Abstract
The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for ...investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa’s public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1–7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country’s progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.
Mobile phone technology has demonstrated the potential to improve health service delivery, but there is little guidance to inform decisions about acquiring and implementing mHealth technology at ...scale in health systems. Using the case of community-based health services (CBS) in South Africa, we apply a framework to appraise the opportunities and challenges to effective implementation of mHealth at scale in health systems.
A qualitative study reviewed the benefits and challenges of mHealth in community-based services in South Africa, through a combination of key informant interviews, site visits to local projects and document reviews. Using a framework adapted from three approaches to reviewing sustainable information and communication technology (ICT), the lessons from local experience and elsewhere formed the basis of a wider consideration of scale up challenges in South Africa.
Four key system dimensions were identified and assessed: government stewardship and the organisational, technological and financial systems. In South Africa, the opportunities for successful implementation of mHealth include the high prevalence of mobile phones, a supportive policy environment for eHealth, successful use of mHealth for CBS in a number of projects and a well-developed ICT industry. However there are weaknesses in other key health systems areas such as organisational culture and capacity for using health information for management, and the poor availability and use of ICT in primary health care. The technological challenges include the complexity of ensuring interoperability and integration of information systems and securing privacy of information. Finally, there are the challenges of sustainable financing required for large scale use of mobile phone technology in resource limited settings.
Against a background of a health system with a weak ICT environment and limited implementation capacity, it remains uncertain that the potential benefits of mHealth for CBS would be retained with immediate large-scale implementation. Applying a health systems framework facilitated a systematic appraisal of potential challenges to scaling up mHealth for CBS in South Africa and may be useful for policy and practice decision-making in other low- and middle-income settings.
Monitoring Caesarean Section (CS) rates is essential to ensure optimal use of the procedure. Information on CS rates in the South African private sector is limited and information from this study ...will assist in planning for the proposed NHI in South Africa.
The objectives of this paper are to assess mode of delivery patterns and to determine CS rates amongst South African private health insurance scheme members; and to assess the extent to which CS rates are influenced by age and health status of the mother.
The 2015 claims for members of 10 health insurance schemes were analysed to assess delivery type patterns. Mode of delivery patterns were assessed by 6 delivery types: emergency, elective and "other" for caesarean deliveries; and non-assisted, assisted and "other" for vaginal deliveries; as well as by age and health condition of the mother.
Of a total of 6,542 births analysed, 4,815 were CS giving a CS rate of 73·6% (95% CI 72·5%;74·7%). Emergency CS were the most common mode of delivery (39·7%), followed by elective CS (39·5%). CS rates increased with increasing maternal age and were higher for women with a medical condition.
CS rates for the South African private sector are considerably higher than the safe rates recommended by the WHO. The high CS rates is a cause for concern for the health system under the proposed NHI. To support initiatives encouraging evidence based practice, further research is required to understand the drivers for the high CS rates.
As South Africa embarks on the implementation of the community health care worker (CHW) 2018 policy, quantifying the resource requirements to effectively manage the programme across different ...geographical communities is essential. This study was conducted to quantify and compare costs associated with travel and service delivery demands on CHWs between area types in two districts.
This economic analysis adopted a provider perspective to cost CHW services between January and November 2016. A total of 221 CHWs completed diaries for 10 days to document their activities. Quintile regression and the Kruskall Wallis test were used to test for differences in time and activities across urban and rural sites.
While travel time across rural and urban settings within each district did differ it was not the most significant predictor of differences in time utilization. Time on activities showed more significant differences with overall median time by unit of activity being 15% longer in rural than urban areas in Sedibeng and 10% longer in uMzinyathi respectively. Most CHW time was spent conducting home visits (57% in rural,66% in peri-urban/urban). Median time per home visit in uMzinyathi was 50% longer in deep-rural areas than urban areas and 20% longer in rural than urban areas in Sedibeng. Referrals and number of home visits per capita (0.4 visits in rural and 0.7 in urban/peri-urban areas) were low in both districts. Expenditure on the programme translated to under 4% of PHC expenditure per capita and remains under 5% if despite the new national minimum wage (R3,500/$245).
Because home visits take longer and CHWs spend a lower share of time on visits, a higher number is required in rural and deep rural areas (33% and 66% respectively) than in urban areas. Effective budget planning will therefore need to recognize the different geographical needs.
Primary care services in South Africa have been challenged by increasing numbers of people with communicable and non-communicable chronic diseases. There was a need to develop alternative approaches ...for stable patients to access medication. With the onset of the coronavirus pandemic there was an urgent need to decongest facilities and protect people from infection. In this crisis the Metro Health Services rapidly implemented home delivery of medication by community health workers. This study aimed to evaluate the implementation of home delivery of medication by community health workers during the coronavirus pandemic in Cape Town, South Africa.
