Healthcare System In South Africa Research Articles

A reflection of the current status of the mental healthcare system in South Africa

In this paper we begin by highlighting the large treatment gap in South Africa for mental health conditions. We then describe the mental health services available, including the provision of evidence-based treatments in South Africa at each level of care, using the WHO's optimal mix of mental healthcare services as a framework. The optimal mix of services pyramid includes the following domains: informal services, which comprise self-care and informal community mental health care (including religious and traditional healers), primary care mental health services, psychiatric services provided at general hospitals, community mental health services, specialist services and long-stay facilities. In South Africa, mental healthcare services are concentrated at the apex of the pyramid within secondary hospital and specialist services, with fewer resources available at other levels of care, particularly at the community level. Barriers to access and delivery of evidence-based treatments at each level of care are discussed, including the current mental healthcare system resourcing and structure which drives the focus on the provision of medications and specialized services for patients with serious mental health conditions. The results of research conducted locally in collaboration with the Department of Health to address this gap, particularly regarding care for common mental health conditions in community settings, are described. Finally, we provide recommendations for the way forward to ensure that high-quality mental health services at all levels of care are delivered in an equitable, acceptable and effective manner.

Perceptions of and Practical Experience with the National Surveillance Centre in Managing Medicines Availability Amongst Users within Public Healthcare Facilities in South Africa: Findings and Implications.

The introduction of the National Surveillance Centre (NSC) has improved the efficiency and effectiveness of managing medicines availability within the public healthcare system in South Africa. However, at present, there is limited data regarding the perceptions among users of the NSC and challenges that need addressing. A descriptive quantitative study was performed among all registered active NSC users between August and November 2022. Overall, 114/169 users responded to a custom-developed, self-administered questionnaire (67.5% response rate). Most respondents used the Stock Visibility System (SVS) National Department of Health (NDoH) (66.7% for medicines and 51.8% for personal protective equipment (PPE) or SVS COVID-19 (64.9% for COVID-19 vaccines) or RxSolution (57.0% manual report or 42.1% application programming interface (API)) for reporting medicines, PPE, and COVID-19 vaccines to the NSC and were confident in the accuracy of the reported data. Most respondents focused on both medicines availability and reporting compliance when accessing the NSC, with the integrated medicines availability dashboard and the COVID-19 vaccine dashboard being the most popular. The respondents believed the NSC allowed ease of access to data and improved data quality to better monitor medicines availability and use. Identified areas for improvement included improving internet connectivity, retraining some users, standardising the dashboards, adding more data points and reports, and expanding user adoption by increasing licence limits. Overall, this study found that the NSC in South Africa provides an effective solution for monitoring and improving medicines availability.

Critical success factors of smart card technology in South African public hospitals

Background: Even though the government has set several admirable targets for raising the standard of healthcare, as highlighted by communities and media reports, public health institutions’ services continue to fall short of patients’ expectations and basic standards of care. For this reason, the general public has lost faith in the healthcare system. The public healthcare system in South Africa is completely dysfunctional and urgently needs to be transformed to serve the majority of those who use public hospitals.Objectives: The study aimed to improve healthcare for the majority of South Africans by investigating the critical success factors (CSFs) that influence the adoption of smart card technology (SCT) in South African public hospitals.Methods: A thorough review of peer-reviewed literature was conducted to determine potential barriers to adopting SCT. Furthermore, a hybrid model that combines the Health Unified Technology of Acceptance Theory (HUTAUT) model, DeLone and McLean IS success model (DM) and the diffusion of innovation (DOI) theory will be developed, validated and tested to identify the CSFs adoption of SCT in public hospitals in South Africa.Results: The validated research model has been developed to be adopted by nurses at public hospitals.Conclusion: This research will contribute to the development of a new framework that identifies the CSFs for SCT adoption in South African public hospitals.Contribution: The study’s results will make a special contribution to the body of knowledge in the fields of health informatics, particularly e-health.

Development, validation and reliability of the Smith Toolkit for Integrated Health Related Quality of Life (STI-HRQoL)

The current burden on the public healthcare system in South Africa has been exacerbated by a shortage of medical staff, insufficient consultation time and patients’ inability to have regular health screenings due to financial constraints and logistical challenges. An integrated toolkit assessing health-related quality of life would be useful in identifying the areas that need improvement in disease management, enabling patients to reach their full potential.

