stationery and databases at 24 public health facilities in SA. We describe each register and type of clinical stationery we encountered, their primary uses, and the quality of completion. We also mapped the ideal flow of data through a site to better understand how its data collection works. Results. We identified 13 registers (9 standard, 4 non-standard), 5 types of stationery and 4 databases as sources of medical information within a site. Not all clinics used all the standardised registers, and in those that did, registers were kept in various degrees of completeness: a common problem was inconsistent recording of folder numbers. The quality of patient stationery was generally high, with only the chronic patient record being considered of varied quality. The TIER.Net database had high-quality information on key variables, but national identification (ID) number was incompletely captured (42% complete). Very few evaluation sites used electronic data collection systems for conditions other than HIV/AIDS. Conclusion. Registers, databases and clinical stationery were not implemented or completed consistently across the 24 evaluation sites. For those considering using routinely collected data for research and evaluation purposes, we would recommend a thorough review of clinic data collection systems for both quality and completeness before considering them to be a reliable data source.
Objectives To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pr... more Objectives To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts. Methods Retrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014-March 2017) and post-implementation period (April 2018-September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted timeseries analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation. Results Overall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (-0.09, 95% CI -1.18 to 0.01; p=0.059), early neonatal deaths (-0.09, 95% CI -0.14 to 0.04; p=<0.001) and perinatal mortality (-1.18, 95% CI -0.27 to -0.09; p<0.001) in the postimplementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34-38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002).
This paper attempts to document the successes and failures of the Department of Health during the... more This paper attempts to document the successes and failures of the Department of Health during the first 1,000 days of the Government of National Unity. The achievements of the Department are reflected against the backdrop of the legacies inherited by the current Ministry and Department.
Human resources for health (HRH) remains a critical challenge, according to the Kampala Declarati... more Human resources for health (HRH) remains a critical challenge, according to the Kampala Declaration and Agenda for Global Action of 2008 and the 2030 Sustainable Development Agenda. Available literature on health system reforms does not provide a detailed narrative on strategies that have been used to reform HRH challenges in peri-urban communities. This study explores such strategies implemented in Epworth, Zimbabwe, during 2009ร2014, and the implications these strategies might have on other peri-urban areas. Design: Qualitative and quantitative methods were used in an exploratory and cross-sectional design. Purposive sampling was used to select key informants, a sample of healthcare workers that participated in in-depth interviews and community members who took part in focus group discussions. Secondary data were collected through a documentary search. Qualitative data were analysed through thematic analysis. Quantitative secondary data were examined using descriptive statistics and then compared with qualitative data to reinforce analysis. Results: The HRH reform policy strategies that were identified included ministerial intervention; policy review; and revival of the human resource for health planning, financial planning, multi-sector collaboration, and community engagement. These had some positive effects; however, desired outcomes were undermined by financial, material, human resource, and social constraints. Conclusions: Despite constraints, the strategies helped revive the health delivery system in Epworth. In turn, this had a favourable outlook on post-2008 efforts by the Global Health Alliance towards healthcare worker reform and the 2030 Sustainable Development Agenda in peri-urban communities.
We thank the participants in the Consultation for sharing their time and expertise. Special thank... more We thank the participants in the Consultation for sharing their time and expertise. Special thanks also to Tim Sladden for providing feedback. Financial support for the consultation from the Special Programme for Human Reproduction funded by the United Nations Development Programme, United Nations Population Fund, UNICEF, WHO, and World Bank is gratefully acknowledged. The contents are the responsibility of the authors and do not necessarily reflect the views of the World Health Organization.
