An evaluation of the cervical screening programme in Johannesburg Metro District, Gauteng Province

MMed, Community Medicine, Faculty of Health Sciences, University of the WitwatersrandINTRODUCTION: Cervical cancer continues to be a significant cause of morbidity and mortality, particularly in women in the developing world, due to the lack of effective population screening. It has proven difficult to implement and sustain cytological screening programmes as health systems in these settings are not functional. South Africa has adopted an organised cervical screening programme, and the goal is to screen 70% of women over 30 years nationally, within ten years of initiating the programme. However, it is also necessary to ensure that women with abnormal Pap smears are treated if we are to reduce cervical cancer incidence. Ensuring treatment of abnormal Pap smears is a challenge, and current data on this is needed to inform service delivery. AIM: The study aims to assess the current status of the cervical screening programme in the Johannesburg Metro District, specifically looking at screening coverage, and referral for treatment in women with abnormal Pap smears. METHODOLOGY: Secondary analysis of data in the District Health Information System was done; and registers at a sample of primary health care clinics and their referral colposcopy services were evaluated for the period April 2007 – March 2008. Descriptive statistics were employed to analyse the data. Multivariate analysis was also done to evaluate factors associated with colposcopy attendance. vi RESULTS: Screening coverage for the district was 6.3% for 2008 and the cumulative coverage from 2000 to 2008 was 35.8%, with significant variation between subdistricts. A high proportion (19%) of smears was done in women less than 30 years. Of 557 women with abnormal Pap smears requiring further treatment, 57% were informed of their results and referred, 38% had appointments for colposcopy, and only 28% attended these appointments. Women experienced long waiting times for appointments (up to 15 months), and there was inadequate record keeping and client tracing. HIV status and the sub-district and health authority where women were screened were associated with colposcopy attendance; the referral hospital was associated with length of waiting time between Pap smear and colposcopy. CONCLUSION: Cervical screening coverage is below target, and the referral for diagnosis and treatment remains a challenge. Unless referral and access to colposcopy services is improved, increasing screening coverage will not have an impact on decreasing cervical cancer incidence and mortality. It is hoped that this study will provide the data to target interventions to improve cervical screening coverage and effective referral and treatment in the district

Enhancing Funders’ and Advocates’ Effectiveness: The Processes Shaping Collaborative Advocacy for Health System Accountability in South Africa

This article describes the roles of five advocacy groups that built collaborative initiatives to address the collapsing health system in South Africa. The findings presented are based on retrospective reviews of annual reports, organizational evaluations, interviews, and focus group discussions with each of four participating organizations and existing literature on the fifth. The key findings, for both advocacy groups shaping alliance strategies and for funders, are that flexible funding and a shared value system among groups with diverse capacities, constituencies, and reputational resources is a good approach for enabling adaptive and innovative strategies for holding the public sector accountable

The role of emergent champions in policy implementation for decentralised drug-resistant tuberculosis care in South Africa

Champions are recognised as important to driving organisational change in healthcare quality improvement initiatives in high-income settings. In low-income and middle-income countries with a high disease burden and constrained human resources, their role is highly relevant yet understudied. Within a broader study on policy implementation for decentralised drug-resistant tuberculosis care in South Africa, we characterised the role, strategies and organisational context of emergent policy champions

‘We had to manage what we had on hand, in whatever way we could’: Adaptive responses in policy for decentralized drug-resistant tuberculosis care in South Africa

In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors’ capacity to implement change in resourceconstrained facilities

Comparing a paper based monitoring and evaluation system to a mHealth system to support the national community health worker programme, South Africa: an evaluation

BACKGROUND: In an attempt to address a complex disease burden, including improving progress towards MDGs 4 and 5, South Africa recently introduced a re-engineered Primary Health Care (PHC) strategy, which has led to the development of a national community health worker (CHW) programme. The present study explored the development of a cell phone-based and paper-based monitoring and evaluation (M&E) system to support the work of the CHWs. METHODS: One sub-district in the North West province was identified for the evaluation. One outreach team comprising ten CHWs maintained both the paper forms and mHealth system to record household data on community-based services. A comparative analysis was done to calculate the correspondence between the paper and phone records. A focus group discussion was conducted with the CHWs. Clinical referrals, data accuracy and supervised visits were compared and analysed for the paper and phone systems. RESULTS: Compared to the mHealth system where data accuracy was assured, 40% of the CHWs showed a consistently high level (>90% correspondence) of data transfer accuracy on paper. Overall, there was an improvement over time, and by the fifth month, all CHWs achieved a correspondence of 90% or above between phone and paper data. The most common error that occurred was summing the total number of visits and/or activities across the five household activity indicators. Few supervised home visits were recorded in either system and there was no evidence of the team leader following up on the automatic notifications received on their cell phones. CONCLUSIONS: The evaluation emphasizes the need for regular supervision for both systems and rigorous and ongoing assessments of data quality for the paper system. Formalization of a mHealth M&E system for PHC outreach teams delivering community based services could offer greater accuracy of M&E and enhance supervision systems for CHWs.Web of Scienc

The COVID-19 crisis in South Africa : protecting the vulnerable

As of 3 July 2020, global cases of COVID-19 surpassed 10 million with over half a million deaths in more than 210 countries. South Africa (SA) too reached a milestone last week, recording a total of 100 000 laboratory-confirmed cases and 2 500 deaths since March (as of 7 July 2020, total number of positive cases 215 855, total number of deaths 3 502). The epidemic’s epicentre in the Western Cape, where a major surge has resulted in record hospital bed occupancy rates, is quickly being surpassed by Gauteng in the number of new cases. Similar trends in case numbers are being reported in Eastern Cape Province, stretching valiant healthcare workers in all three provinces. The remaining provinces are likely to follow suit.http://www.samj.org.zaam2021Veterinary Tropical Disease

How to stop public health conferences becoming trade fairs.

