An analysis of adherence & equity in access to TB services in Mitchell's Plain, South Africa

Includes bibliographical references.The control of tuberculosis (TB) in South Africa has fallen short of the targets outlined by the World Health Organization and without improvement; TB is expected to have grave consequences for both the mortality and morbidity of South Africans as well as crippling financial consequences for the public health system. While services in the public sector are free at the point of use, little is known about overall access barriers and their implications for treatment adherence. This paper explores these barriers from the perspective of TB patients enrolled in Directly Observed Treatment, Short-Course (DOTS) in Mitchell's Plain, South Africa. Using a comprehensive framework of access, in-depth interviews were conducted with 334 TB patients across five facilities in Mitchell's Plain, to assess barriers across the dimensions of availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between adherent and non-adherent groups, and between socioeconomic groups were explored using bivariate, multivariate linear and logistic regressions. Among the respondents, 244 (73.05%) met the criteria for adherence (i.e. reported that they had never missed a dose of TB medication) while 90 (26.95%) met the criteria for non-adherence. Marital status, age, birth province, costs of self-care and costs of other providers were found to be significantly associated with adherence (P-values 0.05). Nonetheless, the results revealed that the poor face increased costs of accessing TB-services, compared to the rich, though this association was not deemed to be significant

Economic costs, impacts and financing strategies for mental health in South Africa

Over the past decade, calls to address the increasing burden of mental, neurological and substance-use (MNS) disorders and to include mental health care as an essential component of universal health coverage (UHC) have attracted mounting interest from governments. With the inclusion of mental health in the 2015 Sustainable Development Goals (SDGs) there is now a global policy commitment to invest in mental health as a health, humanitarian and development priority. Low and middle-income countries (LMICs) such as South Africa, contemplating mental health system scale-up embedded into wider SDG- and UHC-related health-sector transformations, must address a number of key mental health financing policy considerations for attaining population-based improvements in mental health. Despite ongoing transformations in the South African health sector, there has been an implicit neglect of the integration of mental health services into general health service development. This has been driven in part by a lack of locally-derived evidence in several areas, including: the economic basis for investing in mental health, the current resourcing of the mental health system, opportunities for improved efficiency and equity, and how reforms may be structured and paid for in light of the country's ongoing efforts to implement a National Health Insurance (NHI) scheme. This thesis therefore attempts to address these gaps and aims to generate new knowledge on the economic costs, impacts and financing strategies for mental health in South Africa. This aim is achieved by fulfilling the following research objectives: 1. To examine the impact of social, national and community-based health insurance on health care utilization for MNS disorders in low- and middle-income countries. 2. To examine the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa. 3. To quantify public health system expenditure on mental health services, by service level and province, and to document and evaluate the resources and constraints of the mental health system in South Africa. 4. To examine the household economic costs and levels of financial risk protection associated with depression symptoms in South Africa. In the first part, the systematic review reports on the impact of social, national and community based health insurance on health care utilization for MNS disorders in LMICs, published until October 2018. As a secondary goal, the systematic review identifies whether there are any specific lessons that can be learnt from existing approaches to integrate mental health care into financing reforms towards universal health coverage. In the second part, a qualitative examination of the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa was conducted through a situational analysis that was complimented with a synthesis of key stakeholder consultations. The findings provide recommendations for how scaled-up mental health services can best be paid for in a way that is feasible, fair and appropriate within the fiscal constraints and structures of the country. In the third part, the thesis then empirically quantified public health system expenditure on mental health services, by service-level and province for the 2016/17 financial year, and documented and evaluated the resources and constraints of existing mental health investments in South Africa through a national survey; achieving one of the highest sample sizes of any costing study conducted for mental health in LMICs. In the fourth and final part, a household survey study was conducted to determine the level of financial protection for persons living with depression symptoms in the Dr. Kenneth Kaunda health district of South Africa, which is serving as a pilot site for the NHI. The household economic factors associated with increased depression symptom severity on a continuum are reported; and demonstrate that financial risk protection efforts are needed across this continuum. The thesis concludes by synthesizing findings towards an improved understanding of the key lessons that can be learned from other LMICs toward sustainable financing for mental health; the economic burden of inadequate mental health care to households in South Africa; and the efficiency of existing mental health investments and inequities in resourcing and access. Through this lens, and borrowing from the experiences of other LMICs, recommendations for key priorities for health service and financing reforms towards the scaled-up delivery of mental health services in South Africa are generated. The thesis is presented as papers embedded in a narrative that includes an introduction and synthesis discussion. Four papers (3 published and 1 under review) form the basis of the results chapters

Sustainable financing mechanisms for strengthening mental health systems in Nigeria

