Antibiotic resistance (ABR) is an important global threat to public health. This issue is particularly critical for South Africa which has a high burden of infectious diseases and among the highest rates of ABR in the world. The use of antibiotics when they are not strictly necessary is an important factor contributing to the development of ABR.
A collaborative study by Wits University and the London School of Economics using qualitative (observations, in-depth interviews and focus groups) and quantitative (online survey, standardised patients) research methodologies was conducted to study antibiotic prescribing in primary care in South Africa. The study found very high rates of unnecessary antibiotic prescribing for acute respiratory tract infections by public and private primary care providers.
This is one of the first studies to document the extent of this problem using rigorous methods. An overview of the study and its objectives can be found in the following link… [brief 0]
Antibiotic resistance (ABR) is particularly critical for South Africa which has a high burden of infectious diseases and among the highest rates of ABR in the world. Previous research in South Africa has focused more on antibiotic use in hospitals. However, data from other countries has shown that the majority of antibiotics are usually prescribed in primary care. Respiratory tract infections (RTIs) such as the common cold and acute bronchitis are one of the main problem areas because primary care providers prescribe antibiotics for these infections even though they are caused by viruses rather than bacteria.
The Antibiotic resistance (ABR) project was a study in response to the high antibiotic resistance rates globally and especially in South Africa. The project was divided into three parts. Part 1 was a qualitative study using in-depth interviews, observations and focus group discussions to try to understand the behaviours and perceptions of patients and providers towards antibiotic resistance and its current impacts in South Africa. Data was collected from patient interviews, patient consultations and key witnesses or providers including pharmacists and academics researching ABR in upper respiratory tract infections. A total of 65 interviews, observations and focus group discussions were conducted. Overall, part 1 found that patients and providers had concerning levels of ABR knowledge and perceived the problem too narrowly that is only affecting their individual immunity and not the resistance of bacteria.
The second part of the study presents findings on the knowledge and behavioural practices of primary care doctors and nurses that influenced unnecessary antibiotic prescribing. An online survey using experimental vignettes was designed and administered to general practitioners (GPs) in the whole of South Africa. The findings of part 2 showed that the role ABR knowledge played was important in reducing unnecessary antibiotic prescribing, although the problem was also systemic since many GPs believed that patient demand was a strong determinant and that their peers would prescribe antibiotics even when it was not indicated.
Finally, the third part of the study conducted a field experiment using a methodology known as standardised patients (SPs). The methodology of SPs is the gold standard for collecting data that is objective, unbiased and measures the direct causes of prescribing antibiotics. Part 3 was conducted in a large metropolitan area in South Africa where primary care providers from the public and private sector received SPs who acted as mystery patients with the specific clinical case of acute bronchitis. Our SPs underwent extensive training to portray a convincing SP with acute bronchitis. The findings of part 3 showed that unnecessary antibiotic prescribing rates were very high with 67% in the private sector and 78% in the public sector.
The findings from parts 1, 2 and 3 are summarised in the following policy briefs[brief 1][brief 2][brief 3]
Antibiotic resistance (ABR) is particularly critical for South Africa which has a high burden of infectious diseases and among the highest rates of ABR in the world. A recent study conducted by Wits University and the London School of Economics on antibiotic prescribing behaviour in primary care in South Africa found that 78% of patients sent to a public clinic and 67% of patients sent to a private general practitioner (GP) received antibiotics even though antibiotics were not clinically indicated for these patients.
The causes of such high and unnecessary rates are often associated with patient demand and financial incentives. As a part of the ABR project, interventions addressing patient demand and financial incentives were investigated to explain if these two factors were significant determinants that influenced unnecessary antibiotic prescribing behaviours in South Africa.
The findings of the study indicated that patient demand was an important although not as significant a factor as providers made it out to be, and similarly for financial incentives. The study used the standardised patient methodology to test whether more informed patients who were reluctant to get antibiotics could influence providers behaviours – it did, however, unnecessary prescribing rates dropped by 10 percentage points with still more than half of providers prescribing antibiotics. Financial incentives did not change the unnecessary rates of prescribing, providers who received patients with better insurance plans (more comprehensive and expensive insurance plans) were more likely to prescribe more expensive drugs... [brief 4]
Improving hypertension management: how can lay health workers help?
South African primary care clinics are facing a rapidly increasing demand for services. This is because the population is ageing and anti-retroviral drugs to treat HIV are delivered here.
Endurance, resistance and resilience: lessons from patients and healthcare providers in a constrained South African health system
Despite positive developments in recent years such as better leadership and an improved response to the major challenge of HIV/AIDS and tuberculosis (TB), providers and patients alike often experience South Africa’s health system as a very constrained environment.
