A pre-experimental design evaluation of brief harm reduction interventions to improve coping self-efficacy of carers of people with substance use disorder.

BACKGROUND: Globally, the rise in the number of people living with a substance use disorder (SUD) carries a multitude of individual and social health implications for carers and their families, often impacting negatively on their quality of life. Considered from a harm reduction approach, SUD is understood as a chronic protracted, complex health and social condition. From the extant literature, there is no evidence of the harm reduction approach being applied to address the needs of carers/family members who carry the burden of SUD care. This study preliminarily evaluated the Care4Carers Programme. It is a purposively designed set of brief interventions to improve the coping self-efficacy of carers of people with SUD (PwSUD carers) by equipping them to think about ways to exert control over their motivation, behaviours and social environment. METHODS: A pre-experimental, one group pretest-posttest design was implemented with 15 purposively selected participants in the Gauteng Province of South Africa. The intervention was conducted by the lead researcher, a registered social worker. Eight brief intervention sessions were held, over 5-6 weeks at research sites where the participants were identified. The coping self-efficacy scale was completed before and directly after exposure to the programme. Results were analysed using paired t-tests. RESULTS: There were statistically significant (p < .05) improvements in carers' coping self-efficacy, both overall and in respect of each of its constituent components: problem-focused coping, emotion-focused coping and social support strategies. CONCLUSIONS: The Care4Carers Programme improved the coping self-efficacy of carers of people living with SUDs. The application of this programmatic harm reduction intervention to support PwSUD carers should be tested on a larger scale across South Africa.

Opioid use and HIV treatment services experiences among male criminal justice-involved persons in South Africa: a qualitative study.

BACKGROUND: Opioid use disorder (OUD) is overrepresented among people with criminal justice involvement; HIV is a common comorbidity in this population. This study aimed to examine how formerly incarcerated men living with HIV and OUD in South Africa experienced HIV and OUD services in correctional facilities and the community. METHODS: Three focus group discussions were conducted with 16 formerly incarcerated men living with HIV and OUD in Gauteng, South Africa. Discussions explored available healthcare services in correctional facilities and the community and procedural and practice differences in health care between the two types of settings. Data were analyzed thematically, using a comparative lens to explore the relationships between themes. RESULTS: Participants described an absence of medical services for OUD in correctional facilities and the harms caused by opioid withdrawal without medical support during incarceration. They reported that there were limited OUD services in the community and that what was available was not connected with public HIV clinics. Participants perceived correctional and community HIV care systems as readily accessible but suggested that a formal system did not exist to ensure care continuity post-release. CONCLUSIONS: OUD was perceived to be medically unaddressed in correctional facilities and marginally attended to in the community. In contrast, HIV treatment was widely available within the two settings. The current model of OUD care in South Africa leaves many of the needs of re-entrants unmet. Integrating harm reduction into all primary care medical services may address some of these needs. Successful HIV care models provide examples of approaches that can be applied to developing and expanding OUD services in South Africa.

Infrastructural Inequality and Household COVID-19 Vulnerability in a South African Urban Settlement.

COVID-19 has highlighted the importance of household infrastructure in containing the spread of SARS-CoV-2, with Global South urban settlements particularly vulnerable. Targeted interventions have used area or dwelling type as proxies for infrastructural vulnerability, potentially missing vulnerable households. We use infrastructural determinants of COVID-19 (crowding, water source, toilet facilities, and indoor pollution) to create an Infrastructural Vulnerability Index using cross-sectional household data (2018-2019) from Mamelodi, a low-income urban settlement in South Africa. Households were stratified into vulnerability groups by index results; sociodemographic variables were assessed as predictors of index scores; and inequality analysis and decomposition were conducted. Thirty-three percent of households fell in the lowest risk group, 32% in the second, 21% in the third, and 14% in the highest. Dwelling type and geographical ward were associated with changes in index scores, with a shack (adjusted ß (aß) = 3.45, CI = 3.39-3.51) associated with highest increase compared to a house. Wards in more developed areas were not consistently associated with lower index scores in the final regression model. The infrastructural vulnerability of the top 10% of households was greater than the bottom 40%, and inequality was predominantly within (80%) rather than between (20%) wards, and more between (60%) than within (40%) dwelling types. Our results show a minority of households account for the majority of infrastructural vulnerability, with its distribution only partially explained by area and dwelling type. Efforts to contain COVID-19 can be improved by using local-level data, and a vulnerability index, to target infrastructural support to households in greatest need.

