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Fraser HL, Feldhaus I, Edoka IP, Wade AN, Kohli-Lynch CN, Hofman K, Verguet S. Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa. Health Policy Plan 2024; 39:253-267. [PMID: 38252592 DOI: 10.1093/heapol/czae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 12/07/2023] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.
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Affiliation(s)
- Heather L Fraser
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, Clarice Pears Building (Level 3), 90 Byres Road, United Kingdom
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Isabelle Feldhaus
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Ijeoma P Edoka
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 32 Princess of Wales Terrace, Johannesburg 2193, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Alisha N Wade
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - Ciaran N Kohli-Lynch
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, 680 N. Lake Shore Drive, Chicago, IL 60611, United States
| | - Karen Hofman
- SA MRC/Centre for Health Economics and Decision Science-PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 27 St Andrews Road, Johannesburg 2193, South Africa
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
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Moyo S, Ismail F, Mkhondo N, van der Walt M, Dlamini SS, Mthiyane T, Naidoo I, Zuma K, Tadolini M, Law I, Mvusi L. Healthcare seeking patterns for TB symptoms: Findings from the first national TB prevalence survey of South Africa, 2017-2019. PLoS One 2023; 18:e0282125. [PMID: 36920991 PMCID: PMC10016667 DOI: 10.1371/journal.pone.0282125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/08/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Although tuberculosis (TB) symptoms have limited sensitivity they remain an important entry point into the TB care cascade. OBJECTIVES To investigate self-reported healthcare seeking for TB symptoms in participants in a community-based survey. METHODS We compared reasons for not seeking care in participants reporting ≥1 of four TB screening symptoms (cough, weight loss, night sweats, fever) in the first South African national TB prevalence survey (2017-2019). We used logistic regression analyses to identify sociodemographic and clinical characteristics associated with healthcare seeking. RESULTS 5,168/35,191 (14.7%) survey participants reported TB symptoms and 3,442/5168 had not sought healthcare. 2,064/3,442(60.0%) participants intended to seek care, 912 (26.5%) regarded symptoms as benign, 399 (11.6%) reported access barriers(distance and cost), 36 (1.0%) took other medications and 20(0.6%) reported health system barriers. Of the 57/98 symptomatic participants diagnosed with bacteriologically confirmed TB who had not sought care: 38(66.7%) intended to do so, 8(14.0%) regarded symptoms as benign, and 6(10.5%) reported access barriers. Among these 98, those with unknown HIV status(OR 0.16 95% CI 0.03-0.82), p = 0.03 and those who smoked tobacco products(OR 0.39, 95% CI 0.17-0.89, p = 0.03) were significantly less likely to seek care. CONCLUSIONS People with TB symptoms delayed seeking healthcare, many regarded symptoms as benign while others faced access barriers. Those with unknown HIV status were significantly less likely to seek care. Strengthening community-based TB awareness and screening programmes together with self-screening models could increase awareness of the significance of TB symptoms and contribute to improving healthcare seeking and enable many people with TB to enter the TB care cascade.
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Affiliation(s)
- Sizulu Moyo
- Human Sciences Research Council, Cape Town, South Africa
- School of Public Health and Family, University of Cape Town, Cape Town, South Africa
- * E-mail: ,
| | - Farzana Ismail
- National Institute for Communicable Diseases Division of the National Health Laboratory Services, Johannesburg, South Africa
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Nkateko Mkhondo
- Tuberculosis Programme, World Health Organization, Pretoria, South Africa
| | | | | | - Thuli Mthiyane
- South African Medical Research Council, Pretoria, South Africa
| | | | | | - Marina Tadolini
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Irwin Law
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Lindiwe Mvusi
- National Department of Health, Pretoria, South Africa
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Manderson L, Brear M, Rusere F, Farrell M, Gómez-Olivé FX, Berkman L, Kahn K, Harling G. Protocol: the complexity of informal caregiving for Alzheimer's disease and related dementias in rural South Africa. Wellcome Open Res 2022; 7:220. [PMID: 37538406 PMCID: PMC10394391 DOI: 10.12688/wellcomeopenres.18078.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2022] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND With aging, many people develop Alzheimer's disease or related dementias (ADRD) as well as chronic physical health problems. The consequent care needs can be complicated, with heavy demands on families, households and communities, especially in resource-constrained settings with limited formal care services. However, research on ADRD caregiving is largely limited to primary caregivers and high-income countries. Our objectives are to analyse in a rural setting in South Africa: (1) how extended households provide care to people with ADRD; and (2) how the health and wellbeing of all caregivers are affected by care roles. METHODS The study will take place at the Agincourt health and socio-demographic surveillance system site of the MRC/Wits Rural Public Health and Health Transitions Research Unit in Mpumalanga Province, northeast South Africa. We will recruit 100 index individuals predicted to currently have ADRD or cognitive impairment using data from a recent dementia survey. Quantitative surveys will be conducted with each index person's nominated primary caregiver, all other household members aged over 12, and caregiving non-resident kin and non-kin to determine how care and health are patterned across household networks. Qualitative data will be generated through participant observation and in-depth interviews with caregivers, select community health workers and key informants. Combining epidemiological, demographic and anthropological methods, we will build a rich picture of households of people with ADRD, focused on caregiving demands and capacity, and of caregiving's effects on health. DISCUSSION Our goal is to identify ways to mitigate the negative impacts of long-term informal caregiving for ADRD when formal supports are largely absent. We expect our findings to inform the development of locally relevant and community-oriented interventions to improve the health of caregivers and recipients, with implications for other resource-constrained settings in both higher- and lower-income countries.
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Affiliation(s)
- Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- School of Social Sciences, Monash University, Clayton, Australia
| | - Michelle Brear
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- School of Social Sciences, Monash University, Clayton, Australia
- School of Public Health and Preventive Medicine, Monash University, Clayton, Australia
| | - Farirai Rusere
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Meagan Farrell
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Berkman
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathleen Kahn
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
| | - Guy Harling
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Institute for Global Health, University College London, London, UK
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing & Public Health, College of Health Sciences, University of KwaZulu Natal, Durban, South Africa
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Binyaruka P, Borghi J. An equity analysis on the household costs of accessing and utilising maternal and child health care services in Tanzania. HEALTH ECONOMICS REVIEW 2022; 12:36. [PMID: 35802268 PMCID: PMC9264712 DOI: 10.1186/s13561-022-00387-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/30/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Direct and time costs of accessing and using health care may limit health care access, affect welfare loss, and lead to catastrophic spending especially among poorest households. To date, limited attention has been given to time and transport costs and how these costs are distributed across patients, facility and service types especially in poor settings. We aimed to fill this knowledge gap. METHODS We used data from 1407 patients in 150 facilities in Tanzania. Data were collected in January 2012 through patient exit-interviews. All costs were disaggregated across patients, facility and service types. Data were analysed descriptively by using means, medians and equity measures like equity gap, ratio and concentration index. RESULTS 71% of patients, especially the poorest and rural patients, accessed care on foot. The average travel time and cost were 30 minutes and 0.41USD respectively. The average waiting time and consultation time were 47 min and 13 min respectively. The average medical cost was 0.23 USD but only18% of patients paid for health care. The poorest and rural patients faced substantial time burden to access health care (travel and waiting) but incurred less transport and medical costs compared to their counterparts. The consultation time was similar across patients. Patients spent more time travelling to public facilities and dispensaries while incurring less transport cost than accessing other facility types, but waiting and consultation time was similar across facility types. Patients paid less amount in public than in private facilities. Postnatal care and vaccination clients spent less waiting and consultation time and paid less medical cost than antenatal care clients. CONCLUSIONS Our findings reinforce the need for a greater investment in primary health care to reduce access barriers and cost burdens especially among the worse-offs. Facility's construction and renovation and increased supply of healthcare workers and medical commodities are potential initiatives to consider. Other initiatives may need a multi-sectoral collaboration.
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Affiliation(s)
- Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, PO Box 78373, Dar es Salaam, Tanzania
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK
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Shimira F. Tetradenia riparia, an ethnobotanical plant with diverse applications, from antimicrobial to anti-proliferative activity against cancerous cell lines: A systematic review. J Herb Med 2022. [DOI: 10.1016/j.hermed.2022.100537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jooste S, Mabaso M, Taylor M, North A, Shean Y, Simbayi LC. Socio-economic differences in the uptake of HIV testing and associated factors in South Africa. BMC Public Health 2021; 21:1591. [PMID: 34445996 PMCID: PMC8390264 DOI: 10.1186/s12889-021-11583-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 08/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improved understanding of barriers to HIV testing is important for reaching the first of the UNAIDS 90-90-90 targets, which states that 90% of HIV positive individuals ought to know their HIV status. This study examined socio-economic status (SES) differences in HIV testing uptake and associated factors among youth and adults 15 years and older in South Africa. METHODS This study used data from a national cross-sectional, population-based household survey conducted in 2017 using a multi-stage sampling design. A composite SES score was created using multiple correspondence analyses of household assets; households were classified into wealth quintiles and dichotomised into low SES/poorest (lowest 3 quintiles) and high SES/less-poor (highest 2 quintiles). Bivariate and multivariate logistic regression models were used to examine factors associated with the uptake of HIV testing in low and high SES households. RESULTS HIV testing uptake was 73.8 and 76.7% among low and high SES households, respectively, both of which were below the first 90 targets. Among both low and high SES households, increased HIV testing uptake was significantly associated with females than males. The decreased likelihood was significantly associated with residing in rural formal areas than urban areas, those with no education or low levels of educational attainment and alcohol drinkers among low SES households. Whites and Indians/Asians had a decreased likelihood than Black Africans in high SES households. CONCLUSIONS HIV testing interventions should target males, residents in rural formal areas, those with no or low education and those that consume alcohol in low SES households, including Whites and Indians/Asians from high SES households in order to bridge socio-economic disparities in the uptake of HIV testing. This should entail expanding HIV testing beyond traditional centres for voluntary counselling and testing through outreach efforts, including mobile testing and home-based testing.
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Affiliation(s)
- Sean Jooste
- Human and Social Capabilities Research Division, Human Sciences Research Council, 118 Buitengracht St, Cape Town City Centre, Cape Town, 8000, South Africa.
