Browsing by Subject "Health systems"

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    Open Access
    A comparative evaluation of PDQ-Evidence
    (BioMed Central, 2018-03-15) Johansen, Marit; Rada, Gabriel; Rosenbaum, Sarah; Paulsen, Elizabeth; Motaze, Nkengafac V; Opiyo, Newton; Wiysonge, Charles S; Ding, Yunpeng; Mukinda, Fidele K; Oxman, Andrew D
    Background A strategy for minimising the time and obstacles to accessing systematic reviews of health system evidence is to collect them in a freely available database and make them easy to find through a simple ‘Google-style’ search interface. PDQ-Evidence was developed in this way. The objective of this study was to compare PDQ-Evidence to six other databases, namely Cochrane Library, EVIPNet VHL, Google Scholar, Health Systems Evidence, PubMed and Trip. Methods We recruited healthcare policy-makers, managers and health researchers in low-, middle- and high-income countries. Participants selected one of six pre-determined questions. They searched for a systematic review that addressed the chosen question and one question of their own in PDQ-Evidence and in two of the other six databases which they would normally have searched. We randomly allocated participants to search PDQ-Evidence first or to search the two other databases first. The primary outcomes were whether a systematic review was found and the time taken to find it. Secondary outcomes were perceived ease of use and perceived time spent searching. We asked open-ended questions about PDQ-Evidence, including likes, dislikes, challenges and suggestions for improvements. Results A total of 89 people from 21 countries completed the study; 83 were included in the primary analyses and 6 were excluded because of data errors that could not be corrected. Most participants chose PubMed and Cochrane Library as the other two databases. Participants were more likely to find a systematic review using PDQ-Evidence than using Cochrane Library or PubMed for the pre-defined questions. For their own questions, this difference was not found. Overall, it took slightly less time to find a systematic review using PDQ-Evidence. Participants perceived that it took less time, and most participants perceived PDQ-Evidence to be slightly easier to use than the two other databases. However, there were conflicting views about the design of PDQ-Evidence. Conclusions PDQ-Evidence is at least as efficient as other databases for finding health system evidence. However, using PDQ-Evidence is not intuitive for some people. Trial registration The trial was prospectively registered in the ISRCTN registry 17 April 2015. Registration number: ISRCTN12742235 .
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    Open Access
    Child and adolescent mental health services in the Western Cape Province of South Africa: the perspectives of service providers
    (2022-07-14) Mokitimi, Stella; Jonas, Kim; Schneider, Marguerite; de Vries, Petrus J
    Background Current work in the field point to the need to strengthen child and adolescent mental health services (CAMHS) globally, and especially in low- and middle-income countries (LMICs). Policy development, planning and service provision must be relevant to the needs of stakeholders at grassroots level, and should include their perspectives. This study set out to explore the perspectives and lived experiences of service providers, including their recommendations to strengthen CAMHS in South Africa. Methods Using focus group discussions (FGDs) and semi-structured individual interviews (SSIIs), qualitative data were collected from 46 purposefully selected multidisciplinary health service providers across the Western Cape, one of the nine provinces of South Africa. Audio-recorded data were entered into NVivo 11 (QSR), and thematic analysis was performed by two independent raters. Results Results highlighted a significant lack of CAMH resources, poor intersectoral collaboration, limited access to training, absence of consistency and uniformity in service delivery, weak support for staff, and high rates of negative attitudes of staff. External factors contributing to poor CAMHS identified by service providers included poor socioeconomic circumstances, high rates of HIV/AIDS, substance use and stigma. The eight recommendations to strengthen CAMHS included a need to (1) increase CAMH staffing, (2) provide dedicated CAMHS at secondary care and child-friendly infrastructure at primary care, (3) review current service focus on number of patients seen versus quality of care provided to children, (4) formalise intersectoral collaborations, (5) increase learning opportunities for trainees, (6) employ a lead professional for CAMHS in the province, (7) increase support for staff, and (8) acknowledge staff initiatives. Conclusions Findings underlined the need for quality improvement, standardisation and scale-up of mental health services for children and adolescents in South Africa. Whilst we used the Western Cape as a ‘case study’, we propose that our findings may also be relevant to other LMICs. We recommend that the perspectives of service users, including children and adolescents, be sought to inform service transformation.
