Browsing by Author "Smith, Anja"

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    Human resources for health planning and national health insurance : the urgency and the opportunity
    (Health Systems Trust, 2018) Smith, Anja; Ranchod, Shivani; Strugnell, Dave; Wishnia, Jodi
    The implementation of National Health Insurance (NHI) amplifies the urgent need for coordinated, comprehensive health workforce planning in South Africa. Planning for and estimating the cost of adequate human resources for health (HRH) is of paramount importance to a well-functioning health system. Planning is also a central requirement for a strategic purchaser of health services tasked with matching healthcare needs with the supply of services. The NHI is likely to alter health staffing requirements in South Africa as it strives to improve quality of and equitable access to health care. Increased healthseeking behaviour anticipated under NHI implies increased need for all cadres of healthcare workers, particularly specialists and general practitioners (GPs), who are underrepresented in the public sector. The creation of the NHI Fund also provides the opportunity for much-needed HRH planning on a more systematic and regular basis. At present there is no ongoing process for HRH planning and no single, high-quality, integrated data source in South Africa to enable such planning. A review of the available data, together with the limitations of these data, is presented. There are no publicly available, audited and regularly updated statistics on the number and mix of health workers available and required for South Africa’s population. This chapter considers both global best practice in health workforce planning and the South African context of critical shortages in order to recommend a way forward. The creation of a timely, accurate and integrated repository of human resources data is an essential first step. We recommend the creation of a multi-stakeholder structure tasked with the development of integrated plans that consider the health system as a whole, based on models that account for both supply-side dynamics and the need for services, and that explicitly model the interactions between cadres of healthcare workers.
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    Measuring quality gaps in TB screening in South Africa using standardised patient analysis
    (MDPI, 2018) Christian, Carmen S.; Gerdtham, Ulf-G.; Hompashe, Dumisani; Smith, Anja; Burger, Ronelle
    This is the first multi-district Standardised Patient (SP) study in South Africa. It measures the quality of TB screening at primary healthcare (PHC) facilities. We hypothesise that TB screening protocols and best practices are poorly adhered to at the PHC level. The SP method allows researchers to observe how healthcare providers identify, test and advise presumptive TB patients, and whether this aligns with clinical protocols and best practice. The study was conducted at PHC facilities in two provinces and 143 interactions at 39 facilities were analysed. Only 43% of interactions resulted in SPs receiving a TB sputum test and being offered an HIV test. TB sputum tests were conducted routinely (84%) while HIV tests were offered less frequently (47%). Nurses frequently neglected to ask SPs whether their household contacts had confirmed TB (54%). Antibiotics were prescribed without taking temperatures in 8% of cases. The importance of returning to the facility to receive TB test results was only explained in 28%. The SP method has highlighted gaps in clinical practice, signalling missed opportunities. Early detection of sub-optimal TB care is instrumental in decreasing TB-related morbidity and mortality. The findings provide the rationale for further quality improvement work in TB management.
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    The nurse did not even greet me : how informed versus non-informed patients evaluate health systems responsiveness in South Africa
    (BMJ Publishing Group, 2021) Hompashe, Dumisani MacDonald; Gerdtham, Ulf G.; Christian, Carmen S.; Smith, Anja; Burger, Ronelle
    Introduction: Universal Health Coverage is not only about access to health services but also about access to high-quality care, since poor experiences may deter patients from accessing care. Evidence shows that quality of care drives health outcomes, yet little is known about non-clinical dimensions of care, and patients’ experience thereof relative to satisfaction with visits. This paper investigates the role of non-clinical dimensions of care in patient satisfaction. Methods: Our study describes the interactions of informed and non-informed patients with primary healthcare workers at 39 public healthcare facilities in two metropolitan centres in two South African provinces. Our analysis included 1357 interactions using standardised patients (for informed patients) and patients’ exit interviews (for non-informed patients). The data were combined for three types of visits: contraception, hypertension and tuberculosis. We describe how satisfaction with care was related to patients’ experiences of non-clinical dimensions. Results: We show that when real patients (RPs) reported being satisfied (vs dissatisfied) with a visit, it was associated with a 30% increase in the probability that a patient is greeted at the facilities. Likewise, when the RPs reported being satisfied (vs dissatisfied) with the visit, it was correlated with a 15% increase in the prospect that patients are pleased with healthcare workers’ explanations of health conditions. Conclusion: Informed patients are better equipped to assess health-systems responsiveness in healthcare provision. Insights into responsiveness could guide broader efforts aimed at targeted education and empowerment of primary healthcare users to strengthen health systems and shape expectations for appropriate care and conduct.
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    The rise and fall of mortality inequality in South Africa in the HIV era
    (Elsevier, 2018-08) Haal, Karel; Smith, Anja; Van Doorslaer, Eddy
    Post-apartheid South Africa has seen an unprecedented rise and fall of mortality in less than two decades as a result of the HIV/AIDS epidemic and the subsequent rollout of free antiretroviral therapy (ART). Since the incidence of both was not equal for rich and poor, it is likely to also have affected disparities in health and survival chances by income. We use large nationwide surveys for 2001, 2007 and 2011 to obtain estimates of average income and mortality at the aggregate level of a municipality, and then to examine changes in mortality – and in inequality in mortality by income ─ over time. Using concentration indices to measure health inequality, we demonstrate that both the mean mortality level and absolute inequality in mortality by income rose rapidly until 2006, and declined again sharply since the rollout of free ART. Relative inequalities in mortality by income, however, remained fairly stable over the 2001–2011 period. The analysis of age-sex-specific mortality rates shows that it was in particular for adults aged 18–59 years that mortality and absolute inequality increased substantially between 2001 and 2006, followed by a rapid drop thereafter. These trends were far more pronounced for males than females. This means that the HIV/AIDS epidemic has taken a serious death toll, which was concentrated disproportionately among the poorest segments of the population and especially affected (older) males. While South Africa has been very successful in curbing the overall mortality trend since 2006, large disparities in survival prospects by income, race and gender continue to exist. Targeted efforts are required if it wants to further reduce the very unequal chances of living to old age for richer and poorer population groups of all ages.
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    South Africa’s hospital sector : old divisions and new developments
    (Health Systems Trust, 2017) Ranchod, Shivani; Adams, Cheryl; Burger, Ronelle; Carvounes, Angeliki; Dreyer, Kathryn; Smith, Anja; Stewart, Jacqui; Van Biljon, Chloe
    The hospital sector in South Africa mirrors deep inequalities in the country as a whole. The private, for-profit hospital sector is well resourced and caters to a population that tends to be wealthier, urban and more likely to be formally employed. The public-hospital sector, catering to the majority of South Africans, faces lower human-resourcing ratios, financial constraints and ageing infrastructure. This chapter contextualises the development of the two sectors, describes the current divide, and considers the implications in terms of equity, access and quality of care. A unique dataset of quality-accreditation-survey scores was used, which allowed for analysis of the two sectors according to a common yardstick. These data reflect a wide array of structure- and process-related quality indicators; in addition, the patient perspective reflected in data from the General Household Survey was used to illustrate the quality differential. The research provides evidence of the polarisation between public and private facilities: private facilities consistently scored above public facilities across a range of accreditation categories, and there was far greater variability in the scores achieved by public facilities. The same polarised relationship was found to hold across key sub-components of the scores, such as management and leadership of hospitals in the two sectors. We conclude that there is a need for the measurement of health outcomes across the system. Policy attention is required in terms of accountability and quality improvement. A focus on improving value in the system will, by necessity, have to engage with the discrepancies between the sectors.