South African Public Healthcare Research Articles

Survival of South African children with cerebral palsy.

The South African (SA) public healthcare sector has experienced a surge in birth injury claims in recent years, particularly in respect of cerebral palsy (CP). The lump sum settlements in these matters are a function of the expected survival curve of the individual concerned. It is known from international studies that the life expectancy of children with CP is shorter than that of the general population, and depends on the pattern and severity of their disabilities. However, empirical estimates of survival for children with CP in SA are not available. To construct survival curves according to the pattern of gross motor skills for CP children in SA and compare these with international studies. We collected data on mortality and functional status for 339 CP childrenon whose behalf claims for medical negligence had been instituted. Motor disabilities were classified according to the five-level Gross Motor Function Classification System (GMFCS). Children who were unable to walk unaided were further classified according to more basic motor skills, including the ability to lift their heads or chests in the prone position, rolling and sitting. Mortality rates were calculated and survival curves were estimated using the Kaplan-Meier method. No deaths were observed among 119 children in GMFCS levels I - IV. Among the 220 children in GMFCS V, there were 20 observed deaths. The proportions surviving to ages 10 and 15 years were 85% (standard error (SE) 5%) and 55% (SE 11%), respectively. The former is comparable to what has been reported for children in California and Sweden, but the survival to age 15 is lower. Among 82 children who could not lift their heads in the prone position, there were 11 observed deaths for a mortality rate of 48.5 (95% confidence interval (CI) 24.2 - 86.9) deaths per 1 000 person-years. Among 72 children who could lift their heads but not their chests, there were 6 observed deaths for a mortality rate of 33.5 (95% CI 12.3 - 73.0) deaths per 1 000 person-years. These mortality rates are 22% and 15% higher than the corresponding figures documented for children with comparable abilities and disabilities in California. Life expectancy of children with CP in SA is lower than that of children with comparably severe disabilities in high-income countries.

The strategic development and strengthening of the profession of biokinetics

Continuous planning for the future of any profession is wise. The profession of biokinetics has made remarkable advances since the 1980s. However, new opportunities for development need to be embarked on. This short commentary explores three such areas: training and education; entry into the South African public healthcare system; and interprofessional healthcare collaboration. The intention is to encourage the Biokinetics Association of South Africa and biokineticists to work together to attain these goals, thereby strengthening the profession.

Palliative care for children with cancer in South Africa

At the Red Cross War Memorial Children's Hospital in Cape Town, South Africa, an innovative psychosocial and spiritual collaboration for children with cancer and their families was established in 2012 from a mixture of public and non-governmental organisations, and private sources. This care service integrates carers and resources to address the dearth of child psychiatrists, psychologists, and other integrated therapists in the South African public health care system, providing an opportunity for more complex psychological support.

A review of South African Public Healthcare policies addressing Service Delivery for wheelchairs through a Primary Health Care lens

ABSTRACT INTRODUCTION: In some areas of South Africa, people with impaired mobility are known to have difficulty accessing wheelchairs. This study aimed to critically appraise public healthcare policies addressing service delivery in terms of assistive devices in general, and more specifically wheelchairs within primary health care METHOD: South African public healthcare policies that address assistive device service delivery were identified and thematically analysed using retrospective deductive document analysis. The themes used correspond to the WHO guidelines for the provision of wheelchairs within the context of the guiding principles of primary health care i.e., accessibly, affordability, acceptability, appropriateness, and availability. An analysis was undertaken on how the provision of assistive devices under these principles was addressed RESULTS: Three policies were identified addressing assistive device service delivery i.e. The National Rehabilitation Policy, The Policy Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015 - 2020, and the National Health Insurance Policy. The National Rehabilitation Policy addressed the majority of the WHO guiding principles on wheelchair provision. Guidelines for non-discriminatory and evidence-based service delivery and the availability of assistive devices were identified in all the documents. Scant attention was paid to service delivery of assistive devices for people residing in urban or peri-urban areas. There was a paucity of guidance on service delivery to people with impaired mobility who were unable to access health services, those unaware of the services available and those who were not aware of the benefits of an assistive device CONCLUSION: The policies, viewed together, addressed all the WHO guiding principles, although some gaps were observed in each policy. A proposal emanating from this review was that an update of the National Rehabilitation Policy would address these deficiencies Keywords: assistive devices, health policy, impaired mobility, disability, rehabilitation

Information Needs of Black Prostate Cancer Patients Receiving Treatment Within the South African Public Healthcare System.