The issues that weigh on providers include strained relationships with their managers, too few staff, high workloads, resource shortages, dissatisfaction with how the system works, and wanting to do more to increase its responsiveness. Patients face challenges such as poor quality care, services and treatments that are unacceptable for cultural or other reasons, and negative staff attitudes.
Indeed, suspicion, blame and mistrust in the provider-patient relationships significantly constrain the functioning of the health system and make it all the more challenging to deliver the caring, efficient, effective and equitable services that so many desperately need (Figure 1).
Although there are many examples of positive provider-patient relationships, mistrust, when it occurs, can lead to negative outcomes that include a tense working environment in health facilities, as well as patients interrupting their treatment, withholding information about side effects or treatment complications, and experiencing feelings of being unwanted and less than human.
Against the backdrop of a challenged system, this brief highlights selected strategies that providers and patients use to cope with their circumstances in order to access services and provide care in a meaningful way.Click here
Beyond supplying HIV and TB treatment: improved access to acceptable care in South Africa by engaging with patients’ health contexts, experiences and illness perceptions
HIV/AIDS and TB are much more than chronic diseases requiring medical treatment. As illnesses, they entail more than physical discomforts or difficulties. Instead they are deeply affecting how patients perceive their own emotional well-being, self-worth, and bodies – and how others in society perceive and interact with patients.
Such perceptions, beliefs and experiences are central to patients’ lives because they frame the options available to them, affect relationships within families and communities, and influence their decisions and actions. Crucially, these factors fundamentally impact on the treatment pathways that patients decide on and the acceptability of the care that the health system provides.
Access to acceptable care, however, is not only about the perceptions and circumstances of each patient, but transcends the individual to encompass the broader social context or “healthworld”; the socially shared, collective ways in which societies pursue health and well-being. This brief explores how HIV and TB patients in South Africa construct their illnesses through their beliefs, experiences and perceptions and how these constructions and patients’ healthworlds influence their access to care, in particular, the acceptability of that care.
Understanding acceptability and access is crucial as South Africa, a country with a history of polarizing debates around HIV, has experienced the world’s fastest growing HIV/AIDS epidemic, is the country with the highest number of people living with HIV, has seen TB become the leading cause of death, manages what is now the world’s largest anti-retroviral (ART) programme, and is challenged to deliver uninterrupted ART and TB treatment. Click here
The mediating influence of the sub-‐national: working through lower levels of government to enhance the implementation of national UHC initiatives
Over the last 15 years, the concept of universal health coverage (UHC) has become ever more central to international health policy discussions.
Many countries have adopted UHC – the essence of which is that people should receive the quality, essential health services they need without financial hardship - as an important goal and a way of framing national-level healthcare delivery improvement initiatives.
Sub-national levels of government such as states, provinces and districts often play a central role in the implementation, and eventual success or failure, of national attempts to achieve and deepen UHC.
In the implementation chain, the political, economic, social and policy contexts of sub-national levels of government mediate national UHC initiatives, so that they might not be automatically implemented or not be implemented as intended.
Sub-national levels of government are therefore key to the fidelity with which national initiatives are implemented and have a major impact on how citizens experience the frontline delivery of these initiatives.
This policy brief synthesizes the results of research in Nigeria, Ghana and South Africa to highlight key lessons for enhancing the implementation of national UHC initiatives through sub-national levels of government. Click here
Doing with, not doing to or doing for: the continuing challenge of transforming the institutions and practices of the South African health system.
Historically, South Africa’s health system was, in part, a site of injustice. After its hearing into the apartheid health sector (1960-1994), the Truth and Reconciliation Commission (TRC) found "millions of South Africans were denied access to appropriate, affordable healthcare...Healthcare workers, through acts of commission and omission, ignorance, fear and failure to exercise clinical independence, subjected many… to further abuse".
Across this time, healthcare was broadly delivered in authoritarian (doing to patients) and paternalistic (doing for patients) ways, especially for black South Africans. Since the advent of democracy in 1994, laws and policies have sought to protect human rights, address disparities in health and wealth, and encourage the delivery of care in more restorative, participatory (doing with patients) ways. Alongside the TRC, itself a vehicle for restorative justice, we find the Constitution’s Bill of Rights, Batho Pele (People First) Principles, Patients’ Rights Charter, and proposed National Health Insurance system.
However, those who suffered most under apartheid still struggle most to access care and continue to experience the poorest health outcomes. Mistrustful provider-patient relationships and provider hostility, neglect, sometimes even abuse, remain part of the health system.
This brief shows how authoritarian and paternalistic practices persist in the new democratic context. Click here......