- University of KwaZulu-Natal, School of Nursing and Public Health, 238 Mazisi Kunene Rd, Glenwood, Durban, 4041, South Africa.
| | - Musawenkosi Mabaso
- Human and Social Capabilities Research Division, Human Sciences Research Council, 118 Buitengracht St, Cape Town City Centre, Cape Town, 8000, South Africa
| | - Myra Taylor
- University of KwaZulu-Natal, School of Nursing and Public Health, 238 Mazisi Kunene Rd, Glenwood, Durban, 4041, South Africa
| | - Alicia North
- Human and Social Capabilities Research Division, Human Sciences Research Council, 118 Buitengracht St, Cape Town City Centre, Cape Town, 8000, South Africa
| | - Yolande Shean
- Human and Social Capabilities Research Division, Human Sciences Research Council, 118 Buitengracht St, Cape Town City Centre, Cape Town, 8000, South Africa
| | - Leickness Chisamu Simbayi
- Deputy CEO for Research, Human Sciences Research Council, 118 Buitengracht St, Cape Town City Centre, Cape Town, 8000, South Africa
- Department of Psychiatry & Mental Health, University of Cape Town, Groote Schuur Dr, Observatory, Cape Town, 7700, South Africa
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Newberry Le Vay J, Fraser A, Byass P, Tollman S, Kahn K, D'Ambruoso L, Davies JI. Mortality trends and access to care for cardiovascular diseases in Agincourt, rural South Africa: a mixed-methods analysis of verbal autopsy data. BMJ Open 2021; 11:e048592. [PMID: 34172550 PMCID: PMC8237742 DOI: 10.1136/bmjopen-2020-048592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Cardiovascular diseases are the second leading cause of mortality behind HIV/AIDS in South Africa. This study investigates cardiovascular disease mortality trends in rural South Africa over 20+ years and the associated barriers to accessing care, using verbal autopsy data. DESIGN A mixed-methods approach was used, combining descriptive analysis of mortality rates over time, by condition, sex and age group, quantitative analysis of circumstances of mortality (CoM) indicators and free text narratives of the final illness, and qualitative analysis of free texts. SETTING This study was done using verbal autopsy data from the Health and Socio-Demographic Surveillance System site in Agincourt, rural South Africa. PARTICIPANTS Deaths attributable to cardiovascular diseases (acute cardiac disease, stroke, renal failure and other unspecified cardiac disease) from 1993 to 2015 were extracted from verbal autopsy data. RESULTS Between 1993 and 2015, of 15 305 registered deaths over 1 851 449 person-years of follow-up, 1434 (9.4%) were attributable to cardiovascular disease, corresponding to a crude mortality rate of 0.77 per 1000 person-years. Cardiovascular disease mortality rate increased from 0.34 to 1.12 between 1993 and 2015. Stroke was the dominant cause of death, responsible for 41.0% (588/1434) of all cardiovascular deaths across all years. Cardiovascular disease mortality rate was significantly higher in women and increased with age. The main delays in access to care during the final illness were in seeking and receiving care. Qualitative free-text analysis highlighted delays not captured in the CoM, principally communication between the clinician and patient or family. Half of cases initially sought care outside a hospital setting (50.9%, 199/391). CONCLUSIONS The temporal increase in deaths due to cardiovascular disease highlights the need for greater prevention and management strategies for these conditions, particularly for the women. Strategies to improve seeking and receiving care during the final illness are needed.
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Affiliation(s)
| | - Andrew Fraser
- Education Centre, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Peter Byass
- Department of Epidemiology & Global Health, Umea Universitet, Umeå, Sweden
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Stephen Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Lucia D'Ambruoso
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- WHO Collaborating Centre for Verbal Autopsy, Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Justine I Davies
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Meyer NT, Meyer GD, Gaunt CB. What presents to a rural district emergency department: A case mix. Afr J Prim Health Care Fam Med 2020; 12:e1-e6. [PMID: 32787404 PMCID: PMC7433284 DOI: 10.4102/phcfm.v12i1.2275] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 04/28/2020] [Accepted: 04/30/2020] [Indexed: 11/01/2022] Open
Affiliation(s)
- Nadishani T Meyer
- Jabulani Rural Health Foundation, Mqanduli, South Africa; and, Zithulele Hospital, Mqanduli.
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Reed-Embleton H, Arambepola S, Dixon S, Maldonado BN, Premawardhena A, Arambepola M, Khan JAM, Allen S. A cost-of-illness analysis of β-Thalassaemia major in children in Sri Lanka - experience from a tertiary level teaching hospital. BMC Pediatr 2020; 20:257. [PMID: 32460774 PMCID: PMC7251920 DOI: 10.1186/s12887-020-02160-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background Sri Lanka has a high prevalence of β-thalassaemia major. Clinical management is complex and long-term and includes regular blood transfusion and iron chelation therapy. The economic burden of β-thalassaemia for the Sri Lankan healthcare system and households is currently unknown. Methods A prevalence-based, cost-of-illness study was conducted on the Thalassaemia Unit, Department of Paediatrics, Kandy Teaching Hospital, Sri Lanka. Data were collected from clinical records, consultations with the head of the blood bank and a consultant paediatrician directly involved with the care of patients, alongside structured interviews with families to gather data on the personal costs incurred such as those for travel. Results Thirty-four children aged 2–17 years with transfusion dependent thalassaemia major and their parent/guardian were included in the study. The total average cost per patient year to the hospital was $US 2601 of which $US 2092 were direct costs and $US 509 were overhead costs. Mean household expenditure was $US 206 per year with food and transport per transfusion ($US 7.57 and $US 4.26 respectively) being the highest cost items. Nine (26.5%) families experienced catastrophic levels of healthcare expenditure (> 10% of income) in the care of their affected child. The poorest households were the most likely to experience such levels of expenditure. Conclusions β-thalassaemia major poses a significant economic burden on health services and the families of affected children in Sri Lanka. Greater support is needed for the high proportion of families that suffer catastrophic out-of-pocket costs.
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Affiliation(s)
| | | | | | | | - Anuja Premawardhena
- Hemal's Thalassemia Care Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka. .,Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.
| | | | | | - Stephen Allen
- Liverpool School of Tropical Medicine, Liverpool, UK
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Morris-Paxton AA, Reid S, Ewing RMG. Primary healthcare services in the rural Eastern Cape, South Africa: Evaluating a service-support project. Afr J Prim Health Care Fam Med 2020; 12:e1-e7. [PMID: 32242430 PMCID: PMC7203186 DOI: 10.4102/phcfm.v12i1.2207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/29/2019] [Accepted: 10/29/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2012, 38% of the South African population resided in the rural areas of the country. The professional healthcare services are concentrated in the urban areas, resulting in an imbalance between urban and rural healthcare services. AIM The aim of this study was to evaluate the use of a non-governmental organisation (NGO)-supported mobile healthcare service in a remote area. SETTING Eastern Cape Province in South Africa. METHODS The walking distance between the community and the nearest fixed government healthcare service was evaluated and compared with the recommendations of World Health Organization (WHO). Services provided to people visiting the mobile community service were recorded, and descriptive data were analysed and compared with the anonymised patient records of the nearest fixed service clinic. RESULTS Of the 30 outreach points served by the NGO, 24 points were at a distance more than the WHO-designated walking distance and 11 points were more than twice the WHO-designated distance from the perspective of fixed clinic. The average headcount per annum of the outreach NGO mobile clinics exceeded those of the fixed Department of Health (DoH) clinics by an average of 250 patients per clinic session. The increase in services was also noteworthy, with a mean differential of 1774 services per annum for the same day above that of the DoH clinics. CONCLUSION Mobile services could make a difference to the utilisation of essential healthcare facilities. The provision of augmented NGO-led mobile clinical outreach services and joint government-NGO partnerships holds possibilities for improving healthcare for those living in remote rural areas.
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Affiliation(s)
- Angela A Morris-Paxton
- Drug Utilisation Research Unit, Department of Pharmacy, Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth.
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Anstey Watkins J, Wagner F, Xavier Gómez-Olivé F, Wertheim H, Sankoh O, Kinsman J. Rural South African Community Perceptions of Antibiotic Access and Use: Qualitative Evidence from a Health and Demographic Surveillance System Site. Am J Trop Med Hyg 2020; 100:1378-1390. [PMID: 30994091 PMCID: PMC6553901 DOI: 10.4269/ajtmh.18-0171] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Knowledge and practices of rural South African populations with regard to antibiotic access and use (ABACUS) remain understudied. By using the case of four villages in the north east of the country, our aim was to investigate popular notions and social practices related to antibiotics to inform patient-level social interventions for appropriate antibiotic use. To achieve this, we investigated where community members (village residents) were accessing and sourcing medication, and what they understood antibiotics and antibiotic resistance (ABR) to be. Embedded within the multicountry ABACUS project, this qualitative study uses interviews and focus group discussions. A sample of 60 community members was recruited from the Agincourt Health and Demographic Surveillance System, situated in Mpumalanga Province, from April to August, 2017. We used the five abilities of seek, reach, pay, perceive, and engage in access to healthcare as proposed by Levesque’s “Access to Healthcare” framework. Respondents reported accessing antibiotics prescribed from legal sources: by nurses at the government primary healthcare clinics or by private doctors dispensed by private pharmacists. No account of the illegal purchasing of antibiotics was described. There was a mix of people who finished their prescription according to the instructions and those who did not. Some people kept antibiotics for future episodes of infection. The concept of “ABR” was understood by some community members when translated into related Xitsonga words because of knowledge tuberculosis and HIV/AIDS treatment regimens. Our findings indicate that regulation around the sale of antibiotics is enforced. Safer use of antibiotics and why resistance is necessary to understand need to be instilled. Therefore, context-specific educational campaigns, drawing on people’s understandings of antibiotics and informed by the experiences of other diseases, may be an important and deployable means of promoting the safe use of antibiotics.
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Affiliation(s)
- Jocelyn Anstey Watkins
- Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry, United Kingdom
| | - Fezile Wagner
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council, Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Heiman Wertheim
- Department of Medical Microbiology, Radboudumc Center for Infectious Diseases, Nijmegen, The Netherlands.,Nuffield Department of Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hanoi, Vietnam
| | - Osman Sankoh
- Statistics Sierra Leone, Freetown, Sierra Leone.,International Network for the Demographic Evaluation of Populations and their Health (INDEPTH) Network, Accra, Ghana.,Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - John Kinsman
- Department of Public Health Sciences, Global Health (Division of International Health - IHCAR), Karolinska Institutet, Stockholm, Sweden.,Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health (Umeå Centre for Global Health Research), Umeå University, Umeå, Sweden
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12
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Le Roux KW, Davis EC, Gaunt CB, Young C, Koussa M, Harris C, Rotheram-Borus MJ. A Case Study of an Effective and Sustainable Antiretroviral Therapy Program in Rural South Africa. AIDS Patient Care STDS 2019; 33:466-472. [PMID: 31682167 DOI: 10.1089/apc.2019.0055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The delivery of high-quality HIV care in rural settings is a global challenge. Despite the successful expansion of antiretroviral therapy (ART) in Africa, viral load (VL) monitoring and ART adherence are poor, especially in rural communities. This article describes a case study of an ART program in the deeply rural Eastern Cape of South Africa. The Zithulele ART Program initiated five innovations over time: (1) establishing district hospital as the logistical hub for all ART care in a rural district, (2) primary care clinic delivery of prepackaged ART and chronic medications for people living with HIV (PLH), (3) establishing central record keeping, (4) incentivizing VL monitoring, and (5) providing hospital-based outpatient care for complex cases. Using a pharmacy database, on-time VL monitoring and viral suppression were evaluated for 882 PLH initiating ART in the Zithulele catchment area in 2013. Among PLH initiating ART, 12.5% (n = 110) were lost to follow-up, 7.7% (n = 68) transferred out of the region, 10.2% (n = 90) left the program and came back at a later date, and 4.0% (n = 35) died. Of the on-treatment population, 82.9% (n = 480/579) had VL testing within 7 months and 92.6% (n = 536/579) by 1 year. Viral suppression was achieved in 85.2% of those tested (n = 457/536), or 78.9% (n = 457/579) overall. The program's VL testing and suppression rates appear about twice as high as national data and data from other rural centers in South Africa, despite fewer resources than other programs. Simple system innovations can ensure high rates of VL testing and suppression, even in rural health facilities.