A convergent mixed methods study evaluated six implementation outcomes: adoption, feasibility, fidelity, coverage, cost, and sustainability of the initiative. Data sources included routinely collected data, a telephonic survey of 138 patients, an analysis of set-up and recurrent costs as well as 17 descriptive exploratory qualitative semi-structured interviews with 68 key informants.
Over a 6-month period 1,054,657 pre-packaged parcels were sent to primary care facilities, 819,649 (77.7%) were delivered and of those 97,297 (11.9%) returned. The additional costs were estimated as 1.3% of a total health budget of R2,2 billion. The initiative was rapidly adopted as it decongested facilities and protected vulnerable patients. Although it was feasible to implement at scale, numerous challenges were encountered, such as incorrect addresses and contact details, transporting parcels, communicating with patients, having a reliable audit trail, and handling out-of-area patients. All role players thought the service should continue and 42.3% of patients reported better adherence to their medication.
Home delivery of medication by community health workers is feasible at scale and affordable. It should continue, but as one of a menu of options for alternative delivery of medication. The following need to be improved: efficiency of the system, the audit trail, adequate support and resources for community health workers, transport of medication, communication with patients, empanelment of patients, governance of the system and training of the community health workers.
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.
To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa.
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.
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.
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.
Summary South Africa is one of only 12 countries in which mortality rates for children have increased since the baseline for the Millennium Development Goals (MDGs) in 1990. Continuing poverty and ...the HIV/AIDS epidemic are important factors. Additionally, suboptimum implementation of high-impact interventions limits programme effectiveness; between a quarter and half of maternal, neonatal, and child deaths in national audits have an avoidable health-system factor contributing to the death. Using the LiST model, we estimate that 11 500 infants' lives could be saved by effective implementation of basic neonatal care at 95% coverage. Similar coverage of dual-therapy prevention of mother-to-child transmission with appropriate feeding choices could save 37 200 children's lives in South Africa per year in 2015 compared with 2008. These interventions would also avert many maternal deaths and stillbirths. The total cost of such a target package is US$1·5 billion per year, 24% of the public-sector health expenditure; the incremental cost is $220 million per year. Such progress would put South Africa squarely on track to meet MDG 4 and probably also MDG 5. The costs are affordable and the key gap is leadership and effective implementation at every level of the health system, including national and local accountability for service provision.
Within the integrated community case management of childhood illnesses (iCCM) programme, the traditional health promotion and prevention role of community health workers (CHWs) has been expanded to ...treatment. Understanding both the impact and the implementation experience of this expanded role are important. In evaluating UNICEF's implementation of iCCM, this qualitative case study explores the implementation experience in Ghana.
Data were collected through a rapid appraisal using focus groups and individual interviews during a field visit in May 2013 to Accra and the Northern Region of Ghana. We sought to understand the experience of iCCM from the perspective of locally based UNICEF staff, their partners, researchers, Ghana health services management staff, CHWs and their supervisors, nurses in health facilities and mothers receiving the service. Our analysis of the findings showed that there is an appreciation both by mothers and by facility level staff for the contribution of CHWs. Appreciation was expressed for the localisation of the treatment of childhood illness, thus saving mothers from the effort and expense of having to seek treatment outside of the village. Despite an overall expression of value for the expanded role of CHWs, we also found that there were problems in supporting and sustaining their efforts. The data showed concern around CHWs being unpaid, poorly supervised, regularly out of stock, lacking in essential equipment and remaining outside the formal health system.
Expanding the roles of CHWs is important and can be valuable, but contextual and health system factors threaten the sustainability of iCCM in Ghana. In this and other implementation sites, policymakers and key donors need to take into account historical lessons from the CHW literature, while exploring innovative and sustainable mechanisms to secure the programme as part of a government owned and government led strategy.
ObjectiveResearching 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.DesignWe 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.SettingThe study was conducted in five rural district hospitals in the Western Cape province, South Africa.ResultsThe 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.ConclusionThe 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.
South Africa has a high burden of MDR-TB, and to provide accessible treatment the government has introduced different models of care. We report the most cost-effective model after comparing cost per ...patient successfully treated across 5 models of care: centralized hospital, district hospitals (2), and community-based care through clinics or mobile injection teams.
In an observational study five cohorts were followed prospectively. The cost analysis adopted a provider perspective and economic cost per patient successfully treated was calculated based on country protocols and length of treatment per patient per model of care. Logistic regression was used to calculate propensity score weights, to compare pairs of treatment groups, whilst adjusting for baseline imbalances between groups. Propensity score weighted costs and treatment success rates were used in the ICER analysis. Sensitivity analysis focused on varying treatment success and length of hospitalization within each model.
In 1,038 MDR-TB patients 75% were HIV-infected and 56% were successfully treated. The cost per successfully treated patient was 3 to 4.5 times lower in the community-based models with no hospitalization. Overall, the Mobile model was the most cost-effective.
Reducing the length of hospitalization and following community-based models of care improves the affordability of MDR-TB treatment without compromising its effectiveness.
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