Harm reduction in an emergency response to homelessness during South Africa's COVID-19 lockdown.

BACKGROUND: Caledonian Stadium, the main mass temporary shelter for homeless people in the City of Tshwane, was created as a local response to the imperatives of the novel coronavirus disease (COVID-19) National State of Disaster lockdown in South Africa. This is a case study of the coordinated emergency healthcare response provided by the University of Pretoria's Department of Family Medicine between 24 March and 6 April 2020. METHODS: This study uses a narrative approach to restory situated, transient, partial and provisional knowledge. Analysis is based on documented data and iteratively triangulated interviews on the operational experiences of selected healthcare first responders directly involved in the shelter. RESULTS: The impending lockdown generated intense interactions by UP-DFM to prepare for the provision of COVID-19 and essential generalist primary with partners involved in the Community Oriented Substance Use Programme (COSUP). With approximately 2000 people at the shelter at its peak, the numbers exceeded expectations. Throughout, while government officials tried to secure bedding, food and toilets, the shelter was poorly equipped and without onsite management. The COSUP clinical team prioritised opioid substitution therapy using methadone and COVID-19 screening over generalist healthcare to manage withdrawal and contain tension and anxiety. COSUP and its partners helped the city plan and implement the safe re-sheltering of all Caledonian residents. CONCLUSION: The Caledonian shelter is an account of organisational resilience in the face of homelessness and substance use emergencies triggered by lockdown. Through community-oriented, bottom-up self-organisation, a clinically led team navigated a response to the immediate needs of people who are homeless and/or use drugs that evolved into a more sustainable intervention. Key lessons learnt were the importance of communicating with people directly affected by emergencies, the value of using methadone to reduce harms during emergencies and the imperative of including OST in essential primary healthcare.

The socio-demographic profile of family physician graduates of blended-learning courses in India.

Context: India's lean cadre of 250,000 general practitioners and 30,000 government doctors has limited options to update themselves. Since 2006, Christian Medical College (CMC) Vellore has run blended-learning programs in family medicine, namely, postgraduate diploma in family medicine (PGDFM) and master in medicine in family medicine (M.MED FM) training more than 3000 doctors. A graduate follow-up study was undertaken in 2022. Aim: The aim of the study was to describe the socio-demographic characteristics of family physicians (FPs) in India who graduated between 2008 and 2018 from the FM blended-learning programs run by the CMC, Vellore. Settings and Design: Informed by an empirical-analytic paradigm, this descriptive study used a cross-sectional survey design to uncover graduate FPs' profiles, practices and experiences. Methods and Materials: Using a purposively designed, piloted and validated electronic questionnaire, data were collected between March and July 2022, deidentified and analysed using Statistical Package for Social Sciences (SPSS)TM and Epi InfoTM. Results: Among the 438 FP respondents (36%), there was an almost even split in gender (49.3% male, 50.7% female). Moreover, 25.8% were below the age of 40 years, 37.4% were in the 40-49 age group, and 33.8% were 50 years of age or older; 86% lived and worked in urban areas. The PGDFM or M.MED FM was the highest educational qualification of 64.4% of the doctors. Male FPs pursued postgraduate studies at a significantly younger age and earned significantly more than their female counterparts. Conclusions: The blended learning model creates an important pathway for doctors, especially women, to pursue higher education with flexibility. Preferential selection criteria can target rural-based physicians. Strong policy-level advocacy is needed to establish FM as a specialty with equitable pay scales. Socio-demographic profiling can be used as an effective advocacy tool.

An ICT-enabled community oriented primary care intervention in mining communities during COVID-19 (2019-2022): perceived changes in the role and place of community health workers.

