South African Public Healthcare Research Articles

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.

Access to colorectal cancer (CRC) chemotherapy and the associated costs in a South African public healthcare patient cohort

Reported colorectal cancer incidence is increasing in South Africa and places strain on the public healthcare system especially as costs associated with chemotherapy globally are rising. The exact costs associated with colorectal cancer chemotherapy in South Africa however have not been previously determined. This study aimed to determine the costs of early and advanced colorectal cancer chemotherapy based on the clinical pathways used in the public healthcare sector. A retrospective chemotherapy medicine utilisation review (2012–2014) was conducted at a public healthcare Medical Oncology Clinic and the costs of chemotherapy, administration and concomitant/supportive therapies calculated based on the patient cohort (n=162). These costs were compared to theoretical costs, based on the developed clinical pathways, standard dosages and treatment cycles. First line treatments for early and advanced colorectal cancer comprised mainly of oral capecitabine, either alone or in combination. The medicine utilisation shows the use of capecitabine to be favoured over infusional 5-FU/LV for convenience reasons. Oxaliplatin was usually combined with either fluoropyrimidine (early and advanced disease) however some patients received second line irinotecan albeit was not on the Essential Medicine List at the time. Our findings reflect the complexity of CRC chemotherapy treatment with more pharmacoeconomic and outcomes research required in order to refine the clinical pathways as well as improve access to care in resource constrained settings.

Scrambling for access: availability, accessibility, acceptability and quality of healthcare for lesbian, gay, bisexual and transgender people in South Africa

BackgroundSexual orientation and gender identity are social determinants of health for people identifying as lesbian, gay, bisexual and transgender (LGBT), and health disparities among sexual and gender minority populations are increasingly well understood. Although the South African constitution guarantees sexual and gender minority people the right to non-discrimination and the right to access to healthcare, homo- and transphobia in society abound. Little is known about LGBT people’s healthcare experiences in South Africa, but anecdotal evidence suggests significant barriers to accessing care. Using the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, this study analyses the experiences of LGBT health service users using South African public sector healthcare, including access to HIV counselling, testing and treatment.MethodsA qualitative study comprised of 16 semi-structured interviews and two focus group discussions with LGBT health service users, and 14 individual interviews with representatives of LGBT organisations. Data were thematically analysed within the framework of the UN International Covenant on Economic, Social and Cultural Rights General Comment 14, focusing on availability, accessibility, acceptability and quality of care.ResultsAll interviewees reported experiences of discrimination by healthcare providers based on their sexual orientation and/or gender identity. Participants recounted violations of all four elements of the UN General Comment 14: 1) Availability: Lack of public health facilities and services, both for general and LGBT-specific concerns; 2) Accessibility: Healthcare providers' refusal to provide care to LGBT patients; 3) Acceptability: Articulation of moral judgment and disapproval of LGBT patients’ identity, and forced subjection of patients to religious practices; 4) Quality: Lack of knowledge about LGBT identities and health needs, leading to poor-quality care. Participants had delayed or avoided seeking healthcare in the past, and none had sought out accountability or complaint mechanisms within the health system.ConclusionSexual orientation and gender identity are important categories of analysis for health equity, and lead to disparities in all four dimensions of healthcare access as defined by General Comment 14. Discriminatory and prejudicial attitudes by healthcare providers, combined with a lack of competency and knowledge are key reasons for these disparities in South Africa.

The need for biokineticists in the South African public health care system

Background: Noncommunicable diseases (NCDs) are increasingly prevalent within South Africa. Physical inactivity is a significant, independent and modifiable risk factor increasing the prevalence of NCDs.Discussion: The integration of physical activity programmes into the primary health care system through multidisciplinary platforms is thus advocated for and envisioned to be more cost-effective than current practices. However, currently within the primary health care setting of South Africa, there is an absence of health care professionals adequately equipped to develop and implement physical activity programmes. Biokineticists, whose scope of practice is to improve physical functioning and health through exercise as a modality, are ideally suited to developing and implementing physical activity programmes in the public sector. Yet despite their evident demand, the role of the biokineticist is not incorporated into the national public health care system.Conclusion: This short report calls firstly, for the inclusion of biokinetics into the public health care sector, and secondly, for the funding of multidisciplinary community health programmes supporting education, healthy eating and physical activity levels.

