African Health System Research Articles

Challenges facing South Africa's mental health care system: stakeholders' perceptions of causes and potential solutions

In recent years South Africa has taken some important steps forward in strengthening its mental health systems. Mental health legislation has been reformed and there is some level of policy commitment to mental health. However, there remain ongoing challenges, largely related to implementation. The aim of this paper is to review the major challenges facing the South African mental health system, to provide a greater understanding of these challenges (as articulated by stakeholders from a wide range of sectors) and to highlight stakeholders' recommendations about the best way to address them. Ninety nine interviews and 12 focus group discussions were conducted with stakeholders drawn from the national, provincial and district levels. The major challenges identified include: the lack of officially endorsed mental health policy; the continued low priority of mental health; limited intersectoral policy integration; stigma and discrimination; inadequate integration of mental with primary health care; and ‘de-h...

Innovation to improve health care provision and health systems in sub-Saharan Africa – Promoting agency in mid-level workers and district managers

Initiatives to address the human resource crisis in African health systems have included expanded training of mid-level workers (MLWs). Currently, MLWs are the backbone of many health systems in Africa but they are often de-motivated and they often operate in circumstances in which providing high quality care is challenging. Therefore, assuming that introducing additional people will materially change health system performance is unrealistic. We briefly critique such unifocal interventions and review the literature to understand the factors that affect the motivation and performance of MLWs. Three themes emerge: the low status and inadequate recognition of MLWs, quality of care issues and working in poorly managed systems. In response we propose three interrelated interventions: a regional association of MLWs to enhance their status and recognition, a job enrichment and mentoring system to address quality and a district managers’ association to improve health systems management. The professionalisation of MLWs and district managers to address confidence, self-esteem and value is considered. The paper describes the thinking behind these interventions, which are currently being tested in Kenya, Nigeria, South Africa and Uganda for their acceptability and appropriateness. We offer the policy community a complementary repertoire to existing human resource strategies in order to effect real change in African health systems.

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys.

BackgroundInequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.MethodsSeveral rounds (2002, 2004, 2006, and 2008) of the South African General Household Surveys (GHS) data were used, with standardized and normalized self-reported illness and disability concentration indices to assess the distribution of illness and disability across socio-economic groups. Composite indices of socio-economic status were created using a set of common assets and household characteristics.ResultsThis study demonstrates the existence of socio-economic gradients in self-reported ill-health in South Africa. The burden of the major categories of ill-health and disability is greater among lower than higher socio-economic groups. Even non-communicable diseases, which are frequently seen as diseases of affluence, are increasingly being reported by lower socio-economic groups. For instance, the concentration index of flu (and diabetes) declined from about 0.17 (0.10) in 2002 to 0.05 (0.01) in 2008. These results have also been confirmed internationally.ConclusionThe current burden and distribution of ill-health indicates how critical it is for the South African health system to strive for access to and use of health services that is in line with need for such care. Concerted government efforts, within both the health sector and other social and economic sectors are therefore needed to address the significant health inequalities in South Africa.

Is the Bamako Initiative Still Relevant for West African Health Systems?

Faced with the difficulty of implementing primary health care services as proposed at Alma-Ata, UNICEF and the World Health Organization launched a new public health policy in 1987, the Bamako Initiative, to improve access to health care by revitalizing primary health care. The key principle was to decentralize retention of user fees to the local level in health centers managed by a committee of community representatives. Initially, measures were envisioned to exempt the worst-off who were unable to pay; however, these measures were never applied. Today, with most funding agencies in favor of abolishing user fees and some African countries already starting to do so, the relevance of this public policy is being reconsidered for West African countries.

Can disease control priorities improve health systems performance in South Africa?

Improving health systems performance in order to achieve good health care outcomes and meet the Millennium Development Goals (MDGs) has received increased global attention. Using the World Health Organization (WHO)’s framework on health system strengthening, an overview is presented of key aspects of performance of the South African (SA) health system that are likely to impact on the Disease Control Priorities (DCP) initiative.