Perspectives and Experiences of Young Mothers Utilizing Public Healthcare Services in a South African Township

The prevalence of disrespectful and abusive care by public healthcare workers toward women during labor has been widely described as a health concern in the continent of Africa. Studies conducted in South Africa have outlined the different forms of abusive care, which include disrespect, neglect as well as abandonment. Research conducted on the mistreatment have focused on matured and married women as it has been assumed that childbearing occurs after marriage. This study placed emphasis on the experiences of young women utilizing public healthcare services during childbirth. Using a qualitative method, the study aimed to shed insights into the experiences of young women utilizing public healthcare services. Semi-structured interviews were conducted with 20 young women aged 20 to 25 years living in a South African township. The study findings were thematically analyzed. The interviews suggest that young women experienced different forms of abusive care including, disrespect, abandonment and lack of privacy. The study recommends that the healthcare system in South Africa should effectively address the causes of abusive care and take appropriate action to ensure accountability and that women receive professional and dignified childbirth experience.

Healthcare disparity and its associations with cytomegalovirus disease in pediatric liver transplant recipients in South Africa.

Cytomegalovirus (CMV) infection and disease are preventable complications following pediatric liver transplantation (PLT), despite the use of prophylaxis to minimize the risk of CMV disease. We evaluated the incidence and complications of CMV disease in PLT recipients in South Africa (SA), with particular reference to potential differences in outcome between state and private sector patients. Medical records of patients younger than 16 years of age who received liver transplants between January 1, 2012, and August 31, 2018 were analyzed. Records of all 150 PLT patients were retrieved. The median age at transplant was 29.2 months (95% confidence interval 15.6-58.4) and follow-up was 46.3 months (interquartile range 27.6-63.1). Sixty-six (44%) patients were high risk, 79 (52.7%) were intermediate risk, and five (3.3%) were low risk for CMV infection. Forty-three (28.9%) patients had CMV DNAemia following transplantation, and 30 (20.1%) developed CMV disease. Receipt of care in the private sector was consistently associated with a lower hazard of CMV disease (adjusted hazard ratio [aHR] ranging from 0.36 to 0.43) and a consistently lower hazard of death among recipients at high risk for CMV disease and/or those who developed CMV disease (aHR ranging from 0.28 to 0.33). Receipt of care in the private health sector was associated with a consistently lower hazard of CMV disease and death in individuals with CMV disease and/or at high risk for CMV disease. Policies aimed at creating a more equitable healthcare system in SA may mitigate the differential burden of illness associated with CMV in PLT recipients.

Financial literacy in South African healthcare professionals: An unmet need in health professions education

The holistic training of healthcare professionals as a strategy to build the healthcare system has received considerable attention. As part of training a holistic workforce, it is expected the healthcare professionals be component in management and governance. Financial literacy is low globally and impacts financial decision-making and business management. Despite high levels of education, medical professionals elsewhere in the world have low financial literacy. Financial literacy levels in South African healthcare professionals are unknown. This study investigated the degree of and contributors to financial literacy in South African healthcare professionals. A validated financial literacy questionnaire was completed by 473 healthcare professionals, of whom 130 owned private practices. Financial literacy scores were determined as a composite score based on financial knowledge, financial behaviour and financial attitudes. The independent contribution of demographic factors to financial literacy were determined in multivariate linear regression analysis. Financial literacy in healthcare professionals was relatively high (73%). Of the total cohort 24%, 27% and 63% did not reach acceptable scores for financial knowledge, behaviour, and attitudes, respectively. Sex, medical specialty and being in private healthcare predicted financial knowledge scores. Higher income and self-rated financial knowledge were associated with financial literacy. In business owners, business-specific financial literacy was low (51%), and not associated with general financial literacy (r=-0.11, p=0.40). Education in economics and finance predicted business-related financial literacy scores (p=0.02). Financial attitudes that favour the short term may impact financial decision-making in healthcare professionals in managing small businesses and state healthcare facilities. Current approaches in health professions education may impact the success of the healthcare system in South Africa.

Occupational Risk of Airborne Mycobacterium tuberculosis Exposure: A Situational Analysis in a Three-Tier Public Healthcare System in South Africa.

