Valuing Academic Freedom and Advocacy.

This is a correspondence letter in response to an article published in the journal: Flaherman VJ, Nankabirwa V, Ginsburg AS. Promoting Transparent and Equitable Discussion of Controversial Research. Journal of Empirical Research on Human Research Ethics 2023; 18(4): 248-9.

Models using private general practitioners to provide caesarean deliveries at five South African district public hospitals: insights for public-private contracting for obstetric care in rural areas.

BACKGROUND: Harnessing of private sector resources could play an important role in efforts to promote universal access to safe obstetric care including caesarean delivery in low- and middle-income countries especially in rural contexts but any such attempt would need to ensure that the care provided is appropriate and patterns of inappropriate care, such as high caesarean delivery rates, are not reproduced for the entire population. OBJECTIVE: To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa. METHOD: We utilised a mixed-method study design to examine the contracting models adopted by five rural district hospitals in the Western Cape, South Africa. Between April 2021 and March 2022, we collected routine data from delivery and theatre registers to capture the profile of deliveries and utilisation of contracted private GPs. We also conducted 23 semi-structured qualitative interviews with key stakeholders to explore perceptions of the contracting arrangements. RESULTS: All five hospitals varied in the level of use of private general practitioners and the contracting models (three private in-sourcing models - via locum agencies, sessional contracts, and tender contracts) used to engage them. Qualitative interviews revealed insights related to the need for flexibility in the use of contractual models to meet local contextual needs, cost implications and administrative burden. CONCLUSION: Structured appropriately, private public partnerships can fill important gaps in human resources in rural district hospitals. Policy makers should look to developing a 'contracting framework' which requires compliance with a set of underlying principles but allows for flexibility in developing context specific contracting arrangements. These underlying principles should include a 'risk' based delivery model, adherence to public sector- evidence-based protocols, time-based rather than per delivery/type of delivery remuneration models, group liability arrangements, and processes to monitor outcomes.

Laboratory services in the context of prevention of mother-to-child transmission of HIV testing requirements in Copperbelt Province, Zambia: a qualitative inquiry.

INTRODUCTION: Reliable and timely laboratory results are crucial for monitoring the Prevention of the Mother-to-Child Transmission (PMTCT) cascade, particularly to enable early HIV diagnosis and early intervention. We sought to explore whether and how laboratory services have been prepared to absorb new testing requirements following PMTCT Test-and-Treat policy changes in three districts of Zambia. METHOD: We employed in-depth interviews and thematic data analysis, informed by the health system dynamic framework. Twenty-Six health workers were purposively selected and a document review of laboratory services in the context of PMTCT was undertaken. All face-to-face interviews were conducted in three local government areas in the Copperbelt Province (one urban and two rural) between February 2019 and July 2020. We extracted notes and markings from the transcripts for coding. Different codes were sorted into potential themes and the data extracted were put within the identified themes. Trustworthiness was confirmed by keeping records of all data field notes, transcripts, and reflexive journals. RESULTS: The findings revealed that the health system inputs (infrastructure and supplies, human resources, knowledge, and information and finance) and service delivery were unequal between the rural and urban sites, and this affected the ability of health facilities to apply the new testing requirements, especially, in the rural-based health facilities. The major barriers identified include gaps in the capacity of the existing laboratory system to perform crucial PMTCT clinical and surveillance functions in a coordinated manner and insufficient skilled human resources to absorb the increased testing demands. The centralized laboratory system for HIV testing of mothers and exposed neonates meant facilities had to send specimens to other facilities and districts which resulted in high turnaround time and hence delayed HIV diagnosis. CONCLUSION: New guidelines implemented without sufficient capacitation of health system laboratory capacity severely limited the effectiveness of PMTCT program implementation. This study documented the areas relating to health system inputs and laboratory service delivery where greater support to enable the absorption of the new testing requirements is needed.

Knowledge, understanding and perceptions of key stakeholders on the maternity protection available and accessible to female domestic workers in South Africa.

