Browsing by Author "Brey, Zameer"
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- ItemHealth system determinants of tuberculosis mortality in South Africa : a causal loop model(BMC (part of Springer Nature), 2021-04-26) Osman, Muhammad; Karat, Aaron S.; Khan, Munira; Meehan, Sue-Ann; Von Delft, Arne; Brey, Zameer; Charalambous, Salome; Hesseling, Anneke C.; Naidoo, Pren; Loveday, MarianBackground: Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results: Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socioeconomic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TBrelated mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions: Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.
- ItemHome delivery of medication during Coronavirus disease 2019, Cape Town, South Africa(AOSIS, 2020-06-04) Brey, Zameer; Mash, Robert; Goliath, Charlyn; Roman, Darrinhe public sector primary care facilities in Cape Town serve a large number of patients with chronic diseases such as human immunodeficiency virus, tuberculosis, diabetes, hypertension, asthma and chronic obstructive pulmonary disease. Prior to the Coronavirus disease 2019 (COVID-19) epidemic, stable patients with chronic conditions attended the facility or support groups to obtain their medication. During the COVID-19 epidemic, these patients would be put at risk if they had to travel and gather in groups to receive medication. The Metropolitan Health Services, therefore, decided to offer home delivery of medication. A system of home delivery was rapidly established by linking the existing chronic dispensing unit system with the emerging approach to community-orientated primary care in the Metro. Medication was delivered as usual to primary care pharmacies, but then a variety of means were used to disseminate the parcels to local non-profit organisations, where they could be delivered by a city-wide network of community health workers (CHWs). Innovations included various ways of delivering the parcels, including via Uber, bicycles and electric scooters, as well as Google forms to monitor the success of the initiative. It was estimated that up to 200 000 parcels per month could be delivered in this way via 2500 CHWs. The new system was established throughout the Metropole, and its strengths, weaknesses, opportunities and threats are further discussed. The initiative may prevent COVID-19 amongst people with comorbidities who would be at risk of more severe diseases. It may also have de-congested primary care facilities ahead of the expected surge in COVID-19 cases.