Risk equalisation and voluntary health insurance: The South Africa experience

South Africa intends implementing major reforms in the financing of healthcare. Free market reforms in private health insurance in the late 1980s have been reversed by the new democratic government since 1994 with the re-introduction of open enrolment, community rating and minimum benefits. A system of national health insurance with income cross-subsidies, risk-adjusted payments and mandatory membership has been envisaged in policy papers since 1994. Subsequent work has seen the design of a Risk Equalisation Fund intended to operate between competing private health insurance funds. The paper outlines the South African health system and describes the risk equalisation formula that has been developed. The risk factors are age, gender, maternity events, numbers with certain chronic diseases and numbers with multiple chronic diseases. The Risk Equalisation Fund has been operating in shadow mode since 2005 with data being collected but no money changing hands. The South African experience of risk equalisation is of wider interest as it demonstrates an attempt to introduce more solidarity into a small but highly competitive private insurance market. The measures taken to combat over-reporting of chronic disease should be useful for countries or funders considering adding chronic disease to their risk equalisation formulae.

Corrections to ‘The use of sterilised polyester mosquito net mesh for inguinal hernia repair in Ghana’

Dear Editors, Calculations related to cost-eVectiveness included in the paper by Clarke et al. [1] were drawn from a previous version of Shillcutt et al. [2], which contained several errors that should be highlighted. The correct values within the following sentence are in parentheses: “DALYs were calculated in the reference case, with an average of 18.90 (9.32) DALYs averted per person, and a total of 2,136 (1,052) DALYs averted in the study. Cost-eVectiveness analyses identiWed an average cost of $636.65 ($120.02) per hernia repair from a provider perspective, with a resultant cost of $33.69 ($12.88) per DALY averted. Adjusting costs to the societal perspective resulted in an overall cost of $32.27 ($11.04) per DALY averted.” Corrections and modiWcations made to the calculations included the following: provider costs were pro-rated to the length of the program, consistent with Gosselin et al. [3], instead of being simply annualized. InXation to 2008 US$ was previously done with Ghanaian inXation rates instead of US rates. Personnel costs collected on site were replaced with WHO–CHOICE Wgures to improve within-study consistency and acrossstudy comparability for decisions beyond the Ghanaian context. Transportation costs for European teams, costs of a 2-h radio campaign, eight water tanks to all hospitals, and multivitamin costs were added to augment the robustness of the costing. Corrections to DALY calculations were made in a previous erratum [4], which highlight the importance of using formulas directly from the Global Burden of Disease (GBD) website [5]. Our evidence is based on a small cohort study and there are several areas where it could be strengthened. Costs should be measured in similar settings to corroborate or challenge our Wndings. Empirically based disability weights should be deWned to reXect true patient or provider preferences. The rationale behind our modeling of outcomes from longstanding hernias is based on the best available evidence and is open for debate. Testing the eVectiveness and costeVectiveness of this kind of program on a larger scale would strengthen evidence for policy decisions. Monitoring these programs as they develop local self-suYciency, as African health systems strengthen, and as the epidemiology of hernias evolve is an exciting area for future research.

Saving South Africa's mothers, newborns and children - can the health system deliver? : hot topics

In summary, almost 50 000 newborn and child lives could be saved in the year 2015 if South Africa reached high, effective coverage, especially of PMTCT and newborn care. This would put South Africa right on target for MDG 4 (Fig. 1), and also contribute significantly to progress for maternal health (MDG 5). However, to save these lives in the real world of the South African health system, the challenge is to ensure not only high coverage for all but also higher-quality coverage. Too often the high-impact interventions are being performed sub-optimally. For example, even though more than 90% of women complete at least one antenatal visit a recent assessment showed that only about 11% received the full set of interventions required.

Low uptake of HIV testing during antenatal care: a population-based study from eastern Uganda

This article discusses a population-based study from rural eastern Uganda that examines the uptake and determinants for HIV testing among pregnant women in Iganga/Mayuge Demographic Surveillance Site (DSS) where field assistants regularly collect data from households on vital events and other variables in a population of 67200 inhabitants. It finds that intensified counseling at health facilities and referral follow-up are needed as well as HIV testing services at ANC facilities to increase the coverage of HIV testing among pregnant women.

Programme evaluation training for health professionals in francophone Africa: process, competence acquisition and use

