Browsing by Author "Schneider, Helen"

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    Differences in antiretroviral scale up in three South African provinces: the role of implementation management
    (BioMed Central Ltd, 2010) Schneider, Helen; Coetzee, David; Van Rensburg, Dingie; Gilson, Lucy
    BACKGROUND:South Africa's antiretroviral programme is governed by defined national plans, establishing treatment targets and providing funding through ring-fenced conditional grants. However, in terms of the country's quasi-federal constitution, provincial governments bear the main responsibility for provision of health care, and have a certain amount of autonomy and therefore choice in the way their HIV/AIDS programmes are implemented. METHODS: The paper is a comparative case study of the early management of ART scale up in three South African provincial governments - Western Cape, Gauteng and Free State - focusing on both operational and strategic dimensions. Drawing on surveys of models of ART care and analyses of the policy process conducted in the three provinces between 2005 and 2007, as well as a considerable body of grey and indexed literature on ART scale up in South Africa, it draws links between implementation processes and variations in provincial ART coverage (low, medium and high) achieved in the three provinces. RESULTS: While they adopted similar chronic disease care approaches, the provinces differed with respect to political and managerial leadership of the programme, programme design, the balance between central standardisation and local flexibility, the effectiveness of monitoring and evaluation systems, and the nature and extent of external support and programme partnerships. CONCLUSIONS: This case study points to the importance of sub-national programme processes and the influence of factors other than financing or human resource capacity, in understanding intervention scale up.
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    Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross-sectional study
    (BioMed Central Ltd, 2012) Moshabela, Mosa; Schneider, Helen; Silal, Sheetal; Cleary, Susan
    BACKGROUND: In low-resource settings, patients' use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. METHODS: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant's clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. RESULTS: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. CONCLUSION: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients' dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.
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    An integrated approach of community health worker support for HIV/AIDS and TB care in Angonia district, Mozambique
    (BioMed Central Ltd, 2009) Simon, Sandrine; Chu, Kathryn; Frieden, Marthe; Candrinho, Baltazar; Ford, Nathan; Schneider, Helen; Biot, Marc
    BACKGROUND:The need to scale up treatment for HIV/AIDS has led to a revival in community health workers to help alleviate the health human resource crisis in sub-Saharan Africa. Community health workers have been employed in Mozambique since the 1970s, performing disparate and fragmented activities, with mixed results. METHODS: A participant-observer description of the evolution of community health worker support to the health services in Angonia district, Mozambique. RESULTS: An integrated community health team approach, established jointly by the Ministry of Health and Medecins Sans Frontieres in 2007, has improved accountability, relevance, and geographical access for basic health services. CONCLUSION: The community health team has several advantages over 'disease-specific' community health worker approaches in terms of accountability, acceptability, and expanded access to care.
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    Local level inequalities in the use of hospital-based maternal delivery in rural South Africa
    (2014-07-15) Silal, Sheetal P; Penn-Kekana, Loveday; Bärnighausen, Till; Schneider, Helen
    Abstract Background There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. Methods We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. Results In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. Conclusions The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services.
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    Practicing governance towards equity in health systems: LMIC perspectives and experience
    (BioMed Central, 2017-09-15) Gilson, Lucy; Lehmann, Uta; Schneider, Helen
    The unifying theme of the papers in this series is a concern for understanding the everyday practice of governance in low- and middle-income country (LMIC) health systems. Rather than seeing governance as a normative health system goal addressed through the architecture and design of accountability and regulatory frameworks, these papers provide insights into the real-world decision-making of health policy and system actors. Their multiple, routine decisions translate policy intentions into practice – and are filtered through relationships, underpinned by values and norms, influenced by organizational structures and resources, and embedded in historical and socio-political contexts. These decisions are also political acts – in that they influence who accesses benefits and whose voices are heard in decision-making, reinforcing or challenging existing institutional exclusion and power inequalities. In other words, the everyday practice of governance has direct impacts on health system equity. The papers in the series address governance through diverse health policy and system issues, consider actors located at multiple levels of the system and draw on multi-disciplinary perspectives. They present detailed examination of experiences in a range of African and Indian settings, led by authors who live and work in these settings. The overall purpose of the papers in this series is thus to provide an empirical and embedded research perspective on governance and equity in health systems.
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    Scaling up health policies and services in low- and middle-income settings
    (BioMed Central Ltd, 2010) Hanson, Kara; Cleary, Susan; Schneider, Helen; Tantivess, Sripen; Gilson, Lucy
    "Scaling up" effective health services is high on the policy agendas of many countries and international agencies. The current concern has been driven by growing recognition both of the challenges of achieving the health-related Millennium Development Goals (MDGs) in many countries, and of the need to ensure that the increased resources for health channelled through disease-specific health initiatives are able generate health gain at scale. Effective and cost-effective interventions exist to address many of the major causes of disease burden in the developing world, but coverage of many of these services remains low. There is a substantial gap between what could be achieved and what is actually being achieved in terms of health improvement in low- and middle-income countries.
