A critical assessment of the quality of decentralised primary health care services in the cape metro district of the Western Cape

Magister Administrationis - MAdminThe complex and multi-facet decentralisation process of Primary Health Care services in the Cape Metro District of the Western Cape will be critically assessed in this thesis. Primary Health Care is the provision of promotive; preventative; curative and rehabilitative services within the community setting. South Africa initially adopted the Primary Health Care strategy in 1978 as a member state of the World Health Organisation but this was during the Apartheid regime which did very little about implementing the strategy. In 1994 the Government of National Unity (GNU) came into power and there was a renewed commitment to implementing Primary Health Care in order to render health care services to the previously underprivileged masses. The GNU set an eight year time frame for the full implementation of this process from the date of commitment. Now more than ten years later an assessment of the process is necessary to determine if the objectives of the process has been achieved. An independent organisation such as the Health System Trust has in 1998 and 2003 provided some form of evaluation of the process and this will also be discussed in thesis. The District Health system is part of a unitary Provincial Health System that is decentralised to enable the centre (Provincial Management) and the periphery (District and Sub-district Management) to function more effectively and cooperatively. The District Health System is the management structure for primary health care services as this system allows for interaction of all the role-players involved in delivering health care at district level as it puts in place a decentralised Health Management team who is responsible for the planning, managing, implementing and monitoring of the Primary Health Care Package of care at district level. In summary the district is the place where community needs and national priorities are reconciled. This thesis will therefore show the disjuncture that exists between the Primary Health Care policy intent, the policy implementation and the service delivery outcomes on the ground level. The general objective is to do a critical assessment of the Quality of Decentralised Primary Health Care Services in the Cape Metro District of the Western Cape. More specific objectives for the research include: Defining and discussing the Primary Health Care Approach and the District Health System using the target indicators currently used by the City of Cape Town and the Provincial government of the Western Cape Health department to assess the impact of this process. To document the implementation process of the District Health System in the Cape Town Metro District as a case study while analysing the findings in terms of successes, constraints, challenges; and make recommendations for the way forward. The methodology of the study is of a qualitative and descriptive nature. The research design is a case study of the Cape Metro District. The target population will be all those accessing primary health care services in this district. The sample technique is selected by convenience. Data will be gathered directly and indirectly by doing observation and semi – structured interviews and the administration of questionnaires. The framework criteria for assessing the quality would for example include key indicators such as for example the ratio of Professional Nurse to patient; number of health services per three kilometre radius as per the Comprehensive Service Plan 2007 goals and the availability of essential drugs as per primary health care protocol. This directly relates to the key elements that underpin the District Health System namely: equity, access, quality, effectiveness, efficiency, sustainability, overcoming fragmentation, intersectoral approach and community participation. The main findings indicate that not enough resources have been allocated to the decentralising process causing much delay in its implementation. Shortages of health professionals, infrastructure constraints and poor adherence to legislation also contribute to the delay in implementation. This is why to date the four health districts of the Cape Town Metro District is not fully functional and the quality of the service they provide do not fully adhere to the 2010 Health Care Plan Model

Antiretroviral treatment uptake in patients with HIV-associated TB attending co-located TB and ART services

Background. Delivery of integrated care for patients with HIV-associated TB is challenging. We assessed the uptake and timing of antiretroviral treatment (ART) among eligible patients attending a primary care service with co-located ART and TB clinics. Methods. In a retrospective cohort study, all HIV-associated TB patients (≥18 years old) who commenced TB treatment in 2010 were included. Data were analysed using basic descriptive statistics and log-binomial regression analysis. Results. Of a total of 497 patients diagnosed with HIV-associated TB, 274 were eligible to start ART for the first time (median CD4 count, 159 cells/µl). ART was started during TB treatment by 220 (80.3%) patients. Among the 54 (19.7%) who did not start ART, 23 (42.6%) were either lost to follow-up (LTFU) or died before enrolling for ART; 12 (22.2%) were either LTFU or died after enrolling but before starting ART; 5 (9.3%) were transferred out; and 14 (25.9%) only started ART after completion of TB treatment. The median delay between starting TB treatment and starting ART was 51 days (IQR 29 - 77). Overall, only 58.6% of patients started ART within 8 weeks of TB treatment, and 12.7% of those with CD4 count

Baseline CD4 Count and Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis.

