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

The following terminology was erroneously reported: “non-white race” should be “people of colour”, or “black African, coloured and people of Indian descent”

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

Exploring the municipal ward based primary health care outreach teams implementation in the context of primary health care re-engineering in Gauteng

A Research Report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of: Master of Public Health (MPH) School of Public Health Faculty of Health Sciences University of the Witwatersrand 19 June 2017Background In order to achieve the Millennium Development Goals, South Africa embarked on a strategy in 2011 to re-engineer its Primary Health care (PHC) system. This included the creation of Ward-based Outreach Teams (WBOTs). Each team comprises six community health workers (CHWs) led by a professional nurse linked to a clinic. The national guidelines prescribe that each municipal ward should have at least one WBOT to improve access to health care and strengthen the decentralised district health system. Implementation of the WBOT policy has varied across the country. Methodology This qualitative study explored WBOT staff and manager views on initial WBOT implementation in the Ekurhuleni health district. Research methods included five focus group discussions with CHWs; 14 in-depth interviews with team leaders and managers; and ethnographic observations. Using the framework analysis approach, data were coded based on themes relevant to the National Implementation Research Network’s (NIRN) Implementation Drivers’ Framework, including: competency, leadership and organizational drivers of the initial implementation processes. The context in which implementation occurred was also an important theme, as derived from the NIRN formula for successful implementation. Results There were significant weaknesses underscoring the current implementation of WBOTs in the district. The experiences of WBOT staff and managers illustrate that competence to perform the ideal roles was compromised by poor staff selection, inadequate training and limited coaching. CHWs complained of precarious working conditions, payment delays and uncertainty of employment contracts. Within the community context, CHWs experienced both positive and negative attitudes from the community and clinic staff from inter alia: traditional beliefs; stigma; and, the perception that CHWs were increasing clinic workloads. Despite this, CHWs valued their expanded role, including the ability to refer to services beyond the clinic such a social services, police and home affairs, and felt motivated by the impact of their work in the communities they serve. Weak organisational processes, compounded by poor planning, budgeting and rushed implementation, resulted in problems with procurement of resources. The lack of support for robust data management led to poor data verification, quality and use for decision-making. Communication challenges revealed leadership deficiencies at the national and implementation levels. This led to confusion about the ownership of the programme and poor integration of WBOT into the service delivery package in traditional clinic settings. Conflicting departmental mandates (between provincial and municipal departments), fragmented leadership and accountability, all lack of insight into the policy objectives and a disabling and ill-prepared context, constrained efforts of WBOTs at the local level. This also affected the embeddedness and acceptance of the programme in clinics and the community, impacting on implementation fidelity. Conclusion Sustainable systemic change requires clear, detailed planning guidelines, defined leadership structures, budgetary commitments, and continuous communication strategies. Furthermore, successful change is dependent on the on-going commitment to human resources development and capacity building, including investment in supervision, quality training, organisational support and competent staff. This study highlights the critical importance of organisational readiness that includes health systems and actor readiness when implementing policies across decentralised systems. Furthermore, adaptation to local contexts must be heeded in policy processes. This study further illustrates that in order to re-engineer PHC, to achieve the vision and values set out by the Alma Ata Declaration, and, to strengthen outreach services across relevant sectors, participation of all relevant actors in the implementation process.MT201

Exploring the municipal ward based primary health care outreach teams implementation in the context of primary health care re-engineering in Gauteng