Developing leadership competencies in the health system: practical lessons from a South African district
Decentralization has been widely implemented in South Africa and other developing countries. It transfers authority over functions such as financial management and human resources from higher to lower levels of the health system, seeking to achieve efficiency, innovation and service adaptation to local contexts.
Achieving these outcomes requires effective management and leadership in the health system, particularly at district level. Management entails coordinating technical processes such as planning and budgeting. Leadership refers to individuals who create a vision, inspire, motivate and enable staff to achieve results in complex conditions.
Although some researchers have treated management and leadership separately, we have found them to overlap in practice and to both be crucial to strengthening the district health system. However, despite its centrality to the success of decentralisation and the implementation of health reforms, there are significant leadership challenges at the district level.
Effective leadership requires a range of competencies (Figure 1). This policy brief highlights district-level informal, workplace-based learning through which these key leadership competencies can be learnt and developed. This adds to the relatively small body of empirical literature on informal learning in the health system and complements existing leadership development thinking, much of which is focused on formal training through courses or workshops. Click here
In South Africa, clinical management of non-communicable diseases such as hypertension and diabetes is often poor. Community health workers (CHWs) have played an important role in providing effective HIV and TB care, but there is little evidence on the effectiveness of their role in managing hypertension and diabetes. Click here to read more about how CHWs could improve the management of hypertension.
Adolescent health is increasingly seen as an important international priority. The World Health Organisation’s Youth Friendly Health Services (YFHS) programme aims to address the needs of youth aged 10-24 years. Community Health Workers (CHW) have potential for strengthening delivery, but the CHW approach has been criticised on several fronts. Click here for the findings of this systematic review.
The right to access healthcare in South Africa is constitutionally protected and part of a socio-political effort to bring justice after apartheid. Yet, 20 years into democracy, access barriers such as high transport costs, large distances to services, varied quality of care and a fragmented health system continue to disproportionately affect many who experienced the dispossession and violence of apartheid. Click here to read more.
South Africa’s right to access health care is part of a broader socio-political endeavour to ‘bring justice’ in the aftermath of apartheid. Street-level bureaucrats are tasked with delivering health services and enabling this right. However, authoritarian provider practices persist in post-apartheid health services and negative, even abusive, street-level bureaucracy may impede the right to access health care. Click here to read more.
South Africa has established ward-based community health worker (CHW) outreach teams as part of several strategies to strengthen primary health care. The Sedibeng district in Gauteng pioneered a complementary 'health post approach in its sub-district of Emfuleni. Reach about the challenges and successes here.
What influences job satisfaction of PHC Clinic Nursing Managers? Findings from two South African provincesNursing studies have shown a strong link between workload, exhaustion, absenteeism, staff conflict and job satisfaction. Identifying what gives PHC clinic managers job satisfaction can inform health workforce management strategies. This study was also one of the first to examine the association between verbal abuse and nurses' job satisfaction. Click here to read more.
This first large survey on the topic in sub-Saharan Africa explores the extent of agency nursing, moonlighting and overtime in South Africa. It fills in knowledge gaps and provides evident to inform policies on nursing casualization, nursing agencies and moonlighting. Click here to read more.
Although maternal mortality rates are declining globally, only 13 countries are likely to achieve the targets of Millennium Development Goal 5 by 2015. Inequities in maternal health persist, both within and between higher and lower income countries. Poor and rural women continue die of maternal related causes at far greater rates than their richer, urban-dwelling counterparts. To read more, Click here.
Though pregnancy is a normal life occurrence, it marginalises vulnerable women and children by reducing their income-generating potential and by introducing a host of new financial needs. There is evidence that poor pregnant women are at high risk of malnutrition, which can have lifelong effects on children through disability, short stature, cognitive delay and poor academic achievement among other things. Major causes of maternal deaths and still births are low utilisation of and delay in seeking antenatal and childbirth services. To read more, Click here.
Financial incentives are a commonly used strategy to improve health worker motivation and retention; however, there are few studies that analyze the implementation of policies on remuneration or financial incentives. In 2007, the South African government introduced the occupation specific dispensation (OSD), a financial incentive strategy to attract, motivate and retain health professionals in the public health sector. Starting with nurses who form the bulk of healthcare professionals, the implementation of this policy experienced several problems and some unintended negative consequences. Read more here .
Community health worker (CHW) programmes strive to improve access to care. As the interface between health systems and communities, they provide outreach services and help households to overcome barriers to care such as lack of access to transport, clean water, sanitation and nutrition, which relate to the social determinants of health. While there is growing evidence that CHWs can help to improve certain health outcomes, research suggests that programmes often fail because of lack of support and skills. Click here for the full policy brief.