Evaluating the accessibility and utility of HIV-related point-of-care diagnostics for maternal health in rural South Africa: a study protocol

IntroductionPoor healthcare access is a major barrier to receiving antenatal care and a cause of high maternal mortality in South Africa (SA). ‘Point-of-care’ (POC) diagnostics is a powerful emerging healthcare...

The need for biokineticists in the South African public health care system

Background: Noncommunicable diseases (NCDs) are increasingly prevalent within South Africa. Physical inactivity is a significant, independent and modifiable risk factor increasing the prevalence of NCDs. Discussion: The integration of physical activity programmes into the primary health care system through multidisciplinary platforms is thus advocated for and envisioned to be more cost-effective than current practices. However, currently within the primary health care setting of South Africa, there is an absence of health care professionals adequately equipped to develop and implement physical activity programmes. Biokineticists, whose scope of practice is to improve physical functioning and health through exercise as a modality, are ideally suited to developing and implementing physical activity programmes in the public sector. Yet despite their evident demand, the role of the biokineticist is not incorporated into the national public health care system. Conclusion: This short report calls firstly, for the inclusion of biokinetics into the public health care sector, and secondly, for the funding of multidisciplinary community health programmes supporting education, healthy eating and physical activity levels.

Multiprovider and Patient Perspectives on Conveying Diagnostic Imaging Investigation Results in a South African Public Health Care System

IntroductionThis study explored interaction processes in conveying messages about the results of diagnostic imaging investigations in a public hospital complex in South Africa from the perspective of health care providers and patients. MethodsThe study was part of a qualitative inquiry into the interaction and communication processes relating to diagnostic imaging investigations in the public health care system. Data collection included individual interviews with 24 patients and 62 health care providers (ie, medical practitioners, specialists, radiologists, registrars, radiographers, and nurses). In addition, 12 focus group interviews were conducted with health care providers. The transcribed data were coded and analysed to identify categories and themes. ResultsThree main themes emerged from the study. The first theme deals with the medical territory, specifically who should interpret and convey the diagnostic results to the patient. The second theme highlights the role of radiographers and nurses in communicating parts of the diagnostic results. The last theme focuses on patient experience, interpretation, and comprehension in the provider-patient communication process. ConclusionsThe findings provide a multidimensional view about the disclosure of imaging results to patients by medical and nonmedical health care providers. Further research is needed on the role of nonmedical providers in the context of ethical and moral obligation toward patients and the professional restrictions inherent in their scope of practice.

The emotional wellbeing of lay HIV counselling and testing counsellors

The HIV testing, treatment and care programme of the South African public healthcare system depends on HIV counselling and testing (HCT) that is primarily delivered by lay counsellors. Lay counsellors are expected to educate clients about HIV/AIDS, advocate behaviour change, convey test results and support those infected and affected to cope with the emotional and social challenges associated with HIV/AIDS. This research focuses on the emotional wellbeing of lay HCT counsellors because this influences the quality of services they provide. A mixed methods approach was used. The emotional wellbeing, level of burnout, depression and coping style of 50 lay HCT counsellors working at the City of Tshwane clinics were assessed. Additionally, five focus group discussions were conducted. The results showed that HCT counsellors reported average emotional wellbeing, high levels of emotional exhaustion and depression. They had a sense of personal accomplishment and positive coping skills. The results revealed that they may have difficulty dealing with clients’ emotional distress without adequate training and supervision. This creates a dilemma for service delivery. In the light of the important role they play in service delivery, the role of the lay HCT counsellor needs to be reconsidered. HCT should develop as a profession with specific training and supervision to develop their emotional competencies to conduct effective counselling sessions.

Authentic leadership as a source of optimism, trust in the organisation and work engagement in the public health care sector

