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.
Equitable health services
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.
The authors of this study set out to identify the progress made by the Tanzanian Ministry of Health and Social Welfare (MOHSW) in achieving the objective it had set in its National Adolescent Health and Development Strategy: 2002–2006, namely to systematise and extend the reach of Adolescent Friendly Health Services (AFHS) in the country. They reviewed plans and reports from the MOHSW and journal articles on AFHS. Results showed that the MOHSW identified four key problems with what was being done to make health services adolescent friendly in the country – firstly, it was not fully aware of the various efforts under way; secondly, there was no standardised definition of AFHS; thirdly, it had received reports that the quality of the AFHS being provided by some organisations was poor; and fourthly, only small numbers of adolescents were being reached by the efforts that were under way. The MOHSW responded to these problems by mapping existing services, developing a standardised definition of AFHS, charting out what needed to be done to improve their quality and expand their coverage, and integrating AFHS within wider policy and strategy documents and programmatic measurement instruments. It has also taken important preparatory steps to stimulate and support implementation. The authors argue that the focus of the effort must now shift from the national to the regional, council and local levels, with substantial and ongoing support from the Ministry.
Timely access within 24 hours to an authorised artemisinin-based combination treatment (ACT) outlet is one of the determinants of effective malaria treatment coverage. In this study, timely access was assessed in two district health systems in rural Tanzania: Kilombero-Ulanga and Rufiji. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data was collected on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. In Kilombero-Ulanga 41.8% and in Rufiji 36.8% of fever cases had access to an authorised ACT provider within 24 hours of fever onset. In neither site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. The poor results fly in the face of government interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. The authors call for more innovative interventions to raise effective coverage of malaria treatment in Tanzania.
The objective of this study was to investigate factors, including uptake of the offer of HIV testing, associated with availability and utilisation of healthcare by TB patients in a rural programme devolved to primary care in Hlabisa sub-district, KwaZulu-Natal. Three hundred TB patients at primary healthcare clinics (PHC) were randomly selected for the study. Most patients (75.2%) received care for a first episode of TB, mainly pulmonary. Nearly all (94.3%) were offered an HIV test during their current TB treatment episode, patients using their closest clinic being substantially more likely to have been offered HIV testing than those not using their closest clinic. About one-fifth (20.3%) of patients did not take medication under observation, and 3.4% reported missing taking their tablets at some stage. Average travelling time to the clinic and back was 2 hours, most patients (56.8%) using minibus taxis. The study demonstrates high HIV testing rates among TB patients and the authors suggest appropriate management of HIV-TB co-infected patients.
Timely tuberculosis treatment initiation and compliance are the two key factors for a successful tuberculosis control programme. However, studies to understand patents’ perspective on tuberculosis treatment initiation and compliance have been limited in Ethiopia. In this qualitative, phenomenological study, researchers conducted 26 in-depth interviews with tuberculosis patients. Results indicated that a lack of geographic access to health facilities, financial burdens, use of traditional healing systems and delay in diagnosis by health care providers were the main reasons for not initiating tuberculosis treatment timely. Lack of geographic access to health facilities, financial burdens, quality of health services provided and social support were also identified as the main reasons for failing to fully comply with tuberculosis treatments. The authors argue that decentralisation of tuberculosis diagnosis and treatment services to peripheral health facilities, including health posts, is of vital importance to make progress toward achieving tuberculosis control targets in Ethiopia.
The objective of this study was to assess the current integration of TB and HIV services in South Africa, using data from 2011. Forty-nine randomly selected health facilities were included, at which interviewers administered a standardised questionnaire to one staff member responsible for TB and HIV in each facility on aspects of TB/HIV policy, integration and recording and reporting. Of the 49 health facilities 35 (71%) provided isoniazid preventive therapy (IPT) and 35 (71%) offered antiretroviral therapy (ART). Among assessed sites in February 2011, 2,512 patients were newly diagnosed with HIV infection, of whom 1,913 (76%) were screened for TB symptoms, and 616 of 1,332 (46%) of those screened negative for TB were initiated on IPT. Of 1,072 patients newly registered with TB in February 2011, 144 (13%) were already on ART prior to TB clinical diagnosis, and 451 (42%) were newly diagnosed with HIV infection. Of those, 84 (19%) were initiated on ART. Primary health clinics were less likely to offer ART compared to district hospitals or community health centres.
South Africa has no policy to prevent malaria in pregnancy, despite the adverse effects of the disease in pregnancy. However, malaria control measures consisting of indoor residual spraying and specific antimalarial treatment have been in place since the 1970s. This study was conducted to determine if the country needs a specific policy for malaria prevention in pregnancy, by determining the burden of malaria in pregnancy in KwaZulu-Natal (KZN) province, South Africa. Pregnant women were enrolled at their first antenatal care visit to three health facilities in Umkhanyakude health district in northern KZN during May 2004-September 2005 and followed up until delivery. Of the 1,406 study participants, 33.2% of the women were anaemic, but this was not related to malaria. The prevalence and incidence of malaria were very low, and low birth weight was only weakly associated with malaria (1:10). In conclusion, the low burden of malaria in these pregnant women suggests that they have benefited from malaria control strategies in the study area. The implication is that additional measures specific for malaria prevention in pregnancy are not required. However, ongoing monitoring is needed to ensure that malaria prevalence remains low.