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Affiliation(s)
- Karl W. Le Roux
- Zithulele Hospital, Mqanduli District, South Africa
- Woodrow Wilson School of Public International Affairs at Princeton University, Princeton, New Jersey
| | - Emily C. Davis
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
| | | | - Catherine Young
- Jabulani Rural Health Foundation, Mqanduli District, South Africa
| | - Maryann Koussa
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
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13
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Olanya OM, Hoshide AK, Ijabadeniyi OA, Ukuku DO, Mukhopadhyay S, Niemira BA, Ayeni O. Cost estimation of listeriosis (Listeria monocytogenes) occurrence in South Africa in 2017 and its food safety implications. Food Control 2019. [DOI: 10.1016/j.foodcont.2019.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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14
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Vasudevan U, Akkilagunta S, Kar SS. Household out-of-pocket expenditure on health care - A cross-sectional study among urban and rural households, Puducherry. J Family Med Prim Care 2019; 8:2278-2282. [PMID: 31463242 PMCID: PMC6691471 DOI: 10.4103/jfmpc.jfmpc_302_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/12/2019] [Accepted: 05/22/2019] [Indexed: 11/04/2022] Open
Abstract
CONTEXT A major proportion of health expenditure is by households as out-of-pocket expenditure (OOPE) in India. Recent estimates at district level are required for planning implementation of Universal Health Coverage. AIMS To estimate the proportion of households incurring OOPE and the average amount spent by the household for healthcare. SETTINGS AND DESIGN A cross-sectional study was conducted during August 2016 in the field practice areas of a medical college in Puducherry. A random sample of 240 households (120 rural and 120 urban) with 1,029 participants (531 rural and 498 urban) were surveyed. SUBJECTS AND METHODS A pretested questionnaire was used to collect information on sociodemographic details, morbidity, healthcare services utilized, and expenses incurred. Recall period of 1 month was fixed for OP/Pharmacy Services and 6 months for IP services. RESULTS In total, 120 rural and 120 urban households were surveyed; out of which, majority of the households were below poverty line [rural (83.3%, n = 100), urban (69.2%, n = 83)] and belonged to other backward classes [rural (60.8%, n = 73), urban (83.3%, n = 100)]. The proportion (95% CI) of households which incurred OOPE was 68.3% (59.5%-76%) in rural and 65.8% (57%-73.7%) in urban areas. The median (inter quartile range) proportion of OOPE out of the household budget was 3.31% (0.4%-10.96%) in rural and 5.15% (0.83%-16.3%) in urban areas. CONCLUSIONS Even in a resource rich setting as the selected areas of Puducherry, majority of the households (67%) reported OOPE. The study estimates are lesser than the national estimates, but the availability and accessibility of resources are higher in Puducherry compared with the other parts of country.
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Affiliation(s)
- Uma Vasudevan
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sujiv Akkilagunta
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
| | - Sitanshu S. Kar
- Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India
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15
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Mutyambizi C, Pavlova M, Hongoro C, Booysen F, Groot W. Incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment for diabetes care in South Africa: a study at two public hospitals in Tshwane. Int J Equity Health 2019; 18:73. [PMID: 31118033 PMCID: PMC6530010 DOI: 10.1186/s12939-019-0977-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/02/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Direct out of pocket (OOP) payments for healthcare may cause financial hardship. For diabetic patients who require frequent visits to health centres, this is of concern as OOP payments may limit access to healthcare. This study assesses the incidence, socio-economic inequalities and determinants of catastrophic health expenditure and impoverishment amongst diabetic patients in South Africa. METHODS Data were taken from a cross-sectional survey conducted in 2017 at two public hospitals in Tshwane, South Africa (N = 396). Healthcare costs and transport costs related to diabetes care were classified as catastrophic if they exceeded the 10% threshold of household's capacity to pay (WHO standard method) or if they exceeded a variable threshold of total household expenditure (Ataguba method). Erreygers concentration indices (CIs) were used to assess socio-economic inequalities. A multivariate logistic regression was applied to identify the determinants of catastrophic health expenditure and impoverishment. RESULTS Transport costs contributed to over 50% of total healthcare costs. The incidence of catastrophic health expenditure was 25% when measured at a 10% threshold of capacity to pay and 13% when measured at a variable threshold of total household expenditure. Depending on the method used, the incidence of impoverishment varied from 2 to 4% and the concentration index for catastrophic health expenditure varied from - 0.2299 to - 0.1026. When measured at a 10% threshold of capacity to pay factors associated with catastrophic health expenditure were being female (Odds Ratio 1.73; Standard Error 0.51), being within the 3rd (0.49; 0.20), 4th (0.31; 0.15) and 5th wealth quintile (0.30; 0.17). When measured using a variable threshold of total household expenditure factors associated with catastrophic health expenditure were not having children (3.35; 1.82) and the 4th wealth quintile (0.32; 0.21). CONCLUSION Financial protection of diabetic patients in public hospitals is limited. This observation suggests that health financing interventions amongst diabetic patients should target the poor and poor women in particular. There is also a need for targeted interventions to improve access to healthcare facilities for diabetic patients and to reduce the financial impact of transport costs when seeking healthcare. This is particularly important for the achievement of universal health coverage in South Africa.
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Affiliation(s)
- Chipo Mutyambizi
- Research Use and Impact Assessment, Human Sciences Research Council, HSRC Building, 134 Pretorius Street, Pretoria, 0002 South Africa
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Charles Hongoro
- Research Use and Impact Assessment, Human Sciences Research Council, HSRC Building, 134 Pretorius Street, Pretoria, 0002 South Africa
| | - Frederik Booysen
- School of Economic and Business Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Centre, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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16
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McAnerney JM, Cohen C, Cohen AL, Tempia S, Walaza S, Wong KK, Im J, Marks F, Dawood H, Panzner U, Keddy KH, Von Mollendorf C. Healthcare utilisation patterns for respiratory and gastrointestinal syndromes and meningitis in Msunduzi municipality, Pietermaritzburg, KwaZulu-Natal Province, South Africa, 2013. S Afr Med J 2019; 109:333-339. [PMID: 31131801 PMCID: PMC7804386 DOI: 10.7196/samj.2019.v109i5.13024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Public health facilities are used by the majority of South Africans, and healthcare utilisation surveys have been a useful tool to estimate the burden of disease in a given area. OBJECTIVES To describe care-seeking behaviour in a periurban site with a high prevalence of HIV infection, as well as barriers to seeking appropriate healthcare. METHODS We conducted a cross-sectional household survey in 22 wards of the Msunduzi municipality in KwaZulu-Natal Province, South Africa, from October to December 2013 using a simple random sample of households selected from a 2011 census enumeration. A primary caregiver/adult decision-maker was interviewed regarding demographic data as well as health status and recent self-reported episodes of selected illnesses and healthcare utilisation. RESULTS Of the 2 238 eligible premises visited, 1 936 households (87%) with a total of 9 733 members were enrolled in the study. Of these, 635 (7%) reported one or more episodes of infectious illness during the study period. Public health clinics were most frequently consulted for all illnesses (361/635, 57%). Private healthcare (general practitioner, private clinic, private hospital) was sought by 90/635 of individuals (14%), only 13/635 (2%) reported seeking care from traditional healers, religious leaders or volunteers, and 71/635 (11%) did not seek any medical care for acute illnesses. Individuals in the lowest income group were more likely to seek care at public health facilities than those in the highest income group (70% v. 32%). CONCLUSIONS Public health facility-based surveillance may be representative of disease patterns in this community, although surveillance at household level shows that high-income individuals may be excluded because they were more likely to use private healthcare, and the proportion of individuals who died at home would have been missed by facility-based surveillance. Data obtained in such surveys may be useful for public health planning.
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Affiliation(s)
- J M McAnerney
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.
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17
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Harling G, Payne CF, Davies JI, Gomez-Olive FX, Kahn K, Manderson L, Mateen FJ, Tollman SM, Witham MD. Impairment in Activities of Daily Living, Care Receipt, and Unmet Needs in a Middle-Aged and Older Rural South African Population: Findings From the HAALSI Study. J Aging Health 2019; 32:296-307. [PMID: 30600746 PMCID: PMC6675676 DOI: 10.1177/0898264318821220] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objectives: The objective of this study is to analyze the degree to which care needs are met in an aging rural African population. Method: Using data from the Health and Aging in Africa: Longitudinal Study of an INDEPTH Community (HAALSI) baseline survey, which interviewed 5,059 adults aged older than 40 years in rural South Africa, we assessed the levels of limitations in activities of daily living (ADLs) and in unmet care for these ADLs, and evaluated their association with sociodemographic and health characteristics. Results: ADL impairment was reported by 12.2% of respondents, with the proportion increasing with age. Among those with ADL impairment, 23.9% reported an unmet need and 51.4% more a partially met need. Relatives provided help most often; formal care provision was rare. Unmet needs were more frequent among younger people and women, and were associated with physical and cognitive deficits, but not income or household size. Discussion: Unmet care needs in rural South Africa are often found among individuals less expected to require care.
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Affiliation(s)
- Guy Harling
- University College London, UK
- Harvard University, Cambridge, MA, USA
| | - Collin F. Payne
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Justine I. Davies
- King’s College London, UK
- University of the Witwatersrand, Johannesburg, South Africa
| | - F. Xavier Gomez-Olive
- Harvard University, Cambridge, MA, USA
- University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Umeå University, Sweden
| | - Lenore Manderson
- University of the Witwatersrand, Johannesburg, South Africa
- Brown University, Providence, RI, USA
| | - Farrah J. Mateen
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephen M. Tollman
- University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Umeå University, Sweden
| | - Miles D. Witham
- University of the Witwatersrand, Johannesburg, South Africa
- Newcastle University, Newcastle upon Tyne, UK
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18
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Women's (health) work: A population-based, cross-sectional study of gender differences in time spent seeking health care in Malawi. PLoS One 2018; 13:e0209586. [PMID: 30576388 PMCID: PMC6303093 DOI: 10.1371/journal.pone.0209586] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/08/2018] [Indexed: 11/19/2022] Open
Abstract
Background There has been a notable expansion in routine health care in sub-Saharan Africa. While heath care is nominally free in many contexts, the time required to access services reflects an opportunity cost that may be substantial and highly gendered, reflecting the gendered nature of health care guidelines and patterns of use. The time costs of health care use, however, have rarely been systematically assessed at the population-level. Methods Data come from the 2015 wave of a population-based cohort study of young adults in southern Malawi during which 1,453 women and 407 men between the ages of 21 and 31 were interviewed. We calculated the time spent seeking health care over a two-month period, disaggregating findings by men, recently-pregnant women, mothers with children under two years old, and “other women”. We then extrapolated the time required for specific services to estimate the time that would be needed for each subpopulation to meet government recommendations for routine health services over the course of a year. Results Approximately 60% of women and 22% of men attended at least one health care visit during the preceding two months. Women spent six times as long seeking care as did men (t = -4.414, p<0.001), with an average 6.4 hours seeking care over a two-month period compared to 1 hour for men. In order to meet government recommendations for routine health services, HIV-negative women would need to spend between 19 and 63 hours annually seeking health care compared to only three hours for men. An additional 40 hours would be required of HIV-positive individuals initiating antiretroviral care. Conclusions Women in Malawi spend a considerable amount of time seeking routine health care services, while men spend almost none. The substantial time women spend seeking health care exacerbates their time poverty and constrains opportunities for other meaningful activities. At the same time, few health care guidelines pertain to men who thus have little interaction with the health care system. Additional public health strategies such as integration of services for those services frequently used by women and specific guidelines and outreach for men are urgently needed.