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Background. ... more This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Background. Many people living with HIV in South Africa (SA) are not aware of their seropositive status and are diagnosed late during the course of HIV infection. These individuals do not obtain the full benefit from available HIV care and treatment services. Objectives. To describe the prevalence of late presentation for HIV care among newly diagnosed HIV-positive individuals and evaluate sociodemographic variables associated with late presentation for HIV care in three high-burden districts of SA. Methods. We used data abstracted from records of 8 138 newly diagnosed HIV-positive individuals in 35 clinics between 1 June 2014 and 31 March 2015 to determine the prevalence of late presentation among newly diagnosed HIV-positive individuals in selected highprevalence health districts. Individuals were categorised as 'moderately late' , 'very late' or 'extremely late' presenters based on specified criteria. Descriptive analysis was performed to measure the prevalence of late presentation, and multivariate regression analysis was conducted to identify variables independently associated with extremely late presentation. Results. Overall, 79% of the newly diagnosed cases presented for HIV care late in the course of HIV infection (CD4+ count โค500 cells/ ยตL and/or AIDS-defining illness in World Health Organization (WHO) stage III/IV), 19% presented moderately late (CD4+ count 351 -500 cells/ยตL and WHO clinical stage I or II), 27% presented very late (CD4+ count 201 -350 cells/ยตL or WHO clinical stage III), and 33% presented extremely late (CD4+ count โค200 cells/ยตL and/or WHO clinical stage IV) for HIV care. Multivariate regression analysis indicated that males, non-pregnant women, individuals aged >30 years, and those accessing care in facilities located in townships and inner cities were more likely to present late for HIV care. Conclusions. The majority of newly diagnosed HIV-positive individuals in the three high-burden districts (Gert Sibande, uThukela and City of Johannesburg) presented for HIV care late in the course of HIV infection. Interventions that encourage early presentation for HIV care should be prioritised in SA and should target males, non-pregnant women, individuals aged >30 years and those accessing care in facilities located in inner cities and urban townships.
The recent release of the South Africa Human Rights Commission's report on the status of mental h... more The recent release of the South Africa Human Rights Commission's report on the status of mental health services on 28 March 2019 should cause all of us to pause and reflect on what needs to be done to provide quality, rights-based mental health services for the people of South Africa. A blog in the South African College of Applied Psychology (2018) website entitled 'The shocking state of mental health in South Africa in 2018' noted the following: The global burden of disease attributable to mental disorders has risen in all countries in the context of major demographic, environmental, and socio-political transitions. Human rights violations and abuses
Background: We characterize engagement with HIV care in South Africa in 2012 to identify areas fo... more Background: We characterize engagement with HIV care in South Africa in 2012 to identify areas for improvement towards achieving global 90-90-90 targets. Methods: Over 3.9 million CD4 รพ cell count and 2.7 million viral load measurements reported in 2012 in the public sector were extracted from the national laboratory electronic database. The number of persons living with HIV (PLHIV), number and proportion in HIV care, on antiretroviral therapy (ART) and with viral suppression (viral load <400 copies/ml) were estimated and stratified by sex and age group. Modified Poisson regression approach was used to examine associations between sex, age group and viral suppression among persons on ART. Results: We estimate that among 6511 000 PLHIV in South Africa in 2012, 3300 000 individuals (50.7%) accessed care and 32.9% received ART. Although viral suppression was 73.7% among the treated population in 2012, the overall percentage of persons with viral suppression among all PLHIV was 23.8%. Linkage to HIV care was lower among men (38.5%) than among women (57.2%). Overall, 47.1% of those aged 0-14 years and 47.0% of those aged 15-49 years were linked to care compared with 56.2% among those aged above 50 years. Around a quarter of all PLHIV have achieved viral suppression in South Africa. Men and younger persons have poorer linkage to HIV care. Expanding HIV testing, strengthening prompt linkage to care and further expansion of ART are needed for South Africa to reach the 90-90-90 target. Focus on these areas will reduce the transmission of new HIV infections and mortality in the general population.
Southern African Journal of Hiv Medicine, Mar 10, 2021
Objective: To review policy and implementation related progress and continuing challenges towards... more Objective: To review policy and implementation related progress and continuing challenges towards eliminating HIV as a public health threat by 2030. Method: Policy analysis and review of modeling data from Thembisa 4.3. Results: South Africa has made significant progress in the adoption of policies with two exceptions. While there are gaps in reaching the 90-90-90 implementation targets, progress has been made in the past decade. While progress has been made in the past decade towards the global targets, much work remains to ensure that HIV transmission is curtailed and those that require treatment are initiated on treatment and are virally suppressed.