BackgroundWhile evaluation is, in theory, a component of training programmes in health planning, training needs in this area remain significant. Improving health systems necessarily calls for having more professionals who are skilled in evaluation. Thus, the Université de Ouagadougou (Burkina Faso) and the Université de Montréal (Canada) have partnered to establish, in Burkina Faso, a master's-degree programme in population and health with a course in programme evaluation. This article describes the four-week (150-hour) course taken by two cohorts (2005–2006/2006–2007) of health professionals from 11 francophone African countries. We discuss how the course came to be, its content, its teaching processes and the master's programme results for students.MethodsThe conceptual framework was adapted from Kirkpatrick's (1996) four-level evaluation model: reaction, learning, behaviour, results. Reaction was evaluated based on a standardized questionnaire for all the master's courses and lessons. Learning and behaviour competences were assessed by means of a questionnaire (pretest/post-test, one year after) adapted from the work of Stevahn L, King JA, Ghere G, Minnema J: Establishing Essential Competencies for Program Evaluators. Am J Eval 2005, 26(1):43–59. Master's programme effects were tested by comparing the difference in mean scores between times (before, after, one year after) using pretest/post-test designs. Paired sample tests were used to compare mean scores.ResultsThe teaching is skills-based, interactive and participative. Students of the first cohort gave the evaluation course the highest score (4.4/5) for overall satisfaction among the 16 courses (3.4–4.4) in the master's programme. What they most appreciated was that the forms of evaluation were well adapted to the content and format of the learning activities. By the end of the master's programme, both cohorts of students considered that they had greatly improved their mastery of the 60 competences (p < 0.001). This level was maintained one year after completing the master's degree, except for reflective practice (p < 0.05). Those who had carried out an evaluation in the intervening 12 months reported a negative gap between their declared mastery and their actual application. However, this is only statistically significant for reflective practice (p < 0.05).ConclusionThis study shows the importance of integrating summative evaluation into the learning process. Skills-based teaching is much appreciated and well-adapted. Creating a master's programme in population and health in Africa and providing training in evaluation to high-level health professionals from many countries augurs well for scaling up the practice of evaluation in African health systems.

Abandoning Presumptive Antimalarial Treatment for Febrile Children Aged Less Than Five Years—A Case of Running Before We Can Walk?

Background to the debate: Current guidelines recommend that all fever episodes in African children be treated presumptively with antimalarial drugs. But declining malarial transmission in parts of sub-Saharan Africa, declining proportions of fevers due to malaria, and the availability of rapid diagnostic tests mean it may be time for this policy to change. This debate examines whether enough evidence exists to support abandoning presumptive treatment and whether African health systems have the capacity to support a shift toward laboratory-confirmed rather than presumptive diagnosis and treatment of malaria in children under five.

Time To Move from Presumptive Malaria Treatment to Laboratory-Confirmed Diagnosis and Treatment in African Children with Fever

Background to the debate: Current guidelines recommend that all fever episodes in African children be treated presumptively with antimalarial drugs. But declining malarial transmission in parts of sub-Saharan Africa, declining proportions of fevers due to malaria, and the availability of rapid diagnostic tests mean it may be time for this policy to change. This debate examines whether enough evidence exists to support abandoning presumptive treatment and whether African health systems have the capacity to support a shift toward laboratory-confirmed rather than presumptive diagnosis and treatment of malaria in children under five.

Pediatric Pharmacotherapy Issues in Africa

Pediatric pharmacotherapy in Africa is constrained by a variety of factors, not all of them unique to the continent. While affordability of medicines and the availability of sustainable financing for healthcare are constant challenges to African health systems, other issues of particular importance for pediatric care are also hampering access. These include the burden of disease in such settings, the lack of appropriate human resources for health, and the lack of child-appropriate dosage forms, especially for ambulatory care. Access to medicines for children has been recognized as a global priority. Examples of developments that have the potential to improve pediatric pharmacotherapy in resource-constrained settings are the WHO Essential Medicines List for Children and the 'Make medicines child size' campaign.