BACKGROUND: In light of recent changes to antiretroviral treatment (ART) guidelines of the World Health Organization and ongoing concerns about adherence with earlier initiation of ART, we conducted a systematic review of published literature to review the association between baseline (pre-ART initiation) CD4 count and ART adherence among adults enrolled in ART programs worldwide. METHODS: We performed a systematic search of English language original studies published between January 1, 2004 and September 30, 2015 using Medline, Web of Science, LILACS, AIM, IMEMR, and WPIMR databases. We calculated the odds of being adherent at higher CD4 count compared with lower CD4 count according to study definitions and pooled data using random effects models. RESULTS: Twenty-eight articles were included in the review and 18 in the meta-analysis. The odds of being adherent was marginally lower for patients in the higher CD4 count group (pooled odds ratio, 0.90; 95% confidence interval, 0.84 to 0.96); however, the majority of studies found no difference in the odds of adherence when comparing CD4 count strata. In analyses restricted to comparisons above and below a CD4 count of 500 cells per microliter, there was no difference in adherence (pooled odds ratio, 1.01; 95% confidence interval: 0.97 to 1.05). CONCLUSIONS: This review was unable to find consistent evidence of differences in adherence according to baseline CD4 count. Although this is encouraging for the new recommendations to treat all HIV-positive individuals irrespective of CD4 count, there is a need for additional high-quality studies, particularly among adults initiating ART at higher CD4 cell counts

Antiretroviral treatment uptake in patients with HIV-associated TB attending co-located TB and ART services.

BACKGROUND: Delivery of integrated care for patients with HIV-associated TB is challenging. We assessed the uptake and timing of antiretroviral treatment (ART) among eligible patients attending a primary care service with co-located ART and TB clinics. METHODS: In a retrospective cohort study, all HIV-associated TB patients (≥18 years old) who commenced TB treatment in 2010 were included. Data were analysed using basic descriptive statistics and log-binomial regression analysis. RESULTS: Of a total of 497 patients diagnosed with HIV-associated TB, 274 were eligible to start ART for the first time (median CD4 count, 159 cells/µl). ART was started during TB treatment by 220 (80.3%) patients. Among the 54 (19.7%) who did not start ART, 23 (42.6%) were either lost to follow-up (LTFU) or died before enrolling for ART; 12 (22.2%) were either LTFU or died after enrolling but before starting ART; 5 (9.3%) were transferred out; and 14 (25.9%) only started ART after completion of TB treatment. The median delay between starting TB treatment and starting ART was 51 days (IQR 29 - 77). Overall, only 58.6% of patients started ART within 8 weeks of TB treatment, and 12.7% of those with CD4 counts <50 cells/µl started ART within 2 weeks. CONCLUSIONS: In a setting with co-located TB and ART clinics, delays to starting ART were substantial, and one-fifth of eligible patients did not start ART during TB treatment. Co-location of services alone is insufficient to permit timely initiation of ART; further measures need to be implemented to facilitate integrated treatment

Motivating people living with HIV to initiate antiretroviral treatment outside national guidelines in three clinics in the HPTN 071 (PopART) trial, South Africa

Background: The HPTN 071 (PopART) trial implemented universal test and treat (UTT) in three clinics in the Western Cape, South Africa at a time when antiretroviral treatment (ART) was only offered by CD4 threshold and World Health Organization clinical staging. This required a concomitant shift in the way health workers communicated ART initiation messages. We provide insight into front-line ART initiation communication pre-national policy shift.Method: The design of this study was exploratory with a case descriptive analysis of ART initiation in three clinics. To characterise their demographic profiles, we reviewed 134 randomly selected patient clinical folders of people who initiated ART at CD4 counts greater than the recommended standard. Further, we conducted 12 key informant interviews with health workers at these facilities and thematically analysed health workers’ responses.Results: The median age of patients initiating ART regardless of CD4 count (above the threshold level) was 33 years and most were women (73.9%), married (76.1%), and unemployed (48.5%). The median CD4 count of patients initiating outside guidelines was 566.5 cells/µl. Contrary to expectations, key informants indicated no radical shift in messaging to explain ART initiation regardless of CD4 count. Rather, they encouraged people living with HIV (PLHIV) to initiate ART while they still “feel well”. The reduced risk of onward HIV transmission did not factor significantly in how health workers motivated clients.Conclusion: Motivating PLHIV to initiate ART regardless of CD4 count in high burden settings is possible. However, there are still opportunities to improve messaging about immediate ART initiation or at high CD4 counts for the prevention of onward transmission. Keywords: ART initiation, immediate ART, treatment as prevention, universal testing and treatment (UTT