Maternity protection enables women to combine reproductive and productive roles. Domestic workers are a vulnerable group due to heterogeneous non-standard employment relationships and are unlikely to have access to comprehensive maternity protection. This study aimed to explore the knowledge, understanding and perceptions of key stakeholders in government, trade unions, non-governmental organisations and other relevant organisations of the maternity protection entitlements that should be available and accessible to female domestic workers in South Africa. This qualitative cross-sectional study included in-depth interviews with fifteen stakeholders working in different sectors in South Africa and mainly at a national level involved in maternity protection availability and access. Results show that stakeholders appear to have limited understanding of comprehensive maternity protection. Many challenges related to accessing cash payments while on maternity leave were described and suggestions were provided for how this could be improved. Participants described how certain labour-related characteristics unique to the domestic work sector were barriers in accessing maternity protection. Ensuring greater awareness of all components of maternity protection and improving implementation of existing labour legislation intended to guarantee maternity protection for non-standard workers in South Africa is important to improve access to maternity protection for this vulnerable group. Improved access to maternity protection would contribute to optimal maternal and new-born health and ensure economic security for women around the time of childbirth.

Experiences of public-private contracting for caesarean delivery in rural district public hospitals: A qualitative interview study.

Governments in sub-Saharan Africa are exploring public-private-engagements for the delivery of health services. While there is existing empirical literature on public-private-engagements in high-income countries, we know much less about their operation in low and middle-income countries. Obstetric services are a priority area where the private sector can make an important contribution in terms of skilled providers. The objective of this study was to describe the experiences of managers and generalist medical officers, of private general practitioner (GP) contracting for caesarean deliveries in five rural district hospitals in the Western Cape, South Africa. A regional hospital was also included to explore perceptions of public-private contracting needs amongst obstetric specialists. Between April 2021 and March 2022, we conducted 26 semi-structured interviews with district managers (n = 4), public sector medical officers (n = 8), an obstetrician in a regional hospital (1), a regional hospital manager (1) and private GPs (n = 12) with public service contracts. Thematic content analysis using an inductive, iterative approach was applied. Interviews with medical officers and managers revealed justifications for entering into these partnerships, including retention of medical practitioners with anaesthetic and surgical skills and economic considerations in staffing small rural hospitals. The arrangements held benefits for the public sector in terms of bringing in required skills and having after hours cover; and for the contracted private GPs who could supplement their income, maintain their surgical and anaesthetic skills and keep up to date with clinical protocols from visiting specialists. The arrangements held benefits for both the public sector and the contracted private GPs and were deemed to be an example of how national health insurance could be operationalised for rural contexts. Perspectives of a specialist and manager from a regional hospital provided insight into the need for different public-private solutions for this level of care in which contracting out of elective obstetric services should be considered. The sustainability of any GP contracting arrangement, such as described in this paper, will require ensuring that medical education programmes include basic surgical and anaesthetic skills training so that GPs opening practice in rural areas have the required skills to provide these services for district hospitals where needed.

Utilisation of private general practitioners to provide caesarean deliveries in five rural district public hospitals in South Africa: a mixed-methods study.

OBJECTIVE: Researching how public-private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general practitioners (GPs) contracted to provide caesarean delivery services in five rural district hospitals in the Western Cape, the profile and outcomes of caesarean deliveries. We also describe stakeholder experiences of these arrangements in order to inform potential models of public-private contracting for obstetric services. DESIGN: We used a mixed-methods study design to describe rural district hospitals' utilisation of private GP contracting for caesarean deliveries. Between April 2021 and March 2022, we collated routine data from delivery and theatre registers to capture the profile of deliveries and maternal outcomes. We conducted 23 semistructured qualitative interviews with district managers, hospital-employed doctors and private GPs to explore their experiences of the contracting arrangements. SETTING: The study was conducted in five rural district hospitals in the Western Cape province, South Africa. RESULTS: The use of private GPs as surgeon or anaesthetist for caesarean deliveries differed widely across the hospitals. Overall, the utilisation of private GPs for anaesthetics was similar (29% of all caesarean deliveries) to the utilisation of private GPs as surgeons (33% of all caesarean deliveries). The proportion of caesarean deliveries undertaken by private GPs as the primary surgeon was inversely related to size of hospital and mean monthly deliveries. Adverse outcomes following a caesarean delivery were rare. Qualitative data provided insights into contributions made by private GPs and the contracting models, which did not incentivise overservicing. CONCLUSION: The findings of this study suggest that private GPs can play an important role in filling gaps and expanding quality care in rural public facilities that have insufficient obstetric skills and expertise. Different approaches to enable access to safe caesarean delivery are needed for different contexts, and contracting with experienced private GP's is one resource for rural district hospitals to consider.

