Primary healthcare seeking behaviour of low-income patients across the public and private health sectors in South Africa

Receipt of antimalarials among children aged 6-59 months in Nigeria from 2010 to 2021

BACKGROUND

Nigeria has the highest malaria burden globally, and anti-malarials have been commonly used to treat malaria without parasitological confirmation. In 2012, Nigeria implemented rapid diagnostic tests (RDTs) to reduce the use of anti-malarials for those without malaria and to increase the use of artemisinin-based combination therapy (ACT) for malaria treatment. This study examined changes in anti-malarial receipt among children aged 6-59 months during a 12-year period of increasing RDT availability.

METHODS

A cross-sectional analysis was conducted using the Nigeria Malaria Indicator Survey (NMIS) data from 2010 (before RDT implementation in 2012), 2015, and 2021. The analysis assessed trends in prevalence of malaria by survey RDT result, and fever and anti-malarial/ACT receipt in the 2 weeks prior to the survey. A multivariable logistic regression was used to account for the complex survey design and to examine factors associated with anti-malarial receipt, stratified by survey RDT result, a proxy for recent/current malaria infection.

RESULTS

In a nationally-representative, weighted sample of 22,802 children aged 6-59 months, fever prevalence remained stable over time, while confirmed malaria prevalence decreased from 51.2% in 2010 to 44.3% in 2015 and 38.5% in 2021 (trend test p < 0.0001). Anti-malarial use among these children decreased from 19% in 2010 to 10% in 2021 (trend test p < 0.0001), accompanied by an increase in ACT use (2% in 2010 to 8% in 2021; trend test p < 0.0001). Overall, among children who had experienced fever, 30.6% of survey RDT-positive and 36.1% of survey RDT-negative children had received anti-malarials. The proportion of anti-malarials obtained from the private sector increased from 61.8% in 2010 to 80.1% in 2021 for RDT-positive children; most of the anti-malarials received in 2021 were artemisinin-based combinations. Factors associated with anti-malarial receipt for both RDT-positive and RDT-negative children included geographic region, greater household wealth, higher maternal education, and older children.

CONCLUSION

From 2010 to 2021 in Nigeria, both malaria prevalence and anti-malarial treatments among children aged 6-59 months decreased, as RDT availability increased. Among children who had fever in the prior 2 weeks, anti-malarial receipt was similar between children with either positive or negative survey RDT results, indicative of persistent challenges in reducing inappropriate anti-malarials uptake.

Barriers to accessing and utilising under-five primary health care services in Vhembe District

BACKGROUND

 Sub-Saharan Africa continues to be the region with the highest under-five mortality rate globally, with 74 deaths per 1000 live births. Even though under-five child primary health care (PHC) services are free in South Africa, accessing such services remains challenging. Children under 5 years reportedly die from common illnesses such as pneumonia, diarrhoea and malaria, which are treatable in PHC facilities.

AIM

 The study explored the barriers to accessing and utilising under-five PHC services in the Vhembe District.

SETTING

 The study was conducted in two PHC centres in Vhembe District among guardians accessing care for under-five child health services.

METHODS

 An interpretative phenomenology design was followed using a semi-structured individual interview guide. Sixteen participants were purposively sampled for the study. Colaizzi's steps of data analysis were followed, and trustworthiness as well as ethical principles were ensured throughout the study.

RESULTS

 Four themes emerged as health system barriers, health personnel-related behaviours, health facility infrastructure barriers and guardians-related barriers. Subthemes emerged as distance from the facility, lack of resources, long waiting times; poor time management, lack of commitment and work devotion, insufficient waiting space; challenges with water and sanitation, guardians' healthcare beliefs and the urgency of the illness.

CONCLUSION

 It is imperative that an enabling professional and friendly environment is created to facilitate better access to PHC services for children under 5 years.Contribution: The study's findings brought insight into considering the context of the guardians in improving quality care for under 5 years.

Developing mental health curricula and a service provision model for clinical associates in South Africa: a Delphi survey of family physicians and psychiatrists

BACKGROUND

Clinical associates are a health professional cadre that could be utilised in mental health task sharing in South Africa but this is training dependent. The objectives of the study were to identify the potential curricula content, training sites, and teaching modalities for undergraduate and potential postgraduate clinical associate mental health training and to identify the tasks that they should perform based on these curricula.

METHODS

We utilised the Delphi method to reach consensus on items with the panel comprising psychiatrists and family physicians. The first round questionnaire of the Delphi survey was developed based on a literature review and the results from earlier phases of the overall study. The survey was administered electronically and consisted of three rounds. Following both the first and second rounds, an updated questionnaire was constructed omitting the items on which consensus was reached. The questionnaire consisted primarily of nine-point scales with consensus based on 70% of participants rating 1,2,3 or 7,8,9.

