CHP has launched a series of mini-symposia on topicalhealth policy and systems research
issues to promote networking and engagement between researchers and policy makers.
On 29 March 2012, CHP co-hosted a mini-symposium onAccess, Inclusion and Exclusion: Health Care at a District Level, with REACH project partners the Health Economics Unit (University of Cape Town); McMaster University (Canada); School of Public Health (University of the Western Cape), RADAR (Wits), Africa Centre for Health and Population Studies (University of KwaZulu-Natal).
Nearly 50 delegates from all levels of the Department of Health and local and international academics attended the meeting which aimed to stimulate engagement with district-level health teams to share research findings, discuss and identify research questions, and explore ways for getting more evidence into policy. To see the gallery,click here.
Presenters showcased results of the five-year REACH project which used maternal deliveries, tuberculosis (TB) and antiretroviral (ARV) services at sub-district level to trace health system equity and access. About 4000 adults using these tracer services at two rural sites - Hlabisa (KwaZulu-Natal) and Bushbuckridge (Mpumalanga) - and two urban sites - Mitchell’s Plain (Western Cape) and Soweto Region D of the city of Johannesburg (Gauteng) – were involved in the studies which explored socio-economic, race, gender and citizenship factors.
Prof. Helen Schneiderof the School of Public health at the University of the Western Cape provided an overview of the REACH project. She explained that access is a strong manifestation of the inequities in SA, and conceptual frameworks around access were used to form the REACH multi-partner research project, funded by the Global Health Research Initiative, a collaborative research funding partnership of the Canadian institutes of Health Research, the Canadian International Development Agency, Health Canada, the International Development Research Centre and the Public health Agency of Canada.
Dr Duane Blaauwof the Centre for Health Policy (CHP) at Wits demonstrated modelling complex barriers to access which highlighted the methodological difficulties for health systems research which is complex with unpredictable results at times, and which requires new tools and approaches. He explained that one strategy was to use qualitative research more extensively, and to explore new ways of dealing with quantitative data. Using exit interviews and quality assessments, he used the analytical techniques of structural equation modelling, and multi-level modelling which facilitates analysis of hierarchical data, helping to incorporate context into the equation. He concluded that advanced statistical methods were better at modelling complex data and relationships, although they are more difficult to use and have some limitations (e.g. require complex software), but do allow analysis of elements of health systems complexity and are increasingly being used.
Prof. Susan Clearyof the Health Economics Unit at the University of Cape Town discussed determinants of adherence among TB patients. The research questions were whether access to care differed between individuals with different frequencies of clinic-based TB treatment delivery, and whether access barriers impact differently on patients coming to the clinic on a daily basis as compared to patients who receive their medication through weekly or monthly visits. South Africa's treatment approach is to use DOTS (directly observed therapy) for the full course which may be implemented differently according to settings. This mixed method study examined quantitative data from 1200 patient exit interviews, and conducted 17 qualitative in-depth interviews. Among the results were that a higher proportion of respondents missing doses among those who were employed, wealthier and in an urban setting. In terms of access barriers, those who visited clinics daily experienced greater access barriers than those coming weekly or monthly. The qualitative findings supported this, with people describing exhaustion and lengthy walks to get to the clinics, and transport costs. The DOTS requirement of coming on a daily basis does impact substantially on costs which may impact on adherence.
Dr Mosa Moshabelaof the Rural AIDS & Development Action Research Programme (RADAR) was unable to present in person, and Prof Schneider gave his presentation on down-referral and accessibility of ART. Given the massive challenge to achieving universal coverage on ART in South Africa, originally envisaged as a hospital- and doctor-based programme a shift has been made to decentralised, nurse-based provisioning through the primary health care system to increase coverage and reduce access barriers. The study question was whether access to antiretroviral therapy improves following down-referral of patients from hospital to clinic care. This cross sectional study in Bushbuckridge compared access experience of patients in hospitals (220) and clinic based care (109). The results showed that from an access point of view, there was largely a positive response to down-referral, with clinic patients reporting less stigma and more respect. However, self-care practices of clinic patients were five times greater than those attending hospitals which meant additional costs. Down-referral thus ironically removed and installed access barriers, with 27% of down-referred patients spending 15% or more of their income on complementary health care than hospital-based patients.
Loveday Penn-Kekanaof CHP presented on maternal deliveries: access and barriers. While the overwhelming majority of women do deliver in facilities, the researchers wanted to explore the barriers they faced and overcame, who was not accessing maternal delivery services, and whether some women received better or worse treatment than others. Using 1231 exist interviews and matched record reviews, 12 patient and 16 provider interviews among other methods, they found that women overcome considerable affordability, accessibility and accpetability barriers to deliver in facilities, and the poorest women are disproportionately not delivering in facilities. Research needs to be directed at how to target them, and how to make services more accessible and pleasant. She concluded that it is where women deliver - and not who they are - that seems to decide the level of clinical care they receive.
Natsayi Chimbindiof the Africa Centre for Health and Population Studies presented on TB-ART access patterns in Hlabisa, which uses a decentralised integrated approach in 17 Primary Health Care clinics, which includes close proximity between TB and HIV teams; cross training of these health providers; a database; and central TB clinic on the hospital premises for referral of patients. Among the findings are that there was almost universal test coverage of HIV testing among TB patients with 94% of TB patients being offered an HIV test. A total of 96% (274) had access to other healthcare services they needed in the same facilities which they utilised for their TB treatment, while 97% of patients used the clinic closest to their homes and received HIV testing there. 97% of TB patients and 95% of HIV patients were satisfied with the services they received when interviewed. There were high levels of self-reported use of alternative healthcare providers and self-care by both ART and TB patients, and high levels of borrowing money to pay for Healthcare in both ART and TB patients. Policy implications included improvements regarding health worker attitudes, efficiency, patient engagement on problems related to treatment and facility cleanliness.
Bronwyn Harrisof CHP presented ‘Small stories from patients and providers’ – practicing inclusion and exclusion which analysed everyday access barriers to maternal delivery services, ART and TB treatment in Mitchell's Plain, Soweto and Bushbuckridge through observations at 12 facilities, 45 patient interviews, and 67 provider interviews. Quoting from Wachtel & McCold (2004), she explained that human beings are happier, more cooperative and productive, and more likely to make positive changes in their behaviour when those in positions of authority do things with them, rather than to them or for them.
The research revealed cases of punitive, authoritarian modes of engagement, where providers did to patients by ridiculing, silencing, shouting at, ordering, ignoring them, sometimes coupled with discretionary and narrow application of policies where, for example, TB patients were observed taking their pills but which were later vomited because the patient had not eaten. Providers also experienced punitive and authoritarian modes of engagement, with one saying: “There is no joy in being a nurse today. When you get out the room, you want to take your epaulets and hide them because being a nurse is being nobody, is being a doormat where even the patients, they don’t take us seriously […] So, you know, negative things and ugly things. People laugh."
Doing for patients was regarded as permissive and paternalistic modes of engagement which stressed clinic expertise over patient knowledge and led to patient blaming. Doing with demonstrated a restorative and participatory mode which was caring, respectful, engaging and person-centred. She concluded that 'small stories' are rehearsals for the future, and to change the big story, the small stories - the everyday experience of access - needs to change. Doing with patients will enhance engagement, agency and empowerment while health policy makers, providers and researchers tackle the wider dimensions of exclusion.