IntroductionProstate cancer is the leading cancer type in black South African men. The South African public healthcare sector serves more than 84% of the population, which includes many of these men. Previous evidence suggests that patients’ information needs are influenced by culture. No studies could be found that explored the information needs of black men diagnosed with prostate cancer in a developing country from the patients’ perspectives. Therefore, this study set out to investigate the information needs of black men diagnosed with prostate cancer in a South African public healthcare setting.MethodsNine participants who had completed a radical course of external beam radiation therapy for prostate cancer were interviewed. These participants had gained experience from their cancer journey in this setting and could therefore provide information-rich perspectives about their information needs from the time of diagnosis to end of treatment. Interviews were conducted in the participants’ preferred language, with three interviews conducted in Zulu with an English translator.ResultsImportant themes that emerged included patients' desire to receive more information regarding what was happening in the diagnosis stage, the implications of having prostate cancer and the origin of their symptoms. The participants expressed a need to understand the potential side effects of radiation therapy, the reason for bladder filling and on-treatment set-up imaging verification. Participants also wanted to know how they should care for themselves and adjust their lifestyles, and required more information about follow-up tests and appointments.ConclusionIn South Africa, black men with prostate cancer expressed the need for more information about the implications of a prostate cancer diagnosis, the reasons for these treatments and what they were expected to do. They also require information about where to go and what will happen in the different parts of the healthcare system with regard to the diagnosis and treatment of the prostate cancer. Communities should also be educated about cancer to avoid misconceptions. In South Africa, healthcare workers should consider the life-worlds of black men in the public healthcare system when attending to their information needs.

ASSESSING THE LEVEL OF PATIENT SATISFACTION ON PUBLIC HEALTHCARE FACILITIES IN SOUTH AFRICA

Purpose of study: The purpose of this study was to assess patient satisfaction levels within South African public healthcare facilities. The influence of gender and ethnic grouping (race) perceptions of satisfaction of healthcare services was investigated.
 Methodology: The study followed a cross-sectional research design and a quantitative research method. The data was collected as part of the General Household Survey in 2018 by Statistics South Africa (the national statistics service of South Africa). Descriptive statistics and cross-tabulation were performed to address the research objectives of the study.
 Main findings: The results show that the majority of the patients who participated in the survey are satisfied with the public healthcare service they received. The leading provinces that achieved very satisfied patients are Limpopo, the Eastern Cape, Mpumalanga, KwaZulu-Natal, and Gauteng.
 Applications of the study: The study is important in many ways as it highlights the discrepancies of healthcare provision to the public health decision-makers. For example, the results show that generally, the male patients were slightly more satisfied with the healthcare services than their female counterparts. In terms of ethnic grouping, it appears that white patients are generally more satisfied with the public healthcare services they receive than other race groups.
 Novelty/originality of study: A study of this nature has not been conducted in South Africa apart from the anecdotal reports of the department of health and Statistics South Africa. The study delved to analyze the public healthcare service in all provinces of the republic and also provided insight into gender and racial perception of healthcare services in the country.

Affordable digital innovation to reduce SARS-CoV-2 transmission among healthcare workers.

In the South African public healthcare sector, patient medical records are still written on paper and stored in filing rooms. There has been an attempt to move towards a paperless electronic system in many public healthcare facilities, but owing to lack of funding, this has been a challenge to achieve. During the current COVID-19 pandemic, the virus could be transmitted through the physical manipulation of patient records by various categories of staff who handle the records with or without gloves for protection. We discuss a digital option that has been partially used at Tygerberg Hospital (TBH), Cape Town, to avoid SARS-CoV-2 patient hard-copy record manipulation. It includes assignment of a QR code to every patient admitted as a person under investigation or confirmed COVID-19 case. The QR code is synced to one of the many free online medical notes smartphone applications (apps), which are password-protected with patient information privacy regulations (Trello is used at TBH), for daily medical notes review and editing. Upon discharge, all notes made during the patient's hospital stay, together with the discharge summary, are printed to generate a hard copy of notes for filing to avoid violation of the current national and provincial patient records policy. Doing this means that a patient will have a virtual online file through the designated app until discharge, when a physical file will be made for storage and safekeeping. It will keep physical manipulation of patient records to the minimum, and potentially assist in reducing transmission of the SARS-CoV-2 virus among healthcare workers.