RESULTS

There were 26 participants in the first round with this number falling to 23 in later rounds. There was strong consensus on a training attachment to a mental health clinic at a community health centre (CHC) at undergraduate (96.2%) and postgraduate level (100%). Consensus was reached on the importance of training on the management of six categories of disorders at the undergraduate level and nine categories of disorders at the postgraduate level. Clerking patients as a teaching modality reached 100% consensus at both undergraduate and postgraduate levels. PHC clinics, CHCs and district hospitals reached consensus as appropriate settings for clinical associates to provide mental health services. In addition, GP practices and secondary hospitals reached consensus for those with postgraduate training. Consensus was reached on ten of the 21 listed tasks that could be performed based on undergraduate training and 20 of the 21 tasks based on a postgraduate qualification in mental health.

CONCLUSIONS

The Delphi panel's recommendations provide a clear roadmap for enhancing mental health curricula for clinical associates, enabling their utilisation in mental health service provision. A future postgraduate mental health qualification for clinical associates would allow for expanded task sharing.

A resuscitation systems analysis for South Africa: A narrative review

With a growing incidence in cardiovascular diseases in Africa, including South Africa, and with it a greater incidence of out-of-hospital cardiac arrest (OHCA) there is a need to understand the readiness of these emergency care systems to support a response. Yet, OHCA is expensive and requires comprehensive development across an entire chain of survival in order to gain any benefit in mortality or morbidity. In this narrative review, we provide a resuscitation systems analysis using the Global Resuscitation Alliance's Frame of Survival. We provide evidence or commentary on the elements of the outer frame and inner frame, and make an assessment of the South African system's readiness to support OHCA care, and provide suggestions for priority areas that need to be developed. The South African resuscitation system demonstrates reasonable readiness to respond to OHCA but is characterised by considerable variation and fragmentation. Given the cost ineffectiveness of many interventions and the anticipated rise in OHCA incidence, there is a pressing need for context-specific strategies in South Africa. These strategies should focus on enhancing both outcomes and resource efficiency, while respecting community ethics and sociocultural dynamics.

Disparity in organ distribution in Gauteng province in South Africa: Challenges and solutions

BACKGROUND

Despite South Africa's rich heritage as pioneers in organ transplantation, access to organs remains a major issue in the Gauteng province. This is secondary to an array of socioeconomic and political factors that have implications for organ distribution. Our aim was to assess the contribution of the public sector to solid organ transplantation in Gauteng province and compare the distribution of solid organs between the recipient groups.

METHODS

This was a retrospective registry review of consented brain-dead donors from the public sector within Gauteng from January 1, 2016, to June 30, 2021, coordinated at Charlotte Maxeke Johannesburg Academic Hospital, a tertiary academic hospital.

RESULTS

Records of 49 deceased donors were analyzed. Mean donor age was 31.5 years with the age group 30-39 years constituting the majority of deceased donors at 15/49 (30.6%); 10/49 (16%) were from pediatric donors. There was a significant discrepancy in allocation between public and private sector in cardiac (p = .012) and liver allocation (p < .001) and adult and pediatric recipients for all solid organs (p < .001). There was a significant increase in the rate and number (p = .0026) of pediatric kidney transplants occurring after March 1, 2020, when there was a transition to a public sector-mandated kidney transplant waitlist.

CONCLUSION

Current disparities in organ distribution have a significant impact on public sector recipients, especially pediatric patients. This is likely secondary to paucity of legislation and resource limitations which would benefit from improved governmental policies and explicit pediatric prioritization policies in transplant units.

Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort

BACKGROUND

Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease.

METHODS

Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes.

RESULTS

Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes.

CONCLUSIONS

Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.

Comparing Cardiovascular Outcomes and Costs of Perindopril-, Enalapril- or Losartan-Based Antihypertensive Regimens in South Africa: Real-World Medical Claims Database Analysis

INTRODUCTION

Differences in class or molecule-specific effects between renin-angiotensin-aldosterone system (RAAS) inhibitors have not been conclusively demonstrated. This study used South African data to assess clinical and cost outcomes of antihypertensive therapy with the three most common RAAS inhibitors: perindopril, losartan and enalapril.

METHODS

Using a large, South African private health insurance claims database, we identified patients with a hypertension diagnosis in January 2015 receiving standard doses of perindopril, enalapril or losartan, alone or in combination with other agents. From claims over the subsequent 5 years, we calculated the risk-adjusted rate of the composite primary outcome of myocardial infarction, ischaemic heart disease, heart failure or stroke; rate of all-cause mortality; and costs per life per month (PLPM), with adjustments based on demographic characteristics, healthcare plan and comorbidity.