BACKGROUND: This is a study of service provider perceptions of the place, role and practices of CHWs in a four-year, large-scale private sector funded, public service ICT-enabled COPC intervention with rural and remote mining communities. Like all South African communities, apart from large mining house employees and some contractors, most people use available public healthcare services and private traditional as well as limited allopathic private sector providers. In addition to the limitations of facility centred primary healthcare and a fragmented health care system, the many negative health effects of mining on the communities, go unattended. METHODS: This is a rapid, qualitative pragmatic study. Using site and participation convenience sampling, 37 semi-structured individual or group interviews were conducted with 57 stakeholders from 38 of the 135 intervention PHC facilities. Using a data driven, inductive approach, the results were analysed thematically in terms of perceived changes in the role and place of CHWs. RESULTS: CHWs registered 42 490 households and captured the demographic and social profiles as well as the health status of over 154 910 individuals using AitaHealth™. These data provided healthcare professionals and managers with knowledge about community demographics, at-risk groups and vulnerable individuals. The intervention changed the locational focus of CHW practice and expanded their scope of work and competencies in household comprehensive health education, advice and care. It led to a growth in community and professional confidence in CHWs as trusted members of mining community PHC teams and to more focused and efficient clinic work. CONCLUSION: This ICT-enabled COPC intervention adopted a comprehensive approach to healthcare delivery that started by including CHWs in PHC teams and locating them in communities. Inclusive and systematic continuous learning, clinically-led CHW service support and ICT-enabled information technology engendered trust in CHWs as competent PHC members, and grew community confidence in them and the PHC system as a whole. Although health, care and other professionals and workers valued the changes the intervention brought to their work as well as people's lives in underserved and vulnerable mining communities, its sustainability is contingent on the vagaries of political will and financial commitment.

Assessment of service quality of public antiretroviral treatment (ART) clinics in South Africa: a cross-sectional study.

BACKGROUND: In South Africa the ever increasing demand for antiretroviral treatment (ART) runs the risk of leading to sub-optimal care in public sector ART clinics that are overburdened and under resourced. This study assessed the quality of ART services to identify service areas that require improvement. METHODS: A cross-sectional study was carried out at 16 of 17 public ART clinics in the target area in greater Pretoria, South Africa. Trained participant observers presented as ART qualifying HIV positive patients that required a visit to assess treatment readiness. They evaluated each facility on five different occasions between June and November 2009, assessing the time it took to get an appointment, the services available and accessed, service quality and the duration of the visit. Services (reception area, clinician's consultation, HIV counselling, pharmacy, nutrition counselling and social worker's assessment) were assessed against performance standards that apply to all clinics. Service quality was expressed as scores for clinic performance (CPS) and service performance (SPS), defined as the percentage of performance standards met per clinic and service area. RESULTS: In most of the clinics (62.5%) participant observers were able to obtain an appointment within one week, although on the day of their visit essential services could not always be accessed. The median CPS of the assessed facilities was 68.5 with four clinics not meeting minimum standards (CPS > 60). The service areas that performed least well were the clinician's consultation (SPS 67.3) and HIV counselling (SPS 70.7). Most notably, clinicians performed a physical examination in only 41.1% of the visits and rarely did a complete TB symptom screening. Counsellors frequently failed to address prevention of HIV transmission. CONCLUSIONS: Overall public sector ART clinics in greater Pretoria were easily accessible and their services were of an acceptable quality. However, the time spent at the clinic to complete the services was found to be very long and there was considerable variation in adherence to performance standards within the services, particularly in respect of clinician's consultation and counselling. Clinic management needs to ensure efficient clinic organisation and to improve adherence to performance standards in key service areas.

How to measure person-centred practice - An analysis of reviews of the literature.

BACKGROUND: Facilitation and collaboration differentiates person-centred practice (PcP) from biomedical practice. In PcP, a person-centred consultation requires clinicians to juggle three processes: facilitation, clinical reasoning and collaboration. How best to measure PcP in these processes remains a challenge. AIM: To assess the measurement of facilitation and collaboration in selected reviews of PcP instruments. METHODS: Ovid Medline and Google Scholar were searched for review articles evaluating measurement instruments of patient-centredness or person-centredness in the medical consultation. RESULTS: Six of the nine review articles were selected for analysis. Those articles considered the psychometric properties and rigour of evaluation of reviewed instruments. Mostly, the articles did not find instruments with good evidence of reliability and validity. Evaluations in South Africa rendered poor psychometric properties. Tools were often not transferable to other socio-cultural-linguistic contexts, both with and without adaptation. CONCLUSION: The multiplicity of measurement tools is a product of many dimensions of person-centredness, which can be approached from many perspectives and in many service scenarios inside and outside the medical consultation. Extensive research into the myriad instruments found no single valid and reliable measurement tool that can be recommended for general use. The best hope for developing one is to focus on a specific scenario, conduct a systematic literature review, combine the best items from existing tools, involve multiple disciplines and test the tool in real-life situations.