The role of aid in the long term

At some level, I am in agreement with the opinions expressed by Ooms and Van Damme. There is virtually no dispute that, currently, total health expenditure in Africa falls far below what is required to address the health challenges facing the vast majority of the continent’s population. It is also likely that this situation will continue for a long time to come. Thus, Ooms and Van Damme are right in observing that more international donor aid is needed urgently to enable African health systems to meet their health goals. I also concede that some of the proposals made by Kirigia and Diarra-Nama may not make a big impact on resource availability in many African countries in the short term. Therefore, I agree that African countries should not wean themselves from donor aid in the short term. However, I have just a few points of disagreement with Ooms and van Damme. First, strictly speaking, there is no technical reason why a country with an income of US$ 366 per capita cannot increase its domestic health spending from US$ 20 to US$ 34. Several countries in Africa would possibly increase their per capita total health spending to US$ 34 and still have a total health expenditure-to-GDP ratio below 10%. It is the value of forgone alternative benefits (as perceived through either collective decision making or unilateral decisions of political authority) that puts a limit on how much a society can spend on health, not some health expenditure-GDP ratio technical limit. Further, general lessons of experience from parts of east and south-east Asia and Latin America show that, as countries experience substantial broad-based economic and social progress, greater health funding becomes feasible. Such a situation requires time, but has been realized in these countries within about 20 to 40 years. Furthermore, one could argue that achieving independence from donor aid does not mean that external aid should not contribute anything at all to financing health care in Africa. Even rapidly growing economies like China are still recipients of aid from donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. With regard to corruption, if, as has been demonstrated by a number of public health expenditure tracking surveys in Sierra Leone, Uganda and Zambia, a large proportion of disbursed resources do not reach the intended service facilities, there will always be a perceived need for more money because population health indicators would remain dismal. This then might suggest that countries would perceive a funding gap (to be filled by an appeal to donor aid) even if countries were spending US$ 34 per capita of their own resources. As indicated in the WHO Statistical Information System,1 Zambia’s total health expenditure per capita in 2005 was US$ 36. It cannot be ignored that productivity of health spending is also important. Overall, it is my belief that it would take a long time to reduce the high dependency on donor aid. But Africa’s strategic vision should be to progressively increase domestic resource mobilization. ■

Acceptability of evidence-based neonatal care practices in rural Uganda – implications for programming

BackgroundAlthough evidence-based interventions to reach the Millennium Development Goals for Maternal and Neonatal mortality reduction exist, they have not yet been operationalised and scaled up in Sub-Saharan African cultural and health systems. A key concern is whether these internationally recommended practices are acceptable and will be demanded by the target community. We explored the acceptability of these interventions in two rural districts of Uganda.MethodsWe conducted 10 focus group discussions consisting of mothers, fathers, grand parents and child minders (older children who take care of other children). We also did 10 key informant interviews with health workers and traditional birth attendants.ResultsMost maternal and newborn recommended practices are acceptable to both the community and to health service providers. However, health system and community barriers were prevalent and will need to be overcome for better neonatal outcomes. Pregnant women did not comprehend the importance of attending antenatal care early or more than once unless they felt ill. Women prefer to deliver in health facilities but most do not do so because they cannot afford the cost of drugs and supplies which are demanded in a situation of poverty and limited male support. Postnatal care is non-existent. For the newborn, delayed bathing and putting nothing on the umbilical cord were neither acceptable to parents nor to health providers, requiring negotiation of alternative practices.ConclusionThe recommended maternal-newborn practices are generally acceptable to the community and health service providers, but often are not practiced due to health systems and community barriers. Communities associate the need for antenatal care attendance with feeling ill, and postnatal care is non-existent in this region. Health promotion programs to improve newborn care must prioritize postnatal care, and take into account the local socio-cultural situation and health systems barriers including the financial burden. Male involvement and promotion of waiting shelters at selected health units should be considered in order to increase access to supervised deliveries. Scale-up of the evidence based practices for maternal-neonatal health in Sub-Saharan Africa should follow rapid appraisal and adaptation of intervention packages to address the local health system and socio-cultural situation.

Child PIP : making mortality meaningful by using a structured mortality review process to improve the quality of care that children receive in the South African health system

The Child Healthcare Problem Identification Programme (Child PIP) uses the mortality review process to assess the quality of care that children receive in the South African health system, and to suggest solutions for improvement. This paper describes the origins, growth and development of Child PIP over the last 5 years, and provides an overview of the findings and recommendations to date. South African Journal of Child Health Vol. 2 (2) 2008: pp. 38-43

The interface between research and policy: Experience from South Africa

Increasing attention has been paid in recent years to efforts to strengthen the impact of research on policy in low- and middle-income countries. However, the processes by which such research might have policy impact remain a subject of debate. This paper presents an analysis of the research/policy interface, drawing on the experiences of two South African health policy and systems research (HPSR) units and one specific study which traced the development and implementation of three areas of health care financing policy change and debate between 1994 and 1999. The analysis is based primarily on the authors' own experiences and has been developed through a deliberate process of reflection. It suggests, first, that it is important to acknowledge the conceptual and symbolic uses and impacts of research – perhaps, particularly in relation to the system-oriented work of HPSR groups. These uses may not be verifiable by specific changes in policy and practice but are important contributions to the policy environment and do filter into policy-makers' understandings and actions. Second, achieving any form of impact on policy is linked to the attention researchers pay to the context in which the research is undertaken, the nature and credibility of the research; and the importance of nesting any single project in a broader programme of engagement with the policy environment that builds trust in the researchers.