Access to Maternity Protection and Potential Implications for Breastfeeding Practices of Domestic Workers in the Western Cape of South Africa.

Access to comprehensive maternity protection could contribute to improved breastfeeding practices for working women. Domestic workers are a vulnerable group. This study aimed to explore perceptions of and accessibility to maternity protection among domestic workers in the Western Cape, South Africa, and potential implications of maternity protection access for breastfeeding practices. This was a mixed-method cross-sectional study including a quantitative online survey with 4635 South African domestic workers and 13 individual in-depth interviews with domestic workers. Results from the online survey showed that domestic workers had inconsistent knowledge of maternity-protection entitlements. Data from individual in-depth interviews showed that most participants struggled to access all components of comprehensive maternity protection, with some entitlements being inconsistently and informally available. Most domestic workers were unfamiliar with the concept of breaks to breastfeed or express milk. Participants provided suggestions for improving domestic workers' access to maternity protection. We conclude that improved access to all components of maternity protection would result in improved quality of care for women during pregnancy, around the time of childbirth and on return to work, and for their newborns, especially if an enabling environment for breastfeeding were created. Universal comprehensive maternity protection could contribute to improved care for all working women and their children.

Maternity protection entitlements for non-standard workers in low-and-middle-income countries and potential implications for breastfeeding practices: a scoping review of research since 2000.

BACKGROUND: Recommended breastfeeding practices contribute to improved health of infants, young children, and mothers. Access to comprehensive maternity protection would enable working women to breastfeed for longer. Women working in positions of non-standard employment are particularly vulnerable to not accessing maternity protection entitlements. The objective of this scoping review was to determine the current research conducted on maternity protection available and accessible to non-standard workers in low-and-middle-income countries and any potential implications for breastfeeding practices. METHODS: Nine databases were searched using search terms related to maternity protection, non-standard employment, and breastfeeding. Documents in English published between January 2000 and May 2021 were included. The approach recommended by the Joanna Briggs Institute was used to select sources, extract, and present data. The types of participants included in the research were female non-standard workers of child-bearing age. The core concept examined by the scoping review was the availability and access to comprehensive maternity protection entitlements of pregnant and breastfeeding women. Research from low-and-middle-income countries was included. The types of evidence sources were limited to primary research. RESULTS: Seventeen articles were included for data extraction mainly from research conducted in Africa and Asia. Research on maternity protection for non-standard workers mostly focused on childcare. Components of maternity protection are inconsistently available and often inaccessible to women working in non-standard employment. Inaccessibility of maternity protection was described to disrupt breastfeeding both directly and indirectly, but certain characteristics of non-standard work were found to be supportive of breastfeeding. CONCLUSIONS: Published information on maternity protection for non-standard workers is limited. However, the available information indicates that non-standard workers have inadequate and inconsistent access to maternity protection rights. The expansion of comprehensive maternity protection to all women working in positions of non-standard employment could encourage significant social and economic benefits.

Health system response to preventing mother-to-child transmission of HIV policy changes in Zambia: a health system dynamics analysis of primary health care facilities.