The use and value of maps in Community-Oriented Primary Care: Does process matter?

BACKGROUND: Maps are important tools in healthcare delivery. In Community-Oriented Primary Care (COPC), they are expected to be used to plan services and resources for defined geographical areas, delineate team practice areas, allocate healthcare workers to households and support service delivery and performance management. AIM: This is a study of the use and value of maps and mapmaking in the delivery of healthcare services through Ward-Based Outreach Teams (WBOTs). SETTING: This study was conducted between 2014 and 2016 in Mamelodi (South Africa), an urban settlement selected to begin the City of Tshwane's WBOT implementation programme in 2013. METHODS: This study is based on three qualitative participatory mapmaking projects with WBOT healthcare professionals and workers. Data generated through mapmaking, focused group discussions, individual semi-structured interviews, reflective writing and feedback workshops were analysed thematically. RESULTS: Through mapmaking and discussions about the maps, healthcare providers took ownership of the maps they were creating or viewing, added their own information onto the maps, voiced issues about their practice, generated new knowledge and shared ideas and solutions for challenges. These processes expanded the use and value of maps beyond assisting participants to gain insights into the context, people and organisations of their places of work. CONCLUSION: Maps become creative learning tools that can be used in emergent ways to solve healthcare service and other problems when they are actively generated and engaged through facilitated discussion and reflection. This allows WBOTs to see maps as dynamic canvasses that they can use to improve service delivery.

Peer-learning reviews to improve Gauteng community-oriented primary care: Findings from AitaHealth™-enabled ward-based outreach teams.

BACKGROUND: In 2016 the Gauteng Department of Health engaged University of Pretoria Family Medicine to provide` education, training and information and communication technology support for the phased scale-up of ward-based outreach teams (WBOTs) through community-oriented primary care (ICT-enabled COPC). As in all service delivery, quality assurance is essential. In contemporary best practice, it brings together peer-to-peer learning and quality improvement (QI) in what is termed here as peer-learning reviews (PLRs). AIM: To assess implementation fidelity and assure the quality of community-based healthcare services. SETTING: This study was conducted in two districts of Gauteng province, South Africa. METHODS: A 3-day PLR of paired WBOTs was conducted by multi-disciplinary teams of academics, partners and site-selected healthcare practitioners. Guided by a benchmark survey distilled from the seven COPC practice elements, they conducted individual interviews, accompanied WBOT members in field and facilitated solution-focused peer exchange workshops with all participants. RESULTS: At all sites there was clear evidence of achievements and practical challenges with respect to mapping; support, networks and partnerships; infrastructure and functional equipment; work integrated learning; data and service activities; and performance status and management. Methodologically, PLRs supported inclusive, context-specific learning for all along the healthcare service pathway. They generated action plans derived from shared understanding and joint decision-making. CONCLUSION: The PLRs and the implementation results demonstrate the importance of structuring learning into service and research. Both helped develop participants' abilities to understand what they do, do their work, grow their sense of self-worth and improve their relationship with others.

Evaluating community health worker education policy through a National Certificate (Vocational) Primary Health qualification lens.

BACKGROUND: In 2018, the South African National Department of Health (NDoH) published a 5-year policy framework and strategy for Ward-Based Primary Healthcare Outreach teams to improve team management and leadership and support service delivery. In the same year, the World Health Organization (WHO) published guidelines on health policy and system support to optimise Community Health Worker (CHW) programmes. AIM: This article aims to assess the National Certificate (Vocational), or NC(V), Primary Health qualification in terms of the education and training guidelines and recommendations of the 2018 NDoH and WHO policy documents. SETTING: The qualification was initiated in 2013 at 12 Technical and Vocational Education and Training (TVET) colleges across South Africa. The evaluation covered the period 2013-2017. METHODS: Pragmatic qualitative enquiry was used to examine the context, design, implementation and outcomes of the qualification. Data collection involved document reviews, key informant in-depth interviews and focused group discussions, and individual reflections with respondents from one part-time and two full-time offerings at two colleges. Analyses of emergent themes were interpreted using appropriate models and theoretical frameworks. RESULTS: The Department of Higher Education and Training (DHET) created and implemented a standardised, curriculated national programme for CHW education that structured theoretical and practical learning over time to ensure assimilation of content and its application in practice. CONCLUSION: NC(V) Primary Health, as a single, national, quality-assured qualification for CHWs, meets WHO 2018 guidelines and recommendations, NDoH training needs and CHWs learning expectations, especially when offered part-time. Despite the termination of the programme, it remains a relevant option for CHWs in South Africa and elsewhere.

