The authors of this study undertook a programme evaluation of HIV and TB prevention and therapeutic services at facility level in South Africa to describe integration and how it is implemented. They evaluated 26 rural and 146 urban public primary-care facilities using secondary data generated from December 2008 and May 2009. Evidence of integration was found across two dimensions: disease programmes and the prevention–therapeutic axis. Smaller rural facilities did not always have staff trained in all the required services, nurses worked without the support of a doctor and supervision was weaker, threatening quality of care. However, in the rural district there were instances of clients receiving more integrated services. The quality of care in the TB programme was high in both districts. In both the districts evaluated, integration across programmes and the prevention-care-rehabilitation axis of services was achieved through co-location at primary-care level. Coupled with health system strengthening, this has the potential to improve access across the HIV/TB/STI cluster of services. The benefit is likely to be greater in rural areas. Quality of care was maintained in the long-established TB programmes in both settings.
Equitable health services
Little is known about the health conditions and support needs of people living with intellectual disability (ID) in the African context. To address this gap, the authors conducted this study in residential facilities in the Western Cape Province, South Africa, for people over the age of 18 years with ID. They conducted in face-to-face interviews with the managers of 37 out of 41 identified facilities, as well as a survey of 2,098 residents (54% of them female), representing less than 2% of the estimated population of persons with ID in the province. The survey suggests that such persons experience a wide range of health conditions (notably mental health and behavioural issues) but have limited access to general healthcare and rehabilitation services. Furthermore, the daily living supports required for an acceptable quality of life are limited. The findings highlight the need for better health and support provision to persons with ID.
The authors of this paper hypothesised that just as integrated antenatal and maternity services have contributed to improved care for HIV-positive pregnant women, so too could integrated care for mother and infant after birth improve follow-up of HIV-exposed infants. They present results of a study testing the viability of such integrated care, and its effects on follow-up of HIV-exposed infants, in Tete Province, Mozambique. Between April 2009 and September 2010, we conducted their study in six rural public primary healthcare facilities and found that one-stop, integrated care for mother and child was feasible in all participating healthcare facilities, and staff evaluated this service organisation positively. They observed in both study groups an improvement in follow-up of HIV-exposed infants (registration, follow-up visits, serological testing) but despite these improvements, no progress attributable to one-stop, integrated MCH services was observed. Structural healthcare system limitations, such as staff absences and an irregular supply of essential commodities, appear to have a larger effect. Regular technical support and adequate basic working conditions form valuable motivators and are of critical importance for improved staff performance in the follow-up of HIV-exposed infants in peripheral public healthcare facilities in Mozambique.
Malaria importation from neighbouring high-endemic Mozambique through Swaziland’s eastern border remains a major factor that could prevent elimination from being achieved. A nationwide formative assessment was conducted over eight weeks to determine if the imported cases of malaria identified by the Swaziland National Malaria Control Programme could be linked to broader social networks and to explore methods to access these networks. Interviews were carried out with malaria surveillance agents (6), health providers (10), previously identified imported malaria cases (19) and people belonging to the networks identified through these interviews (25). Network members and key informants revealed common congregation points, such as the urban market places in Manzini and Malkerns, as well as certain bus stations, where people with similar travel patterns and malaria risk behaviours could be located and tested for malaria. The authors of this study conclude that imported cases of malaria belong to networks of people with similar travel patterns. This study may provide novel methods for screening high-risk groups of travellers using both snowball sampling and time-location sampling of networks to identify and treat additional malaria cases. The authors argue that implementation of a proactive screening programme of importation networks may help Swaziland halt transmission and achieve malaria elimination by 2015.
In this study, the authors collected data as part of a multi-site cross sectional study, Researching Equity in Access to Healthcare (REACH), to examine HIV testing coverage in tuberculosis (TB) patients. They administered a structured questionnaire to 300 patients accessing TB treatment in five rural primary health care clinics in Hlabisa subdistrict, KwaZulu-Natal, South Africa, a high TB and HIV burden area. Results showed high HIV testing rates among TB patients, suggesting that TB-HIV co-infected patients can be managed appropriately for treatment of both infections. The decentralised programme appears largely successful in attaining universal HIV testing in TB patients in this resource-limited setting. However, there is scope for further improvement such as in DOTS delivery, which is a sustainable and effective way of ensuring good adherence to TB treatment, the authors argue. Patients mostly use the closest clinic for both TB treatment and HIV testing, suggesting a receding fear of stigma of HIV. But the small number of patients not using the closest clinic are far less likely to undergo HIV testing, possibly indicating vulnerability expressed both in the location of seeking TB treatment and HIV testing uptake. Policy makers should encourage integration of services and cross-testing in HIV-TB facilities, the authors conclude.
