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.
Equitable health services
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.
This study aimed to evaluate vaccination coverage, identify reasons for non-vaccination and assess satisfaction with two innovative strategies for distributing second doses in an oral cholera vaccine campaign in 2016 in Lake Chilwa, Malawi, in response to a cholera outbreak. The authors performed a two-stage cluster survey. The population interviewed was divided in three strata according to the second-dose vaccine distribution strategy: (i) a standard strategy in 1477 individuals (68 clusters of 5 households) on the lake shores; (ii) a simplified cold-chain strategy in 1153 individuals (59 clusters of 5 households) on islands in the lake; and (iii) an out-of-cold-chain strategy in 295 fishermen (46 clusters of 5 to 15 fishermen) in floating homes, called zimboweras. Vaccination coverage with at least one dose was 79.5%, on the lake shores, 99.3% on the islands and 84.7% on zimboweras. Coverage with two doses was 53.0% 91.1% and 78.8% in the three strata, respectively. The most common reason for non-vaccination was absence from home during the campaign. Most interviewees liked the novel distribution strategies. Vaccination coverage on the shores of Lake Chilwa was moderately high and the innovative distribution strategies tailored to people living on the lake provided adequate coverage, even among hard-to-reach communities. Community engagement and simplified delivery procedures were critical for success. Off-label, out-of-cold-chain administration of oral cholera vaccine should be considered as an effective strategy for achieving high coverage in hard-to-reach communities. Nevertheless, coverage and effectiveness must be monitored over the short and long term.
Global efforts to strengthen primary healthcare are observed by the authors to have generally not focused on the critical interface between provider and patient but rather on policy, financing and infrastructure. Over the past two decades the Knowledge Translation Unit at the University of Cape Town has worked with government, academic, and non-governmental organisation partners to develop and evaluate health systems innovations that empower frontline providers. The unit developed the Practical Approach to Care Kit (PACK), a programme that covers primary healthcare needs across the life course. At the centre of the programme are concise clinical decision support tools (guides) comprising standardised and user friendly algorithms and checklists that provide a comprehensive and integrated approach to screening, diagnosing, and treating common symptoms and chronic conditions in adults, adolescents, and children. The accompanying training programme uses case-based, short training sessions delivered by existing health staff to support frontline providers and their teams. PACK provides decision support tools and training to support frontline providers in low and middle income countries. It prompts primary care health workers to claim “system agency” based on an intervention that resonates with their primary identity as clinicians. The authors suggest that delivering on universal primary healthcare requires a change in investments to prioritise comprehensive approaches that can meet the changing burden of disease
In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two- dose regimen of the ShancholTM OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess oral cholera vaccine coverage, frequency of adverse events following immunization, vaccine acceptability and reasons for non-vaccination. In the absence of a household listing and clear administrative neighborhood delimitations, the authors used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose was 69.5% and the two-dose coverage was 51.2%. The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 reported minor and non-specific complaints, and 78 mentioned they did not receive any information before the campaign. In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. The authors’ results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks.
This paper interrogated the relationship between data collection and the delivery of patient care in Kayunga, Uganda in five public health centres. The authors undertook ethnographic research from July 2015 to September 2016 in health centres, at project workshops, meetings and training sessions. This included three months of observations by three fieldworkers, in-depth interviews with health workers and stakeholders and six focus group discussions with health workers. The authors observed that the attempt to improve data collection within health facilities transferred data-value into health centres with little consideration among project staff for its impact on care, and noted both acquiescence and resistance to data-value by health workers. The authors also described the rare moments when senior health workers reconciled these two forms of value, where care-value and data-value were enacted simultaneously. The authors suggest that those seeking to make changes in health systems must take into account local forms of value and devise health systems interventions that reinforce and enrich existing ethically driven practice.