The Albertina Sisulu Executive Leadership Programme enhancing the competencies and performance of public health service managers in South Africa

PurposeThe purpose of this paper is to evaluate the effect of the Albertina Sisulu Executive Leadership Programme in Health (ASELPH) in improving the competencies and performance of public healthcare managers in South Africa (SA).Design/methodology/approachThis study used a quasi-experimental study design, with pre-post assessments to assess the performance and competencies of students participating in a public health leadership programme. Students were assessed using a 360° assessment of 14 competencies and 56 performance indicators.FindingsStudents improved significantly in 11 competencies and 44 performance indicators; they perceived improvements in their own performance. The assessors observed the same improvements, which confirmed performance change at the students’ workplaces. The study showed the positive effect of the ASELPH Fellowship in improving the competencies and performance of public healthcare managers in SA.Originality/valueThe ASELPH Fellowship enhanced the leadership competencies and the performance of South African public healthcare managers. South African public healthcare managers face significant challenges and concerns have been raised regarding the competencies of healthcare managers to deal with these challenges. This study shows that leadership programmes can improve competencies and performance of managers to have an impact on the South African healthcare system

Use of simulated patients to assess hypertension case management at public healthcare facilities in South Africa.

Our study aims to evaluate hypertensive case management in South Africa's public health sector using simulated patients. Our study describes interactions between hypertensive simulated patients and primary healthcare workers at 39 public sector healthcare facilities in two metropolitan centres in the Eastern and Western Cape Provinces of South Africa. Our analysis focus on 97 interactions where our eight simulated patients tested within range for stage 1 hypertension, that is with SBP 140-159 mmHg and/or DBP 90-99 mmHg. For this subset, we describe how healthcare workers communicated the outcome of the blood pressure test, and whether they follow government guidelines on risk assessment and lifestyle advice. Healthcare workers highlighted the risks associated with hypertension in one out of three cases and stressed the importance of regular monitoring of blood pressure in less than half of cases. Hypertensive patients received advice on all six lifestyle risk factors in 8% of cases. 39% of patients received no lifestyle advice at all. In one out of four cases, hypertensive patients left the facility without a hypertension diagnosis and with no prospect of a follow-up visit. Simulated patients can assess the quality of hypertension case management, yielding granular and comprehensive information that can help mobilize resources to improve care. The management of hypertension patients in South African public healthcare facilities is critically insufficient. Given that hypertension is responsible for a rising share of deaths in South Africa and many of these deaths are preventable, urgent intervention is needed.

Ethical dilemmas in paediatric intensive care in the South African public healthcare sector

The shortage of resources in the public healthcare sector in South Africa (SA) means that healthcare providers face difficult choices in terms of rationing of care. This is particularly challenging in paediatrics. This article reviews the ethical and legal issues that arise in this regard. Principlism is the ethical framework most commonly used by clinicians, but perhaps other approaches, such as the ethics of caring, and ubuntu , would be more appropriate for the SA situation.

Estimating the future health care cost of population aging in South Africa

ABSTRACTThis paper analyses the relationship between health care expenditure and population aging in South Africa using yearly data from 1983 to 2015. Empirical evidence from an Autoregressive Distributed Lag approach to cointegration indicates that old dependency and life expectancy are major drivers of public health expenditure in South Africa besides the income. Particularly, when structural breaks are controlled for, income exhibits a long-term elasticity with respect to health spending greater than unity; suggesting that South African public health care has become a luxury good over time. Interestingly, South African public health spending is found to be responsive to demographic development only in the long run. This is consistent with the micro evidence that health expenditure increases with individual age with significant impacts in the long term. Finally, using economic and demographic projections statistics, we find that public health expenditure could roughly double in the next fifteen years ceteris paribus.

Exploring women's preferences for HPV-based cervical cancer screening in South Africa.

To determine preferences for HPV-based cervical cancer screening among South African women. A discrete choice experiment survey was conducted among 298 women who attended two public-sector clinics in South Africa from February 1 to May 31, 2018. Participants chose between hypothetical screening scenarios: method of swab collection (self or provider); timing of treatment (same day or return visit); type of clinic (static or mobile); cost of services (US $0 or US $4); and time spent at the clinic (30, 60, or 120minutes). A logistic regression model was generated to evaluate the importance of each attribute. A market simulation analysis was performed to determine potential uptake of the various screening strategies. The participants expressed strong preferences for free services (β=0.50; P<0.001) and same-day HPV testing and treatment (β=0.40; P<0.001). The market simulation indicated that 83.8% of women would be willing to undergo screening if services were free; the swab was collected by the provider; and treatment was offered at a return visit. Including same-day testing and treatment in the model increased uptake to 96.4%. Offering same-day HPV testing and treatment could substantially improve uptake of cervical cancer screening in the South African public healthcare sector.