BACKGROUND: Zambia is focusing on attaining HIV epidemic control by 2021, including eliminating Mother to Child Transmission (eMTCT) of HIV. However, there is little evidence to understand frontline healthcare workers' experience with the policy changes and the readiness of different health system elements to contribute to this goal. OBJECTIVE: To understand frontline healthcare workers' experience of preventing mother-to-child transmission (PMTCT) of human immunodeficiency (HIV) policy changes and to explore the health system readiness to respond to rapid changes in PMTCT policy by using the health system dynamic framework. METHOD: We conducted a qualitative study in which 35 frontline healthcare workers were selected and interviewed using a snowball sampling technique. All transcripts were analysed through thematic content analysis and deductive coding. Themes were derived and presented according to the health system dynamics framework. RESULTS: Among the ten elements of the health system dynamics framework, service delivery, context, and resources (i.e. infrastructure and supplies, knowledge and information, human resource, and finance) were critical in implementing the continuously evolving PMTCT policies. Furthermore, due to the fragmented primary health care platform in Zambia, non-governmental organisations (NGOs) were instrumental in ensuring that the PMTCT programme met the demand and requirements of the general population. Frontline healthcare workers who participated in the study described inequity in access to ART services due to the service delivery model employed in the selected study sites. CONCLUSION: The study highlights challenges when policies are implemented without consideration for the readiness, context, and capacity in which the policy is implemented. We offer lessons that can inform implementation of universal health coverage of antiretroviral therapy (ART), a strategy many countries have adopted, despite weak health systems.

Maternity protection for female non-standard workers in South Africa: the case of domestic workers.

BACKGROUND: Many women work in positions of non-standard employment, with limited legal and social protection. Access to comprehensive maternity protection for all working women could ensure that all women and children can access health and social protection. This study aimed to describe the maternity protection benefits available to women in positions of non-standard employment in South Africa, using domestic workers as a case study. METHODS: A qualitative descriptive study design was used. National policy documents containing provisions on maternity protection were identified and analysed. Interviews were conducted with purposively selected key informants. Data extracted from published policy documents and information obtained from interviews were triangulated. A thematic analysis approach was used for evaluation of policy content and analysis of the interviews. RESULTS: Twenty-nine policy and legislative documents were identified that contain provisions on maternity protection relevant to non-standard workers. These documents together with three key informant interviews and two media releases are used to describe availability and accessibility of maternity protection benefits for non-standard workers in South Africa, using domestic workers as a case study. Maternity protection is available in South Africa for some non-standard workers. However, the components of maternity protection are dispersed through many policy documents and there is weak alignment within government on maternity protection. Implementation, monitoring, and enforcement of existing maternity protection policy is inadequate. It is difficult for non-standard workers to access maternity protection benefits, particularly cash payments. Some non-standard workers have unique challenges in accessing maternity protection, for example domestic workers whose place of work is a private household and therefore difficult to monitor. CONCLUSION: The heterogeneity of non-standard employment makes it challenging for many women to access maternity protection. There are policy amendments that could be made and improvements to policy implementation that would enhance non-standard workers' access to maternity protection. Potential long-term benefits to women and children's health and development could come from making comprehensive maternity protection available and accessible to all women.

Exploring women's exposure to marketing of commercial formula products: a qualitative marketing study from two sites in South Africa.

BACKGROUND: Regulating the marketing of commercial formula products is a long-term commitment required to protect breastfeeding. Marketing strategies of formula manufacturers, retailers and distributors evolve at a rapid rate. OBJECTIVE: The aim of this research was to describe exposure of pregnant women and mothers of young children in South Africa to marketing of commercial formula products, compared to international recommendations and national legislation. METHODS: Using mobile phone marketing diaries twenty participants in Cape Town and Johannesburg documented the formula marketing they were exposed to for one week. Ten mothers were interviewed to explore their perceptions towards marketing exposure in more depth. RESULTS: Women reported limited infant formula advertising, but an abundance of strategies used to market growing-up formula and powdered drinks for children over 36 months. Strategies included product packaging, in-store displays, online distribution channels and educational material about product ranges. Online strategies were reported, namely social media marketing (sponsored adverts and support groups), websites and mobile phone applications providing infant and young child feeding information and price discounts, print and TV advertisements, and competitions. Products for children over 36 months are cross-promoted with products prohibited to be advertised by national legislation. CONCLUSIONS: South African women are being exposed to covert marketing of infant, follow-up, and growing-up formula. Explicit marketing of products for children over 36 months of age allows formula companies to provide messages about branding and use of commercial formula products to mothers. National legislation should be updated and effectively implemented to address changing marketing strategies.