Journal of Health Politics Policy and Law, Aug 1, 2001
This essay evaluates the transformation of the health care system in South Africa in the five yea... more This essay evaluates the transformation of the health care system in South Africa in the five years following the end of apartheid. This period has witnessed dramatic and wide-ranging changes in the roles of the central and provincial governments as well as many of the same problems related to decentralization as have been seen elsewhere in the world. The importance of effective intergovernmental relations to the creation of a national health system is highlighted. Negotiation, contracting, and coordination skills and mechanisms need to be strengthened to ensure a more effective national health system within a decentralized political system.
... Also, given the centrality of PHC services to the health system, the possibility of ringfenci... more ... Also, given the centrality of PHC services to the health system, the possibility of ringfencing PHC funding in each province should be urgently considered. Read this article. For subscription and additional information please contact us on: ...
Background. An essential part of providing high-quality patient care and a means of efficiently c... more Background. An essential part of providing high-quality patient care and a means of efficiently conducting research studies relies upon high-quality routinely collected medical information. Objectives. To describe the registers, paper records and databases used in a sample of primary healthcare clinics in South Africa (SA) with the view to conduct an impact evaluation using routine data. Methods. Between October 2015 and December 2015, we collected information on the presence, quality and completeness of registers, clinical stationery and databases at 24 public health facilities in SA. We describe each register and type of clinical stationery we encountered, their primary uses, and the quality of completion. We also mapped the ideal flow of data through a site to better understand how its data collection works. Results. We identified 13 registers (9 standard, 4 non-standard), 5 types of stationery and 4 databases as sources of medical information within a site. Not all clinics used all the standardised registers, and in those that did, registers were kept in various degrees of completeness: a common problem was inconsistent recording of folder numbers. The quality of patient stationery was generally high, with only the chronic patient record being considered of varied quality. The TIER.Net database had high-quality information on key variables, but national identification (ID) number was incompletely captured (42% complete). Very few evaluation sites used electronic data collection systems for conditions other than HIV/AIDS. Conclusion. Registers, databases and clinical stationery were not implemented or completed consistently across the 24 evaluation sites. For those considering using routinely collected data for research and evaluation purposes, we would recommend a thorough review of clinic data collection systems for both quality and completeness before considering them to be a reliable data source.
Objectives To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pr... more Objectives To investigate if the implementation of the 2016 WHO Recommendations for a Positive Pregnancy Experience reduced perinatal mortality in a South African province. The recommendations were implemented which included increasing the number of contacts and also the content of the contacts. Methods Retrospective interrupted time-series analysis was conducted for all women accessing a minimum of one antenatal care contact from April 2014 to September 2019 in Mpumalanga province, South Africa. Retrospective interrupted time-series analysis of province level perinatal mortality and birth data comparing the pre-implementation period (April 2014-March 2017) and post-implementation period (April 2018-September 2019). The main outcome measure was unadjusted prevalence ratio (PR) for perinatal deaths before and after implementation; interrupted timeseries analyses for trends in perinatal mortality before and after implementation; stillbirth risk by gestational age; primary cause of deaths (and maternal condition) before and after implementation. Results Overall, there was a 5.8% absolute decrease in stillbirths after implementation of the recommendations, however this was not statistically significant (PR 0.95, 95% CI 0.90% to 1.05%; p=0.073). Fresh stillbirths decreased by 16.6% (PR 0.86, 95% CI 0.77% to 0.95%; p=0.003) while macerated stillbirths (p=0.899) and early neonatal deaths remained unchanged (p=0.499). When stratified by weight fresh stillbirths >2500 g decreased by 17.2% (PR 0.81, 95% CI 0.70% to 0.94%; p=0.007) and early neonatal deaths decreased by 12.8% (PR 0.88, 95% CI 0.77% to 0.99%; p=0.041). The interrupted time-series analysis confirmed a trend for decreasing stillbirths at 0.09/1000 births per month (-0.09, 95% CI -1.18 to 0.01; p=0.059), early neonatal deaths (-0.09, 95% CI -0.14 to 0.04; p=<0.001) and perinatal mortality (-1.18, 95% CI -0.27 to -0.09; p<0.001) in the postimplementation period. A decrease in stillbirths, early neonatal deaths or perinatal mortality was not observed in the pre-implementation period. During the period when additional antenatal care contacts were implemented (34-38 weeks), there was a decrease in stillbirths of 18.4% (risk ratio (RR) 0.82, 95% CI 0.73% to 0.91%, p=0.0003). In hypertensive disorders of pregnancy, the risk of stillbirth decreased in the post-period by 15.1% (RR 0.85; 95% CI 0.76% to 0.94%; p=0.002).
