Health policy and integrated mental health care in the SADC region : strategic clarification using the Rainbow Model

Background: Mental illness is a well-known challenge to global development, particularly in low-to-middle income countries. A key health systems response to mental illness is different models of integrated health care, especially popular in the South African Development Community (SADC) region. This complex construct is often not well-defined in health policy, hampering implementation efforts. A key development in this vein has been the Rainbow Model of integrated care, a comprehensive framework and taxonomy of integrated care based on the integrative functions of primary care. The purpose of this study was to explore the nature and strategic forms of integrated mental health care in selected SADC countries, specifically how integrated care is outlined in state-driven policies. Methods: Health policies from five SADC countries were analysed using the Rainbow Model as framework. Electronic copies of policy documents were transferred into NVivo 10, which aided in the framework analysis on the different types of integrated mental health care promoted in the countries assessed. Results: Several Rainbow Model components were emphasised. Clinical integration strategies (coordination of person-focused care) such as centrality of client needs, case management and continuity were central considerations, while others such as patient education and client satisfaction were largely lacking. Professional integration (inter-professional partnerships) was mentioned in terms of agreements on interdisciplinary collaboration and performance management, while organisational integration (inter-organisational relationships) emerged under the guise of inter-organisational governance, population needs and interest management. Among others, available resources, population management and stakeholder management fed into system integration strategies (horizontally and vertically integrated systems), while functional integration strategies (financial, management and information system functions) included human resource, information and resource management. Normative integration (a common frame of reference) included collective attitude, sense of urgency, and linking cultures, though aspects such as conflict management, quality features of the informal collaboration, and trust were largely lacking. Conclusions: Most countries stressed the importance of integrating mental health on primary healthcare level, though an absence of supporting strategies could prove to bar implementation. Inter-service collaboration emerged as a significant goal, though a lack of (especially) normative integration dimensions could prove to be a key omission. Despite the usefulness of the Rainbow Model, it failed to adequately frame regional governance aspects of integration, as the SADC Secretariat could play an important role in coordinating and supporting the development and strengthening of better mental health systems

Governance and power in mental health integration processes in South Africa

On the back of centuries of scholarship, mental illness remains a deeply political challenge in modern societies. Although much headway has been made in researching mental health service provision in low-to-middle income countries, a distinct gap exists in understanding the crucial roles of governance and power in care provision. Concerning integrated care, understanding the relations among state and non-state entities is paramount. This doctoral study sought to explore how power relations shape the governance of integrated mental health care in South Africa. More specifically, the purpose was to illuminate the dimensions and structure of integrated mental health care; to describe referral and collaborative ties in a service provider network; and to examine the relations between state and non-state mental health service providers. A pragmatic, theory driven case study was undertaken in Mangaung Metropolitan District, Free State province, South Africa, employing multiple methodologies. The macro contexts of integrated mental health care were explored by means of a framework analysis of health policy, while the case study employed social network analysis and semi-structured interviews with key stakeholders. The findings suggested that integrated mental health care is pursued in South Africa in two ways: 1) by integrating mental health care into primary healthcare, and 2) by fostering collaboration between state and non-state role players. The service delivery network exhibited fragmentation, low density, hospital-centrism and suggestions of significant professional power. Key points of state and non-state collaboration included housing and treatment adherence, though proportional interactions between state and non-state services were lower than interstate service collaboration. Governance-related fragmentation emerged in terms of state and non-state service providers, biomedical and social approaches to care, and departments of health and social development. Gaps in state stewardship included weak strategic leadership and poor information systems. Power emerged in both its mainstream and second stream conceptions, rooted in, for example, professional power, and through an apparent commodification of people living with mental illness. The ambiguities of mental illness were concluded to be an important undercurrent to the dynamics of power that play out in service provision processes. Key policy recommendations focused on improving the following: 1) availability of financial resources; 2) relationships between service providers; 3) overly myopic organisation of government departments; and 4) political relationships between state and non-state partners. Ultimately, the study lays a strong foundation for further research into the mechanisms of power in the governance of mental health care in South Africa

Collaborative mental health care in the bureaucratic field of post-apartheid South Africa

South Africa's long and arduous journey from colonial and apartheid-era care for people with mental illness to more comprehensive, equitable mental health care is well-described. Deeper engagement with the structural power dynamics involved in providing collaborative mental health services are less-well described, especially in its post-apartheid era. This conceptual article positions state and non-state mental health service providers - along with their relationships and conflicts - within Bourdieu's bureaucratic field. It is suggested that key internecine struggles in South Africa's post-apartheid socio-political arena have influenced the ways in which collaborative mental health care is provided. Drawing from two recent examples of conflict within the bureaucratic field, the article illustrates the ways in which neoliberal forces play out in contemporary South Africa's mental health service delivery. Struggles between the state and private healthcare in the Life Esidimeni tragedy receive focus, as well as the shifting of responsibility onto civil society. A court case between the state and a coalition of non-profit organisations provides further evidence that neoliberal rationalities significantly influences the position and power of non-state service providers. Unless serious consideration is given to these dynamics, collaborative mental health care in South Africa will remain out of reach

Tuberculosis infection control practices in a high-burden metro in South Africa : a perpetual bane for efficient primary health care service delivery

Background: Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines. Aim: To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa. Setting: The research was undertaken in a high TB-and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), that among other services also diagnosed TB. Methods: A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa. Results: Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and non-coughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%). Conclusion: All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection

Politics of mental healthcare in post-apartheid South Africa

Recent events in post-apartheid South Africa have exposed a decidedly political dimension to mental healthcare. This was exemplified in three important cases: the recent grants crisis of the South African Social Security Agency, a court case between the state and non-governmental organisations, and the Life Esidimeni tragedy. These events demonstrate that despite significant policy shifts toward basic human rights and care of people living with mental illness, these cases demonstrate the contradictory elements of macroeconomic and health policy exposed a neoliberal tendency towards providing public mental healthcare. In examining these case, key features emerged, including: the commodification of people living with mental illness, the pertinence of auditing, accounting practices, and dynamics of globalisation, de- and re-nationalisation. This article speaks to a tangible gap in the discourse on mental healthcare in South Africa, by highlighting the political dimensions that are involved under an era of neoliberalism

State and non-state mental health service collaboration in a South African district : a mixed methods study

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Unpacking the dynamics of double stigma : how the HIV-TB co-epidemic alters TB stigma and its management among healthcare workers

Background HIV and tuberculosis (TB) are intricably interlinked in South Africa. The social aspects of this co-epidemic remain relatively unexplored. More specifically, no research has quantitatively explored the double stigma associated with HIV and TB in this context, and more specifically the impact of the co-epidemic on [1] the stigmatisation of TB and [2] the TB stigma mangement strategy of covering (i.e. the use of TB as a cover for having HIV). The current study aims to address this research gap by disentangling the complex mechanisms related to HIV-TB stigma. Methods Using Structural Equation Modelling (SEM), data of 882 health care workers (HCWs) in the Free State province, South Africa, are analysed to investigate the link between the stigmatization of HIV and TB and the stigma management by those affected. The current study focuses on health care workers (HCWs), as both TB and HIV have a severe impact on this professional group. Results The results demonstrate that the perceived link between the epidemics is significantly associated with double HIV-TB stigmatization. Furthermore, the link between the illnesses and the double stigma are driving the stigmatization of TB. Finally, the link between HIV and TB as well as the stigmatization of both diseases by colleagues are associated with an increased use of covering as a stigma management strategy. Conclusions This is the first quantitative study disentagling the mediating role of double stigma in the context of the co-epidemic as well as the impact of the co-epidemic on the social connotations of TB. The results stress the need for an integrated approach in the fight against HIV and TB recognizing the intertwined nature of the co-epidemic, not only in medical-clinical terms, but also in its social consequences

Applying learning health systems thinking in codeveloping integrated tuberculosis interventions in the contexts of COVID-19

The COVID-19 pandemic reversed much of global progress made in combatting tuberculosis, with South Africa experiencing one of the largest impacts on tuberculosis detection. The aim of this paper is to share our experiences in applying learning health systems (LHS) thinking to the codevelopment of an intervention improving an integrated response to COVID-19 and tuberculosis in a South African district. A sequential partially mixed-methods study was undertaken between 2018 and 2021 in the district of Amajuba in KwaZulu-Natal. Here, we report on the formulation of a Theory of Change, codesigning and refining proposed interventions, and piloting and evaluating codesigned interventions in primary healthcare facilities, through an LHS lens. Following the establishment and formalisation of a district Learning Community, diagnostic work and a codevelopment of a theory of change, intervention packages tailored according to pandemic lockdowns were developed, piloted and scaled up. This process illustrates how a community of learning can generate more responsive, localised interventions, and suggests that the establishment of a shared space of research governance can provide a degree of resilience to facilitate adaption to external shocks. Four main lessons have been gleaned from our experience in adopting an LHS approach in a South African district, which are (1) the importance of building and sustaining relationships, (2) the utility of colearning, coproduction and adaptive capacity, (3) the centrality of theory-driven systems strengthening and (4) reflections on LHS as a framework

Factors associated with good TB infection control practices among primary healthcare workers in the Free State Province, South Africa

Abstract Background Despite the availability of TB infection control guidelines, and good levels of healthcare worker knowledge about infection control, often these measures are not well implemented. This study sought to determine the factors associated with healthcare workers’ good TB infection control practices in primary health care facilities in the Free State Province, South Africa. Methods A cross-sectional self-administered survey among nurses (n = 202) and facility-based community healthcare workers (n = 34) as well as facility observations were undertaken at all 41 primary health care facilities in a selected district of the Free State Province. Results The majority of respondents were female (n = 200; 87.7 %) and the average age was 44.19 years (standard deviation ±10.82). Good levels of knowledge were recorded, with 42.8 % (n = 101) having an average score (i.e. 65–79 %) and 31.8 % (n = 75) a good score (i.e. ≥ 80 %). Most respondents (n = 189; 80.4 %) had positive attitudes towards TB infection control practices (i.e. ≥ 80 %). While good TB infection control practices were reported by 72.9 % (n = 161) of the respondents (i.e. ≥75 %), observations revealed this to not necessarily be the case. For every unit increase in attitudes, good practices increased 1.090 times (CI:1.016–1.169). Respondents with high levels of knowledge (≥80 %) were 4.029 (CI: 1.550–10.469) times more likely to have good practices when compared to respondents with poor levels of knowledge (<65 %). The study did not find TB/HIV-related training to be a predictor of good practices. Conclusions Positive attitudes and good levels of knowledge regarding TB infection control were the main factors associated with good infection control practices. Although many respondents reported good infection control practices - which was somewhat countered by the observations - there are areas that require attention, particularly those related to administrative controls and the use of personal protective equipment