This study aimed to detect airborne Mycobacterium tuberculosis (MTB) at nine public health facilities in three provinces of South Africa and determine possible risk factors that may contribute to airborne transmission. Personal samples (n = 264) and stationary samples (n = 327) were collected from perceived high-risk areas in district, primary health clinics (PHCs) and TB facilities. Quantitative real-time (RT) polymerase chain reaction (PCR) was used for TB analysis. Walkabout observations and work practices through the infection prevention and control (IPC) questionnaire were documented. Statistical analysis was carried out using Stata version 15.2 software. Airborne MTB was detected in 2.2% of samples (13/572), and 97.8% were negative. District hospitals and Western Cape province had the most TB-positive samples and identified risk areas included medical wards, casualty, and TB wards. MTB-positive samples were not detected in PHCs and during the summer season. All facilities reported training healthcare workers (HCWs) on TB IPC. The risk factors for airborne MTB included province, type of facility, area or section, season, lack of UVGI, and ineffective ventilation. Environmental monitoring, PCR, IPC questionnaire, and walkabout observations can estimate the risk of TB transmission in various settings. These findings can be used to inform management and staff to improve the TB IPC programmes.

Sexuality post gynaecological cancer treatment: a qualitative study with South African women

ObjectivesThis study investigated women’s experiences of their sexuality post gynaecological cancer treatment. Using a holistic sexuality framework, the study explored how women felt their sexual functioning, sexual relationships and sexual...

Technical efficiency of provincial public healthcare in South Africa

BackgroundForty-nine million people or 83 per cent of the entire population of 59 million rely on the public healthcare system in South Africa. Coupled with a shortage of medical professionals, high migration, inequality and unemployment; healthcare provision is under extreme pressure. Due to negligence by the health professionals, provincial health departments had medical-legal claims estimated at R80 billion in 2017/18. In the same period, provincial health spending accounted for 33 per cent of total provincial expenditure of R570.3 billion or 6 per cent of South Africa’s Gross Domestic Product. Despite this, healthcare outcomes are poor and provinces are inefficient in the use of the allocated funds. This warrants a scientific investigation into the technical efficiency of the public health system.MethodsThe study uses data envelopment analysis (DEA) to assess the technical efficiency of the nine South African provinces in the provision of healthcare. This is achieved by determining, assessing and comparing ways that individual provinces can benchmark their performance against peers to improve efficiency scores. DEA compares firms operating in homogenous conditions in the usage of multiple inputs to produce multiple outputs. Therefore, DEA is ideal for measuring the technical efficiency of provinces in the provision of public healthcare. In DEA methodology, the firms with scores of 100 per cent are technically efficient and those with scores lower than 100 per cent are technically inefficient. This study considers six DEA models using the 2017/18 total health spending and health staff as inputs and the infant mortality rate as an output. The first three models assume the constant returns to scale (CRS) while the last three use the variable return to scale (VRS) both with an input-minimisation objective.ResultsThe study found the mean technical efficiency scores ranging from 35.7 to 87.2 per cent between the health models 1 and 6. Therefore, inefficient provinces could improve the use of inputs within a range of 64.3 and 20.8 per cent. The Gauteng province defines the technical efficiency frontiers in all the six models. The second-best performing province is the North West province. Other provinces like KwaZulu-Natal, Limpopo and the Eastern Cape only perform well under the VRS. The other three provinces are inefficient.ConclusionsBased on the VRS models 4 to 6, the study presents three policy options. Policy option 1 (model 4): the efficiency gains from addressing health expenditure wastage in four inefficient provinces amounts to R17 billion. Policy option 2 (model 5): the potential savings from the same provinces could be obtained from reducing 17,000 health personnel, advisably, in non-core areas. In terms of Policy option 3 (model 6), three inefficient provinces should reduce 6940 health workers while the same provinces, inclusive of KwaZulu-Natal could realise health expenditure savings of R61 million. The potential resource savings from improving the efficiency of the inefficient provinces could be used to refurbish and build more hospitals to alleviate pressure on the public health system. This could also reduce the per capita numbers per public hospital and perhaps their performance as overcrowding is reportedly negatively affecting their performance and health outcomes. The potential savings could also be used to appoint and train medical practitioners, specialists and researchers to reduce the alarming numbers of medical legal claims. Given the existing challenges, South Africa is not ready to implement the National Health Insurance (NHI) Scheme, as it requires additional financial and human resources. Instead, huge improvements in public healthcare provision could be achieved by re-allocating the resources ‘saved’ through efficiency measures by increasing the quality of public healthcare and extending healthcare to more recipients.

Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review

BackgroundThere is overwhelming evidence that the quality of health care in South Africa has been compromised by various challenges that impact negatively on healthcare quality. Improvement in quality care means fewer errors, reduced delays in care delivery, improvement in efficiency, increased market share and lower cost. Decline in quality health care has caused the public to lose trust in the healthcare system in South Africa.ObjectivesThe purpose of this study was to identify challenges that are being incurred in practice that compromise quality in the healthcare sector, including strategies employed by government to improve the quality of health delivery.MethodLiterature search included the following computer-assisted databases and bibliographies: Medline (Medical Literature Online), EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google, Google Scholar and ScienceDirect. Furthermore, websites were used to source policy documents of organisations such as the National Department of Health in South Africa and the World Health Organization.ResultsSeventy-four articles were selected from 1366 retrieved. These articles quantify problems facing quality care delivery and strategies used to improve the healthcare system in South Africa.ConclusionThe findings revealed that there were many quality improvement programmes that had been initiated, adapted, modified and then tested but did not produce the required level of quality service delivery as desired. As a result, the Government of South Africa has a challenge to ensure that implementation of National Core Standards will deliver the desired health outcomes, because achieving a lasting quality improvement system in health care seems to be an arduous challenge.

VP14 Cost Analysis For HD And Peritoneal Dialysis For ESRD In South Africa

IntroductionHemodialysis (HD) and peritoneal dialysis (PD) are commonly used to treat patients with end-stage renal disease (ESRD). However, their costs have grown considerably in recent years as the rates of non-communicable diseases including diabetes and hypertension have grown. This will adversely impact on national health budgets especially in low- and middle-income countries (LMICs). Currently, there is limited knowledge about the costs of ESRD and the different components within the public healthcare system in South Africa. Consequently, our objective was to examine the direct medical costs of both approaches from a public provider perspective to provide future guidance.MethodsA prospective observational study undertaken at a leading public hospital in South Africa based principally on patients’ notes and costs from nationally procured lists. A micro-costing approach was used to estimate health care costs among adult patients with ESRD who had received either HD and PD for at least 3 months.ResultsThe majority of patients (35 percent) were aged 40 to 50 years. Patients aged 29-39 years were mostly on HD (28 percent) while those between 51-59 years mostly on PD (29 percent), with HD typically managed in the private sector with limited facilities in the public sector. The average age of patients on HD and PD was 41 and 42 years respectively. Variable costs (USD 20, 488.79) were the highest cost component for PD patients with fixed costs the highest component for HD patients ((USD 16,231.45). The annual cost of HD (USD 31,993.12) was higher than PD (USD 25,282 per patient) but not statistically significant (p = 0.816). The overall burden if appreciably more patients with ESRD are managed appropriately within the public system (covering 80 percent of the population) would be considerable and become unaffordable.ConclusionsHD costs more than PD. These cost estimates are useful for carrying out future health economic analyses and for allocating greater resources to prevent progress to ESRD.

The direct medical cost of type 2 diabetes mellitus in South Africa: a cost of illness study

ABSTRACTBackground: Type 2 diabetes mellitus (T2DM) is known to require continuous clinical care and management that consumes significant health-care resources. These costs are not well understood, particularly in low- and middle-income countries.Objective: The aim of this study was to estimate the direct medical costs associated with T2DM in the South African public health sector and to project an estimate of the future direct costs of T2DM by 2030.Methods: A cost of illness study was conducted to estimate the direct medical costs of T2DM in South Africa in 2018 and to make projections for potential costs in 2030. Costs were estimated for diagnosis and management of T2DM, and related complications. Analyses were implemented in Microsoft Excel, with sensitivity analysis conducted on particular parameters.Results: In 2018, public sector costs of diagnosed T2DM patients were approximately ZAR 2.7 bn and ZAR 21.8 bn if both diagnosed and undiagnosed patients are considered. In real terms, the 2030 cost of all T2DM cases is estimated to be ZAR 35.1 bn. Approximately 51% of these estimated costs for 2030 are attributable to the management of T2DM, and 49% are attributable to complications.Conclusion: T2DM imposes a significant financial burden on the public healthcare system in South Africa. Treatment of all prevalent cases would incur a cost equivalent to approximately 12% of the total national health budget in 2018. With rising prevalence, direct costs will grow if current care regimes are maintained and case-finding improved. Increased financial resources are necessary in order to deliver effective services to people with T2DM.