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    Open Access
    The feasibility and ongoing use of electronic decision support to strengthen the implementation of IMCI in KwaZulu-Natal, South Africa
    (2022-02-07) Jensen, Cecilie; McKerrow, Neil H
    Background Continued efforts are required to reduce preventable child deaths. User-friendly Integrated Management of Childhood Illness (IMCI) implementation tools and supervision systems are needed to strengthen the quality of child health services in South Africa. A 2018 pilot implementation of electronic IMCI case management algorithms in KwaZulu-Natal demonstrated good uptake and acceptance at primary care clinics. We aimed to investigate whether ongoing electronic IMCI implementation is feasible within the existing Department of Health infrastructure and resources. Methods In a mixed methods descriptive study, the electronic IMCI (eIMCI) implementation was extended to 22 health facilities in uMgungundlovu district from November 2019 to February 2021. Training, mentoring, supervision and IT support were provided by a dedicated project team. Programme use was tracked, quarterly assessments of the service delivery platform were undertaken and in-depth interviews were conducted with facility managers. Results From December 2019 – January 2021, 9 684 eIMCI records were completed across 20 facilities, with a median uptake of 29 records per clinic per month and a mean (range) proportion of child consultations using eIMCI of 15% (1–46%). The local COVID-19-related movement restrictions and epidemic peaks coincided with declines in the monthly eIMCI uptake. Substantial inter- and intra-facility variations in use were observed, with the use being positively associated with the allocation of an eIMCI trained nurse (p < 0.001) and the clinician workload (p = 0.032). Conclusion The ongoing eIMCI uptake was sporadic and the implementation undermined by barriers such as low post-training deployment of nurses; poor capacity in the DoH for IT support; and COVID-19-related disruptions in service delivery. Scaling eIMCI in South Africa would rely on resolving these challenges.
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    Open Access
    Health systems and social values: the case of the South African health system
    (2023) Whyle, Eleanor; Olivier, Jill
    Health systems are complex social systems – driven by people and the relationships between them, characterised by feedback loops and path-dependency, and open to contextual influences. This entails that social values are an important determinant of health system change. In addition, health systems play a vital social role as generators of social value. However, the influence of social values on health systems is an under-explored field of study, and the evidence-based on the topic is weakened by conceptual confusion, a lack of theoretical models to support rigorous research, a dearth of empirical evidence, and methodological challenges attendant to the study of intangible factors such as values. In this theory-building study I explore the relationship between health systems and social values. Firstly, I use evidence mapping, interpretive synthesis and scoping review approaches to identify gaps in the existing evidence-base, develop an initial explanatory theory for the social value of health systems, and integrate insights from social sciences to establish a working definition of values, explore the social dynamics of values, and develop an account of the relationship between social systems – including health systems – and social values. Secondly, I conduct a case study of social values in the South African National Health Insurance policy process in its social and political context to gather empirical evidence on the role of social values in health system reform processes, and the mechanisms by which health systems shape social values. Lastly, I integrate the findings from the first two phases to develop a conceptual framework of the relationship between health systems and social values and offer methodological and conceptual insights intended to support further research on the topic. This study finds that social values, often borne out of social and political history, are cemented in health systems through daily practices and procedures. In this way, health systems serve to shape social values – by changing the way people think about what is just with respect to healthcare, their health rights and entitlements, and the appropriate role of the state in providing healthcare and regulating the behaviour of other health system actors.
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    Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study
    (2020-06-26) Mutabazi, Jean Claude; Gray, Corie; Muhwava, Lorrein; Trottier, Helen; Ware, Lisa J; Norris, Shane; Murphy, Katherine; Levitt, Naomi; Zarowsky, Christina
    Background Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework. Methods A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis. Results Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation. Conclusions Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.
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    Multiple pathways to scaling up and sustainability: an exploration of digital health solutions in South Africa
    (2021-07-06) Swartz, Alison; LeFevre, Amnesty E.; Perera, Shehani; Kinney, Mary V.; George, Asha S.
    Background With the aim to support further understanding of scaling up and sustaining digital health, we explore digital health solutions that have or are anticipated to reach national scale in South Africa: the Perinatal Problem Identification Programme (PPIP) and Child Healthcare Problem Identification Programme (Child PIP) (mortality audit reporting and visualisation tools), MomConnect (a direct to consumer maternal messaging and feedback service) and CommCare (a community health worker data capture and decision-support application). Results A framework integrating complexity and scaling up processes was used to conceptually orient the study. Findings are presented by case in four domains: value proposition, actors, technology and organisational context. The scale and use of PPIP and Child PIP were driven by ‘champions’; clinicians who developed technically simple tools to digitise clinical audit data. Top-down political will at the national level drove the scaling of MomConnect, supported by ongoing financial and technical support from donors and technical partners. Donor preferences played a significant role in the selection of CommCare as the platform to digitise community health worker service information, with a focus on HIV and TB. A key driver of scale across cases is leadership that recognises and advocates for the value of the digital health solution. The technology need not be complex but must navigate the complexity of operating within an overburdened and fragmented South African health system. Inadequate and unsustained investment from donors and government, particularly in human resource capacity and robust monitioring and evaluation, continue to threaten the sustainability of digital health solutions. Conclusions There is no single pathway to achieving scale up or sustainability, and there will be successes and challenges regardless of the configuration of the domains of value proposition, technology, actors and organisational context. While scaling and sustaining digital solutions has its technological challenges, perhaps more complex are the idiosyncratic factors and nature of the relationships between actors involved. Scaling up and sustaining digital solutions need to account for the interplay of the various technical and social dimensions involved in supporting digital solutions to succeed, particularly in health systems that are themselves social and political dynamic systems.