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19
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Wong KKL, von Mollendorf C, Martinson N, Norris S, Tempia S, Walaza S, Variava E, McMorrow ML, Madhi S, Cohen C, Cohen AL. Healthcare utilization for common infectious disease syndromes in Soweto and Klerksdorp, South Africa. Pan Afr Med J 2018; 30:271. [PMID: 30637056 PMCID: PMC6317391 DOI: 10.11604/pamj.2018.30.271.14477] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 12/27/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Understanding healthcare utilization helps characterize access to healthcare, identify barriers and improve surveillance data interpretation. We describe healthcare-seeking behaviors for common infectious syndromes and identify reasons for seeking care. Methods We conducted a cross-sectional survey among residents in Soweto and Klerksdorp, South Africa. Households were interviewed about demographic characteristics; recent self-reported episodes of pneumonia, influenza-like illness (ILI), chronic febrile respiratory illness and meningitis in individuals of all ages; recent diarrhea in children aged < 5 years; and consultation with healthcare facilities and providers. Results From July-October 2012, we interviewed 1,442 households in Klerksdorp and 973 households in Soweto. Public clinics were consulted most frequently for pneumonia, ILI and diarrhea in a child <5 years old at both sites; public hospitals were most frequently consulted for chronic respiratory and meningitis syndromes. Of all illness episodes reported, there were 110 (35%) in Klerksdorp and 127 (32%) in Soweto for which the person did not seek care with a licensed medical provider. Pharmacies were often consulted by individuals with pneumonia (Klerksdorp: 17, 16%; Soweto: 38, 22%) or ILI (Klerksdorp: 35, 24%; 44, 28%). Patients who did not seek care with a licensed provider reported insufficient time (Klerksdorp: 7%; Soweto, 20%) and lack of medications at the facility (Klerksdorp: 4%; Soweto: 8%) as barriers. Conclusion Public government healthcare facilities are commonly consulted for infectious syndromes and pharmacies are frequently consulted particularly for respiratory diseases. Improving medication availability at healthcare facilities and streamlining healthcare delivery may improve access of licensed providers for serious illnesses.
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Affiliation(s)
- Karen Kai-Lun Wong
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
| | - Claire von Mollendorf
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Neil Martinson
- MRC Developmental Pathways for Health Research Unit, University of Witwatersrand, Johannesburg, South Africa.,Johns Hopkins University, Baltimore, Maryland USA
| | - Shane Norris
- University of Witwatersrand, Johannesburg, South Africa
| | - Stefano Tempia
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Sibongile Walaza
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Ebrahim Variava
- University of Witwatersrand, Johannesburg, South Africa.,Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Meredith Lynn McMorrow
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
| | - Shabir Madhi
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Cheryl Cohen
- National Institute for Communicable Diseases, Johannesburg, South Africa.,University of Witwatersrand, Johannesburg, South Africa
| | - Adam Lauren Cohen
- Centers for Disease Control and Prevention, Atlanta, Georgia USA.,United States Public Health Service
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20
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Access to health care in post-apartheid South Africa: availability, affordability, acceptability. HEALTH ECONOMICS POLICY AND LAW 2018; 15:43-55. [PMID: 29996951 DOI: 10.1017/s1744133118000300] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We use a reliable, intuitive and simple set of indicators to capture three dimensions of access - availability, affordability and acceptability. Data are from South Africa's 2009 and 2010 General Household Surveys (n=190,164). Affordability constraints were faced by 23% and are more concentrated amongst the poorest. However, 73% of affordability constraints are due to travel costs which are aligned with findings of the availability constraints dimension. Availability constraints, involving distances and transport costs, particularly in underdeveloped rural areas, and inconvenient opening times, were faced by 27%. Acceptability constraints were noted by only 10%. We approximate acceptability with an indicator measuring the share of community members bypassing the closest health care facility, as we argue that reported health care provider choice is more reliable than stated preferences. However, the indicator assumes a choice of available and affordable providers, which may often not be an accurate assumption in rural areas. We recommend further work on the measurement of acceptability in household surveys, especially considering this dimension's importance for health reform.
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Robert E, Samb OM, Marchal B, Ridde V. Building a middle-range theory of free public healthcare seeking in sub-Saharan Africa: a realist review. Health Policy Plan 2018; 32:1002-1014. [PMID: 28520961 PMCID: PMC5886156 DOI: 10.1093/heapol/czx035] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2017] [Indexed: 11/16/2022] Open
Abstract
Realist reviews are a new form of knowledge synthesis aimed at providing middle-range theories (MRTs) that specify how interventions work, for which populations, and under what circumstances. This approach opens the ‘black box’ of an intervention by showing how it triggers mechanisms in specific contexts to produce outcomes. We conducted a realist review of health user fee exemption policies (UFEPs) in sub-Saharan Africa (SSA). This article presents how we developed both the intervention theory (IT) of UFEPs and a MRT of free public healthcare seeking in SSA, building on Sen’s capability approach. Over the course of this iterative process, we explored theoretical writings on healthcare access, services use, and healthcare seeking behaviour. We also analysed empirical studies on UFEPs and healthcare access in free care contexts. According to the IT, free care at the point of delivery is a resource allowing users to make choices about their use of public healthcare services, choices previously not generally available to them. Users’ ability to choose to seek free care is influenced by structural, local, and individual conversion factors. We tested this IT on 69 empirical studies selected on the basis of their scientific rigor and relevance to the theory. From that analysis, we formulated a MRT on seeking free public healthcare in SSA. It highlights three key mechanisms in users’ choice to seek free public healthcare: trust, risk awareness and acceptability. Contextual elements that influence both users’ ability and choice to seek free care include: availability of and control over resources at the individual level; characteristics of users’ and providers’ communities at the local level; and health system organization, governance and policies at the structural level.
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Affiliation(s)
- Emilie Robert
- Research Institute of the McGill University Health Centre (RI-MUHC), Montréal, QC, Canada.,Division of Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada.,Equipe de recherche et d'intervention transculturelles (ERIT), CSSS de la Montagne, Montréal, QC
| | - Oumar Mallé Samb
- Division of Social and Transcultural Psychiatry, McGill University, Montréal, QC, Canada.,Department of Health Sciences, Université du Québec en Abitibi-Témiscamingue, QC, Canada
| | - Bruno Marchal
- Institute of Tropical Medicine of Antwerp, Health Services Management Unit, Antwerp, Belgium
| | - Valéry Ridde
- School of public health (ESPUM), Montreal University, Montréal, QC, Canada.,University of Montreal Public Health Research Institute (IRSPUM), Montréal, QC, Canada
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22
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A Mabunda S, London L, Pienaar D. An Evaluation of the Role of an Intermediate Care Facility in the Continuum of Care in Western Cape, South Africa. Int J Health Policy Manag 2018. [PMID: 29524940 PMCID: PMC5819376 DOI: 10.15171/ijhpm.2017.52] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care
pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care
(IC) services in the health system. This study described the model of service provision at one facility in Cape Town,
including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome
and articulation with other services across the spectrum of care.
Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics
and skills. Cox regression was used to identify predictors of survival.
Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively.
Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care
was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most
patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed
HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up,
21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio:
0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice
and there was a mismatch between what staff reported doing and their actual tasks.
Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services.
A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation
with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.
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Affiliation(s)
| | - Leslie London
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - David Pienaar
- Western Cape Department of Health, Cape Town, South Africa
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23
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Kagabo DM, Kirk CM, Bakundukize B, Hedt-Gauthier BL, Gupta N, Hirschhorn LR, Ingabire WC, Rouleau D, Nkikabahizi F, Mugeni C, Sayinzoga F, Amoroso CL. Care-seeking patterns among families that experienced under-five child mortality in rural Rwanda. PLoS One 2018; 13:e0190739. [PMID: 29320556 PMCID: PMC5761861 DOI: 10.1371/journal.pone.0190739] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 12/11/2017] [Indexed: 02/03/2023] Open
Abstract
Background Over half of under-five deaths occur in sub-Saharan Africa and appropriate, timely, quality care is critical for saving children’s lives. This study describes the context surrounding children’s deaths from the time the illness was first noticed, through the care-seeking patterns leading up to the child’s death, and identifies factors associated with care-seeking for these children in rural Rwanda. Methods Secondary analysis of a verbal and social autopsy study of caregivers who reported the death of a child between March 2013 to February 2014 that occurred after discharge from the child’s birth facility in southern Kayonza and Kirehe districts in Rwanda. Bivariate analyses using Fisher’s exact tests were conducted to identify child, caregiver, and household factors associated with care-seeking from the formal health system (i.e., community health worker or health facility). Factors significant at α = 0.10 significance level were considered for backwards stepwise multivariate logistic regression, stopping when remaining factors were significantly associated with care-seeking at α = 0.05 significance level. Results Among the 516 eligible deaths among children under-five, 22.7% (n = 117) did not seek care from the health system. For those who did, the most common first point of contact was community health workers (45.8%). In multivariate logistic regression, higher maternal education (OR = 3.36, 95% CI: 1.89, 5.98), having diarrhea (OR = 4.21, 95%CI: 1.95, 9.07) or fever (OR = 2.03, 95%CI: 1.11, 3.72), full household insurance coverage (3.48, 95%CI: 1.79, 6.76), and longer duration of illness (OR = 22.19, 95%CI: 8.88, 55.48) were significantly associated with formal care-seeking. Conclusion Interventions such as community health workers and insurance promote access to care, however a gap remains as many children had no contact with the health system prior to death and those who sought formal care still died. Further efforts are needed to respond to urgent cases in communities and further understand remaining barriers to accessing appropriate, quality care.