‘Telephone Triage’: a possible means of managing the after-hours patient load at primary health care facilities in South Africa

The rate at which routine patients are using the emergency department (ED) as a path to enter into the healthcare system in South Africa’s community healthcare facilities and district hospitals is alarming. The increasing number of acutely presenting, less stable and routine patients are being left to the care of a reduced number of health carers after hours, at weekends and during public holidays. This circumstantial disproportionality forms the breeding ground for poor patient care, healthcare workers’ burnout and inappropriate use of referral pathways. Not all the patients occupying the ED waiting rooms actually need emergency care. A sizeable number of patients in the waiting line are routine cases that could wait without any undesirable clinical outcomes. This opinion paper looks into the use of telephones to control after-hours patient loads at primary health care facilities in South Africa.

Using mHealth to Deliver a Home-Based Testing and Counseling Program to Improve Linkage to Care and ART Adherence in Rural South Africa.

Community-based HIV testing and counseling (HTC) programs have become an important part of the healthcare system in South Africa and other low- and middle-income countries with a high HIV prevalence and strained primary healthcare system. Current HTC programs excel at identifying people living with HIV (PLH) but leave gaps in linkage to care and antiretroviral therapy (ART) as most HTC programs do not have the capacity to ensure that linkage has occurred. This article presents the protocol for an mHealth study, that is, pilot testing a mobile platform in KwaZulu-Natal (KZN), South Africa, to improve linkage to care and ART adherence after home-based HTC. Testing data are shared with designated clinics. PLH are identified using fingerprint scans, mobile numbers, or South African IDs. If PLH do not present at a designated clinic after testing HIV positive, study field staff are sent SMS alerts to prompt follow-up visits. Similarly, if PLH do not refill ART prescriptions after their initial 1-month dose runs out, SMS alerts that are sent to field staff. This paper presents the mHealth study protocol and baseline sample characteristics (N = 101 PLH). Analyses will summarize rates of linkage to care and ART prescription refills. Cost-effectiveness analyses will examine the costs and benefits of linkage and ART adherence using our mHealth system. Linkage to care rates will be compared between our study and a historical control, that is, provided by a prior HTC program that was conducted in KZN without our mHealth system (n = 615).

‘Telephone Triage’: a possible means of managing the after-hours patient load at primary health care facilities in South Africa

The rate at which routine patients are using the emergency department (ED) as a path to enter into the healthcare system in South Africa’s community healthcare facilities and district hospitals is ...

The unmet needs and health priorities of the urban poor: Generating the evidence base for urban community health worker programmes in South Africa.

There is a growing interest in involving community health workers (CHWs) into the formal healthcare system in South Africa (SA). To generate evidence for defining CHW tasks in urban SA. A cross-sectional survey of residents of Diepsloot, northern Johannesburg, was performed using geographically weighted random sampling, with home-based health assessment and a questionnaire on sociodemographics, medical history, experience of violence, health-seeking behaviour and perceived health priorities. Between May 2013 and March 2014, 1 230 adults participated. Self-reported medical conditions included hypertension (12%), HIV (10%), diabetes (3%), cancer (1%) and mental illness (1%). Health assessments identified a high prevalence of undiagnosed conditions: hypertension (26%), obesity or overweight (46%), mild to severe depression (23%), HIV infection (5.8%) and tuberculosis (TB) (0.4%). Among women, 18% had unmet family planning needs and 77% had never had a Pap smear. Sexually transmitted infection symptoms were reported by 7% of participants. Physical violence was widespread, with 13% having experienced and 16% witnessing violence in the past year, with women mostly experiencing violence at home and men in the community. Participants' top health concerns were crime, safety and violence (49%) and HIV (18%); healthy living/weight control was listed by only 8% of participants. Alignment of CHW roles to unmet health needs and perceived health priorities will be important for optimal impact of CHW programmes in urban communities. Our data suggest that the CHW role should expand from a traditional focus on HIV, TBand maternal health to include non-communicable diseases, healthy lifestyle,and the intersection of violence and health.

On being a caregiver: The experiences of South African family caregivers caring for cancer patients.