Legislation and Policies for the Right to Maternity Protection in South Africa: A Fragmented State of Affairs.

BACKGROUND: Maternity protection rights incorporate comprehensive benefits that should be available to pregnant or breastfeeding working women. RESEARCH AIM: To describe South Africa's maternity protection legal and policy landscape and compare it to global recommendations. METHOD: A prospective cross-sectional comparative policy analysis was used to review and describe national policy documents published from 1994-2021. Entitlements were mapped and compared to International Labour Organization standards. The document analysis was supplemented by interviews conducted with key national government department informants. Thematic analysis was used to evaluate policy and interview content. RESULTS: Elements of maternity protection policy are incorporated into South Africa's constitutional dispensation, and some measures are consistent with international labor and social security standards. However, the policy framework is fragmented and difficult to interpret. The fragmented policy environment makes it challenging for employees to know their maternity rights' entitlements and for employers to understand their responsibilities. Confusion regarding maternity protection rights is amplified by the complexity of ensuring access to different forms of maternal protection in pre- and postnatal stages, oversight by multiple government departments, and heterogenous working environments. CONCLUSIONS: Maternity protection in South Africa is fragmented and difficult to access. Overcoming these challenges requires legislative and implementation measures to ensure greater policy coherence and comprehensive guidance on maternity protection rights. Addressing gaps in maternity protection in South Africa may provide insights for other countries with shortcomings in maternity protection provisions and could contribute to improved breastfeeding practices.

Whole-of-community interventions that address alcohol-related harms: protocol for a scoping review.

INTRODUCTION: Alcohol-related harm is a rising global concern particularly in low-income and middle-income countries where alcohol use fuels the high rates of violence, road traffic accidents and is a risk factor for communicable diseases such as HIV/AIDS and tuberculosis. Existing evidence to address alcohol-related harm recommends the use of intersectoral approaches, however, previous efforts have largely focused on addressing individual behaviour with limited attention to whole-of-community approaches. Whole-of-community approaches are defined as intersectoral interventions that are systematically coordinated and implemented across the whole community. The objective of this scoping review is to synthesise the existing literature on multisectoral, whole-of-community interventions which have been used to modify or prevent alcohol-related harms. METHODS AND ANALYSIS: This scoping review will follow the six-step approach that involves; (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, (5) collating, summarising and reporting the results and (6) expert consultation. Published literature from 2010 to 2021 will be accessed through PubMed, Web of Science, CINAHL Plus and Scopus databases. Search terms will focus on the concepts of 'interventions', 'community-based', 'harm reduction' and 'alcohol'. There will be no restrictions on the type of study methodology or country of origin. Title and abstract followed by full-text screening will be conducted by two reviewers to identify relevant articles based on the inclusion and exclusion criteria. Data from selected articles will be extracted and charted in Excel software. Findings will be analysed qualitatively and presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: Extension for Scoping Review. ETHICS AND DISSEMINATION: This review makes use of published and publicly available data and no ethics approval is required. The results from this study will be disseminated via publication in peer-reviewed journals and presentations at relevant academic research fora and conferences.

COVID-19 hospitalization and mortality and hospitalization-related utilization and expenditure: Analysis of a South African private health insured population.