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Affiliation(s)
- Daniel M. Kagabo
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- * E-mail:
| | | | | | - Bethany L. Hedt-Gauthier
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Neil Gupta
- Partners in Health/Inshuti Mu Buzima (PIH/IMB), Rwinkwavu, Rwanda
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | | | | | | | | | - Felix Sayinzoga
- Rwanda Biomedical Center, Ministry of Health, Kigali, Rwanda
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Audet CM, Ngobeni S, Graves E, Wagner RG. Mixed methods inquiry into traditional healers' treatment of mental, neurological and substance abuse disorders in rural South Africa. PLoS One 2017; 12:e0188433. [PMID: 29261705 PMCID: PMC5736181 DOI: 10.1371/journal.pone.0188433] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/07/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Traditional healers are acceptable and highly accessible health practitioners throughout sub-Saharan Africa. Patients in South Africa often seek concurrent traditional and allopathic treatment leading to medical pluralism. METHODS & FINDINGS We studied the cause of five traditional illnesses known locally as "Mavabyi ya nhloko" (sickness of the head), by conducting 27 in-depth interviews and 133 surveys with a randomly selected sample of traditional healers living and working in rural, northeastern South Africa. These interviews were carried out to identify treatment practices of mental, neurological, and substance abuse (MNS) disorders. Participating healers were primarily female (77%), older in age (median: 58.0 years; interquartile range [IQR]: 50-67), had very little formal education (median: 3.7 years; IQR: 3.2-4.2), and had practiced traditional medicine for many years (median: 17 years; IQR: 9.5-30). Healers reported having the ability to successfully treat: seizure disorders (47%), patients who have lost touch with reality (47%), paralysis on one side of the body (59%), and substance abuse (21%). Female healers reported a lower odds of treating seizure disorders (Odds Ratio (OR):0.47), patients who had lost touch with reality (OR:0.26; p-value<0.05), paralysis of one side of the body (OR:0.36), and substance abuse (OR:0.36) versus males. Each additional year of education received was found to be associated with lower odds, ranging from 0.13-0.27, of treating these symptoms. Each additional patient seen by healers in the past week was associated with roughly 1.10 higher odds of treating seizure disorders, patients who have lost touch with reality, paralysis of one side of the body, and substance abuse. Healers charged a median of 500 South African Rand (~US$35) to treat substance abuse, 1000 Rand (~US$70) for seizure disorders or paralysis of one side of the body, and 1500 Rand (~US$105) for patients who have lost touch with reality. CONCLUSIONS While not all healers elect to treat MNS disorders, many continue to do so, delaying allopathic health services to acutely ill patients.
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Affiliation(s)
- Carolyn M. Audet
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Sizzy Ngobeni
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Erin Graves
- Vanderbilt Institute for Global Health, Vanderbilt University, Nashville, United States of America
| | - Ryan G. Wagner
- MRC/Wits Agincourt Research Unit, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
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25
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Lines M, Suleman F. Patients' perceptions of a rural decentralised anti-retroviral therapy management and its impact on direct out-of-pocket spending. Afr Health Sci 2017; 17:746-752. [PMID: 29085402 PMCID: PMC5656207 DOI: 10.4314/ahs.v17i3.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Geographical and financial barriers hamper accessibility to HIV services for rural communities. The government has introduced the nurse initiated management of anti-retroviral therapy at primary health care level, in an effort to improve patient access and reduce patient loads on facilities further up the system. OBJECTIVES To ascertain the perceptions and satisfaction of patients in terms of the decentralised anti-retroviral policy and the direct out-of-pocket expenses of patients accessing this care in a rural setting. METHOD Using a cross-sectional study design, 117 patients from five different primary health care collection points and a hospital anti-retroviral clinic were interviewed using a standard questionnaire. RESULTS More clinic patients walked to their clinic to collect their medicines as compared to hospital patients (71.2% versus 14.6%). Hospital patients spent more than clinic patients on monthly transport costs (ZAR71.92 versus ZAR25.81, Anova F=12.42, p=0.0009). All clinic patients listed their respective clinic as their preferred medicine collection point despite recording lower levels of satisfaction with anti-retroviral services (89% compared to 95.5%). CONCLUSION Patients seem to indicate that they preferred decentralisation of HIV care to PHC level and that this might minimise out-of-pocket spending. Further studies are required to confirm these findings.
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Affiliation(s)
- Monique Lines
- Postgraduate Student, Discipline of Pharmaceutical Sciences, School of Health Sciences, University of KwaZulu-Natal
| | - Fatima Suleman
- Prof Fatima Suleman, Associate Professor, Discipline of Pharmaceutical Sciences, School of Health Sciences, Westville Campus, University of KwaZulu-Natal
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Bergmann JN, Wanyenze RK, Stockman JK. The cost of accessing infant HIV medications and health services in Uganda. AIDS Care 2017; 29:1426-1432. [PMID: 28521509 DOI: 10.1080/09540121.2017.1330531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patient costs are a critical barrier to the elimination of mother to child HIV transmission. Despite the Ugandan government providing free public HIV services, infant antiretroviral (ARV) prophylaxis coverage remains low (25%). To understand costs mothers incur in accessing ARV prophylaxis for their infants, we conducted a mixed methods study to quantify and identify their direct costs. We used cross-sectional survey data and focus group discussions from 49 HIV-positive mothers in Uganda. Means and standard deviations were calculated for the direct costs (e.g., transportation, caretaker, services/medications) involved in accessing infant HIV services. The direct cost of attending HIV clinic visits averaged $3.71 (SD = $3.52). Focus group discussions identified two costs hindering access to infant HIV services: transportation costs and informal service charges. All participants reported significant costs associated with accessing infant HIV services - the equivalent of 2-3 days' income. To address transportation costs, community and home care models should be explored. Additionally, stricter policies and oversight should be implemented to prevent informal HIV service charges.
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Affiliation(s)
- Julie N Bergmann
- a Division of Global Public Health, Department of Medicine , University of California San Diego , La Jolla , CA , USA.,b Graduate School of Public Health , San Diego State University , San Diego , CA , USA
| | - Rhoda K Wanyenze
- c School of Public Health , Makerere University School of Public Health , Kampala , Uganda
| | - Jamila K Stockman
- a Division of Global Public Health, Department of Medicine , University of California San Diego , La Jolla , CA , USA
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Wang Q, Brenner S, Kalmus O, Banda HT, De Allegri M. The economic burden of chronic non-communicable diseases in rural Malawi: an observational study. BMC Health Serv Res 2016; 16:457. [PMID: 27582052 PMCID: PMC5007731 DOI: 10.1186/s12913-016-1716-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/25/2016] [Indexed: 11/10/2022] Open
Abstract
Background Evidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi. Methods The study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households. Results A total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs. Conclusion Our study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qun Wang
- Institute of Public Health, University of Heidelberg, INF 324, 69120, Heidelberg, Germany.,Faculty of Humanities and Social Sciences, Dalian University of Technology, Linggong Road No. 2, Ganjingzi District, Dalian, China
| | - Stephan Brenner
- Institute of Public Health, University of Heidelberg, INF 324, 69120, Heidelberg, Germany
| | - Olivier Kalmus
- Institute of Public Health, University of Heidelberg, INF 324, 69120, Heidelberg, Germany
| | - Hastings Thomas Banda
- Research for Equity and Community Health Trust (REACH Trust), P.O. Box 1597, Lilongwe, Malawi
| | - Manuela De Allegri
- Institute of Public Health, University of Heidelberg, INF 324, 69120, Heidelberg, Germany.
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Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey. BMC Health Serv Res 2016; 16:208. [PMID: 27353295 PMCID: PMC4924265 DOI: 10.1186/s12913-016-1460-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 06/13/2016] [Indexed: 11/21/2022] Open
Abstract
Background Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care. Methods Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients’ out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined. Results Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic. Conclusions Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1460-0) contains supplementary material, which is available to authorized users.
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Knight L, Hosegood V, Timæus IM. Obligation to family during times of transition: care, support and the response to HIV and AIDS in rural South Africa. AIDS Care 2016; 28 Suppl 4:18-29. [PMID: 27283212 DOI: 10.1080/09540121.2016.1195486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In rural South Africa, high HIV prevalence has the potential to affect the care and support that kin are able to provide to those living with HIV. Despite this, families seem to be largely resilient and a key source of care and support to family affected by HIV. In this article, we explore the motivations for the provision of care and support by kin. We use the results of a small-scale in-depth qualitative study conducted in 10 households over 6 months in rural KwaZulu-Natal, South Africa, to show that family obligation and conditional reciprocity operate in varying degrees and build social capital. We highlight the complexity of kin relations where obligation is not guaranteed or is limited, requiring the consideration of policy measures that provide means of social support that are not reliant on the family.
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Affiliation(s)
- Lucia Knight
- a School of Public Health , University of the Western Cape , Bellville , South Africa
| | - Victoria Hosegood
- b Division of Social Statistics and Demography , University of Southampton , Southampton , UK.,c Africa Centre for Health and Population Studies , Mtubatuba , South Africa
| | - Ian M Timæus
- d Department of Population Health , London School of Hygiene & Tropical Medicine , London , UK.,e Centre for Actuarial Research , University of Cape Town , Cape Town , South Africa
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30
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Probst C, Parry CDH, Rehm J. Socio-economic differences in HIV/AIDS mortality in South Africa. Trop Med Int Health 2016; 21:846-55. [PMID: 27118253 DOI: 10.1111/tmi.12712] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To quantify socio-economic differences in the risk of HIV/AIDS mortality in South Africa for different measures of socio-economic status. METHODS Systematic literature search in Web of Knowledge and PubMed. Measures of relative risk (RR) were pooled separately for education, income, assets score and employment status as measures of socio-economic status, using inverse-variance weighted DerSimonian-Laird random effects meta-analyses. RESULTS Ten studies were eligible for inclusion comprising over 175 000 participants and 6700 deaths. For income (RR 1.55, 95% confidence interval (CI) 1.15-2.09), assets score (RR 1.63, 95% CI 1.12-2.36) and employment status (RR 1.52, 95% CI 1.21-1.92), persons of low socio-economic status had an over 50% higher risk of dying from HIV/AIDS. The RR of 1.10 for education was not significant (95% CI 0.74-1.65). CONCLUSIONS Future research should identify effective strategies to reduce HIV/AIDS mortality and alleviate the consequences of HIV/AIDS deaths, particularly for poorer households.
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Affiliation(s)
- Charlotte Probst
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies, Technische Universität Dresden, Dresden, Germany
| | - Charles D H Parry
- Alcohol, Tobacco & Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa.,Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Institute of Clinical Psychology and Psychotherapy & Center of Clinical Epidemiology and Longitudinal Studies, Technische Universität Dresden, Dresden, Germany.,Addiction Policy, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Braathen SH, Sanudi L, Swartz L, Jürgens T, Banda HT, Eide AH. A household perspective on access to health care in the context of HIV and disability: a qualitative case study from Malawi. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2016; 16:12. [PMID: 27036489 PMCID: PMC4818417 DOI: 10.1186/s12914-016-0087-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 03/22/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Equitable access to health care is a challenge in many low-income countries. The most vulnerable segments of any population face increased challenges, as their vulnerability amplifies problems of the general population. This implies a heavy burden on informal care-givers in their immediate and extended households. However, research falls short of explaining the particular challenges experienced by these individuals and households. To build an evidence base from the ground, we present a single case study to explore and understand the individual experience, to honour what is distinctive about the story, but also to use the individual story to raise questions about the larger context. METHODS We use a single qualitative case study approach to provide an in-depth, contextual and household perspective on barriers, facilitators, and consequences of care provided to persons with disability and HIV. RESULTS The results from this study emphasise the burden that caring for an HIV positive and disabled family member places on an already impoverished household, and the need for support, not just for the HIV positive and disabled person, but for the entire household. CONCLUSIONS Disability and HIV do not only affect the individual, but the whole household, immediate and extended. It is crucial to consider the interconnectedness of the challenges faced by an individual and a household. Issues of health (physical and mental), disability, employment, education, infrastructure (transport/terrain) and poverty are all related and interconnected, and should be addressed as a whole in order to secure equity in health.