In this study, researchers describe the approaches to defining and improving quality of health services across the five country programmes funded through the Doris Duke Charitable Foundation African Health Initiative. They describe the differences and similarities across the programmes in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programmes measured quality across most or all of the six WHO building blocks, with specific areas of overlap in improving quality falling into four main categories: 1) defining and measuring quality; 2) ensuring data quality, and building capacity for data use for decision making and response to quality measurements; 3) strengthened supportive supervision and/or mentoring; and 4) operational research to understand the factors associated with observed variation in quality. Learning the value and challenges of these approaches to measuring and improving quality across the key components of health system strengthening as the projects continue their work, the authors conclude.
The PHIT Partnership’s health systems support aligns with the World Health Organisation’s six health systems building blocks. Health system strengthening (HSS) activities focus across all levels of the health system to improve health care access, quality, delivery, and health outcomes. Interventions are concentrated on three main areas: targeted support for health facilities, quality improvement initiatives, and a strengthened network of community health workers. The impact of health system strengthening activities will be assessed using population-level outcomes data collected through oversampling of the demographic and health survey (DHS) in the intervention districts. The overall impact evaluation is complemented by an analysis of trends in facility health care utilisation. A comprehensive costing project captures the total expenditures and financial inputs of the health care system to determine the cost of systems improvement. Building on early successes, the work of the Rwanda PHIT Partnership approach to HSS has already seen noticeable increases in facility capacity and quality of care. The rigorous planned evaluation of the Partnership’s HSS activities will contribute to global knowledge about intervention methodology, cost, and population health impact.
In this paper, the authors explore affordability, availability and acceptability barriers to obstetric care in South Africa from the perspectives of women who had recently used, or attempted to use, these services. Between June 2008 and September 2009, they conducted a mixed-method study combining 1,231 quantitative exit interviews with 16 qualitative in-depth interviews with women in two urban and two rural health sub-districts in South Africa. Barriers were found to be unequally distributed, with differences between socioeconomic groups and geographic areas being most important. Rural women faced the greatest barriers, including longest travel times, highest costs associated with delivery, and lowest levels of service acceptability. Negative provider-patient interactions also inhibited access and compromised quality of care, including staff inattentiveness, turning away women in early labour, shouting at patients and insensitivity towards those who had experienced stillbirths. To move towards achieving its Millennium Development Goals, the authors argue that South Africa cannot just focus on increasing levels of obstetric coverage, but must systematically address the access constraints facing women during pregnancy and delivery.
In 2007, the Doris Duke Charitable Foundation approved $60 million for the African Health Initiative to support a small portfolio of diverse approaches to health systems strengthening over a period of five to seven years (until 2015). Five projects in sub-Saharan countries were selected. While the Partnerships have all drawn on the World Health Organisation’s six building blocks approach to health systems strengthening, implementation has shown that dynamic, interactive elements of the system are not reflected in the six building blocks, specifically the important role of communities in promoting their own health, nor the growing role of community health workers in primary health care delivery. While not designed to address this question, the interventions offer a range of strategies. Some community health workers undergo several months of training, others just a few weeks. The cadres are drawn varyingly from the communities they serve and have different levels of educational attainment. Their connection to the formal health sectors varies —some are volunteers, others are employees, others received compensation but are not salaried. In addition, whether households are approached singly or through a community mobilisation process also varies. These variations offer a chance to reflect on how different approaches may have a bearing on implementation.
The BHOMA project is being carried out 42 primary health care facilities that serve a largely rural population of more than 450,000 in Zambia’s Lusaka Province. It has deployed six QI teams to implement consensus clinical protocols, forms, and systems at each site. The QI teams define new clinical quality expectations and provide tools needed to deliver on those expectations. They also monitor the care that is provided and mentor facility staff to improve care quality. The programme engages community health workers to actively refer and follow up patients. Project implementation occurs over a period of four years in a stepped expansion to six randomly selected new facilities every three months. The patient-provider interaction is an important interface where the community and the health system meet. This project aims to reduce population mortality by substantially improving this interaction. Success hinges upon the ability of mentoring and continuous QI to improve clinical service delivery. It will also be critical that once the quality of services improves, increasing proportions of the population will recognise their value and begin to utilise them.