Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model.

BACKGROUND: South Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients' and operational managers' satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian's theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care. METHODS: A cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian's theory, using unidirectional, mediation, and reciprocal pathways. RESULTS: The mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs. CONCLUSION: Of the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian's theoretical framework can be used to provide evidence of quality systems in the ICDM model.

Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.

The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model. In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian's structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis. The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic. Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.

Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey.

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.

Changing use of traditional healthcare amongst those dying of HIV related disease and TB in rural South Africa from 2003 - 2011: a retrospective cohort study.

BACKGROUND: In 2011 there were 5.5 million HIV infected people in South Africa and 71% of those requiring antiretroviral therapy (ART) received it. The effective integration of traditional medical practitioners and biomedical providers in HIV prevention and care has been demonstrated. However concerns remain that the use of traditional treatments for HIV-related disease may lead to pharmacokinetic interactions between herbal remedies and ART drugs and delay ART initiation. Here we analyse the changing prevalence and determinants of traditional healthcare use amongst those dying of HIV-related disease, pulmonary tuberculosis and other causes in a rural South African community between 2003 and 2011. ART was made available in this area in the latter part of this period. METHODS: Data was collected during household visits and verbal autopsy interviews. InterVA-4 was used to assign causes of death. Spatial analyses of the distribution of traditional healthcare use were performed. Logistic regression models were developed to test associations of determinants with traditional healthcare use. RESULTS: There were 5929 deaths in the study population of which 47.7% were caused by HIV-related disease or pulmonary tuberculosis (HIV/AIDS and TB). Traditional healthcare use declined for all deaths, with higher levels throughout for those dying of HIV/AIDS and TB than for those dying of other causes. In 2003-2005, sole use of biomedical treatment was reported for 18.2% of HIV/AIDS and TB deaths and 27.2% of other deaths, by 2008-2011 the figures were 49.9% and 45.3% respectively. In bivariate analyses, higher traditional healthcare use was associated with Mozambican origin, lower education levels, death in 2003-2005 compared to the later time periods, longer illness duration and moderate increases in prior household mortality. In the multivariate model only country of origin, time period and illness duration remained associated. CONCLUSIONS: There were large decreases in reported traditional healthcare use and increases in the sole use of biomedical treatment amongst those dying of HIV/AIDS and TB. No associations between socio-economic position, age or gender and the likelihood of traditional healthcare use were seen. Further qualitative and quantitative studies are needed to assess whether these figures reflect trends in healthcare use amongst the entire population and the reasons for the temporal changes identified.

Impact of supplemental immunisation activity (SIA) campaigns on health systems: findings from South Africa.

BACKGROUND: Supplemental immunisation activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other child health interventions including vitamin A supplements, deworming medications and oral polio vaccines. They also require the mobilisation of a large health workforce. We assess the impact of the implementation of SIA campaigns on selected routine child and maternal health services in South Africa (SA). METHODS: We use district-level monthly headcount data for 52 South African districts for the period 2001-2010, sourced from the District Health Information System, SA. The data include 12 child and maternal health headcount indicators including routine immunisation, and maternal and reproductive health indicators. We analyse the association between the implementation of the 2010 SIA campaign and the change (decrease/increase) in headcounts, using a linear regression model. RESULTS: We find a significant decrease for eight indicators. The total number of fully immunised children before age 1 decreased by 29% (95% CI 23% to 35%, p<0.001) during the month of SIA implementation; contraceptive use and antenatal visits decreased by 7-17% (p ≤ 0.02) and about 10% (p<0.001), respectively. CONCLUSIONS: SIA campaigns may negatively impact health systems during the period of implementation by disrupting regular functioning and diverting resources from other activities, including routine child and maternal health services. SIA campaigns present multidimensional costs that need to be explicitly considered in benefit-cost assessments.

Supplementary immunization activities (SIAs) in South Africa: comprehensive economic evaluation of an integrated child health delivery platform.

BACKGROUND: Supplementary immunization activity (SIA) campaigns provide children with an additional dose of measles vaccine and deliver other interventions, including vitamin A supplements, deworming medications, and oral polio vaccines. OBJECTIVE: To assess the cost-effectiveness of the full SIA delivery platform in South Africa (SA). DESIGN: We used an epidemiologic cost model to estimate the cost-effectiveness of the 2010 SIA campaign. We used province-level campaign data sourced from the District Health Information System, SA, and from planning records of provincial coordinators of the Expanded Programme on Immunization. The data included the number of children immunized with measles and polio vaccines, the number of children given vitamin A supplements and Albendazole tablets, and costs. RESULTS: The campaign cost $37 million and averted a total of 1,150 deaths (95% uncertainty range: 990-1,360). This ranged from 380 deaths averted in KwaZulu-Natal to 20 deaths averted in the Northern Cape. Vitamin A supplementation alone averted 820 deaths (95% UR: 670-1,040); measles vaccination alone averted 330 deaths (95% UR: 280-370). Incremental cost-effectiveness was $27,100 (95% UR: $18,500-34,400) per death averted nationally, ranging from $11,300 per death averted in the Free State to $91,300 per death averted in the Eastern Cape. CONCLUSIONS: Cost-effectiveness of the SIA child health delivery platform varies substantially across SA provinces, and it is substantially more cost-effective when vitamin A supplementation is included in the interventions administered. Cost-effectiveness assessments should consider health system delivery platforms that integrate multiple interventions, and they should be conducted at the sub-national level.

Confronting HIV/AIDS in a South African village: the impact of health-seeking behaviour.

Much social science research on HIV/AIDS focuses on its impact within affected communities and how people try to cope with its consequences. Based on fieldwork in rural South Africa, this article shows ways in which the inhabitants of a village react to illness, in general, and the role their reactions play in facilitating the spread of communicable diseases such as HIV/AIDS. There is potentially a strong connection between the manner in which people respond to illness in general, and actual transmission of infection. By influencing the way villagers react to episodes of ill health, folk beliefs about illness and illness causation may create avenues for more people to become infected. This suggests that efforts to combat the HIV/AIDS pandemic cannot succeed without tackling the effects of folk beliefs. Therefore, in addressing the problem of HIV/AIDS, experts should focus on more than disseminating information about cause and transmission, and promoting abstinence, safe sex, and other technocratic fixes. Our findings suggest that people need information to facilitate not only decision-making about how to self-protect against infection, but also appropriate responses when infection has already occurred.