Clinic and hospitals in the public sector in South Africa are stretched, but the author argues that this is not because of immigrants as is being proposed in some quarters, but because of understaffing, poor planning and other problems. A 2018 World Bank study showed that between 1996 and 2011, every immigrant worker generated two jobs for South Africans, mostly because their diverse skill sets led to productivity gains and multiplier effects. Immigrants also contribute to the national fiscus through payment of VAT and purchase goods and services, such as rent, from South Africans. The author calls for xenophobic blaming of foreigners to be resisted and for South Africans to see this for what it is: scapegoating of immigrants to hide domestic failures
Equitable health services
This paper addresses the relationship between knowledge about cervical cancer, attitudes, self-reported behavior, and immediate support system, towards screening and vaccination of cervical cancer of Zambian women and men, as a basis for improving and adjusting existing prevention programs. A cross-sectional mixed methods study was conducted with women and men residing in Chilenje and Kanyama, Zambia. Less than half of the respondents had heard of cervical cancer, 20.7% of women had attended screening and 6.7% of the total sample had vaccinated their daughter. Knowledge of causes and prevention was very low. There was a strong association between having awareness of cervical cancer and practicing screening and vaccination. Social interactions were also found to greatly influence screening and vaccination behaviors. The low level of knowledge of causes and prevention of cervical cancer suggests a need to increase knowledge and awareness among both women and men. The authors note that interpersonal interactions have great impact on practicing prevention behaviors.
This paper investigated the association between maternal overweight and obesity and caesarean births in Malawi. The authors utilised cross-sectional population-based Demographic Health Surveys data collected from mothers aged 18–49 years in 2004/05, 2010, and 2015/16 in Malawi. The results showed that maternal overweight in 2015/16 and from 2004 to 2015 were risk factors for caesarean births in Malawi. Women who had one parity, and lived in the northern region were significantly more likely to have undergone caesarean birth. In order to reduce non-elective caesarean birth in Malawi, the authors propose that public health programs focus on reducing overweight and obesity among women of reproductive age.
This paper investigated socio-demographic inequities in cervical cancer screening and utilization of treatment among women in Harare, Zimbabwe. Two cross sectional surveys were conducted in Harare with a total sample of 277 women aged at least 25 years from high, medium, low density suburbs and rural areas. Only 29% of women reported ever screening for cervical cancer. Cervical cancer screening was less likely in women affiliated to major religions and those who never visited health facilities or doctors or visited once in previous 6 months. Ninety-two of selected patients were on treatment. Women with cervical cancer affiliated to protestant churches were 68 times more likely to utilize treatment and care services compared to those in other religions. Province of residence, education, occupation, marital status, income, wealth, medical aid status, having a regular doctor, frequency of visiting health facilities, sources of cervical cancer information and knowledge of treatability of cervical cancer were not associated with cervical cancer screening and treatment respectively. The authors recommend strengthening health education in communities, including in churches, to improve uptake of screening and treatment of cervical cancer.
This study examined the experiences of sixty HIV care providers in a high patient volume HIV treatment and care program in eastern Africa. The authors conducted in-depth interviews focused on providers’ perspectives on health system factors that impact patient engagement in HIV care. Results from thematic analysis demonstrated that providers perceive a work environment that constrained their ability to deliver high-quality HIV care and encouraged negative patient–provider relationships. Providers described their roles as high strain, low control, and low support. The authors suggest that health system strengthening must include efforts to improve the working environment and easing burden of care providers tasked with delivering antiretroviral therapy to increasing numbers of patients in resource-constrained settings.