RESULTS

Overall, 32,857 individuals received perindopril, 16,693 losartan and 13,939 enalapril. Perindopril-based regimens were associated with a significantly lower primary outcome rate (205 per 1000 patients over 5 years) versus losartan (221; P < 0.0001) or enalapril (223; P < 0.0001). The risk-adjusted all-cause mortality rate was lower with perindopril than enalapril (100 vs. 139 deaths per 1000 patients over 5 years; P = 0.007), but not losartan (100 vs. 94; P = 0.650). Mean (95% confidence interval) overall risk-adjusted cost PLPM was Rands (ZAR) 1342 (87-8973) for perindopril, ZAR 1466 (104-9365) for losartan (P = 0.0044) and ZAR 1540 (77-10,546) for enalapril (P = 0.0003).

CONCLUSION

In South African individuals with private health insurance, a perindopril-based antihypertensive regimen provided better clinical and cost outcomes compared with other regimens.

Health Care Resource Utilization in Adults Living With Type 1 Diabetes Mellitus in the South African Public Health Sector: Protocol for a 1-Year Retrospective Analysis With a 5-, 10-, and 25-Year Projection

BACKGROUND

Type 1 diabetes mellitus (T1DM) is less common than type 2 diabetes mellitus but is increasing in frequency in South Africa. It tends to affect younger individuals, and upon diagnosis, exogenous insulin is essential for survival. In South Africa, the health care system is divided into private and public health care systems. The private system is well resourced, whereas the public sector, which treats more than 80% of the population, has minimal resources. There are currently no studies in South Africa, and Africa at large, that have evaluated the immediate and long-term costs of managing people living with T1DM in the public sector.

OBJECTIVE

The primary objective was to quantify the cost of health care resource utilization over a 12-month period in patients with controlled and uncontrolled T1DM in the public health care sector. In addition, we will project costs for 5, 10, and 25 years and determine if there are cost differences in managing subsets of patients who achieve glycemic control (hemoglobin A_1c [HbA_1c] <7%) and those who do not.

METHODS

The study was performed in accordance with Good Epidemiological Practice. Ethical clearance and institutional permissions were acquired. Clinical data were collected from 2 tertiary hospitals in South Africa. Patients with T1DM, who provided written informed consent, and who satisfied the inclusion criteria were enrolled in the study. Data collection included demographic and clinical characteristics, acute and chronic complications, hospital admissions, and so on. We plan to perform a cost-effectiveness analysis to quantify the costs of health care utilization in the preceding 12 months. In addition, we will estimate projected costs over the next 10 years, assuming that study participants maintain their current HbA_1c level. The cost-effectiveness analysis will be modeled using the IQVIA CORE Diabetes Model. The primary outcome measures are incremental quality-adjusted life years, incremental costs, incremental cost-effectiveness ratios, and incremental life years.

RESULTS

Ethical clearance and institutional approval were obtained (reference number 200407). Enrollment began on February 9, 2021, and was completed on August 24, 2021, with 224 participants. A database lock was performed on October 29, 2021. The statistical analysis and clinical study report were completed in January 2022.

CONCLUSIONS

At present, there are no data assessing the short- and long-term costs of managing patients with T1DM in the South African public sector. It is hoped that the findings of this study will help policy makers optimally use limited resources to reduce morbidity and mortality in people living with T1DM.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/44308.

Reduction in initiations of drug-sensitive tuberculosis treatment in South Africa during the COVID-19 pandemic: Analysis of retrospective, facility-level data

In response to the global pandemic of COVID-19, South Africa implemented a strict lockdown in March 2020 before its first COVID-19 wave started, gradually lifted restrictions between May and September 2020, and then re-imposed restrictions in December 2020 in response to its second wave. There is concern that COVID-19-related morbidity and mortality, the deprioritization of TB activities, fear of transmission, and societal restrictions led to a reduction in tuberculosis (TB) treatment initiations. We analysed monthly public sector, facility-level data from South Africa's District Health Information System (DHIS) from January 2019 to April 2021 to quantify changes in TB treatment initiation numbers stratified by province, setting, and facility type and compared the timing of these changes to COVID-19 case numbers and government lockdown levels. At the 1189 facilities that reported observations for all 28 months of our study period, TB treatment initiations in 2020 were 20.4% lower than in 2019 and 21.9% lower in the first four months of 2021 than in 2019. At the 3669 facilities that reported observations in ≤28 months, numbers of TB treatment initiations declined sharply in all provinces in May-August 2020, compared to the same months in 2019. After recovering somewhat in the last four months of 2020, numbers plummeted again in early 2021. Percentage reductions were somewhat larger in urban and peri-urban areas than in rural areas. Most provinces experienced a clear inverse relationship between COVID-19 cases and TB treatment initiations but little relationship between TB treatment initiations and lockdown level. The COVID-19 pandemic and responses to it resulted in substantial declines in the number of individuals starting treatment for TB in South Africa and risked progress toward achieving TB management goals. Exceptional effort will be needed to sustain gains in combating TB.