BACKGROUND: Evidence on the risk factors for COVID-19 hospitalization, mortality, hospital stay and cost of treatment in the African context is limited. This study aims to quantify the impact of known risk factors on these outcomes in a large South African private health insured population. METHODS AND FINDINGS: This is a cross sectional analytic study based on the analysis of the records of members belonging to health insurances administered by Discovery Health (PTY) Ltd. Demographic data for 188,292 members who tested COVID-19 positive over the period 1 March 2020-28 February 2021 and the hospitalization data for these members up until 30 June 2021 were extracted. Logistic regression models were used for hospitalization and death outcomes, while length of hospital stay and (log) cost per patient were modelled by negative binominal and linear regression models. We accounted for potential differences in the population served and the quality of care within different geographic health regions by including the health district as a random effect. Overall hospitalization and mortality risk was 18.8% and 3.3% respectively. Those aged 65+ years, those with 3 or more comorbidities and males had the highest hospitalization and mortality risks and the longest and costliest hospital stays. Hospitalization and mortality risks were higher in wave 2 than in wave 1. Hospital and mortality risk varied across provinces, even after controlling for important predictors. Hospitalization and mortality risks were the highest for diabetes alone or in combination with hypertension, hypercholesterolemia and ischemic heart disease. CONCLUSIONS: These findings can assist in developing better risk mitigation and management strategies. It can also allow for better resource allocation and prioritization planning as health systems struggle to meet the increased care demands resulting from the pandemic while having to deal with these in an ever-more resource constrained environment.

Optimising scale and deployment of community health workers in Sierra Leone: a geospatial analysis.

BACKGROUND: Little is known about strategies for optimising the scale and deployment of community health workers (CHWs) to maximise geographic accessibility of primary healthcare services. METHODS: We used data from a national georeferenced census of CHWs and other spatial datasets in Sierra Leone to undertake a geospatial analysis exploring optimisation of the scale and deployment of CHWs, with the aim of informing implementation of current CHW policy and future plans of the Ministry of Health and Sanitation. RESULTS: The per cent of the population within 30 min walking to the nearest CHW with preservice training increased from 16.1% to 80.4% between 2000 and 2015. Contrary to current national policy, most of this increase occurred in areas within 3 km of a health facility where nearly two-thirds (64.5%) of CHWs were deployed. Ministry of Health and Sanitation-defined 'easy-to-reach' and 'hard-to-reach' areas, geographic areas that should be targeted for CHW deployment, were less well covered, with 19.2% and 34.6% of the population in 2015 beyond a 30 min walk to a CHW, respectively. Optimised CHW networks in these areas were more efficiently deployed than existing networks by 22.4%-71.9%, depending on targeting metric. INTERPRETATIONS: Our analysis supports the Ministry of Health and Sanitation plan to rightsize and retarget the CHW workforce. Other countries in sub-Saharan Africa interested in optimising the scale and deployment of their CHW workforce in the context of broader human resources for health and health sector planning may look to Sierra Leone as an exemplar model from which to learn.

They push their products through me: health professionals' perspectives on and exposure to marketing of commercial milk formula in Cape Town and Johannesburg, South Africa - a qualitative study.

OBJECTIVE: To understand the views of public and private sector health professionals on commercial milk formula, to describe their exposure to companies that market commercial milk formula within their workplaces and to describe their awareness of South African (SA) regulations. DESIGN: A qualitative study consisting of semistructured interviews. SETTING: The study was conducted in Cape Town and Johannesburg, SA. PARTICIPANTS: Forty health professionals who had regular contact with pregnant or postnatal women were interviewed between February 2020 and February 2021. RESULTS: Analysis of the interviews revealed six themes. Health professionals in the private sector reported frequent contact with industry representatives with over two-thirds reporting exposure to industry representatives to present products, provide training or sponsor educational activities. Participants held strong opinions regarding the equivalency of breastfeeding to commercial milk formula citing information from industry representatives and product packaging. Health professionals were very knowledgeable on so-called formulas for special medical purposes and these were valued as solutions to infant feeding challenges. Of the 40 health professionals interviewed, less than half (19) had ever heard of the SA regulation related to marketing of breast milk substitutes (R991). CONCLUSIONS: This study demonstrates clearly that health professionals, particularly in the private sector, are exposed to and promote the use of commercial milk formula among SA women. The findings of this study should be used to catalyse policy responses, social movements, consumer and professional association action to strengthen monitoring and enforcement of the Code regulations in order to protect breastfeeding and support the optimal health and well-being of the population.