Doctors’ practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study

Background: Unnecessary blood transfusion exposes recipients to potential harms. Aim: The aim of this study was to describe blood transfusion practice and explore doctors’ attitudes towards transfusion. Setting: A hospital providing level 1 and 2 services. Methods: A mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semi-structured interviews. Results: Of 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) < 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs. Conclusion: Most orders were for two or more units. In medical anaemia, doctors’ compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines

Evaluation of the alignment of policies and practices for state-sponsored educational initiatives for sustainable health workforce solutions in selected Southern African countries: A protocol, multimethods study

Introduction Health systems across the world are facing challenges with shortages and maldistribution of skilled health professionals. Return-of-service (ROS) initiatives are government-funded strategies used to educate health professionals by contracting beneficiaries to undertake government work on a year-for-year basis after their qualification. It is envisaged that once they have served their contract, they will be attracted to serve in the same area or government establishment beyond the duration of their obligatory period. Little is known about the processes that led to the development and implementation of ROS policies. Furthermore, there is no systematic evaluation of the strategies that demonstrate their utility. This research aims to evaluate the ROS initiatives, explore their efficacy and sustainability in five Southern African countries. Methods and analysis This study will be conducted in South Africa, Eswatini, Lesotho, Botswana and Namibia in a phased approach through a multimethods approach of policy reviews, quantitative and qualitative research. First, a review will be conducted to explore current ROS schemes. Second, a quantitative retrospective cohort study of ROS scheme recipients for the period 2000-2010 will be undertaken. Information will be sourced from multiple provincial or national information systems and/or databases. Third, we will conduct semistructured group or individual interviews with senior health, education, ROS managing agency managers (where appropriate) and finance managers and/policy makers in each country to determine managers' perceptions, challenges and the costs and benefits of these schemes. Fourth, we will interview or conduct group discussions with health professional regulatory bodies to assess their willingness to collaborate with ROS initiative funders. Ethics and dissemination Ethics approval for this study was obtained through the Human Research Ethics Committees of the University of New South Wales (HC200519), Australia; South Africa and Lesotho (065/2020); Eswatini (SHR302/2020); Namibia (SK001); and Botswana (HPDME 13/18/1). Relevant findings will be shared through presentations to participating governments, publications in peer-reviewed journals and presentations at relevant conferences

Rapid testing for respiratory syncytial virus in a resource-limited paediatric intensive care setting

We analysed the performance characteristics of the respiratory syncytial virus lateral flow rapid antigen assay in use when compared to a multiplex polymerase chain reaction for detection of respiratory viruses. The study was conducted at a tertiary paediatric hospital in Port Elizabeth, South Africa, from 01 January 2017 to 31 December 2018. We found the clinical sensitivity (36.8%) of the rapid test to be too low for routine diagnostic use. Knowledge of assay performance characteristics of rapid tests are important for appropriate interpretation of rapid test results

Performance-based incentives and community health workers’ outputs, a systematic review

Objective To review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low-and middle-income countries. Methods We conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes. Findings Two reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs’ efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported. Conclusion Financial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed

Performance-based incentives and community health workers' outputs, a systematic review.

ObjectiveTo review the evidence on the impact on measurable outcomes of performance-based incentives for community health workers (CHWs) in low- and middle-income countries.MethodsWe conducted a systematic review of intervention studies published before November 2020 that evaluated the impact of financial and non-financial performance-based incentives for CHWs. Outcomes included patient health indicators; quality, utilization or delivery of health-care services; and CHW motivation or satisfaction. We assessed risk of bias for all included studies using the Cochrane tool. We based our narrative synthesis on a framework for measuring the performance of CHW programmes, comprising inputs, processes, performance outputs and health outcomes.FindingsTwo reviewers screened 2811 records; we included 12 studies, 11 of which were randomized controlled trials and one a non-randomized trial. We found that non-financial, publicly displayed recognition of CHWs' efforts was effective in improved service delivery outcomes. While large financial incentives were more effective than small ones in bringing about improved performance, they often resulted in the reallocation of effort away from other, non-incentivized tasks. We found no studies that tested a combined package of financial and non-financial incentives. The rationale for the design of performance-based incentives or explanation of how incentives interacted with contextual factors were rarely reported.ConclusionFinancial performance-based incentives alone can improve CHW service delivery outcomes, but at the risk of unincentivized tasks being neglected. As calls to professionalize CHW programmes gain momentum, research that explores the interactions among different forms of incentives, context and sustainability is needed

Model of delivery of cancer care in South Africa's Eastern Cape and Mpumalanga provinces: A situational analysis protocol