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Affiliation(s)
- Stine Hellum Braathen
- />Department of Health, SINTEF Technology and Society, PB 124 Blindern, 0314 Oslo, Norway
| | - Lifah Sanudi
- />REACH Trust, P.O. Box 1597, Lilongwe, Malawi
- />Department of Psychology, Stellenbosch University, Private Bag X1, Matieland, 7602 South Africa
| | - Leslie Swartz
- />Department of Psychology, Stellenbosch University, Alan J Flisher Centre for Public Mental Health, Private Bag X1, Matieland, 7602 South Africa
| | - Thomas Jürgens
- />LHL International Tuberculosis Foundation, Grensen 3 (7th floor), 0159 Oslo, Norway
| | | | - Arne Henning Eide
- />Department of Health, SINTEF Technology and Society, PB 124 Blindern, 0314 Oslo, Norway
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Watkins DA, Olson ZD, Verguet S, Nugent RA, Jamison DT. Cardiovascular disease and impoverishment averted due to a salt reduction policy in South Africa: an extended cost-effectiveness analysis. Health Policy Plan 2016; 31:75-82. [PMID: 25841771 PMCID: PMC4724166 DOI: 10.1093/heapol/czv023] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 11/13/2022] Open
Abstract
The South African Government recently set targets to reduce cardiovascular disease (CVD) by lowering salt consumption. We conducted an extended cost-effectiveness analysis (ECEA) to model the potential health and economic impacts of this salt policy. We used surveys and epidemiologic studies to estimate reductions in CVD resulting from lower salt intake. We calculated the average out-of-pocket (OOP) cost of CVD care, using facility fee schedules and drug prices. We estimated the reduction in OOP expenditures and government subsidies due to the policy. We estimated public and private sector costs of policy implementation. We estimated financial risk protection (FRP) from the policy as (1) cases of catastrophic health expenditure (CHE) averted or (2) cases of poverty averted. We also performed a sensitivity analysis. We found that the salt policy could reduce CVD deaths by 11%, with similar health gains across income quintiles. The policy could save households US$ 4.06 million (2012) in OOP expenditures (US$ 0.29 per capita) and save the government US$ 51.25 million in healthcare subsidies (US$ 2.52 per capita) each year. The cost to the government would be only US$ 0.01 per capita; hence, the policy would be cost saving. If the private sector food reformulation costs were passed on to consumers, food expenditures would increase by <0.2% across all income quintiles. Preventing CVD could avert 2400 cases of CHE or 2000 cases of poverty yearly. Our results were sensitive to baseline CVD mortality rates and the cost of treatment. We conclude that, in addition to health gains, population salt reduction can have positive economic impacts-substantially reducing OOP expenditures and providing FRP, particularly for the middle class. The policy could also provide large government savings on health care.
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Affiliation(s)
- David A Watkins
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA, Department of Medicine, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa,
| | - Zachary D Olson
- School of Public Health, The University of California, Berkeley, CA, USA
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Rachel A Nugent
- Department of Global Health, University of Washington, Seattle, WA, USA and
| | - Dean T Jamison
- Department of Global Health, University of Washington, Seattle, WA, USA and Global Health Sciences, The University of California, San Francisco, CA, USA
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Abstract
Compared to their urban counterparts, rural and remote inhabitants experience lower life expectancy and poorer health status. Nowhere is the worldwide shortage of health professionals more pronounced than in rural areas of developing countries. Sub-Saharan Africa (SSA) includes a disproportionately large number of developing countries; therefore, this article explores SSA in depth as an example. Using the conceptual framework of access to primary health care, sustainable rural health service models, rural health workforce supply, and policy implications, this article presents a review of the academic and gray literature as the basis for recommendations designed to achieve greater health equity. An alternative international standard for health professional education is recommended. Decision makers should draw upon the expertise of communities to identify community-specific health priorities and should build capacity to enable the recruitment and training of local students from underserviced areas to deliver quality health care in rural community settings.
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Affiliation(s)
- Roger Strasser
- Northern Ontario School of Medicine, Sudbury and Thunder Bay, Ontario, Canada;
| | - Sophia M Kam
- School of Rural and Northern Health, Laurentian University, Sudbury, ON P3E 2C6 Canada
| | - Sophie M Regalado
- Northern Ontario School of Medicine, Sudbury and Thunder Bay, Ontario, Canada;
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Time and Money: The True Costs of Health Care Utilization for Patients Receiving "Free" HIV/Tuberculosis Care and Treatment in Rural KwaZulu-Natal. J Acquir Immune Defic Syndr 2015; 70:e52-60. [PMID: 26371611 DOI: 10.1097/qai.0000000000000728] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND HIV and tuberculosis (TB) services are provided free of charge in many sub-Saharan African countries, but patients still incur costs. METHODS Patient-exit interviews were conducted in primary health care clinics in rural South Africa with representative samples of 200 HIV-infected patients enrolled in a pre-antiretroviral treatment (pre-ART) program, 300 patients receiving antiretroviral treatment (ART), and 300 patients receiving TB treatment. For each group, we calculated health expenditures across different spending categories, time spent traveling to and using services, and how patients financed their spending. Associations between patient group and costs were assessed in multivariate regression models. RESULTS Total monthly health expenditures [1 USD = 7.3 South African Rand (ZAR)] were ZAR 171 [95% confidence interval (CI): 134 to 207] for pre-ART, ZAR 164 (95% CI: 141 to 187) for ART, and ZAR 122 (95% CI: 105 to 140) for TB patients (P = 0.01). Total monthly time costs (in hours) were 3.4 (95% CI: 3.3 to 3.5) for pre-ART, 5.0 (95% CI: 4.7 to 5.3) for ART, and 3.2 (95% CI: 2.9 to 3.4) for TB patients (P < 0.01). Although overall patient costs were similar across groups, pre-ART patients spent on average ZAR 29.2 more on traditional healers and ZAR 25.9 more on chemists and private doctors than ART patients, whereas ART patients spent ZAR 34.0 more than pre-ART patients on transport to clinics (P < 0.05 for all results). Thirty-one percent of pre-ART, 39% of ART, and 41% of TB patients borrowed money or sold assets to finance health care. CONCLUSIONS Patients receiving nominally free care for HIV/TB face large private costs, commonly leading to financial distress. Subsidized transport, fewer clinic visits, and drug pick-up points closer to home could reduce costs for ART patients, potentially improving retention and adherence. Large expenditure on alternative care among pre-ART patients suggests that transitioning patients to ART earlier, as under HIV treatment-as-prevention policies, may not substantially increase patients' financial burden.
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Abdou Illou MM, Haddad S, Agier I, Ridde V. The elimination of healthcare user fees for children under five substantially alleviates the burden on household expenses in Burkina Faso. BMC Health Serv Res 2015; 15:313. [PMID: 26253339 PMCID: PMC4529705 DOI: 10.1186/s12913-015-0957-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/14/2015] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Since September 2008, an intervention has made it possible to provide free care to children under five in public health facilities in two districts of Burkina Faso. This study evaluated the intervention's impact on household expenses incurred for services (consultations and medications) to the children targeted. METHODS The study is based on a survey of a representative panel of 1,260 households encountered in two waves, one month before and 12 months after the introduction of the intervention. The questions explored the illness episodes of all children under five in the 30 days before each wave. The analysis of health expenses incurred during an illness episode distinguished between total expenses and those incurred in public health facilities (charges for services and medications). Analyses based on multilevel simultaneous equation models were used to estimate the probability of spending and the amount spent, in a context where a large number of observations returned a count of zero. RESULTS The burden on household expenses was greatly alleviated under the intervention. Average expenditure dropped from US$11 per episode of care to less than US$2 after the intervention was implemented. The risk of incurring an expense at a public health facility was reduced by two-thirds. The facility users' savings were primarily related to medication purchases. In rural areas, where barriers to access health services are more acute, both poor and non-poor families benefited from the intervention. The probability of spending on medications dropped dramatically for both the poor and the non-poor under the exemption (-75% vs.-77%), and the reduction in expenses for medications generated by the intervention was comparable for both groups in relative values (-86% vs.-89%). CONCLUSION User fees abolition at the point of service substantially alleviated the burden on household expenses. The intervention benefited both poor and non-poor families and provided financial protection.
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Affiliation(s)
- Mahaman Mourtala Abdou Illou
- Cellule d'Analyse et de Prospective en Développement (CAPED), Cabinet du Premier Ministre, République du Niger, 28, Avenue du Mounio, BP 13.568, Niamey, Niger.
| | - Slim Haddad
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Québec, Canada.
- Centre de recherche du CHU de Québec, 1050 chemin de Ste-Foy, Québec, QC, G1S-4L8, Canada.
| | - Isabelle Agier
- University of Montreal Hospital Research Centre (CRCHUM), Saint-Antoine Tower, 850 Saint-Denis St., Montreal, QC, H2X 0A9, Canada.
| | - Valéry Ridde
- University of Montreal Hospital Research Centre (CRCHUM), Saint-Antoine Tower, 850 Saint-Denis St., Montreal, QC, H2X 0A9, Canada.
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Wang Q, Fu AZ, Brenner S, Kalmus O, Banda HT, De Allegri M. Out-of-pocket expenditure on chronic non-communicable diseases in sub-Saharan Africa: the case of rural Malawi. PLoS One 2015; 10:e0116897. [PMID: 25584960 PMCID: PMC4293143 DOI: 10.1371/journal.pone.0116897] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 12/16/2014] [Indexed: 11/25/2022] Open
Abstract
In Sub-Saharan Africa (SSA) the disease burden of chronic non-communicable diseases (CNCDs) is rising considerably. Given weaknesses in existing financial arrangements across SSA, expenditure on CNCDs is often borne directly by patients through out-of-pocket (OOP) payments. This study explored patterns and determinants of OOP expenditure on CNCDs in Malawi. We used data from the first round of a longitudinal household health survey conducted in 2012 on a sample of 1199 households in three rural districts in Malawi. We used a two-part model to analyze determinants of OOP expenditure on CNCDs. 475 respondents reported at least one CNCD. More than 60% of the 298 individuals who reported seeking care incurred OOP expenditure. The amount of OOP expenditure on CNCDs comprised 22% of their monthly per capita household expenditure. The poorer the household, the higher proportion of their monthly per capita household expenditure was spent on CNCDs. Higher severity of disease was significantly associated with an increased likelihood of incurring OOP expenditure. Use of formal care was negatively associated with the possibility of incurring OOP expenditure. The following factors were positively associated with the amount of OOP expenditure: being female, Alomwe and household head, longer duration of disease, CNCDs targeted through active screening programs, higher socio-economic status, household head being literate, using formal care, and fewer household members living with a CNCD within a household. Our study showed that, in spite of a context where care for CNCDs should in principle be available free of charge at point of use, OOP payments impose a considerable financial burden on rural households, especially among the poorest. This suggests the existence of important gaps in financial protection in the current coverage policy.