Background and aims: Current coverage of mental health care in low- and middle-income countries is limited, not only in terms of access to services but also in terms of financial protection of persons in need of care and treatment. This is especially pertinent considering the established relationship between mental illness and poverty and the need to ensure the financial risk protection of persons with mental disorders and their families as part of country's efforts to attain universal health coverage. This study set out to review the health and socio-economic contexts of Nigeria as well as to generate strategies for sustainable mental health financing that will be feasible, within the specific context of the country.Methods: A multi-methods approach was developed and applied, consisting of three steps: a situational analysis of Nigeria's health system, macro-fiscal economic profile, and socio-political status, including a strengths, weaknesses, opportunities and threats (SWOT) analysis of the Nigerian socio-economic, general and mental health context; key informant interviews with 12 expert stakeholders drawn from state and non-state actors in the health and financial sectors; and a policy analysis of sustainable financing options.Results: Key challenges identified were: poor funding; reduced access to care, resulting in a huge treatment gap; and out of pocket payment for services—leading to impoverishment. Comprehensive coverage of mental health conditions within the ongoing health insurance reforms was identified as a key strategy for moving towards sustainable mental health financing in Nigeria. Other identified strategies include enhanced integration of mental health into primary care; incorporation of mental health into other strategic and currently funded programmes; adoption of performance-based financing measures; and renewed engagement with stakeholders, including external donor institutions.Conclusions: A suite of feasible and actionable measures can be implemented to increase mental health service financing, reduce health-related financial burden on households, increase help-seeking and access to quality mental health care and, ultimately, reduce the large treatment and financing gap for mental disorders in Nigeria

Mental health problems and socioeconomic disadvantage: a controlled household study in rural Ethiopia

Abstract Background There is a lack of high quality population-based studies from low- and middle-income countries examining the relative economic status of households with and without a member with a mental health problem. The aim of the study was to explore the socio-economic status of households with a person with severe mental disorder (SMD; psychosis or bipolar disorder) or depression compared to households without an affected person. Methods A population-based, comparative, cross-sectional household survey was conducted in Sodo district, south Ethiopia, between January and November 2015. Two samples were recruited, each with its own comparison group. Sample (1): households of 290 community-ascertained persons with a clinician-confirmed diagnosis of SMD and a comparison group of 289 households without a person with SMD. Sample (2): households of 128 people who attended the primary health care centre and who were identified by primary care staff as having a probable diagnosis of depressive disorder; and comparison households of 129 patients who attended for other reasons and who did not receive a diagnosis of depression. Household socioeconomic status (household income, consumption and asset-based wealth) was assessed using a contextualized version of theWorld Health Organization (WHO) Study on global Ageing and adult health (SAGE) questionnaire. Each disorder group (SMD and depression) was further divided into higher and lower disability groups on the basis of median score on the WHO Disability Assessment Schedule. Results Households of a person with SMD who had higher disability were more likely to have a poorer living standard (no toilet facility; p < 0.001). Having a reliable source of regular income was significantly lower in households of a person with SMD (p = 0.008) or depression (p = 0.046) with higher disability than the comparison group. Households of persons with SMD with higher disability earned less (p = 0.005) and owned significantly fewer assets (p < 0.001) than households without SMD. Households including persons with depression who had higher disability had lower income (p = 0.042) and reduced consumption (p = 0.048). Conclusions Households with a member who had either SMD or depression were socioeconomically disadvantaged compared to the general population. Moreover, higher disability was associated with worse socio-economic disadvantage. Prospective studies are needed to determine the direction of association. This study indicates a need to consider households of people with SMD or depression as a vulnerable group requiring economic support alongside access to evidence-based mental healthcare

Catastrophic health expenditure and impoverishment in households of persons with depression: a cross-sectional, comparative study in rural Ethiopia

Abstract Background The extent of catastrophic health expenditure and impoverishment associated with depression in low-and middle-income countries is not known. The aim of this study was to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) health expenditure, level of impoverishment and coping strategies used by households of persons with and without depression in a rural Ethiopian district. Methods A comparative cross-sectional survey was conducted, including 128 households of persons with depression and 129 households without. Depression screening was conducted using the Patient Health Questionnaire, nine item version (PHQ-9). People in the depression group were classified into high and low disability groups based on the median value on the World Health Organization Disability Assessment Schedule (WHODAS) polytomous summary score. Health expenditure greater than thresholds of 10 and 25% of total household consumption was used for the primary analyses. The poverty headcount, poverty gap and normalized poverty gap were estimated using retrospective recall of total household expenditure pre- and post-OOP payments for health care. Linear probability model using binreg command in STATA with rr option was used to estimate risk ratio for the occurrence of outcomes among households with and without depression based on level of disability. Results Catastrophic OOP payments at any threshold level for households with depression and high disability were higher than control households. At the 10% threshold level, 24.0% of households of persons with depression and high disability faced catastrophic payments compared with 15.3% for depression and low disability and 12.1% for control households (p = 0.041). Depression and high disability level was an independent predictor of catastrophic OOP payments: RR 2.1; 95% CI:1.1, 4.6. An estimated 5.8% of households of persons with depression and high disability were pushed into poverty because of paying for health care compared with 3.5% for households of persons with depression and low disability and 2.3% for control households (p = 0.039). Conclusions Households of people with depression and high disability were more likely to face catastrophic expenditures and impoverishment from OOP payments. Financial protection interventions through prepayment schemes, exemptions and fee waiver strategies need to target households of persons with depression