Community health workers and the response to HIV/AIDS in South Africa: tensions and prospects

After a decline in enthusiasm for national community health worker (CHW) programmes in the 1980s, these have re-emerged globally, particularly in the context of HIV. This paper examines the case of South Africa, where there has been rapid growth of a range of lay workers (home-based carers, lay counsellors, DOT supporters etc.) principally in response to an expansion in budgets and programmes for HIV, most recently the rollout of antiretroviral therapy (ART). In 2004, the term community health worker was introduced as the umbrella concept for all the community/lay workers in the health sector, and a national CHW Policy Framework was adopted. We summarize the key features of the emerging national CHW programme in South Africa, which include amongst others, their integration into a national public works programme and the use of non-governmental organizations as intermediaries. We then report on experiences in one Province, Free State. Over a period of 2 years (2004--06), we made serial visits on three occasions to the first 16 primary health care facilities in this Province providing comprehensive HIV services, including ART. At each of these visits, we did inventories of CHW numbers and training, and on two occasions conducted facility-based group interviews with CHWs (involving a total of 231 and 182 participants, respectively). We also interviewed clinic nurses tasked with supervising CHWs. From this evaluation we concluded that there is a significant CHW presence in the South African health system. This infrastructure, however, shares many of the managerial challenges (stability, recognition, volunteer vs. worker, relationships with professionals) associated with previous national CHW programmes, and we discuss prospects for sustainability in the light of the new policy context.

Faculty of Health Sciences, Walter Sisulu University: Training Doctors from and for Rural South African Communities

Introduction The South African health system has disturbing inequalities, namely few black doctors, a wide divide between urban and rural sectors, and also between private and public services. Most medical training programs in the country consider only applicants with higher-grade preparation in mathematics and physical science, while most secondary schools in black communities have limited capacity to teach these subjects and offer them at standard grade level. The Faculty of Health Sciences at Walter Sisulu University (WSU) was established in 1985 to help address these inequities and to produce physicians capable of providing quality health care in rural South African communities. Intervention Access to the physician training program was broadened by admitting students who obtained at least Grade C (60%) in mathematics and physical science at standard grade, and who demonstrated appropriate personal attributes. An innovative curriculum, combining problem-based learning with community-based education (PBL/CBE) in small tutorial group settings, was also adopted. This approach was aimed at educating and graduating a broader cohort of students, while training future doctors to identify, analyze, and treat health problems in the rural South African context. Outcomes To date, 745 doctors (72% black Africans) have graduated from the program, and 511 students (83% black Africans) are currently enrolled. After the PBL/CBE curriculum was adopted, the attrition rate for black students dropped from 23% to <10%. The progression rate rose from 67% to >80%, and the proportion of students graduating within the minimum period rose from 55% to >70%. Many graduates are still completing internships or post-graduate training, but preliminary research shows that 36% percent of graduates practice in small towns and rural settings. Further research is underway to evaluate the impact of their training on health services in rural Eastern Cape Province and elsewhere in South Africa. Conclusions The WSU program increased access to medical education for black students who lacked opportunities to take advanced math and science courses prior to enrolling in medical school. Innovative admission requirements and adoption of a PBL/CBE curriculum have made the WSU program one of the top training programs for black African doctors in South Africa.

Health promotion in South Africa

Health promotion first entered the South African health system in 1990. Today, Health Promotion is a Directorate located within the Social Sector Cluster (SSC) within Primary Health Care (PHC), District and Development operations which falls under the Deputy Director General for Health Service Delivery in the National Department of Health (DoH). The first significant piece of new policy for health promotion in South Africa appeared in the African National Congress (ANC) health policy document, health care services including reproductive health care. At the moment, health promotion service delivery is the responsibility of the national, provincial and local governments with provincial and local governments mainly implementing and the National Health Promotion Directorate offering support. Funding for health promotion activities comes from the Department of Health budget allocation by the National Treasury. One major problem for Health Promotion development is infrastructure. There is significant community participation in South Africa including health promotion policy and strategy document development. Health Promotion research and evaluation is limited. The National Department of Health considers the settings approach to be crucial in driving the progress of health promotion. There are very few trained health promotion specialists either capable or in the position to inform politicians and opinion leaders about the relationship between health and social determinants, and the evidence of effectiveness of health promotion action. Mechanisms for demonstrating evidence of health promotion effectiveness in terms of health, social, economic and political impact are lacking and occupational standards for health promotion education and training are needed.