How well do we teach the primary healthcare approach? A case study of health sciences course documents, educators and students at the University of Cape Town Faculty of Health Sciences

Background. The comprehensive primary healthcare (PHC) approach has been a lead theme in the University of Cape Town Faculty of Health Sciences(FHS) since 1994. A 2014 institutional academic review recommended that indicators be developed for monitoring and evaluating the PHC theme.Objective. To evaluate PHC teaching and learning of final-year health and rehabilitation sciences and medical students at three community-based education (CBE) sites of the faculty, two in Cape Town and one in a distant and largely rural district.Methods. Course documents were analysed for evidence and alignment of nine indicators of the PHC approach in the documented  learning outcomes, activities and assessments of final-year health sciences students. Clinical educators and students were interviewed to identify factors that facilitate or impede PHC teaching and learning on site.Results. Final-year health sciences disciplines engage inconsistently with PHC principles at the CBE sites. Alignment appears to be  strongest between learning outcomes and teaching activities, but the available data are insufficient to judge whether there is also strong alignment between outcomes and teaching, and formal graded assessment. PHC teaching and learning at the CBE sites are facilitated by good multiprofessional teamwork, educator rolemodelling and good infrastructural and logistical support. Language barriers, staff shortages and high workloads are significant and prevalent barriers.Conclusion. Strong faculty leadership is required to promote the PHC lead theme and to achieve better departmental and  multiprofessional collaboration in teaching the PHC approach. This study provides evidence from well-established CBE sites to inform future work and participatory action research in promoting the PHC approach in teaching and learning in the FHS

Developing indicators for monitoring and evaluating the primary healthcare approach in health sciences education at the University of Cape Town, South Africa, using a Delphi technique

Background. The Faculty of Health Sciences (FHS), University of Cape Town (UCT) adopted the primary healthcare (PHC) approach as its lead theme for teaching, research and clinical service in 1994. A PHC working group was set up in 2017 to build consensus on indicators to monitor and evaluate the PHC approach in health sciences education in the FHS, UCT. Objective. To develop a set of indicators through a Delphi technique for monitoring and evaluating the PHC approach in health sciences curricula in the FHS, UCT. Methods. A national multidisciplinary Delphi panel was presented with 61 indicators of social accountability from the international Training for Health Equity Network (THEnet) for scoring in round 1. Nineteen PHC indicators, derived from a mnemonic used in the FHS, UCT for teaching core PHC principles, were added in round 2 to the 20 highest ranked THEnet indicators from round 1, on recommendation of the panel. Scoring criteria used were relevance (in both rounds), feasibility/measurability (round 1 only) and application of the PHC indicators to undergraduate and postgraduate teaching and assessment (round 2 only). Results. Of the 39 indicators presented in the second round, 11 had an overall relevance score >85% based on the responses of 16 of 20 panellists (80% response rate). These 11 indicators have been grouped by learner needs (safety of learners – 88%, teaching is appropriate to learners’ needs and context – 86%); healthcare user needs (continuity of care – 94%, holistic understanding of healthcare – 88%, respecting human rights – 88%, providing accessible care to all – 88%, providing care that is acceptable to users and their families – 87%, providing evidence-based care – 87%); and community needs (promoting health through health education – 88%, education programme reflects communities’ needs – 86%, teaching embodies social accountability – 86%). Conclusion. The selected indicators reflect priorities relevant to the FHS, UCT and are measurable and applicable to undergraduate and postgraduate curricula. They provided the basis for a case study of teaching the PHC approach to our undergraduate students

Adherence to Drug-Refill Is a Useful Early Warning Indicator of Virologic and Immunologic Failure among HIV Patients on First-Line ART in South Africa