Integrated care for people with long-term mental and physical conditions in low- and middle-income countries: narrative review

Integrated care is defined as health services that are managed and delivered so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, coordinated across the different levels and sites of care within and beyond the health sector and, according to their needs, throughout the life course. This narrative review paper aims to describe the most relevant concepts and models of integrated care for people with chronic (or recurring) mental illness and comorbid physical health conditions, to assess the strength of evidence base for these models in high income countries (HICs) and in low- and middle-income countries (LMICs) through a conceptual overview and a structured narrative review, and to identify opportunities to further test the feasibility and impact of such integrated care models. The results of the review are presented in terms of; (i) the rationale for integrating care for people with mental disorders into chronic care; (ii) models of integrated care; (iii) evidence of the effects of integrating care in HICs and in LMICs; (iv) the key organisational challenges in LMICs to implement integrated chronic care; and (v) practical steps to realise a vision of integrated care in the future

Description of the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program: a methodological overview

Cross-cultural adaptation is an important part of using validated questionnaires across countries and settings. Here we describe the cross-cultural process adopted in the STRiDE (STrengthening Responses to dementia in DEveloping countries) program. We adopted a cross-cultural adaptation process including forward translation, back translations, and cognitive interviews of the STRiDE toolkit. In total, 50 older adults and 41 carers across sites in Indonesia and South Africa participated in cognitive interviews; field notes and verbatim quotes are reported. We describe the cross-cultural adaptation process of the STRiDE toolkit. During the process, issues were identified with the translated toolkit, including aspects related to cultural appropriateness, terminology equivalence, and timings. The data demonstrate that a rigorous, yet pragmatic, cross-cultural adaptation process can be achieved even with limited resources. Our process should help the design and conduct of future dementia research in various contexts

Sustainable financing options for mental health care in South Africa:Findings from a situation analysis and key informant interviews

Background With the implicit neglect for the integration of mental health services into general health service development in South Africa, there is an urgent need for an understanding of the ways in which existing reforms may be leveraged to incorporate the objectives of the National Mental Health Policy Framework and Strategic Plan (MHPF) and the mechanisms by which these reforms can be structured and financed in the context of fiscal constraint. Methods A situational analysis guided by a newly developed analytical framework for sustainable mental health financing was conducted. The review was followed by qualitative, indepth interviews with a range of expert national stakeholders. Results Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing include: increased decentralization of resources to primary and community mental health services; active integration of mental health into ongoing NHI implementation including expanding the mandate of District hospitals and drawing on the private sector; submission of costed budget bids to support a mental health conditional grant and ensuring that explicit outcomes and deliverables are in place to monitor Provincial implementation. Conclusion This paper has suggested several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, revealing critical opportunities for mental health service scale-up to be embedded in South Africa’s future health delivery strategy. The realization of a conditional grant for mental health will require technical expertise to cost existing services towards the development of an investment case for mental health service scale-up nationally, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, the NHI benefit package must be expanded to include comprehensive mental health services at all levels. Explicit results-based financing mechanisms within the NHI Fund must also be incorporated for mental health to incentivise quality of care. Private providers engaged by the NHI must commit to make use of evidence-based mental health interventions

The household economic costs associated with depression symptoms:A cross-sectional household study conducted in the North West province of South Africa

AimThe aim of this study was to assess the association between depression symptom severity and household income, consumption, asset-based wealth, debt and use of distress financing strategies, to understand how depression symptom severity and household economic welfare are related.MethodsA household survey was administered to the households of primary health clinic-attenders who were screened for depression symptoms using the 9-item Patient Health Questionnaire in the chronic care units of four primary health clinics in the North West province of South Africa. Univariate and multivariable regression models were used to assess whether a range of household economic measures were significant predictors of depression symptom severity; and whether depression symptom severity significantly predicted changes to household economic welfare, across a number of different economic measures using both multiple linear regression and logistic regression analyses.ResultsOn univariate analysis, certain characteristics were associated with significantly worse (higher) PHQ-9 scores, namely: households in which the household head was younger, female, and unmarried; households in which the indexed patient was younger, and did not receive an education beyond primary school; increasing household size, receipt of a social grant, households living in housing constructed of metal sheet walls and households making use of a public tap as their primary water source. In addition, univariate analysis demonstrated that higher log-transformed food expenditure, lower log-transformed capacity to pay, the presence of household debt and both reducing the size or frequency of meals and drawing up retail shop accounts in response to financial distress over the past three years were associated with significantly worse (higher) PHQ-9 scores. Multivariable analysis demonstrated that larger household sizes (pConclusionsThis study is the first of its kind in South Africa, identifying household economic factors associated with increased depression symptom severity on a continuum; and demonstrating that financial risk protection efforts are needed across this continuum. The study demonstrates that the relationship between poverty and mental health extends beyond the individual to affect household economic functioning. These findings must be included in policy considerations to achieve effective protection for vulnerable households facing the interaction of depression and adverse economic circumstances