The purpose of our study was to describe the experiences of family caregivers of cancer patients using the public healthcare system in South Africa. We used a qualitative descriptive design and conducted in-depth interviews with 20 purposively selected family caregivers. Data saturation determined the sample size, and qualitative content analysis was used to analyse the data. Three themes arose from the data: emotional responses and feelings towards the cancer diagnosis, fulfilling the role of the caregiver and living and coping with a changed life and a changed person. Caring for a person with cancer was not easy. Participants were overwhelmed with the care responsibilities, which were aggravated by poverty. Some felt emotionally broken and alone in this journey and experienced the rest of their family as uncaring. The lives the participants knew changed and they had to put their own lives on hold and make sacrifices involving their children, work, possible relationships and their normal activities to care for the sick person. For some, the sick person they cared for changed and became a person they did not know. Most participants used religious practices to cope with their situation; however, some used other coping mechanisms, such as recreation and even smoking.

Ongoing Initiatives to Improve the Quality and Efficiency of Medicine Use within the Public Healthcare System in South Africa; A Preliminary Study.

Introduction: South Africa has an appreciable burden of both communicable and non-communicable diseases as well as high maternal, neonatal, and child morbidity. In recent years there have been significant strides with improving the public health system, and addressing current inequalities, with the right to health a constitutional provision in South Africa. Initiatives include the introduction of National Health Insurance, programmes to enhance access to medicines for patients with chronic diseases, as well as activities to improve care in hospitals, including improving pharmacovigilance. Consequently, the objective of this paper is to review ongoing initiatives within the public healthcare sector in South Africa and their influence to provide future direction.Method: Principally a structured review of current and planned activities.Results: There have been a number of major activities and initiatives surrounding the availability and access to medicines in the public system in recent years in South Africa. This includes a National Surveillance Centre and an innovative early warning system for the supply of medicines as well as the development of a National Health Care Pricing Authority and initiatives to improve contracting. There have also been developments to improve the supply chain including instigating Medicine Procurement Units in the provinces and enhancing forecasting capabilities. Access to medicines is improving though the instigation of stable chronic disease management initiatives to increase the number of external pick-up points for medicines. There are also ongoing programmes to enhance adherence to medicines as well as enhance adherence to the Standard Treatment Guidelines and the Essential Medicines List with their increasing availability. In addition, there is a movement to enhance the role of health technology assessment in future decision making. Hospital initiatives include increased focus on reducing antimicrobial resistance through instigating stewardship programmes as well as improving adverse drug reaction reporting and associated activities.Conclusion: Overall, there are an appreciable number of ongoing activities within the public healthcare system in South Africa attempting to ensure and sustain universal healthcare. It is too early to assess their impact, which will be the subject of future research.

Improving active case finding for tuberculosis in South Africa: informing innovative implementation approaches in the context of the Kharitode trial through formative research

BackgroundTuberculosis (TB) is the leading infectious killer worldwide, with approximately 1.8 million deaths in 2015. While effective treatment exists, implementation of active case finding (ACF) methods to identify persons with active TB in a timely and cost-effective manner continues to be a major challenge in resource-constrained settings. Limited qualitative work has been conducted to gain an in-depth understanding of implementation barriers.MethodsQualitative research was conducted to inform the development of three ACF strategies for TB to be evaluated as part of the Kharitode cluster-randomised trial being conducted in a rural province of South Africa. This included 25 semi-structured in-depth interviews among 8 TB patients, 7 of their household members and 10 clinic health workers, as well as 4 focus group discussions (2 rural and 2 main town locations) with 6–8 participants each (n = 27). Interviews and focus group discussions explored the context, advantages and limitations, as well as the implications of three ACF methods. Content analysis was utilised to document salient themes regarding their feasibility, acceptability and potential effectiveness.ResultsStudy participants (TB patients and community members) reported difficulty identifying TB symptoms and seeking care in a timely fashion. In turn, all stakeholder groups felt that more proactive case finding strategies would be beneficial. Clinic-based strategies (including screening all patients regardless of visit purpose) were seen as the most acceptable method based on participants’ preference ranking of the ACF strategies. However, given the resource constraints experienced by the public healthcare system in South Africa, many participants doubted whether it would be the most effective strategy. Household outreach and incentive-based strategies were described as promising, but participants reported some concerns (e.g. stigma in case of household-based and ethical concerns in the case of incentives). Participants offered insights into how to optimise each strategy, tailoring implementation to community needs (low TB knowledge) and realities (financial constraints, transport, time off from work).ConclusionsFindings suggest different methods of TB ACF are likely to engage different populations, highlighting the utility of a comprehensive approach.Trial registrationClinicaltrials.gov (NCT02808507). Registered June 1, 2016. The participants in this formative study are not trial participants.