Orientation: The orientation of this study is towards authentic leadership (AL) and its influence on optimism, trust in the organisation and work engagement of employees in the public health care sector.Research purpose: The objectives of this study were to determine whether the leadership style of AL could predict optimism, trust in the organisation and work engagement amongst a large sample of employees from various functions in public hospitals and clinics in Gauteng and to establish whether optimism and trust in the organisation could mediate the relationship between AL and work engagement.Research approach, design and method: A convenience sample of 633 public health employees from various functions within 27 public hospitals and clinics in the province was used in this research. A cross-sectional research design was implemented. Structural equation modelling was utilised to investigate the Authentic Leadership Inventory (ALI), and the validity and fit of the measurement model, to position AL as a job resource within the nomological net and to test its mediating effects.Main findings: The statistical analysis revealed that AL was a significant predictor of optimism and trust in the organisation and that optimism and trust in the organisation mediated the relationship between AL and work engagement.Practical/managerial implications: The research results suggested that organisations in the public health care sector should encourage their managers to adopt a more authentic leadership style. This will lead to higher levels of optimism, trust in the organisation and eventually work engagement. This will greatly assist employees in the domain of public health care to manage their demanding working environment.Contribution: This study provides evidence that the ALI can be used reliably within the South African context and specifically within the public health care sector. It further substantiates for the implementation of AL as a leadership style in the South African public health care sector, supporting work that has been done internationally in health care where AL has been associated with a number of positive outcomes. Finally, the study puts forward two practical suggestions, on both an individual and an organisational level, to facilitate a culture in which AL can be translated more effectively into an engaged workforce.

The public healthcare sector and governance in South Africa

This article reviews literature on governance in order to facilitate an analysis of the governance of the South African public healthcare sector. Some of the key theoretical perspectives have been presented on how best to organise the state and its bureaucracy. Theorists have long interrogated in what way public institutions foster or impede economic growth. Evans and Rauch point out for example, that the role of bureaucratic authority structures in facilitating economic growth has been a sociological concern since Max Weber’s classic contributions almost 100 years ago. These debates and others are explored in this article with specific reference to the provision of equitable public healthcare. Weber’s theory on rational bureaucracy as well as New Public Management will be reviewed as these theories offer two distinct approaches to governance

Pilot study to detect airborne Mycobacterium tuberculosis exposure in a South African public healthcare facility outpatient clinic

Airborne transmission of Mycobacterium tuberculosis remains an occupational health hazard, particularly in crowded and resource-limited healthcare settings. To quantify airborne M. tuberculosis in a busy outpatient clinic in Gauteng, South Africa. Stationary air samples and samples from healthcare workers (HCWs) were collected in the polyclinic and administrative block. Quantitative real-time polymerase chain reaction (PCR) was used to detect airborne M. tuberculosis. Walkthrough observations and work practices of HCWs were also recorded. In total, M. tuberculosis was detected in 11 of 49 (22.4%) samples: nine of 25 (36%) HCW samples and two of 24 (8.3%) stationary air samples. Samples from five of 10 medical officers (50%) and three of 13 nurses (23%) were positive. Repeat measurements on different days showed variable results. Most of the HCWs (87.5%) with positive results had been in contact with coughing patients and had not worn respiratory masks despite training. The use of air sampling coupled with quantitative real-time PCR is a simple and effective tool to demonstrate the risk of M. tuberculosis exposure. The findings provide an impetus for hospital management to strengthen infection prevention and control measures for tuberculosis.

A critical approach to the development of blended medical communication training materials

Effective communication between doctors and patients improves patient health outcomes (Hewett et al. 2009; Stewart 1995; Watson et al. 2012), and communication skills courses have become an integrated component of the medical curriculum. However, language-discordant contexts are not fully provided for yet, since “[l]anguage support guides (such as the Calgary-Cambridge guides; Silverman et al. 2005) generally target native speakers rather than language learners, and typically mention the use of a second or foreign language as just one of many issues in cross-cultural communication without providing any solutions or prescriptions to address ensuing communication problems” (Gasiorek and Van de Poel 2012:372). In a South African professional healthcare context, communication challenges are manifold because of the number of languages and cultures involved and because of the diverse views on the nature of a medical encounter. South African public healthcare is further hampered by a lack of doctors (KZN Department of Health 2013). Given the need for tailored communication materials, a new vocational training course in Afrikaans as a second language was introduced for first-year medical students at one South African university applying a blended learning approach (i.e. restricted contact teaching and autonomous online learning). To facilitate the development and implementation process, the European project Medics on the Move (MoM) was adapted and adopted as a communication tool. This paper addresses principles and practices underlying the MoM materials as part of the process of adapting the vocational training concept to the specific South African context, needs and learners. The development process is presented as an integral part of a comprehensive needs analysis (Brown 1995), at the end of which new questions and needs are identified. The results corroborate that MoM-SA is a dynamic and effective teaching/learning tool which functions as a language support system that helps build skills for a multilingual professional environment.