In many low- and middle-income countries, the challenges of scaling up successful localized projects to achieve national coverage are well recognized. The wide success of efforts to scale up interventions to prevent and control human immunodeficiency virus (HIV) infection mean that it is now managed as a chronic condition. Lessons from the HIV experience may thus be transferable to the rollout and scale-up of effective interventions for noncommunicable diseases in low- and middle-income countries. WHO’s best buys for reducing noncommunicable diseases in low-resource settings suggest several such interventions. They include measures to improve tobacco control, increase public awareness of the health benefits of physical activity, multidrug therapy for people at high risk of cardiovascular disease and the screening and treatment of cervical cancer. While there is much to learn from the HIV experience, noncommunicable diseases have peculiarities that may limit the transferability of learning or require significant adaptation of such learning, while there are also issues to address in transfering learning on noncommunicable disease prevention and control between high-income and low- and middle-income countries. The authors call for the development of research and practice platforms that allow for progressive and systematic accumulation and sharing of field learning from scale-up efforts of HIV interventions and from the scale-up of noncommunicable disease interventions between settings
This study aimed to understand the challenges in managing hypertension and diabetes care in rural Uganda. The authors conducted semi-structured interviews with 24 patients with hypertension and/or diabetes, 11 health care professionals, and 12 community health workers in Nakaseke District, Uganda. Data were coded using NVivo software and analyzed using a thematic approach. The results included patient knowledge gaps regarding the preventable aspects of hypertension and diabetes, mistrust in the Ugandan health care system rather than in individual health care professionals and skepticism from both health care professionals and patients regarding a potential role for village health team members in hypertension and diabetes management. In order to improve hypertension and diabetes management in this setting, the authors recommend taking actions to help patients to understand non communicable diseases as preventable, for health care professionals and patients to advocate together for health system reform regarding medication accessibility, and promotion of education, screening and monitoring activities at community level in collaboration with village health team members.
The South African National Mental Health Policy Framework and Strategic Plan 2013–2020 was adopted to address the country’s substantial burden and inadequate treatment of mental illness. It outlines measures for full integration of mental health services into primary care by 2020. To evaluate progress and challenges in implementation, the authors conducted a mixed-methods assessment of mental health service provision in tuberculosis and maternal-child healthcare services of forty clinics in four districts in South Africa, interviewing district-level program managers (DPMs) and clinic nurses and mental health practitioners (MHPs). DPMs indicated that nurses should screen for mental illness at every patient visit, but only 73% of nurses reported conducting universal screening and 44% reported using a specific screening tool. For patients who screen positive for mental illness, DPMs described a stepped-care approach in which MHPs diagnose patients and then treat or refer them to specialised care. However, only 41% of MHPs indicated that they diagnose mental illness and 82% offer any treatment for mental illness. The challenges to current integration efforts include insufficient funding and material resources, poor coordination at the district administrative level, and low mental health awareness in district administration and the general population. Though some progress has been made toward integration of mental health services into primary care settings, the authors observe that implementation calls for improved district-level administrative coordination, mental health awareness, and financial and material resources.
An integrated mHealth solution was developed to improve quality of newborn care and survival in a district hospital in Malawi. The NeoTree application described in this paper focused on newborn care in low-income facilities, combining data collection by healthcare workers themselves, with interactive decision support and education for improving quality of care. Focus groups explored the acceptability and feasibility of digital health solutions before and after implementation of the NeoTree in the clinical setting. Healthcare workers perceived the NeoTree to be acceptable, feasible and clinically usable. Healthcare workers reported high perceived improvements in quality of newborn care after using the NeoTree on the ward. They described improved confidence in clinical decision-making, clinical skills, critical thinking and standardisation of care. The authors suggest that such an interactive co-development with healthcare workers can create a highly usable interactive admission platform, providing a teaching resource and improving the perceived quality of care delivered by healthcare workers involved in newborn care.
Despite the rising burden of noncommunicable diseases, access to quality decentralized noncommunicable disease services remain limited in many low- and middle-income countries. The authors describe strategies that were employed to drive the process from adaptation to national endorsement and implementation of the 2016 Botswana primary healthcare guidelines for adults. The strategies included detailed multilevel assessment with broad stakeholder inputs and in-depth analysis of local data; leveraging academic partnerships; facilitating development of policy instruments and embedding noncommunicable disease guidelines within broader primary health-care guidelines in keeping with the health ministry strategic direction. At facility level, strategies included developing a multi-method training programme for health-care providers, leveraging on the experience of provision of human immunodeficiency virus care and engaging health-care implementers early in the process. Through the strategies employed, the country’s first national primary health-care guidelines were endorsed in 2016 and a phased three-year implementation started in August 2017. Provision of primary health-care delivery of noncommunicable disease services was included in the country’s 11th national development plan (2017–2023). During the guideline development process, the authors learnt that strong interdisciplinary skills in communication, organisation, coalition building and systems thinking, and technical grasp of best-practices in low- and middle-income countries were important. They found that delays and poor communication emerged from the misaligned agendas of stakeholders, exaggerated by a siloed approach to guideline development, underestimation of the importance of having policy instruments in place and weak initial coordination of the processes outside the health ministry. The authors share this experience for its relevance to other countries interested in developing and implementing guidelines for evidence-based services for noncommunicable diseases.