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Affiliation(s)
- Qun Wang
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Alex Z. Fu
- Cancer Prevention and Control Program, Georgetown University Medical Center, Washington, D.C., United States of America
| | - Stephan Brenner
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Olivier Kalmus
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | | | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
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Lopes Ibanez-Gonzalez D, Mendenhall E, Norris SA. A mixed methods exploration of patterns of healthcare utilization of urban women with non-communicable disease in South Africa. BMC Health Serv Res 2014; 14:528. [PMID: 25367195 PMCID: PMC4231186 DOI: 10.1186/s12913-014-0528-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 10/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the growing burden of NCDs in South Africa, very little is known about how people living in urban townships manage these illnesses. In this article we expound upon the findings of a study showing that only one-third of women with an NCD participating in the Birth to Twenty (Bt20) cohort study of Soweto-Johannesburg, South Africa, had sought biomedical services in the previous six months. METHODS We evaluated quantitative data from a cross sectional health access survey conducted with adult women (mean age = 44.8) and examined 25 in-depth narrative interviews with twelve women who self-reported at least one NCD from the larger study. RESULTS The qualitative findings highlight the potential role of negative experiences of healthcare services and biomedicine in delaying the seeking of healthcare. Multivariate analysis of the quantitative findings found that the possession of medical aid (OR = 1.7, CI = 1.01-2.84) and the self-reported use of patient strategies in negotiating healthcare access (OR = 1.6, CI = 1.04-2.34) were positively associated with the utilization of healthcare services. Belief in the superior efficacy of traditional healers over doctors was associated with delay of NCD treatment (OR = 2.4, CI = 1.14-4.18). CONCLUSION Our data suggest that low healthcare utilization is due in part to low rates of expectation for consistent and high-quality care and potential mistrust of the medical system. We conclude that both demand-side and supply-side measures focusing on high trust management practices will prove essential in ensuring access to healthcare services.
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Affiliation(s)
- Daniel Lopes Ibanez-Gonzalez
- />MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Emily Mendenhall
- />Walsh School of Foreign Service, Georgetown University, Washington, DC USA
| | - Shane A Norris
- />MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Sartorius K, Sartorius BKD, Collinson MA, Tollman SM. The dynamics of household dissolution and change in socio-economic position: A survival model in a rural South Africa. DEVELOPMENT SOUTHERN AFRICA 2014; 31:775-795. [PMID: 25937697 PMCID: PMC4373160 DOI: 10.1080/0376835x.2014.951991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This paper investigates household dissolution and changes in asset wealth (socio-economic position) in a rural South African community containing settled refugees. Survival analysis applied to a longitudinal dataset indicated that the covariates increasing the risk of forced household dissolution were a reduction in socio-economic position (asset wealth), adult deaths and the permanent outmigration of more than 40% of the household. Conversely, the risk of dissolution was reduced by bigger households, state grants and older household heads. Significant spatial clusters of former refugee villages also showed a higher risk of dissolution after 20 years of permanent residence. A discussion of the dynamics of dissolution showed how an outflow/inflow of household assets (socio-economic position) was precipitated by each of the selected covariates. The paper shows how an understanding of the dynamics of forced household dissolution, combined with the use of geo-spatial mapping, can inform inter-disciplinary policy in a rural community.
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Affiliation(s)
- Kurt Sartorius
- Professor, School of Accountancy, University of the Witwatersrand, Private Bag 3, Wits2050, South Africa
| | - Benn KD Sartorius
- Associate Professor, Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of Kwazulu-Natal, Durban, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark A Collinson
- Professor, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
| | - Stephen M Tollman
- Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
- Senior Researcher, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
Financial risk protection is a key component of universal health coverage (UHC), which is defined as access to all needed quality health services without financial hardship. As part of the PLOS Medicine Collection on measurement of UHC, the aim of this paper is to examine and to compare and contrast existing measures of financial risk protection. The paper presents the rationale behind the methodologies for measuring financial risk protection and how this relates to UHC as well as some empirical examples of the types of measures. Additionally, the specific challenges related to monitoring inequalities in financial risk protection are discussed. The paper then goes on to examine and document the practical challenges associated with measurement of financial risk protection. This paper summarizes current thinking on the area of financial risk protection, provides novel insights, and suggests future developments that could be valuable in the context of monitoring progress towards UHC.
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Affiliation(s)
- Priyanka Saksena
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
- Swiss Tropical and Public Health Institute, University of Basel, Basel Switzerland
| | - Justine Hsu
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - David B. Evans
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
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Ameh S, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Predictors of health care use by adults 50 years and over in a rural South African setting. Glob Health Action 2014; 7:24771. [PMID: 25087686 PMCID: PMC4119936 DOI: 10.3402/gha.v7.24771] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/28/2014] [Accepted: 06/29/2014] [Indexed: 11/14/2022] Open
Abstract
Background South Africa’s epidemiological transition is characterised by an increasing burden of chronic communicable and non-communicable diseases. However, little is known about predictors of health care use (HCU) for the prevention and control of chronic diseases among older adults. Objective To describe reported health problems and determine predictors of HCU by adults aged 50+ living in a rural sub-district of South Africa. Design A cross-sectional study to measure HCU was conducted in 2010 in the Agincourt sub-district of Mpumalanga Province, an area underpinned by a robust health and demographic surveillance system. HCU, socio-demographic variables, reception of social grants, and type of medical aid were measured, and compared between responders who used health care services with those who did not. Predictors of HCU were determined by binary logistic regression adjusted for socio-demographic variables. Results Seventy-five percent of the eligible adults aged 50+ responded to the survey. Average age of the targeted 7,870 older adults was 66 years (95% CI: 65.3, 65.8), and there were more women than men (70% vs. 30%, p<0.001). All 5,795 responders reported health problems, of which 96% used health care, predominantly at public health facilities (82%). Reported health problems were: chronic non-communicable diseases (41% – e.g. hypertension), acute conditions (27% – e.g. flu and fever), other conditions (26% – e.g. musculoskeletal pain), chronic communicable diseases (3% – e.g. HIV and TB), and injuries (3%). In multivariate logistic regression, responders with chronic communicable disease (OR=5.91, 95% CI: 1.44, 24.32) and non-communicable disease (OR=2.85, 95% CI: 1.96, 4.14) had significantly higher odds of using health care compared with those with acute conditions. Responders with six or more years of education had a two-fold increased odds of using health care (OR=2.49, 95% CI: 1.27, 4.86) compared with those with no formal education. Conclusion Chronic communicable and non-communicable diseases were the most prevalent and main predictors of HCU in this population, suggesting prioritisation of public health care services for chronic diseases among older people in this rural setting.
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Affiliation(s)
- Soter Ameh
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Community Medicine Department, College of Medical Sciences, University of Calabar, Cross River State, Nigeria;
| | - Francesc Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana; Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; INDEPTH Network, Accra, Ghana; Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Kerstin Klipstein-Grobusch
- Division of Epidemiology and Biostatistics, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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Houle B, Clark SJ, Gómez-Olivé FX, Kahn K, Tollman SM. The unfolding counter-transition in rural South Africa: mortality and cause of death, 1994-2009. PLoS One 2014; 9:e100420. [PMID: 24959714 PMCID: PMC4068997 DOI: 10.1371/journal.pone.0100420] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 05/28/2014] [Indexed: 01/19/2023] Open
Abstract
The HIV pandemic has led to dramatic increases and inequalities in adult mortality, and the diffusion of antiretroviral treatment, together with demographic and socioeconomic shifts in sub-Saharan Africa, has further changed mortality patterns. We describe all-cause and cause-specific mortality patterns in rural South Africa, analyzing data from the Agincourt health and socio-demographic surveillance system from 1994 to 2009 for those aged 5 years and older. Mortality increased during that period, particularly after 2002 for ages 30-69. HIV/AIDS and TB deaths increased and recently plateaued at high levels in people under age 60. Noncommunicable disease deaths increased among those under 60, and recently also increased among those over 60. There was an inverse gradient between mortality and household SES, particularly for deaths due to HIV/AIDS and TB and noncommunicable diseases. A smaller and less consistent gradient emerged for deaths due to other communicable diseases. Deaths due to injuries remained an important mortality risk for males but did not vary by SES. Rural South Africa continues to have a high burden of HIV/AIDS and TB mortality while deaths from noncommunicable diseases have increased, and both of these cause-categories show social inequalities in mortality.
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Affiliation(s)
- Brian Houle
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
| | - Samuel J. Clark
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- ALPHA Network, London, United Kingdom
| | - F. Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
| | - Stephen M. Tollman
- Institute of Behavioral Science (IBS), University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Global Health Research, Umeå University, Umeå, Sweden
- INDEPTH Network, Accra, Ghana
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Visagie S, Schneider M. Implementation of the principles of primary health care in a rural area of South Africa. Afr J Prim Health Care Fam Med 2014; 6:E1-E10. [PMID: 26245391 PMCID: PMC4502891 DOI: 10.4102/phcfm.v6i1.562] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 08/07/2013] [Indexed: 11/25/2022] Open
Abstract
Background The philosophy of primary healthcare forms the basis of South Africa's health policy and provides guidance for healthcare service delivery in South Africa. Healthcare service provision in South Africa has shown improvement in the past five years. However, it is uncertain as to whether the changes have reached rural areas and if primary healthcare is implemented successfully in these areas. Objectives The aim of this article is to explore the extent to which the principles of primary healthcare are implemented in a remote, rural setting in South Africa. Method A descriptive, qualitative design was implemented. Data were collected through interviews and case studies with 36 purposively-sampled participants, then analysed through Interpretative Phenomenological Analysis. Results Findings indicated challenges with regard to client-centred care, provision of health promotion and rehabilitation, the way care was organised, the role of the doctor, health-worker attitudes, referral services and the management of complex conditions. Conclusion The principles of primary healthcare were not implemented successfully. The community was not involved in healthcare management, nor were users involved in their personal health management. The initiation of a community-health forum is recommended. Service providers, users and the community should identify and address the determinants of ill health in the community. Other recommendations include the training of service managers in the logistical management of ensuring a constant supply of drugs, using a Kombi-type vehicle to provide user transport for routine visits to secondary- and tertiary healthcare services and increasing the doctors’ hours.
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Affiliation(s)
- Surona Visagie
- Centre for Rehabilitation Studies, Stellenbosch University.
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Lopes Ibanez-Gonzalez D, Norris SA. Chronic non-communicable disease and healthcare access in middle-aged and older women living in Soweto, South Africa. PLoS One 2013; 8:e78800. [PMID: 24205316 PMCID: PMC3812146 DOI: 10.1371/journal.pone.0078800] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 09/23/2013] [Indexed: 11/18/2022] Open
Abstract
The aim of the current study was to describe the healthcare access, beliefs, and practices of middle-aged and older women residing in Soweto. This is a cross-sectional study of the primary (female) caregivers of the Birth to Twenty Cohort, based in Soweto, South Africa. The study instrument was administered to 1 102 caregivers as part of routine annual data collection. Over half the respondents (50.7%) reported having at least one chronic non-communicable disease (CND), only a small portion (33.3%) of whom reported accessing a healthcare service in the last 6 months. Reported availability of private medical practice and government clinics was high (75.1% and 61.5% respectively). The low utilisation of healthcare services by women with CND is a concern in terms of healthcare management. There is a need to further investigate how healthcare beliefs are formed, as well as the feasibility of programmes to support the ongoing management of CND in Soweto.
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Affiliation(s)
- Daniel Lopes Ibanez-Gonzalez
- Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Shane A. Norris
- Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Govender V, Chersich MF, Harris B, Alaba O, Ataguba JE, Nxumalo N, Goudge J. Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme. Glob Health Action 2013; 6:19253. [PMID: 23364093 PMCID: PMC3556708 DOI: 10.3402/gha.v6i0.19253] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 11/11/2012] [Accepted: 11/12/2012] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. OBJECTIVES This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. METHODS Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. RESULTS Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. CONCLUSION Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms.