Modelling cost benefit of community-oriented primary care in rural South Africa.

BACKGROUND: Globally, rural populations have poorer health and considerably lower levels of access to healthcare compared with urban populations. Although the drive to ensure universal coverage through community healthcare worker programmes has shown significant results elsewhere, their value has yet to be realised in South Africa. AIM: The aim of this study was to determine the potential impact, cost-effectiveness and benefit-to-cost ratio (BCR) of information and communications technology (ICT)-enabled community-oriented primary care (COPC) for rural and remote populations. SETTING: The Waterberg district of Limpopo province in South Africa is a rural mining area. The majority of 745 000 population are poor and in poor health. METHODS: The modelling considers condition-specific effectiveness, population age and characteristics, health-determined service demand, and costs of delivery and resources. RESULTS: Modelling showed 122 teams can deliver a full ICT-enabled COPC service package to 630 565 eligible people. Annually, at scale, it could yield 35 877 unadjusted life years saved and 994 deaths avoided at an average per capita service cost of R170.37, and R2668 per life year saved. There could be net annual savings of R120 million (R63.4m for Waterberg district) from reduced clinic (110.7m) and hospital outpatient (23 646) attendance and admissions. The service would inject R51.6m into community health worker (CHW) households and approximately R492m into district poverty reduction and economic growth. CONCLUSION: With a BCR of 3.4, ICT-enabled COPC is an affordable systemic investment in universal, pro-poor, integrated healthcare and makes community-based healthcare delivery particularly compelling in rural and remote areas.

Willingness of people with Type 2 diabetes to start insulin therapy: Evidence from the South African Tshwane Insulin Project (TIP).

AIMS: To determine factors associated with 'hypothetical willingness' to start insulin among people with Type 2 diabetes (T2DM). METHODS: A quantitative cross-sectional study with insulin-naïve T2DM patients at 23 primary care facilities in the Tshwane Metropolitan Municipality. Data collected included demographic and clinical data, willingness to start insulin, attitudes and barriers to insulin therapy. Factors associated with unwillingness to start insulin therapy were explored using a multivariable logistic regression model. RESULTS: Of 468 T2DM study patients (mean age 57.2, SD = 11.3 years), more than half (51.9%) expressed unwillingness to starting insulin therapy. Unwillingness was associated with negative attitudes (OR = 1.32, 95% CI = 1.12-1.55, p = 0.001) and reluctance (OR = 1.41, 95% CI = 1.27-1.57, p < 0.001) rather than age, sex, education or diabetes duration. The strongest reasons for patient unwillingness were injection anxieties, fear of needles, insufficient knowledge of insulin, feeling unable to cope with insulin and concerns about out-of-pocket costs. CONCLUSIONS: The prospect of insulin therapy disturbs patients' sense of self and their psychological wellbeing. The high prevalence of psychological insulin resistance among these T2DM patients needs to be addressed for effective diabetes management.

Interpreting Mamelodi Community-Oriented Primary Care data on tuberculosis loss to follow-up through the lens of intersectionality.

BACKGROUND: Tuberculosis (TB) is a persistent major public health challenge in South Africa. This article examines the social determinants and demographic factors associated with TB loss to follow-up through the lens of intersectionality. AIM: The aim of this study was to describe and interpret the social determinants and demographic factors associated with TB patients lost to follow-up (LTFU). SETTING: Mamelodi, an urban settlement in the South African District of Tshwane. METHODS: AitaHealth™ is an Information and Communications Technology (ICT) mobile and web application that is used by community health workers. Data from patients with TB were extracted from the 64 319 households registered on AitaHealth™ over a 3-year period. Univariate and multivariate analyses were used to compare patients who were adherent to TB treatment and those LTFU. RESULTS: Of the 184 351 individuals screened for TB, 788 reported that they were diagnosed with TB (an incidence of 427 cases per 100 000). Of the 704 eligible for inclusion in this analysis, 540 (77%) were on treatment and 164 (23%) were LTFU. The factors associated with LTFU were aged over 60, not having a South African identification document, migration and death in the household, and higher mean household income. CONCLUSION: The results of this study serve as a reminder to clinicians of the importance of the three-stage assessment (biopsychosocial) in the approach to patients with TB. Understanding the intersection of social determinants and demographic factors helps clinicians and others identify and respond to the specificity of patient, health system and non-health policy issues at play in LTFU.