THE DEVELOPMENT OF A HEALTHCARE INNOVATION ADOPTION READINESS ASSESSMENT TOOL (HIARAT)

A disconnect exists between innovations and the adoption of such innovations, specifically within healthcare facilities. This disconnect results in various healthcare challenges — ones that could be addressed by successfully adopting and integrating an innovation into organisational processes — not being addressed. To address the challenge of innovation adoption within healthcare, it is proposed that a tool be developed to identify areas that should be addressed to improve the chances of the successful adoption and integration of innovations into existing systems in a publichealthcare facility. By assessing a facility’s readiness for innovationadoption, it is possible to identify the barriers to the successful adoption of innovations. Knowing what such challenges or barriers to innovation adoption are will allow role players to address these challenges or barriers. The purpose of this paper is to develop the healthcare innovation adoption readiness assessment tool (HIARAT), which measures the maturity of a healthcare facility’s innovationadoption process. The HIARAT was validated through a face validation workshop, and through a case study at a South African public healthcare facility.

PACS Implementation Challenges in a Public Healthcare Institution: A South African Vendor Perspective.

ObjectivesConventional radiological processes have been replaced by digital images and information technology systems within South Africa and other developing countries. Picture Archiving and Communication Systems (PACS) technology offers many benefits to institutions, medical personnel and patients; however, the implementation of such systems can be a challenging task. It has been documented that South Africa has been using PACS for more than a decade in public hospitals with moderate success. The aim of this study was to identify and describe the PACS challenges endured by PACS vendors during implementation in the South African public healthcare sector.MethodsThis was achieved by engaging in a methodological approach that was qualitative in nature collecting data through semi structured interviews from 10 PACS experts/participants which were later analysed qualitatively.ResultsThe findings show that PACS vendors have countless challenges, some of which include space, insufficient infrastructure, image storage capacity, system maturity and vendor related concerns. It was clear that the PACS experts readily offered contextually appropriate descriptions of their encounters during PACS implementations in South African public healthcare institutions.ConclusionsPACS vendors anticipate these challenges when facing a public healthcare institution and it is recommended that the hospital management and potential PACS stakeholders be made aware of these challenges to mitigate their effects and aid in a successful implementation.

Managing and Valuing Diversity in the South African Public Healthcare System

Managing and Valuing Diversity in the South African Public Healthcare System

Standardising evidence strength grading for recommendations from multiple clinical practice guidelines: a South African case study

BackgroundSignificant resources are required to write de novo clinical practice guidelines (CPGs). There are many freely-available CPGs internationally, for many health conditions. Developing countries rarely have the resources for de novo CPGs, and there could be efficiencies in using CPGs developed elsewhere. This paper outlines a novel process developed and tested in a resource-constrained country (South Africa) to synthesise findings from multiple international CPGs on allied health (AH) stroke rehabilitation.MethodsMethodologists, policy-makers, content experts and consumers collaborated to describe the pathway of an ‘average’ stroke patient through the South African public healthcare system and pose questions about best-practice stroke rehabilitation along this pathway. A comprehensive search identified international guidance documents published since January 2010. These were scanned for relevance to the South African AH stroke rehabilitation questions and critically appraised for methodological quality. Recommendations were extracted from guidance documents for each question. Strength of the body of evidence (SoBE) gradings underpinning recommendations were standardised, and composite recommendations were developed using qualitative synthesis. An algorithm was developed to guide assignment of overall SoBE gradings to composite recommendations.ResultsSixteen CPGs were identified, and all were included, as they answered different project questions differently. Methodological quality varied and was unrelated to currency. Seven clusters, outlining 20 composite recommendations were proposed (organise for best practice rehabilitation, operationalise strategies for best practice communication throughout the patient journey, admit to an acute hospital, refer to inpatient rehabilitation, action inpatient rehabilitation, discharge from inpatient rehabilitation and longer-term community-based rehabilitation).ConclusionThe methodological development process, tested by writing a South African AH stroke rehabilitation guideline from existing evidence sources, took 9 months. The process was efficient, collaborative, effective, rewarding and positive. Using the proposed methods, similar synthesis of existing evidence could be conducted in shorter time periods, in other resource-constrained countries, avoiding the need for expensive and time-consuming de novo CPG development.