This paper attempts to document the successes and failures of the Department of Health during the... more This paper attempts to document the successes and failures of the Department of Health during the first 1,000 days of the Government of National Unity. The achievements of the Department are reflected against the backdrop of the legacies inherited by the current Ministry and Department.
Human resources for health (HRH) remains a critical challenge, according to the Kampala Declarati... more Human resources for health (HRH) remains a critical challenge, according to the Kampala Declaration and Agenda for Global Action of 2008 and the 2030 Sustainable Development Agenda. Available literature on health system reforms does not provide a detailed narrative on strategies that have been used to reform HRH challenges in peri-urban communities. This study explores such strategies implemented in Epworth, Zimbabwe, during 2009ร2014, and the implications these strategies might have on other peri-urban areas. Design: Qualitative and quantitative methods were used in an exploratory and cross-sectional design. Purposive sampling was used to select key informants, a sample of healthcare workers that participated in in-depth interviews and community members who took part in focus group discussions. Secondary data were collected through a documentary search. Qualitative data were analysed through thematic analysis. Quantitative secondary data were examined using descriptive statistics and then compared with qualitative data to reinforce analysis. Results: The HRH reform policy strategies that were identified included ministerial intervention; policy review; and revival of the human resource for health planning, financial planning, multi-sector collaboration, and community engagement. These had some positive effects; however, desired outcomes were undermined by financial, material, human resource, and social constraints. Conclusions: Despite constraints, the strategies helped revive the health delivery system in Epworth. In turn, this had a favourable outlook on post-2008 efforts by the Global Health Alliance towards healthcare worker reform and the 2030 Sustainable Development Agenda in peri-urban communities.
We thank the participants in the Consultation for sharing their time and expertise. Special thank... more We thank the participants in the Consultation for sharing their time and expertise. Special thanks also to Tim Sladden for providing feedback. Financial support for the consultation from the Special Programme for Human Reproduction funded by the United Nations Development Programme, United Nations Population Fund, UNICEF, WHO, and World Bank is gratefully acknowledged. The contents are the responsibility of the authors and do not necessarily reflect the views of the World Health Organization.
This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Background. ... more This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. Background. Many people living with HIV in South Africa (SA) are not aware of their seropositive status and are diagnosed late during the course of HIV infection. These individuals do not obtain the full benefit from available HIV care and treatment services. Objectives. To describe the prevalence of late presentation for HIV care among newly diagnosed HIV-positive individuals and evaluate sociodemographic variables associated with late presentation for HIV care in three high-burden districts of SA. Methods. We used data abstracted from records of 8 138 newly diagnosed HIV-positive individuals in 35 clinics between 1 June 2014 and 31 March 2015 to determine the prevalence of late presentation among newly diagnosed HIV-positive individuals in selected highprevalence health districts. Individuals were categorised as 'moderately late' , 'very late' or 'extremely late' presenters based on specified criteria. Descriptive analysis was performed to measure the prevalence of late presentation, and multivariate regression analysis was conducted to identify variables independently associated with extremely late presentation. Results. Overall, 79% of the newly diagnosed cases presented for HIV care late in the course of HIV infection (CD4+ count โค500 cells/ ยตL and/or AIDS-defining illness in World Health Organization (WHO) stage III/IV), 19% presented moderately late (CD4+ count 351 -500 cells/ยตL and WHO clinical stage I or II), 27% presented very late (CD4+ count 201 -350 cells/ยตL or WHO clinical stage III), and 33% presented extremely late (CD4+ count โค200 cells/ยตL and/or WHO clinical stage IV) for HIV care. Multivariate regression analysis indicated that males, non-pregnant women, individuals aged >30 years, and those accessing care in facilities located in townships and inner cities were more likely to present late for HIV care. Conclusions. The majority of newly diagnosed HIV-positive individuals in the three high-burden districts (Gert Sibande, uThukela and City of Johannesburg) presented for HIV care late in the course of HIV infection. Interventions that encourage early presentation for HIV care should be prioritised in SA and should target males, non-pregnant women, individuals aged >30 years and those accessing care in facilities located in inner cities and urban townships.