Affordable strategies to prevent treatment failure on first-line regimens among HIV patients are essential for the long-term success of antiretroviral therapy (ART) in sub-Saharan Africa. WHO recommends using routinely collected data such as adherence to drug-refill visits as early warning indicators. We examined the association between adherence to drug-refill visits and long-term virologic and immunologic failure among non-nucleoside reverse transcriptase inhibitor (NNRTI) recipients in South Africa.In 2008, 456 patients on NNRTI-based ART for a median of 44 months (range 12-99 months; 1,510 person-years) were enrolled in a retrospective cohort study in Soweto. Charts were reviewed for clinical characteristics before and during ART. Multivariable logistic regression and Kaplan-Meier survival analysis assessed associations with virologic (two repeated VL>50 copies/ml) and immunologic failure (as defined by WHO).After a median of 15 months on ART, 19% (n = 88) and 19% (n = 87) had failed virologically and immunologically respectively. A cumulative adherence of <95% to drug-refill visits was significantly associated with both virologic and immunologic failure (p<0.01). In the final multivariable model, risk factors for virologic failure were incomplete adherence (OR 2.8, 95%CI 1.2-6.7), and previous exposure to single-dose nevirapine or any other antiretrovirals (adj. OR 2.1, 95%CI 1.2-3.9), adjusted for age and sex. In Kaplan-Meier analysis, the virologic failure rate by month 48 was 19% vs. 37% among adherent and non-adherent patients respectively (logrank p value = 0.02).One in five failed virologically after a median of 15 months on ART. Adherence to drug-refill visits works as an early warning indicator for both virologic and immunologic failure

Treatment Interruption and Variation in Tablet Taking Behaviour Result in Viral Failure: A Case-Control Study from Cape Town, South Africa

BACKGROUND: Understanding of the impact of non-structured treatment interruption (TI) and variation in tablet-taking on failure of first-line antiretroviral therapy (ART) is limited in a resource-poor setting. METHODS: A retrospective matched case-control analysis. Individuals failing ART were matched by time on ART with 4 controls. Viral load (VL) and CD4 count were completed 4-monthly. Adherence percentages, from tablet returns, were calculated 4-monthly (interval) and from ART start (cumulative). Variation between intervals and TI (>27 days off ART) were recorded. Conditional multivariate logistic regression analysis was performed to estimate the effect of cumulative adherence 10% and TI on virological failure. Age, gender, baseline log VL and CD4 were included as possible confounders in the multivariate model. RESULTS: 244 patients (44 cases, 200 controls) were included. Median age was 32 years (IQR28-37), baseline CD4 108 cells/mm3 (IQR56-151), VL 4.82 log (IQR4.48-5.23). 94% (96% controls, 86% failures) had cumulative adherence >90%. The odds of failure increased 3 times (aOR 3.01, 95%CI 0.81-11.21) in individuals with cumulative adherence 10% and 4.01 times (aOR 4.01, 95%CI 1.45-11.10) in individuals with TIs. For individuals with TI and cumulative adherence >95%, the odds of failing were 5.65 (CI 1.40-22.85). CONCLUSION: It is well known that poor cumulative adherence increases risk of virological failure, but less well understood that TI and variations in tablet-taking also play a key role, despite otherwise excellent adherence

Achieving universal health coverage in sub-Saharan Africa: the role of leadership development

Countries world-wide are striving towards Universal Health Coverage (UHC). Financial resources are extremely limited in developing countries and many developing countries are in the midst of multiple interconnected social, economic, epidemiologic, demographic, technological, institutional, environmental and political transitions. According to the World Health Organization (WHO), accelerating progress towards UHC in Africa will require strong leadership. At the recent Global Conference on Primary Health Care (PHC), the Astana Declaration, the world recommitted to comprehensive Primary Health Care as a keystone of Universal Health Coverage. There is evidence that PHC works. Countries that followed the Alma Ata PHC principles have demonstrated population health outcomes and reduced inequalities at low costs as seen in Chile, Cuba, Ethiopia and Rwanda. What seems to be missing is leadership to apply and uphold these PHC principles. There is consensus that if Astana is to be realized, strong political, economic, education, health, science, institutional, and community leaders are needed to make PHC work this time around. Governments and leaders in Africa have been conveying a constant message, that those leading and managing health systems are not sufficiently prepared to succeed in leadership roles they now occupy. Africa has had different leaders with the same results for decades. Leadership development efforts made to date seem not to be producing desired results. Students taken out of Africa to be trained in leadership at western universities, seem to go back home and carry on as usual. Many students have been taken to the West for education, developed great visions and ideas of how they can transfer knowledge learnt, got home and got swallowed by the system. Pumping more money into a health system with no leadership development will not help us achieve ‘Health for All’ in sub-Saharan Africa. How can accountable leadership with a sense of consciousness for social justice be developed successfully in these contexts? If leadership is key for Universal Health Coverage to be achieved in sub-Saharan Africa, is it not high time attention is paid to leadership development approaches