The three-stage assessment to support hospital-home care coordination in Tshwane, South Africa.

BACKGROUND: In complex health settings, care coordination is required to link patients to appropriate and effective care. Although articulated as system and professional values, coordination and cooperation are often absent within and across levels of service, between facilities and across sectors, with negative consequences for clinical outcomes as well as service load. AIM: This article presents the results of an applied research initiative to facilitate the coordination of patient care. SETTING: The study took place at three hospitals in the sub-district 3 public health complex (Tshwane district). METHOD: Using a novel capability approach to learning, interdisciplinary, clinician-led teams made weekly coordination-of-care ward rounds to develop patient-centred plans and facilitate care pathways for patients identified as being stuck in the system. Notes taken during three-stage assessments were analysed thematically to gain insight into down referral and discharge. RESULTS: The coordination-of-care team assessed 94 patients over a period of six months. Clinical assessments yielded essential details about patients' varied and multimorbid conditions, while personal and contextual assessments highlighted issues that put patients' care needs and possibilities into perspective. The team used the combined assessments to make patient-tailored action plans and apply them by facilitating cooperation through interprofessional and intersectoral networks. CONCLUSION: Effective patient care-coordination involves a set of referral practices and processes that are intentionally organised by clinically led, interprofessional teams. Empowered by richly informed plans, the teams foster cooperation among people, organisations and institutions in networks that extend from and to patients. In so doing, they embed care coordination into the discharge process and make referral to a link-to-care service.

Harm reduction in practice - The Community Oriented Substance Use Programme in Tshwane.

BACKGROUND: The Community Oriented Substance Use Programme (COSUP) is the first publicly funded, community-based programmatic response to the use of illegal substances in South Africa. It is founded on a systems thinking, public health and clinical care harm reduction approach. AIM: To describe the critical components, key issues and accomplishments in the initiation and delivery of evidence-based, community-oriented, substance-use health and care services. SETTING: The Community Oriented Substance Use Programme is implemented by the University of Pretoria in four of seven Tshwane Metropolitan Municipality regions. METHODS: Quantitative and qualitative data were extracted and triangulated from plans, reports, minutes and other documents. RESULTS: Between 2016 and 2019, COSUP engaged in national and local policy and guidelines development. In Tshwane, it created practical working relations with 169 organisations and institutions and set up 17 service sites. These provide counselling, linkage to care and opioid substitution therapy services to 1513 adults (median age of 30 years), most of whom are male (90%), with similar proportions of clients who smoke (51%) or inject (49%) heroin. It also offers needle and syringe services (approximately 17 000 needles distributed/month) and has built human resource capacity in harm reduction among staff, clients and personnel in partner organisations. CONCLUSION: The Community Oriented Substance Use Programme offers an evidence-based, public-health informed, feasible alternative to an abstinence-based approach to substance use. However, to translate the programme's achievements into sustainable outcomes at scale requires health system integration; generalist, patient-centred care; affordable medication in a comprehensive package of harm reduction services; multisectoral partnerships; systematic, continuous capacity development; financial investment; and sustained political commitment.

Scaling community-based services in Gauteng, South Africa: A comparison of three workforce-planning scenarios.

BACKGROUND: The introduction of community-based services through community health workers is an opportunity to redefine the approach and practice of primary health care. Based on bestpractice community oriented primary care (COPC), a COPC planning toolkit has been developed to model the creation of a community-based tier in an integrated district health system. AIM: The article describes the methodologies and assumptions used to determine workforce numbers and service costs for three scenarios and applies them to the poorest 60% of the population in Gauteng, South Africa. SETTING: The study derives from a Gauteng Department of Health, Family Medicine (University of Pretoria) partnership to support information and communication technology (ICT)-enabled COPC through community-based health teams (termed as ward-based outreach teams). METHODS: The modelling uses national census age, gender and income data at small area level, provincial facility and national burden of disease data. Service calculations take into account multidimensional poverty, demand-adjusted burden of disease and available work time adjusted for conditions of employment and geography. RESULTS: Assuming the use of ICT for each, a health workforce of 14 819, 17 925 and 7303 is required per scenario (current practice, national norms and full-time employed COPC), respectively. Total service costs for the respective scenarios range from R1.1 billion, through R947 million to R783 million. CONCLUSION: Modelling shows that delivering ICT-enabled COPC with full-time employees is the optimal scenario. It requires the smallest workforce, is the most economical, even when individual community health worker costs of employment are twice those of current practice, and is systemically the most effective.