Pediatric Physicians' Referral of Children Aged 0-3 Years for Audiological Evaluation in the Public Health Care Sector.

The current study aimed to determine the current practice of pediatric physicians in the referral of children (0-3 years) for further audiological evaluation in the South African public health care sector. Sixty three pediatric physicians comprising of pediatricians, neonatologists, medical officers, registrars and interns from three academic hospitals completed a self- administered questionnaire. Most participants reported referrals to an audiologist when hearing loss was suspected. An average of eight risk factors for hearing loss listed on the Health Professionals Council of South Africa (HPCSA) 2007 position statement were identified by participants, indicating the need for referral. Generally, participants reported that referral/s occurred easily within the respective hospitals. Results highlight that pediatric physicians are aware of the role that audiologists play in the diagnosis and management of hearing loss, are involved in the referral of children that are at risk for hearing loss, and have awareness of some of the known risk factors associated with hearing loss. Further education regarding other risk factors is required in order to increase referral/s, and ensure appropriate referral of children at risk for hearing loss.

Using HPV vaccination for promotion of an adolescent package of care: opportunity and perspectives

BackgroundAdolescents are a difficult population to access for preventive health care, particularly in less resourced countries. Evidence from developed countries indicates that the HPV vaccine schedule may be a useful platform from which to deliver other adolescent health care services. We conducted a qualitative cross sectional study to assess the potential for using the HPV vaccine in the South African public health care system as an opportunity for integrated health care services for adolescents.MethodsParents, young adolescents, community members and key informants participated in interviews and focus group discussions about feasibility and acceptability, particularly the use of the HPV vaccination as the basis for an integrated adolescent package of care. Health care providers in both provinces participated in focus group discussions and completed a pairwise ranking exercise to compare and prioritise interventions for inclusion in an adolescent package of care.ResultsParticipants were in favour of integration and showed preference for detailed information about the HPV vaccine, general health information and specific sexual and reproductive health information. Among health care workers, results differed markedly by location. In North West, prioritisation was given to information, screening and referral for tobacco and alcohol abuse, and screening for hearing and vision. In Gauteng integration with referral for male circumcision, and information, screening and referral for child abuse were ranked most highly.ConclusionsThere is generally support for the delivery of adolescent preventive health services. Despite national priorities to address adolescent health needs, our data suggest that national policies might not always be appropriate for vastly different local situations. While decisions about interventions to include have traditionally been made at country level, our results suggest that local context needs to be taken account of. We suggest low resource strategies for ensuring that national policies are introduced at local level in a manner that addresses local priorities, context and resource availability.

Health information systems to improve health care: A telemedicine case study

Background: E-health has been identified as an integral part of the future of South African public healthcare. Telemedicine was first introduced in South Africa in 1997 and since then the cost of running the Telemedicine projects has increased substantially. Despite these efforts to introduce the system, only 34% of the Telemedicine sites in South Africa are functional at present.Objectives: Literature has suggested that one of the barriers to the successful implementation of health information systems is the user acceptance by health care workers of systems such as Telemedicine. This study investigated the user acceptance of Telemedicine in the public health care system in the Eastern Cape Province, making use of the Unified Theory of the Use and Acceptance of Technology.Method: The study employed a quantitative survey approach. A questionnaire was developed making use of existing literature and was distributed to various clinics around the province where Telemedicine has been implemented. Statistics were produced making use of Statistical Package for the Social Sciences (SPSS).Results: In general, the health care workers did understand the value and benefit of health information systems to improve the effectiveness and efficiency of the health care system. The barriers to the effective implementation of a health information system include the lack of knowledge and the lack of awareness regarding the Telemedicine system. This in turn means that the user is apprehensive when making use of the system thus contributing to less frequent usage.Conclusion: Health care workers do acknowledge that information systems can help to increase the effectiveness of the health care system. In general, the acceptance of Telemedicine in the Eastern Cape Department of Health is positive, but in order to integrate it into standard work practices, more must be done with regards to the promotion and education of telemedicine.