Reflecting the new wave of global public health, which now seems to be finally reoriented towards embracing its social mission and responsibilities, the 12th World Congress on Public Health, recently held in Istanbul, dedicated many of its sessions to ethics and the right to health. Indeed, the Congress title, 'Making a Difference in Global Public Health: Education, Research and Practice', sounded like a call to action. But faultless theory and socially responsible state- ments, set out and declared in Istanbul, were accompanied by corporate sponsorship which we see as inappropriate, and sessions that were in conflict with the interests of public health. This commentary reflects the views of a number of participants at the Congress about the corporate influence on public health conferences and, more generally, inap- propriate corporate influence on public health teaching, research and practice

A call to action: Temporal trends of COVID-19 deaths in the South African Muslim community

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Differential in-hospital mortality and intensive care treatment over time: informing hospital pathways for modelling COVID-19 in South Africa

There are limited published data within sub-Saharan Africa describing hospital pathways of COVID-19 patients hospitalized. These data are crucial for the parameterisation of epidemiological and cost models, and for planning purposes for the region. We evaluated COVID-19 hospital admissions from the South African national hospital surveillance system (DATCOV) during the first three COVID-19 waves between May 2020 and August 2021. We describe probabilities and admission into intensive care units (ICU), mechanical ventilation, death, and lengths of stay (LOS) in non-ICU and ICU care in public and private sectors. A log-binomial model was used to quantify mortality risk, ICU treatment and mechanical ventilation between time periods, adjusting for age, sex, comorbidity, health sector and province. There were 342,700 COVID-19-related hospital admissions during the study period. Risk of ICU admission was 16% lower during wave periods (adjusted risk ratio (aRR) 0.84 [0.82–0.86]) compared to between-wave periods. Mechanical ventilation was more likely during a wave overall (aRR 1.18 [1.13–1.23]), but patterns between waves were inconsistent, while mortality risk in non-ICU and ICU were 39% (aRR 1.39 [1.35–1.43]) and 31% (aRR 1.31 [1.27–1.36]) higher during a wave, compared to between-wave periods, respectively. If patients had had the same probability of death during waves vs between-wave periods, we estimated approximately 24% [19%-30%] of deaths (19,600 [15,200–24,000]) would not have occurred over the study period. LOS differed by age (older patients stayed longer), ward type (ICU stays were longer than non-ICU) and death/recovery outcome (time to death was shorter in non-ICU); however, LOS remained similar between time periods. Healthcare capacity constraints as inferred by wave period have a large impact on in-hospital mortality. It is crucial for modelling health systems strain and budgets to consider how input parameters related to hospitalisation change during and between waves, especially in settings with severely constrained resources

The intersection of age, sex, race and socio-economic status in COVID-19 hospital admissions and deaths in South Africa.

Older age, male sex, and non-white race have been reported to be risk factors for COVID-19 mortality. Few studies have explored how these intersecting factors contribute to COVID-19 outcomes. This study aimed to compare demographic characteristics and trends in SARS-CoV-2 admissions and the health care they received. Hospital admission data were collected through DATCOV, an active national COVID-19 surveillance programme. Descriptive analysis was used to compare admissions and deaths by age, sex, race, and health sector as a proxy for socio-economic status. COVID-19 mortality and healthcare utilisation were compared by race using random effect multivariable logistic regression models. On multivariable analysis, black African patients (adjusted OR [aOR] 1.3, 95% confidence interval [CI] 1.2, 1.3), coloured patients (aOR 1.2, 95% CI 1.1, 1.3), and patients of Indian descent (aOR 1.2, 95% CI 1.2, 1.3) had increased risk of in-hospital COVID-19 mortality compared to white patients; and admission in the public health sector (aOR 1.5, 95% CI 1.5, 1.6) was associated with increased risk of mortality compared to those in the private sector. There were higher percentages of COVID-19 hospitalised individuals treated in ICU, ventilated, and treated with supplemental oxygen in the private compared to the public sector. There were increased odds of non-white patients being treated in ICU or ventilated in the private sector, but decreased odds of black African patients being treated in ICU (aOR 0.5; 95% CI 0.4, 0.5) or ventilated (aOR 0.5; 95% CI 0.4, 0.6) compared to white patients in the public sector. These findings demonstrate the importance of collecting and analysing data on race and socio-economic status to ensure that disease control measures address the most vulnerable populations affected by COVID-19.Significance:• These findings demonstrate the importance of collecting data on socio-economic status and race alongside age and sex, to identify the populations most vulnerable to COVID-19.• This study allows a better understanding of the pre-existing inequalities that predispose some groups to poor disease outcomes and yet more limited access to health interventions.• Interventions adapted for the most vulnerable populations are likely to be more effective.• The national government must provide efficient and inclusive non-discriminatory health services, and urgently improve access to ICU, ventilation and oxygen in the public sector.• Transformation of the healthcare system is long overdue, including narrowing the gap in resources between the private and public sectors