Training, guideline access and knowledge of antiretroviral interactions: Is the South African private sector being left behind?

BACKGROUND

South Africa (SA) has the largest antiretroviral therapy programme in the world. While the majority of the country accesses healthcare in the public sector, 15.2% access private healthcare. In 2019, dolutegravir was introduced as first-line treatment for HIV. Dolutegravir has clinically significant interactions with numerous commonly used medicines, e.g. rifampicin and cation-containing medicines such as calcium and iron. They require dosage adjustments, detailed in public and private HIV guidelines.

OBJECTIVES

To describe SA healthcare workers' guideline access, training and knowledge of dolutegravir's interactions, focusing on differences between the public and private sectors.

METHODS

A cross-sectional, descriptive study was done using an online survey of healthcare workers in the field of HIV in SA, conducted by the National HIV and TB Healthcare Worker Hotline. Convenience sampling was used, with electronic dissemination to users of the hotline and by relevant HIV-focused organisations. Simple descriptive statistics and statistical analyses were used.

RESULTS

A total of 1 939 surveys were analysed, with 22% from the private sector. Training on the dolutegravir guidelines was received by significantly fewer healthcare workers in the private sector v. the public sector: 42.4% (95% confidence interval (CI) 37 - 48) v. 67.5% (95% CI I 65 - 70), respectively. Significantly fewer healthcare workers in the private sector had access to the guidelines (63.8%; 95% CI 59 - 69 v. 78.8%; 95% CI 77 - 81). When asked if they were aware that dolutegravir has interactions, just over half (56.9%) of healthcare workers in the private sector responded 'yes', 24.6% responded 'no' and 18.5% did not answer. Of those who were aware that dolutegravir has interactions, 48.9% knew that dolutegravir interacts with calcium, 44.6% with iron and 82.0% with rifampicin. Private sector knowledge of dosing changes was lower for all interacting drugs, with the difference only significant for calcium and iron. Private sector healthcare workers reported significantly lower levels of counselling on dolutegravir use in all appropriate situations.

CONCLUSION

Private sector healthcare worker access to HIV training and guidelines requires attention. In a high-burden HIV setting such as SA, it is vital that healthcare workers across all professions, in both the public and private sector, know how to adjust antiretroviral dosing due to clinically significant interactions. Without these adjustments, there is a risk of treatment failure, increased mother-to-child transmission and morbidity and mortality.

Accessing HIV care may lead to earlier ascertainment of comorbidities in health care clients in Khayelitsha, Cape Town

Successful antiretroviral rollout in South Africa has greatly increased the health of the HIV-positive population, and morbidity and mortality in PLHIV can increasingly be attributed to comorbidities rather than HIV/AIDS directly. Understanding this disease burden can inform health care planning for a growing population of ageing PLHIV. Anonymized routine administrative health data were analysed for all adults who accessed public health care in 2016-2017 in Khayelitsha subdistrict (Cape Town, South Africa). Selected comorbidities and age of ascertainment for comorbidities were described for all HIV-positive and HIV-negative healthcare clients, as well as for a subset of women who accessed maternal care. There were 172 937 adult individuals with a median age of 37 (IQR:30-48) years in the virtual cohort, of whom 48% (83 162) were HIV-positive. Median age of ascertainment for each comorbidity was lower in HIV-positive compared to HIV-negative healthcare clients, except in the case of tuberculosis. A subset of women who previously accessed maternal care, however, showed much smaller differences in the median age of comorbidity ascertainment between the group of HIV-positive and HIV-negative health care clients, except in the case of chronic kidney disease (CKD). Both HIV-positive individuals and women who link to maternal care undergo routine point-of-care screening for common diseases at younger ages, and this analysis suggests that this may lead to earlier diagnosis of common comorbidities in these groups. Exceptions include CKD, in which age of ascertainment appears lower in PLHIV than HIV-negative groups in all analyses suggesting that age of disease onset may indeed be earlier; and tuberculosis for which age of incidence has previously been shown to vary according to HIV status.