Why high tech needs high touch: Supporting continuity of community primary health care.

BACKGROUND:  Integrated care through community-oriented primary care (COPC) deployed through municipal teams of community health workers (CHWs) has been part of health reform in South Africa since 2011. The role of COPC and integration of information and communication technology (ICT) information to improve patient health and access to care, require a better understanding of patient social behaviour. Aim: The study sought to understand how COPC with CHWs visiting households offering health education can support antenatal follow-up and what the barriers for access to care would be. Method: A mixed methodological approach was followed. Quantitative patient data were recorded on an electronic health record-keeping system. Qualitative data collection was performed through interviews of the COPC teams at seven health posts in Mamelodi and telephonic patient interviews. Interviews were analysed according to themes and summarised as barriers to access care from a social and community perspective. Results: An integrated COPC approach increased the number of traceable pregnant women followed up at home from 2016 - 2017. Wrong addresses or personal identification were given at the clinic because of fear of being denied care. Allocating patients correctly to a ward-based outreach team (WBOT) proved to be a challenge as many patients did not know their street address. Conclusion: Patient health data available to a health worker on a smartphone as part of COPC improve patient traceability and follow-up at home making timely referral possible. Health system developments that support patient care on community level could strengthen patient health access and overall health.

Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa.

Globally, models of extending universal health coverage through primary care are influenced by country-specific systems of health care and disease management. In 2015 a rapid assessment of the ward-based outreach component of primary care reengineering was commissioned to understand implementation and rollout challenges. AIM: This article aims to describe middle- and lower-level managers' understanding of ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and practical functioning that arise from the way the model is constructed and has been operationalised. SETTING: Data are drawn from a rapid assessment of National Health Insurance (NHI) pilot sites in seven provinces. METHODS: The study used a modified version of CASCADE. Peer-review teams of public health researchers and district/sub-district managers collected data in two sites per province between March and July 2015. RESULTS: Respondents unequivocally support the strategy to extend primary health care services to people in their homes and communities both because it is responsive to the family context of individual health and because it reaches marginal people. They, however, identify critical issues that arise from basing WBOTs in facilities, including unspecific team leadership, inadequate supervision, poorly constituted teams, limited community reach and serious infrastructural and material under-provision. CONCLUSION: Many of the shortcomings of a facility-based extension model can be addressed by an independently resourced, geographic, community-based model of fully constituted teams that are clinically and organisationally supported in an integrated district health system. However, a community-oriented primary care approach will still have to grapple with overarching framework problems.

Patient- or person-centred practice in medicine? - A review of concepts.

BACKGROUND: Person-centred practice in medicine may provide solutions to several pressing problems in health care, including the cost of services, poor outcomes in chronic care and the rise in litigation. It is also an ethical imperative in itself. However, patient- or person-centred care is not well researched partly because of a lack of conceptual and definitional clarity. AIM: The aim of this review was to analyse essential elements, ethical principles, logic and the practical application of person-centred practice described in clinician- and researcher-defined conceptual frameworks, terms and practices. METHODS: A search of review articles on patient- and person-centred care or medicine was conducted using Medline and Google Scholar. Secondary searches were conducted using references and citations from selected articles. RESULTS: Five conceptual frameworks were identified in terms of their practical application of the ethical principles of beneficence, autonomy and justice. They converge around a few central ideas such as having a holistic perspective of patients and their illness experience, a therapeutic alliance between the patient and clinician as well as respectful, enabling collaboration with the patient. CONCLUSIONS: Terminological differences appear to owe more to disciplinary origins than to substantive meaning. Beneficence needs to be balanced by and practised through respect for patient autonomy. Core ideas in existing conceptual frameworks of patient or person centredness can guide teaching and research. Considering the value and ethical imperative of person-centred practice, training institutions should train health care students and practitioners in its precepts.