The role of gender in patient-provider trust for tuberculosis treatment

Background: In South Africa, tuberculosis (TB) is the leading cause of death, and Cape Town is among the three cities in the country with the highest TB burden. Despite implementation of Directly Observed Treatment Short-Course (DOTS), and improvements in the organisation and delivery of TB care, poor treatment adherence challenges treatment outcomes and the health system's ability to reach international targets. TB requires long-term care, where the relationship with healthcare providers is one of the important influences on decisions to seek care and adhere to treatment. This study sought to explore and deepen insight into how trust is built and experienced between patients and healthcare providers for TB treatment in primary care settings from a gender perspective. Methods: The research was located in three local government-managed clinics in the City of Cape Town's Metropole health district, similar in TB patient load and performance indicators, but differing in level of TB-HIV integrated services. A case study design employing qualitative data collection approaches (non-participant observations in clinics, focus group discussions and in-depth interviews with patients and providers) was applied. Findings: Trust plays a central role for both patients and providers in treatment for TB. On the part of patients, many expressed a deep desire and motivation to complete their treatment. However, patient vulnerability, a complex outcome of intersecting factors at all levels (personal, community and health service level), across which gender was an underlying influence, emerged as a critical influence over patient trust in providers and the health system, with consequences for a range of outcomes including treatment adherence. The ability of providers and the health system as an institution to recognise and respond to patient vulnerability and needs beyond the illness, including to access socio-economic and psycho-social support for the patient, was critical for building trust and enabling adherence. On the part of healthcare providers, vulnerability was a consequence of a range of factors, including professional status and gender, with implications for how trust was built in patients and managers and its outcomes. Patient trustworthiness was based on judgements of competency, integrity and recognition. The ability of managers to mitigate the challenges healthcare providers faced, through providing a supportive and enabling work environment, had implications for providers' experiences and judgements of institutional trustworthiness. Conclusion: Reflecting on the findings within broader national, provincial and global health policy reforms, specific strategies for building patient and provider trust in each other, and in the health system, are proposed. Recommended strategies addressing both patient and provider vulnerabilities rooted in the personal, community and health facility environment are considered. While many of the recommendations are specific to the TB and TB/HIV model of care, they have wider relevance for building mutual trust between patients and providers and enhancing the responsiveness of the health system as a whole. This is important in the context of South Africa, where the vision espoused under proposed National Health Insurance reforms towards universal coverage is transformative, even revolutionary, but its implementation and ultimate achievements are likely to be dogged by challenges of patient and provider trust in the health system, unless themselves addressed. Globally, the study's conclusions also offer important insights about patient-provider trust relevant to health system development, as well as ideas for future, related research

Sexual and reproductive health and rights in changing health systems

UHC’s attractiveness derives from its affirmation of the right to health. However, the assumption that universality will automatically result in equity on the path to Universal Health Care (UHC) is not valid. As well, reaching equity, quality, and accountability in sexual and reproductive health and rights (SRHR) services on the path to UHC is fundamentally a matter of respecting, protecting and fulfilling the human rights of girls and women. The paper argues that achieving equity on the UHC path will require a combination of system improvements and services that benefit all, paying particular attention to gender inequalities and the poor

Rethinking trust in the context of mistreatment of women during childbirth: a neglected focus

[Extract] The mistreatment of women during childbirth is a global phenomenon.1 Mistreatment includes physical and verbal abuse, violations of privacy, stigma and discrimination, and neglect and abandonment. To date, much of the focus has been on measuring this phenomenon and the interpersonal relationships between women and health workers and the role of and abuse of power by these workers.2 However, more recently, there have been increasing calls for widening the lens on underlying drivers of mistreatment of women during childbirth to include the considerations of social, gender and economic inequalities,3 and systemic failures both at health facility and the health system levels.1 4 5 This recognition and renewed attention on the wider social, economic and political systems in which health systems are embedded is important for two reasons. First, while much of the mistreatment is often carried out by health workers and especially those at the frontline, it is important to recognise that many of these health workers are located lower in the organisational hierarchy, themselves overworked and abused in under-resourced and poorly supervised environments and overall dysfunctional health systems.6–9 This recognition has underpinned nascent investigation of the role of workplace and institutional trust in some settings.10–1

Employment based health financing does not support gender equity in universal health coverage

Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Health financing and entitlement systems linked to employment can disadvantage women, argue Lavanya Vijayasingham and colleaguesOpen access fees were paid by the UN University-International Institute for Global Healthhttps://doi.org/10.1136/bmj.m3384371pubpu

Organisational culture and trust as influences over the implementation of equity-oriented policy in two South African case study hospitals

BACKGROUND: This paper uses the concepts of organisational culture and organisational trust to explore the implementation of equity-oriented policies - the Uniform Patient Fee Schedule (UPFS) and Patients' Rights Charter (PRC) - in two South African district hospitals. It contributes to the small literatures on organisational culture and trust in low- and middle-income country health systems, and broader work on health systems' people-centeredness and "software". METHODS: The research entailed semi-structured interviews (Hospital A n = 115, Hospital B n = 80) with provincial, regional, district and hospital managers, as well as clinical and non-clinical hospital staff, hospital board members, and patients; observations of policy implementation, organisational functioning, staff interactions and patient-provider interactions; and structured surveys operationalising the Competing Values Framework for measuring organisational culture (Hospital A n = 155, Hospital B n = 77) and Organisational Trust Inventory (Hospital A n = 185, Hospital B n = 92) for assessing staff-manager trust. RESULTS: Regarding the UPFS, the hospitals' implementation approaches were similar in that both primarily understood it to be about revenue generation, granting fee exemptions was not a major focus, and considerable activity, facility management support, and provincial support was mobilised behind the UPFS. The hospitals' PRC paths diverged quite significantly, as Hospital A was more explicit in communicating and implementing the PRC, while the policy also enjoyed stronger managerial support in Hospital A than Hospital B. Beneath these experiences lie differences in how people's values, decisions and relationships influence health system functioning and in how the nature of policies, culture, trust and power dynamics can combine to create enabling or disabling micro-level implementation environments. CONCLUSIONS: Achieving equity in practice requires managers to take account of "unseen" but important factors such as organisational culture and trust, which are key aspects of the organisational context that can profoundly influence policies. In addition to implementation "hardware" such as putting in place necessary staff and resources, it emphasises "software" implementation tasks such as relationship management and the negotiation of values, where equity-oriented policies might be interpreted as challenging health workers' status and values, and paying careful attention to how policies are practically framed and translated into practice, to ensure key equity aspects are not neglected

Out-of-pocket payments, health care access and utilisation in south-eastern Nigeria: a gender perspective

Out-of-pocket (OOP) payments have severe consequences for health care access and utilisation and are especially catastrophic for the poor. Although women comprise the majority of the poor in Nigeria and globally, the implications of OOP payments for health care access from a gender perspective have received little attention. This study seeks to fill this gap by using a combination of quantitative and qualitative analysis to investigate the gendered impact of OOPs on healthcare utilisation in south-eastern Nigeria. 411 households were surveyed and six single-sex Focus Group Discussions conducted. This study confirmed the socioeconomic and demographic vulnerability of female-headed households (FHHs), which contributed to gender-based inter-household differences in healthcare access, cost burden, choices of healthcare providers, methods of funding healthcare and coping strategies. FHHs had higher cost burdens from seeking care and untreated morbidity than male-headed households (MHHs) with affordability as a reason for not seeking care. There is also a high utilisation of patent medicine vendors (PMVs) by both households (PMVs are drug vendors that are unregulated, likely to offer very low-quality treatment and do not have trained personnel). OOP payment was predominantly the means of healthcare payment for both households, and households spoke of the difficulties associated with repaying health-related debt with implications for the medical poverty trap. It is recommended that the removal of user fees, introduction of prepayment schemes, and regulating PMVs be considered to improve access and provide protection against debt for FHHs and MHHs. The vulnerability of widows is of special concern and efforts to improve their healthcare access and broader efforts to empower should be encouraged for them and other poor households

Gender differences in experiences of ART services in South Africa: a mixed methods study

Objectives: A mixed methods study exploring gender differences in patient profiles and experiences of ART services, along the access dimensions of availability, affordability and acceptability, in two rural and two urban areas of South Africa. methods Structured exit interviews (n = 1266) combined with in-depth interviews (n = 20) of women and men enrolled in ART care. results Men attending ART services were more likely to be employed (29% vs. 20%, P = 0.001) and were twice as likely to be married ⁄ co-habiting as women (42% vs. 22% P = 0.001). Men had known their HIV status for a shorter time (mean 32 vs. 36 months, P = 0.021) and were also less likely to disclose their status to non-family members (17% vs. 26%, P = 0.001). From both forms of data collection, a key finding was the role of female partners in providing social support and facilitating use of services by men. The converse was true for women who relied more on extended families and friends than on partners for support. Young, unmarried and unemployed men faced the greatest social isolation and difficulty. There were no major gender differences in the health system (supply side) dimensions of access. conclusions Gender differences in experiences of HIV services relate more to social than health system factors. However, the health system could be more responsive by designing services in ways that enable earlier and easier use by men.Web of Scienc