Equity in the use of antiretroviral treatment in the public health care system in urban South Africa

The scaling up of antiretroviral treatment (ART) for HIV-infected adults requires a sizeable investment of resources in the South African public health care system. It is important that these resources are used productively and in ways that reach those in need, irrespective of social status or personal characteristics. In this study we evaluate whether the distribution of ART services in the public system reflects the distribution of need among adults in the urban population. Data from a 2008 national survey were used to estimate the distribution of socioeconomic status (SES) and sex in HIV-positive adults in urban areas. These findings were compared to SES and sex distributions in 635 ART users within 6 urban public ART facilities. Close to 40% of those with HIV are in the lowest SES quintile, while 67% are women. The distributions in users of ART are similar to these distributions in HIV-positive people. Patterns of ART use in study settings correspond to patterns of HIV in the urban population at the national level. This suggests that the South African ART programme is on track to ensure equitable delivery of treatment services in urban settings.

‘Want private sector help? Make State health care managers accountable’

Well-off government health care managers are neither directly affected by the dysfunctional public system they run nor are they held accountable for ‘deliverables’, leaving them with ‘absolutely no incentive’ to partner with the private sector. That’s the opinion of Dr Kgosi Letlape, a former President of the World Medical Association, who founded the HIV/AIDS NGO, the Tshepang Trust, during his recent 9-year tenure as Chairman of the South African Medical Association (SAMA). The Tshepang Trust was set up by SAMA almost a decade ago to initially address, in Letlape’s words, ‘the duality of some people having any treatment they want on one side, and a policy of non-(AIDS) treatment on the other’. Izindaba learnt that the Trust’s struggles to bring its private expertise to the public health care delivery table have made little progress in spite of a dramatic change in government HIV/AIDS policy and a massive health testing and counselling campaign. Letlape believes that if South African public health care managers were held accountable for delivering measurable services, their reluctance to accept private sector offers of help would undergo a sudden transformation. He said the ‘crux of the matter’ was that public sector facility managers were not judged on delivering services to people, nor were they dependent on the services they ran for their own health care. ‘So if it’s not a deliverable in terms of their job and they’re not personally affected by the lack of care, how do we expect them to engage with us?’ he asked.

Rheumatoid arthritis functional disability in a public health care clinic

Median scores for public and private health care patients with RA in the USA range between 1 and 1.25 3 compared with 1.6 for South African public health care patients, 4 indicating more severe disability in our public health care sector. Although the goal of health care for patients with RA is to maximise functioning in everyday life, functional disability is rarely assessed in South African public health care facilities. Owing to staff shortages and resources, patient overload and poor staff morale in South African public health facilities, routine administration of the HAQ-DI by existing staff is extremely difficult to implement. We administered the HAQ-DI to a consecutive sample of 108 outpatients with RA at Pretoria Academic Hospital.

The Need for Tighter Rheumatoid Arthritis Control in a South African Public Health Care Center

Medical facilities are restricted in public health care centers in South Africa and patients that enroll in these centers are socioeconomically deprived. We investigated the impact of rheumatoid arthritis (RA) on disability in both a public health care and a private care center. The disability index of the Health Assessment Questionnaire (HAQ-DI) and an extensive range of disease and non-disease-related patient characteristics were recorded in 359 RA subjects, 196 public care and 163 private care patients. We compared the data between both patient groups and identified potential predictors of the HAQ-DI by univariate and multivariable logistic regression analysis. The median (range) HAQ-DI was 1.625 (0 to 3) in the public care patients and 0.500 (0 to 3) in the private care patients (P < 0.0001). As compared with private care patients, public care patients were more often African (P < 0.0001) and of mixed ancestry (P < 0.01) and less often White (P < 0.0001). Public care patients also had higher current disease activity scores (P < 0.0001) (except for tender joint counts and the erythrocyte sedimentation rate), higher cumulative disease activity or disease severity scores (joint deformities) (P < 0.0001), a higher frequency of tuberculosis (P < 0.01), and were more often treated with prednisone (P < 0.0001). In multivariable logistic regression models, a HAQ-DI of >1 was independently predicted by current disease activity (swollen joint count) (P < 0.004), cumulative disease activity (joint deformities) (P < 0.005), being under public care (P < 0.008), and prednisone use (P < 0.04). Racial differences were not independently predictive of disability. Results of disease outcome measurements were poorer in our public care patients than in our private care patients. Facilities that allow for tighter disease activity control of RA are needed in South African public care centers.