The recent release of the South Africa Human Rights Commission's report on the status of mental h... more The recent release of the South Africa Human Rights Commission's report on the status of mental health services on 28 March 2019 should cause all of us to pause and reflect on what needs to be done to provide quality, rights-based mental health services for the people of South Africa. A blog in the South African College of Applied Psychology (2018) website entitled 'The shocking state of mental health in South Africa in 2018' noted the following: The global burden of disease attributable to mental disorders has risen in all countries in the context of major demographic, environmental, and socio-political transitions. Human rights violations and abuses
Background: We characterize engagement with HIV care in South Africa in 2012 to identify areas fo... more Background: We characterize engagement with HIV care in South Africa in 2012 to identify areas for improvement towards achieving global 90-90-90 targets. Methods: Over 3.9 million CD4 รพ cell count and 2.7 million viral load measurements reported in 2012 in the public sector were extracted from the national laboratory electronic database. The number of persons living with HIV (PLHIV), number and proportion in HIV care, on antiretroviral therapy (ART) and with viral suppression (viral load <400 copies/ml) were estimated and stratified by sex and age group. Modified Poisson regression approach was used to examine associations between sex, age group and viral suppression among persons on ART. Results: We estimate that among 6511 000 PLHIV in South Africa in 2012, 3300 000 individuals (50.7%) accessed care and 32.9% received ART. Although viral suppression was 73.7% among the treated population in 2012, the overall percentage of persons with viral suppression among all PLHIV was 23.8%. Linkage to HIV care was lower among men (38.5%) than among women (57.2%). Overall, 47.1% of those aged 0-14 years and 47.0% of those aged 15-49 years were linked to care compared with 56.2% among those aged above 50 years. Around a quarter of all PLHIV have achieved viral suppression in South Africa. Men and younger persons have poorer linkage to HIV care. Expanding HIV testing, strengthening prompt linkage to care and further expansion of ART are needed for South Africa to reach the 90-90-90 target. Focus on these areas will reduce the transmission of new HIV infections and mortality in the general population.
Southern African Journal of Hiv Medicine, Mar 10, 2021
Objective: To review policy and implementation related progress and continuing challenges towards... more Objective: To review policy and implementation related progress and continuing challenges towards eliminating HIV as a public health threat by 2030. Method: Policy analysis and review of modeling data from Thembisa 4.3. Results: South Africa has made significant progress in the adoption of policies with two exceptions. While there are gaps in reaching the 90-90-90 implementation targets, progress has been made in the past decade. While progress has been made in the past decade towards the global targets, much work remains to ensure that HIV transmission is curtailed and those that require treatment are initiated on treatment and are virally suppressed.
Journal of Health Politics Policy and Law, Aug 1, 2001
This essay evaluates the transformation of the health care system in South Africa in the five yea... more This essay evaluates the transformation of the health care system in South Africa in the five years following the end of apartheid. This period has witnessed dramatic and wide-ranging changes in the roles of the central and provincial governments as well as many of the same problems related to decentralization as have been seen elsewhere in the world. The importance of effective intergovernmental relations to the creation of a national health system is highlighted. Negotiation, contracting, and coordination skills and mechanisms need to be strengthened to ensure a more effective national health system within a decentralized political system.
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