Moving towards universal coverage in South Africa? Lessons from a voluntary government insurance scheme

BackgroundIn 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues.ObjectivesThis study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment.MethodsMulti-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression.ResultsNotwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs.ConclusionBarriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms

Leadership experiences and practices of South African health managers: what is the influence of gender? -a qualitative, exploratory study

Background The importance of strong and transformative leadership is recognised as essential to the building of resilient and responsive health systems. In this regard, Sustainable Development Goals (SDG) 5 prioritises a current gap, by calling for women’s full and effective participation and equal opportunities for leadership, including in the health system. In South Africa, pre-democracy repressive race-based policies, coupled with strong patriarchy, led to women and especially black women, being ‘left behind’ in terms of career development and progression into senior health leadership positions. Methods Given limited prior inquiry into this subject, we conducted a qualitative exploratory study employing case study design, with the individual managers as the cases, to examine the influence of gender on career progression and leadership perceptions and experiences of senior managers in South Africa in five geographical districts, located in two provinces. We explored this through in-depth interviews, including life histories, career pathway mapping and critical incident analysis. The study sample selection was purposive and included 14 female and 5 male senior-managers in district and provincial health departments. Results Our findings suggest that women considerably lag behind their male counterparts in advancing into management- and senior positions. We also found that race strongly intersected with gender in the lived experiences and career pathways of black female managers and in part for some black male managers. Professional hierarchy further compounded the influence of gender and race for black women managers, as doctors, who were frequently male, advanced more rapidly into management and senior management positions, than their female counterparts. Although not widespread, other minority groups, such as male managers in predominantly female departments, also experienced prejudice and marginalisation. Affirmative employment policies, introduced in the new democratic dispensation, addressed this discriminatory legacy and contributed to a number of women being the ‘first’ to occupy senior management positions. In one of the provinces, these pioneering female managers assumed role-modelling and mentoring roles and built strong networks of support for emerging managers. This was aided by an enabling, value-based, organisational culture. Conclusion This study has implications for institutionalising personal and organisational development that recognise and appropriately advances women managers, paying attention to the intersections of gender, race and professional hierarchy. It is important in the context of national and global goals, in particular SDG 5, that women and in particular black women, are prioritised for training and capacity development and ensuring that transformative health system policies and practices recognise and adapt, supporting the multiple social and work roles that managers, in particular women, play

Call to action for health systems integration of point-of-care testing to mitigate the transmission and burden of sexually transmitted infections.

OBJECTIVES: In 2016, WHO estimated 376 million new cases of the four main curable STIs: gonorrhoea, chlamydia, trichomoniasis and syphilis. Further, an estimated 290 million women are infected with human papillomavirus. STIs may lead to severe reproductive health sequelae. Low-income and middle-income countries carry the highest global burden of STIs. A large proportion of urogenital and the vast majority of extragenital non-viral STI cases are asymptomatic. Screening key populations and early and accurate diagnosis are important to provide correct treatment and to control the spread of STIs. This article paints a picture of the state of technology of STI point-of-care testing (POCT) and its implications for health system integration. METHODS: The material for the STI POCT landscape was gathered from publicly available information, published and unpublished reports and prospectuses, and interviews with developers and manufacturers. RESULTS: The development of STI POCT is moving rapidly, and there are much more tests in the pipeline than in 2014, when the first STI POCT landscape analysis was published on the website of WHO. Several of the available tests need to be evaluated independently both in the laboratory and, of particular importance, in different points of care. CONCLUSION: This article reiterates the importance of accurate, rapid and affordable POCT to reach universal health coverage. While highlighting the rapid technical advances in this area, we argue that insufficient attention is being paid to health systems capacity and conditions to ensure the swift and rapid integration of current and future STI POCT. Unless the complexity of health systems, including context, institutions, adoption systems and problem perception, are recognised and mapped, simplistic approaches to policy design and programme implementation will result in poor realisation of intended outcomes and impact