Oral anticoagulants and atrial fibrillation: A South African perspective.

This review evaluates the current literature on available oral anticoagulants and atrial fibrillation with specific relevance to the South African (SA) public healthcare sector, focusing on the pharmacology and monitoring of anticoagulants, current guidelines, initiation of treatment and risk stratification, effectiveness of treatment, cost-effectiveness and specific costing implications. The direct-acting oral anticoagulants (DOACs) are superior to warfarin, with dabigatran being the preferred treatment option in patients with non-valvular atrial fibrillation (NVAF). Warfarin is still the preferred anticoagulant in patients with renal failure and prosthetic heart valves and is still the most cost-effective anticoagulant in the SA public sector setting. There is a growing body of evidence that demonstrates the advantages of DOACs over warfarin in NVAF. Warfarin will remain the anticoagulant of choice until cheaper generic DOACs become available.

Employer-generated complaints to the statutory registration authority: The regulatory framework for the supervision of employed health professionals in the South African public sector

Work as an employed health professional comes with a great number of challenges. Health professionals are often oblivious to the legal and regulatory framework that governs their employment situation. At least three legal frameworks are of relevance in each employer-employee relationship in the South African public healthcare sector, namely the Labour Relations Act, the Public Service Act and the profession-specific Acts such as the Health Professions Act, the Nursing Act or the Pharmacy Act, respectively. Starting with two cases where the profession-specific Act has been used by the employer against the employed health professional, rather than the legislation regulating the employer-employee relationship, it will be illustrated how the three Acts and their regulatory environment are structured. Based on this illustration, the impact that the creation of employer-generated complaints has on the employer-employee relationship, and on the system at large, will be discussed.

Early hearing detection and intervention: Reflections from the South African context

For researchers and clinicians in developing contexts like South Africa, the establishment of universal newborn hearing screening (UNHS) programmes is something which we have strived to achieve. However, we need to ask the question as to whether we have attempted to view our ultimate goal of achieving mandated UNHS programmes from the perspective of the South African healthcare system as a whole. The current manuscript is aimed at providing an overview of audiological services within a broader context, with reflections from a South African perspective, and a suggestion to consider alternatives to UNHS, particularly in the South African public health care sector.

Factors associated with recent unsuppressed viral load in HIV-1-infected patients in care on first-line antiretroviral therapy in South Africa.

Unsuppressed viral load (VL) in patients on antiretroviral therapy (ART) occurs when treatment fails to suppress a person's VL and is associated with decreased survival and increased HIV transmission. The objective of this study was to evaluate factors associated with unsuppressed VL (VL > 400 copies/ml) in patients currently in care on first-line ART for ≥ 6 months attending South African public healthcare facilities. We analysed electronic medical records of ART patients with a VL result on record who started ART between January 2004 and April 2016 from 271 public health facilities. We present descriptive and multivariable logistic regression for unsuppressed VL at last visit using a priori variables. We included 244,370 patients (69% female) on first-line ART in April 2016 for ≥ 6 months. Median age at ART start was 33 years (7% were < 15 years old). Median duration on ART was 3.7 years. Adjusting for other variables, factors associated with having an unsuppressed VL at the most recent visit among patients in care included: (1) < 15 years old at ART start (adjusted odds ratio [aOR]=2.58; 95% CI = 2.37, 2.81) versus 15-49 years at ART start, (2) male gender (aOR = 1.29; 95% CI = 1.25, 1.35), (3) 6-12 months on ART versus longer (aOR = 1.34; 95% CI = 1.29, 1.40), (4) on tuberculosis (TB) treatment (aOR = 1.78; 95% CI = 1.48, 2.13), and (5) prior ART exposure versus none (aOR = 1.20; 95% CI = 1.08, 1.32). Approximately 85% of the ART cohort who were in care had achieved viral suppression, though men, youth/adolescents, patients with prior ART exposure, those with short duration of ART, and patients on TB treatment had increased odds of not achieving viral suppression. There is a need to develop and evaluate targeted interventions for ART patients in care who are at high risk of unsuppressed VL.