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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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    Strengthening child and adolescent mental health systems in South Africa: A multi-stakeholder implementation science initiative
    (2025) Simelane, Simphiwe; De Vries, Petrus
    Background: Child and adolescent mental health services and systems (CAMHSS) in low- and middle-income countries (LMICs), including South Africa, face significant challenges despite 10–20% of under-18-year-olds experiencing mental and neurodevelopmental disorders. In South Africa the mental health treatment gap remains at 90%. This thesis used multi-methods across three aims to explore CAMHSS strengthening innovations in LMICs, the state of CAMHSS in South Africa, and potential strategies for improvement. Methods: A targeted literature review identified CAMHSS strengthening innovations in LMICs from the preceding 18 months. A narrative review examined the state of CAMHSS in South Africa, synthesising findings from two regional situational analyses. A nationwide electronic survey was conducted to assess the relevance of previous regional findings at a national level and to identify system strengthening priorities. Participatory Theory of Change (ToC) workshops were held across care levels in the Western Cape to co-create a shared vision for CAMHSS strengthening. Lastly, a qualitative study evaluated the acceptability, appropriateness, and feasibility of the child mental health module from the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP-IG CMH) at the primary care level in Khayelitsha, Cape Town. Results: CAMHSS innovations in LMICs were identified across WHO health system building blocks, including service provider training, school-based programmes, and digital tools. The integrative review of CAMHSS in South Africa highlighted 38 critical gaps, particularly in clinical care and human resources. Findings from the nationwide survey supported 63% of the previous regional findings, and priorities included quality services close to home, competent teams, and widespread CAMHSS engagement. ToC workshops identified six pathways to strengthen CAMHSS, with a focus on care pathways, capacity building, and political buy-in. The qualitative study on the mhGAP-IG CMH module noted potential utility but also identified many contextual barriers such as time constraints and lack of support. Conclusion: The original contributions of this thesis include a comprehensive assessment of CAMHSS in South Africa including current gaps and priorities, a co-produced roadmap for CAMHSS strengthening, and findings on the mhGAP-IG CMH module as a potential tool in primary care. Actions from the thesis could bridge the treatment gap to improve CAMHSS in the country.
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    Open Access
    Towards 'men who have sex with menappropriate' health services in South Africa
    (2013) Rebe, Kevin Brian; De Swardt, Glenn; Struthers, Helen Elizabeth; McIntyre, James Alisdair
    Health programming for men who have sex with men (MSM) in South Africa has been ignored or absent until fairly recently, despite this population being at high risk for HIV acquisition and transmission. Anova Health Institute, with support from the US President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID) and in collaboration with the South African National Department of Health, launched the first state sector MSM-targeted sexual health clinic in 2010. The clinic has been successful in attracting and retaining MSM in care, and lessons learned are described in this article. Components contributing to the creation of MSM-appropriate healthcare services are discussed.
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    Zero malaria: a mirage or reality for populations of sub-Saharan Africa in health transition
    (BioMed Central, 2022-11-04) Sarpong, Esther; Acheampong, Desmond O.; Fordjour, George N. R.; Anyanful, Akwasi; Aninagyei, Enoch; Tuoyire, Derek A.; Blackhurst, Dee; Kyei, George B.; Ekor, Martins; Thomford, Nicholas E.
    The global burden of malaria continues to be a significant public health concern. Despite advances made in therapeutics for malaria, there continues to be high morbidity and mortality associated with this infectious disease. Sub-Saharan Africa continues to be the most affected by the disease, but unfortunately the region is burdened with indigent health systems. With the recent increase in lifestyle diseases, the region is currently in a health transition, complicating the situation by posing a double challenge to the already ailing health sector. In answer to the continuous challenge of malaria, the African Union has started a "zero malaria starts with me” campaign that seeks to personalize malaria prevention and bring it down to the grass-root level. This review discusses the contribution of sub-Saharan Africa, whose population is in a health transition, to malaria elimination. In addition, the review explores the challenges that health systems in these countries face, that may hinder the attainment of a zero-malaria goal.