Introduction Cancer contributes to a significant proportion of morbidity and mortality globally. Low-income and middle-income countries such as South Africa tend to be characterised by poor and inequitable access to cancer services. Cancer resources are more likely to be found in urban areas, tertiary centres and quaternary hospitals. However, little is known about the linkages to care, continuity of care and packages of cancer care in rural South African settings. This study describes cancer service delivery for South Africa's Eastern Cape and Mpumalanga provinces. Methods and analysis A mixed-methods qualitative and quantitative research methods of three substudies which include semistructured interviews with patients, focus group discussions with health providers and a quantitative record review that will be carried out at both Rob Ferreira hospital, Witbank hospital and Nelson Mandela Academic hospital in Mpumalanga and Eastern Cape province, respectively. Instruments assess demographic characteristics, explore packages of cancer care, explore challenges experienced by health professionals, and maps out the referral pathway of patients with a cancer diagnosis in the study sites. Numerical, quantitative data will be explored for normality using the Shapiro-Wilk test and reported using either the mean, SD and range or the median and IQR depending on the normality of the distribution. Qualitative data will be analysed using the phenomenological approach. Ethics and dissemination Ethics approval was obtained from the Human Research Ethics Committee of Walter Sisulu University (040/2020) and the University of the Witwatersrand (M210211), South Africa. To the research team's knowledge, this is the first study presenting the model of cancer delivery in South Africa's Eastern Cape and Mpumalanga province. This will thus provide better understanding of cancer service delivery systems, packages of cancer care from primary care to quaternary care

How many mosquito nets are needed to achieve universal coverage? Recommendations for the quantification and allocation of long-lasting insecticidal nets for mass campaigns

<p>Abstract</p> <p>Background</p> <p>Long-lasting insecticidal nets are an effective tool for malaria prevention, and "universal coverage" with such nets is increasingly the goal of national malaria control programmes. However, national level campaigns in several countries have run out of nets in the course of distribution, indicating a problem in the method used to estimate the quantity needed.</p> <p>Presentation of hypothesis</p> <p>A major reason for the shortfall in estimation is the mismatch between the quantification factor used to plan procurement and the allocation algorithm used at community level, in particular the effect of needing to add an additional net to households with an odd number of inhabitants. To solve this problem a revised quantification factor is suggested.</p> <p>Testing hypothesis</p> <p>Based on data from a broad range of household surveys across Africa, the effect of odd-numbered households on numbers of nets distributed is estimated via two frequently used allocation methods. The impact of these algorithms on the proportion of households reaching a person to net ratio of 2:1, a frequently used marker of universal coverage is then calculated.</p> <p>Implications</p> <p>In order to avoid stock-outs of nets during national coverage campaigns, it is recommended to use a quantification factor of 1.78 people per net, with an additional allocation factor suggested to account for other common problems at the community level resulting in a final recommended ratio of 1.60 people per net. It is also recommend that community level allocation procedures be aligned with procurement estimates to reduce shortages of nets during campaign distributions. These analyses should enable programme managers to make evidence-based decisions and support a more efficient and effective use of LLIN distribution campaign resources.</p

Lessons learnt during the implementation of WISN for comprehensive primary health care in India, South Africa and Peru

Introduction: The World Health Organization introduced the workload indicators of staffing needs (WISN) in 1998 to improve country-level health workforce planning. This study presents the primary care health workforce planning experiences of India, South Africa and Peru. Methods: A case study approach was used to explore the lessons learnt in the implementation of WISN in India and South Africa. It also describes the methods developed and implemented to estimate health workforce in Peru. We identify the barriers and facilitators faced by countries during the implementation phase through the triangulation of literature, government reports and accounts of involved health planners in the three countries. Results: India implemented WISN in a referral pathway of three district health facilities, including a primary health centre, community health centre and district hospital. Implementation was impeded by limited technical support, poor stakeholder consultation and information systems challenges. South Africa implemented WISN for health workforce planning in primary care and found the skills mix and staff determinations to be unaffordable. The Peruvian Ministry of Health considered using WISN but decided to develop a context-specific tool to estimate the health workforce needed using its available resources such as the National Register of Health Personnel. The main challenge in using WISN was the insufficient information on its inputs. Conclusion: While India and South Africa had unique experiences with the integration of WISN in their health system, none of the countries has yet benefited from the implementation of WISN due to financial, infrastructure and technical challenges. Since the methodology developed by the Peruvian Ministry of Health is context-specific, its implementation has been promising for health workforce planning. The learnings from these countries’ experiences will prove useful in bringing future changes for the health workforce