Health managers and community representatives' views of a system-wide intervention to strengthen public healthcare in the Free State, South Africa.

Background: A system-wide health system strengthening (HSS) initiative, the Health Systems Governance and Accountability (HSGA) intervention, was developed, translated to policy, and implemented in the Free State province. This study assessed health managers (HMs) and community representatives' (CRs) views of the intervention and whether it improved integration and performance. Method: A questionnaire survey among 147 HMs and 78 CRs and 14 focus group discussions (FGDs) with a mean of 10.3 participants and a total of 102 HMs and 42 CRs, were conducted. The questionnaire and FGD data were descriptively and thematically analysed to triangulate findings. Results: Many HMs (44%) mostly positioned at the operational levels indicated that implementation of the HSGA intervention did contribute to integration of health services. Most CRs (54%) believed that communities were actively involved in the intervention. However, both the self-administered questionnaire and the FGD data evidenced lack of policy awareness among, especially, operational-level HMs. Conclusion: From the perspectives of HMs and CRs, the implementation of the intervention was viewed as a step forward in strengthening public healthcare to respond to system deficiencies in the Free State province. Earlier engagement of especially operational-level HMs during reforms may be beneficial in successfully implementing HSS interventions.

Household contact non-attendance of clinical evaluation for tuberculosis: a pilot study in a high burden district in South Africa.

BACKGROUND: In 2012, the World Health Organization launched guidelines for systematically investigating contacts of persons with infectious tuberculosis (TB) in low- and middle-income countries. As such, it is necessary to understand factors that would influence successful scale-up. This study targeted household contacts of newly-diagnosed infectious TB patients in the Mangaung Metropolitan district to explore factors associated with non-attendance of clinical evaluation. METHOD: In September-October 2016, a pilot study of household contacts was conducted. At each of the 40 primary health care (PHC) facilities in the district, at least one out of four types of TB index cases were purposefully selected. These included children <5 years, smear-positive cases, HIV co-infected cases, and multidrug-resistant TB (MDR-TB) cases. Trained fieldworkers administered questionnaires and screened contacts for TB symptoms. Those with TB symptoms as well as children <5 years were referred for clinical evaluation at the nearest PHC facility. Contacts' socio-demographic and clinical characteristics, TB knowledge and perception about TB-related discrimination are described. Logistic regression analysis was used to investigate factors associated with non-attendance of clinical evaluation. RESULTS: Out of the 259 participants, approximately three in every five (59.5%) were female. The median age was 20 (interquartile range: 8-41) years. While the large majority (87.3%) of adult contacts correctly described TB aetiology, almost three in every five (59.9%) thought that it was hereditary, and almost two-thirds (65.5%) believed that it could be cured by herbal medicine. About one-fifth (22.9%) of contacts believed that TB patients were subjected to discrimination. Two in every five (39.4%) contacts were referred for clinical evaluation of whom more than half (52.9%) did not attend the clinic. Non-attendance was significantly associated with inter alia male gender (AOR: 3.4; CI: 1.11-10.24), prior TB diagnosis (AOR: 5.6; CI: 1.13-27.90) and sharing of a bedroom with the index case (AOR: 3.4: CI: 1.07-10.59). CONCLUSION: The pilot study identified gaps in household contacts' knowledge of TB. Further research on important individual, clinical and structural factors that can influence and should be considered in the planning, implementation and scale-up of household contact TB investigation is warranted.