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    "She is my teacher and if it was not for her I would be dead" : exploration of rural South African Community Health Worker's informational and mediating roles in the home
    (2011) Zulliger, Rose Ellen; Schneider, Helen
    This thesis seeks to fill the gap in the literature by exploring CHW IEC roles through: a protocol for the Health Information in the Home (HIH) study of the quality of IEC services by Community Care Workers; a structured literature review of the current state of the evidence and a journal manuscript based on the HIH study findings.
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    Strengthening the health system and ensuring equity in the wide-scale implementation of an antiretroviral therapy programme in South Africa
    (2003) Schneider, Helen; Coetzee, David
    Antiretroviral therapy (ART) makes a dramatic difference to the survival and health of people living with HIV. At present there are over 5 million people infected with HIV in South Africa. Greater access to ART could change the lives of millions of people. In the light of cabinet's announcement to make highly active antiretroviral therapy (HAART) widely available in South Africa and the mandate to develop an implementation plan, some thought should be given to the principles and strategies that should underlie the implementation of such a programme.
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    A systematic review of task- shifting for HIV treatment and care in Africa
    (BioMed Central Ltd, 2010) Callaghan, Mike; Ford, Nathan; Schneider, Helen
    BACKGROUND: Shortages of human resources for health (HRH) have severely hampered the rollout of antiretroviral therapy (ART) in sub-Saharan Africa. Current rollout models are hospital- and physician-intensive. Task shifting, or delegating tasks performed by physicians to staff with lower-level qualifications, is considered a means of expanding rollout in resource-poor or HRH-limited settings. METHODS: We conducted a systematic literature review. Medline, the Cochrane library, the Social Science Citation Index, and the South African National Health Research Database were searched with the following terms: task shift*, balance of care, non-physician clinicians, substitute health care worker, community care givers, primary healthcare teams, cadres, and nurs* HIV. We mined bibliographies and corresponded with authors for further results. Grey literature was searched online, and conference proceedings searched for abstracts. RESULTS: We found 2960 articles, of which 84 were included in the core review. 51 reported outcomes, including research from 10 countries in sub-Saharan Africa. The most common intervention studied was the delegation of tasks (especially initiating and monitoring HAART) from doctors to nurses and other non-physician clinicians. Five studies showed increased access to HAART through expanded clinical capacity; two concluded task shifting is cost effective; 9 showed staff equal or better quality of care; studies on non-physician clinician agreement with physician decisions was mixed, with the majority showing good agreement. CONCLUSIONS: Task shifting is an effective strategy for addressing shortages of HRH in HIV treatment and care. Task shifting offers high-quality, cost-effective care to more patients than a physician-centered model. The main challenges to implementation include adequate and sustainable training, support and pay for staff in new roles, the integration of new members into healthcare teams, and the compliance of regulatory bodies. Task shifting should be considered for careful implementation where HRH shortages threaten rollout programmes.
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    Whole-system change: case study of factors facilitating early implementation of a primary health care reform in a South African province
    (BioMed Central, 2014-11-29) Schneider, Helen; English, Rene; Tabana, Hanani; Padayachee, Thesandree; Orgill, Marsha
    Background: Whole-system interventions are those that entail system wide changes in goals, service delivery arrangements and relationships between actors, requiring approaches to implementation that go beyond projects or programmes. Methods: Drawing on concepts from complexity theory, this paper describes the catalysts to implementation of a whole-system intervention in the North West Province of South Africa. This province was an early adopter of a national primary health care (PHC) strategy that included the establishment of PHC outreach teams based on generalist community health workers. We interviewed a cross section of provincial actors, from senior to frontline, observed processes and reviewed secondary data, to construct a descriptive-explanatory case study of early implementation of the PHC outreach team strategy and the factors facilitating this in the province. Results: Implementation of the PHC outreach team strategy was characterised by the following features: 1) A favourable provincial context of a well established district and sub-district health system and long standing values in support of PHC; 2) The forging of a collective vision for the new strategy that built on prior history and values and that led to distributed leadership and ownership of the new policy; 3) An implementation strategy that ensured alignment of systems (information, human resources) and appropriate sequencing of activities (planning, training, piloting, household campaigns); 4) The privileging of ‘community dialogues’ and local manager participation in the early phases; 5) The establishment of special implementation structures: a PHC Task Team (chaired by a senior provincial manager) to enable feedback and ensure accountability, and an NGO partnership that provided flexible support for implementation. Conclusions: These features resonate with the deliberative, multi-level and context sensitive approaches described as the “simple rules” of successful PHC system change in other settings. Although implementation was not without tensions and weaknesses, particularly at the front-line of the PHC system, the case study highlights how a collective vision can facilitate commitment to and engagement with new policy in complex organisational environments. Successful adoption does not, however, guarantee sustained implementation at scale, and we consider the challenges to further implementation.