A Research Report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of: Master of Public Health (MPH) School of Public Health Faculty of Health Sciences University of the Witwatersrand 19 June 2017Background In order to achieve the Millennium Development Goals, South Africa embarked on a strategy in 2011 to re-engineer its Primary Health care (PHC) system. This included the creation of Ward-based Outreach Teams (WBOTs). Each team comprises six community health workers (CHWs) led by a professional nurse linked to a clinic. The national guidelines prescribe that each municipal ward should have at least one WBOT to improve access to health care and strengthen the decentralised district health system. Implementation of the WBOT policy has varied across the country. Methodology This qualitative study explored WBOT staff and manager views on initial WBOT implementation in the Ekurhuleni health district. Research methods included five focus group discussions with CHWs; 14 in-depth interviews with team leaders and managers; and ethnographic observations. Using the framework analysis approach, data were coded based on themes relevant to the National Implementation Research Network’s (NIRN) Implementation Drivers’ Framework, including: competency, leadership and organizational drivers of the initial implementation processes. The context in which implementation occurred was also an important theme, as derived from the NIRN formula for successful implementation. Results There were significant weaknesses underscoring the current implementation of WBOTs in the district. The experiences of WBOT staff and managers illustrate that competence to perform the ideal roles was compromised by poor staff selection, inadequate training and limited coaching. CHWs complained of precarious working conditions, payment delays and uncertainty of employment contracts. Within the community context, CHWs experienced both positive and negative attitudes from the community and clinic staff from inter alia: traditional beliefs; stigma; and, the perception that CHWs were increasing clinic workloads. Despite this, CHWs valued their expanded role, including the ability to refer to services beyond the clinic such a social services, police and home affairs, and felt motivated by the impact of their work in the communities they serve. Weak organisational processes, compounded by poor planning, budgeting and rushed implementation, resulted in problems with procurement of resources. The lack of support for robust data management led to poor data verification, quality and use for decision-making. Communication challenges revealed leadership deficiencies at the national and implementation levels. This led to confusion about the ownership of the programme and poor integration of WBOT into the service delivery package in traditional clinic settings. Conflicting departmental mandates (between provincial and municipal departments), fragmented leadership and accountability, all lack of insight into the policy objectives and a disabling and ill-prepared context, constrained efforts of WBOTs at the local level. This also affected the embeddedness and acceptance of the programme in clinics and the community, impacting on implementation fidelity. Conclusion Sustainable systemic change requires clear, detailed planning guidelines, defined leadership structures, budgetary commitments, and continuous communication strategies. Furthermore, successful change is dependent on the on-going commitment to human resources development and capacity building, including investment in supervision, quality training, organisational support and competent staff. This study highlights the critical importance of organisational readiness that includes health systems and actor readiness when implementing policies across decentralised systems. Furthermore, adaptation to local contexts must be heeded in policy processes. This study further illustrates that in order to re-engineer PHC, to achieve the vision and values set out by the Alma Ata Declaration, and, to strengthen outreach services across relevant sectors, participation of all relevant actors in the implementation process.MT201

Towards a Feminist Global Health Policy: Power, intersectionality, and transformation

Eger H, Chacko S, El-Gamal S, et al. Towards a Feminist Global Health Policy: Power, intersectionality, and transformation. PLOS Global Public Health. 2024;4(3): e0002959.In the realm of global health policy, the intricacies of power dynamics and intersectionality have become increasingly evident. Structurally embedded power hierarchies constitute a significant concern in achieving health for all and demand transformational change. Adopting intersectional feminist approaches potentially mitigates health inequities through more inclusive and responsive health policies. While feminist approaches to foreign and development policies are receiving increasing attention, they are not accorded the importance they deserve in global health policy. This article presents a framework for a Feminist Global Health Policy (FGHP), outlines the objectives and underlying principles and identifies the actors responsible for its meaningful implementation. Recognising that power hierarchies and societal contexts inherently shape research, the proposed framework was developed via a participatory research approach that aligns with feminist principles. Three independent online focus groups were conducted between August and September 2022 with 11 participants affiliated to the global-academic or local-activist level and covering all WHO regions. The qualitative content analysis revealed that a FGHP must be centred on considerations of intersectionality, power and knowledge paradigms to present meaningful alternatives to the current structures. By balancing guiding principles with sensitivity for context-specific adaptations, the framework is designed to be applicable locally and globally, whilst its adoption is intended to advance health equity and reproductive justice, with communities and policymakers identified as the main actors. This study underscores the importance of dismantling power structures by fostering intersectional and participatory approaches for a more equitable global health landscape. The FGHP framework is intended to initiate debate among global health practitioners, policymakers, researchers and communities. Whilst an undeniably intricate and time-consuming process, continuous and collaborative work towards health equity is imperative to translate this vision into practice

Addressing power asymmetries in global health: Imperatives in the wake of the COVID-19 pandemic.

Seye Abimbola and co-authors argue for a transformation in global health research and practice in the post-COVID-19 world

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

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

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

Original article: https://doi.org/10.17159/sajs.2022/13323 The following terminology was erroneously reported: “non-white race” should be “people of colour”, or “black African, coloured and people of Indian descent”