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Affiliation(s)
- Veloshnee Govender
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
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Clark SJ, Kahn K, Houle B, Arteche A, Collinson MA, Tollman SM, Stein A. Young children's probability of dying before and after their mother's death: a rural South African population-based surveillance study. PLoS Med 2013; 10:e1001409. [PMID: 23555200 PMCID: PMC3608552 DOI: 10.1371/journal.pmed.1001409] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 02/14/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND There is evidence that a young child's risk of dying increases following the mother's death, but little is known about the risk when the mother becomes very ill prior to her death. We hypothesized that children would be more likely to die during the period several months before their mother's death, as well as for several months after her death. Therefore we investigated the relationship between young children's likelihood of dying and the timing of their mother's death and, in particular, the existence of a critical period of increased risk. METHODS AND FINDINGS Data from a health and socio-demographic surveillance system in rural South Africa were collected on children 0-5 y of age from 1 January 1994 to 31 December 2008. Discrete time survival analysis was used to estimate children's probability of dying before and after their mother's death, accounting for moderators. 1,244 children (3% of sample) died from 1994 to 2008. The probability of child death began to rise 6-11 mo prior to the mother's death and increased markedly during the 2 mo immediately before the month of her death (odds ratio [OR] 7.1 [95% CI 3.9-12.7]), in the month of her death (OR 12.6 [6.2-25.3]), and during the 2 mo following her death (OR 7.0 [3.2-15.6]). This increase in the probability of dying was more pronounced for children whose mothers died of AIDS or tuberculosis compared to other causes of death, but the pattern remained for causes unrelated to AIDS/tuberculosis. Infants aged 0-6 mo at the time of their mother's death were nine times more likely to die than children aged 2-5 y. The limitations of the study included the lack of knowledge about precisely when a very ill mother will die, a lack of information about child nutrition and care, and the diagnosis of AIDS deaths by verbal autopsy rather than serostatus. CONCLUSIONS Young children in lower income settings are more likely to die not only after their mother's death but also in the months before, when she is seriously ill. Interventions are urgently needed to support families both when the mother becomes very ill and after her death. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Samuel J. Clark
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Brian Houle
- Department of Sociology, University of Washington, Seattle, Washington, United States of America
- Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
- * E-mail:
| | - Adriane Arteche
- The Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Mark A. Collinson
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Stephen M. Tollman
- Institute of Behavioral Science, University of Colorado at Boulder, Boulder, Colorado, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Alan Stein
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- The Section of Child and Adolescent Psychiatry, Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Sartorius K, Sartorius B, Tollman S, Schatz E, Kirsten J, Collinson M. Rural Poverty Dynamics and Refugee Communities in South Africa: A Spatial-Temporal Model. POPULATION, SPACE AND PLACE 2013; 19:103-123. [PMID: 24348199 PMCID: PMC3860329 DOI: 10.1002/psp.697] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/18/2011] [Indexed: 06/02/2023]
Abstract
The assimilation of refugees into their host community economic structures is often problematic. The paper investigates the ability of refugees in rural South Africa to accumulate assets over time relative to their host community. Bayesian spatial-temporal modelling was employed to analyse a longitudinal database that indicated that the asset accumulation rate of former Mozambican refugee households was similar to their host community; however, they were unable to close the wealth gap. A series of geo-statistical wealth maps illustrate that there is a spatial element to the higher levels of absolute poverty in the former refugee villages. The primary reason for this is their physical location in drier conditions that are established further away from facilities and infrastructure. Neighbouring South African villages in close proximity, however, display lower levels of absolute poverty, suggesting that the spatial location of the refugees only partially explains their disadvantaged situation. In this regard, the results indicate that the wealth of former refugee households continues to be more compromised by higher mortality levels, poorer education, and less access to high-return employment opportunities. The long-term impact of low initial asset status appears to be perpetuated in this instance by difficulties in obtaining legal status in order to access state pensions, facilities, and opportunities. The usefulness of the results is that they can be used to sharpen the targeting of differentiated policy in a given geographical area for refugee communities in rural Africa. Copyright © 2011 John Wiley & Sons, Ltd.
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Affiliation(s)
- Kurt Sartorius
- School of Accountancy, Faculty of Commerce, Law and Management, University of the WitwatersrandJohannesburg, South Africa
| | - Benn Sartorius
- School of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburg, South Africa
| | - Stephen Tollman
- School of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburg, South Africa
- Centre for Global Health Research, Epidemiology and Global Health, Umeå UniversitySweden
- INDEPTH Network, AccraGhana
| | - Enid Schatz
- School of Health Professions, University of MissouriUSA
| | - Johann Kirsten
- Department of Agricultural EconomicsUniversity of Pretoria
| | - Mark Collinson
- School of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburg, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the WitwatersrandJohannesburg, South Africa
- Centre for Global Health Research, Epidemiology and Global Health, Umeå UniversitySweden
- INDEPTH Network, AccraGhana
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Cleary S, Birch S, Chimbindi N, Silal S, McIntyre D. Investigating the affordability of key health services in South Africa. Soc Sci Med 2012; 80:37-46. [PMID: 23415590 DOI: 10.1016/j.socscimed.2012.11.035] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 11/20/2012] [Accepted: 11/29/2012] [Indexed: 11/19/2022]
Abstract
This paper considers the affordability of using public sector health services for three tracer conditions (obstetric care, tuberculosis treatment and antiretroviral treatment for HIV-positive people), based on research undertaken in two urban and two rural sites in South Africa. We understand affordability as the 'degree of fit' between the costs of seeking health care and a household's ability-to-pay. Exit interviews were conducted with over 300 patients for each of the three tracer conditions in each of the four sites (i.e. a total sample of over 3600). Total direct costs for the service used at the time of the interview, as well as other health related costs incurred during the preceding month either for self-care or the use of plural providers were assessed, as were a range of indicators of ability-to-pay. The percentage of households incurring direct costs exceeding 10% of household consumption expenditure and those borrowing money or selling assets as a mechanism for coping with the burden of direct costs were calculated. Logistic regressions were also conducted to identify factors that were significantly associated with these indicators of affordability. There were significant differences in affordability between rural and urban sites; costs were higher, ability-to-pay was lower and there was a greater proportion of households selling assets or borrowing money in rural areas. There were also significant differences across tracers, with a higher percentage of households receiving tuberculosis and antiretroviral treatment borrowing money or selling assets than those using obstetric services. As these conditions require expenses to be incurred on an ongoing basis, the sustainability of such coping strategies is questionable. Policy makers need to explore how to reduce direct costs for users of these key health services in the context of the particular characteristics of different treatment types. Affordability needs to be considered in relation to the dynamic aspects of the costs of treating different conditions and the timing of treatment in relation to diagnosis. The frequently high transport costs associated with treatments involving multiple consultations can be addressed by initiatives that provide close-to-client services and subsidised patient transport for referrals.
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Affiliation(s)
- Susan Cleary
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
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Prenatal diagnosis and termination of pregnancy: perspectives of South African parents of children with Down syndrome. J Community Genet 2012; 4:87-97. [PMID: 23096497 DOI: 10.1007/s12687-012-0122-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 10/03/2012] [Indexed: 10/27/2022] Open
Abstract
This study aims to evaluate the attitudes of a group of South African parents with a preschool child with Down syndrome (DS) towards prenatal diagnosis (PND) and termination of a Down syndrome-affected pregnancy (TAP). This study employs a qualitative phenomenological approach with the use of semi-structured interviews. Twelve participants were recruited from two state sector hospitals in Cape Town, South Africa. Thematic analysis was used to interpret the data. The participants had a positive attitude towards PND and felt that it was every parent's right to have the option. They considered a benefit of PND the fact that it allowed parents time to prepare for the arrival of a baby with DS. The induced miscarriage risk associated with invasive prenatal testing procedures caused major negative feelings. They were totally opposed to the termination of a Down syndrome-affected pregnancy due to their personal experience, moral, ethical or religious convictions. South African parents of preschool children with Down syndrome are comfortable with PND for Down syndrome; however, they do not support TAP. These findings will provide health care providers with further insight into the motivations behind the decisions their patients make.
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Gavaza P, Rascati KL, Oladapo AO, Khoza S. The state of health economic research in South Africa: a systematic review. PHARMACOECONOMICS 2012; 30:925-40. [PMID: 22809450 DOI: 10.2165/11589450-000000000-00000] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
BACKGROUND Economic factors are a limiting factor toward the implementation of many health programmes and interventions. Economic evaluation has a great potential to contribute toward cost-effective healthcare delivery in South Africa. Little is known about the characteristics and quality of health economic (including pharmacoeconomic) research in South Africa. OBJECTIVE AND METHODS This study assessed the state of health economic (including pharmacoeconomic) research in South Africa. PUBMED, MEDLINE, HealthSTAR, EconLit and PsycINFO databases were searched to identify health economic articles pertaining to South Africa published between 1 January 1977 and 30 April 2010. The searches used the following Medical Subject Headings (MeSH) terms and text words alone and in combination: 'costs', 'health' and 'South Africa'. Our study included only original economic studies/analyses that pertained to South Africa, addressed a health-related topic, and had a statement or word in the title, abstract or keywords that indicated that an economic (including cost) analysis had been conducted. The study only included complete peer-reviewed publications (e.g. abstracts were excluded) that were reported in the English language. Two reviewers independently scored each article in the final sample using the data collection form designed for the study. RESULTS In total, 108 studies investigating a wide variety of diseases were included in the study. These articles were published in 39 different journals mostly based outside of South Africa between 1977 and 2010. On average, each article was written by three authors. Most first authors had medical/clinical training and resided in South Africa at the time of publication of their study. Based on a 1-10 scale, with 10 indicating the highest quality, the mean quality score for all studies was 7.59 (SD 1.42) and half of the articles were of good quality (score 8-10) The quality of studies was related to the country in which the journal publishing the article was based (outside South Africa = higher); current residence of the primary author (outside South Africa = higher); method of economic analysis (economic evaluations higher than cost studies); type of data used (secondary higher than primary); primary training of the first author (health economics/pharmacoeconomics = higher); type of medical function (diagnosis = higher); study perspective (societal = higher); primary health intervention (pharmaceuticals = higher); study design (modelling = higher); number of authors (more = higher); and year of publication (more recent = higher) [p ≤ 0.05]. CONCLUSION Half of the articles were of poor or fair quality. Measures are needed to promote the commissioning of more and better quality health economic and pharmacoeconomic studies in South Africa.
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Affiliation(s)
- Paul Gavaza
- Appalachian College of Pharmacy, Oakwood, VA 24631, USA.
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Moshabela M, Schneider H, Silal SP, Cleary SM. Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross-sectional study. BMC Health Serv Res 2012; 12:182. [PMID: 22747971 PMCID: PMC3465179 DOI: 10.1186/1472-6963-12-182] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Accepted: 06/12/2012] [Indexed: 11/28/2022] Open
Abstract
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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Affiliation(s)
- Mosa Moshabela
- Rural AIDS and Development Action Research, School of Public Health, University of Witwatersrand, Acornhoek, Mpumalanga Province, Johannesburg, South Africa.
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