SHS Vol 2, No 1 (2017) by HMPG

Incorporating the Southern African Journal of Public Health JULY 2017 | VOLUME 2 | ISSUE 1

Bridging the divides in health systems intervention and reform Municipal ward-based primary healthcare outreach teams Health technology assessment

EDITOR IN CHIEF Debashis Basu

JULY 2017 | VOLUME 2 | ISSUE 1 Official journal of the South African Public Health Medicine Association, an affiliate of the South African Medical Association

EDITORIAL BOARD Leegail Adonis Michael Asuzu Chauntelle I Bagwandeen Lilian Dudley Francis Hyera Willem Kruger Shan Naidoo Petrus G Rautenbach PUBLISHED BY THE HEALTH AND MEDICAL PUBLISHING GROUP CEO AND PUBLISHER Hannah Kikaya

EDITORIALS 2

Can there really be a ‘science’ of health systems? H Kikaya

Bridging the divides in health systems intervention and reform D Basu

CORRESPONDENCE 4 Stress in humanitarian workers: The case of the UNHCR office in Senegal A S Mohamed, S A Dia, N B Dieng, M Ndiaye

ARTICLES 6

Health-technology assessment: Its role in strengthening health systems in developing countries D Mueller, D Tivey, D Croce

Training needs for primary healthcare clinics in National Health Insurance pilot districts E Holland, D Olivier, C Louwrens

Progress of the municipal ward-based primary healthcare outreach teams in Vhembe, Limpopo Province P Sodo, A Bosman

PUBLIC HEALTH NOTEBOOK Public health biostatistics notebook B V Girdler-Brown

CHIEF OPERATING OFFICER Diane Smith EXECUTIVE EDITOR Bridget Farham PRODUCTION MANAGER Emma Jane Couzens MANAGING EDITORS Claudia Naidu Naadia van der Bergh ONLINE MANAGER Gertrude Fani TECHNICAL EDITOR Kirsten Morreira DESIGN Travis Arendse Clinton Griffin HEAD OFFICE Health and Medical Publishing Group (Pty) Ltd Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext. 3, Pretoria, 0181 Tel. 012 481 2069 Email: dianes@hmpg.co.za CONTACTS Website and online submissions: www.shsjournal.org.za Publisher website: www.hmpg.co.za Editorial queries: shseditor@hmpg.co.za Tel: +27 (0)21 532 1281 ISSN 2312-9360

Published by the Health and Medical Publishing Group (Pty) Ltd Company registration 2004/022032/07, a subsidiary of the South African Medical Association Suite 11 Lonsdale Building, Gardener Way, Pinelands, 7405 Tel: +27 (0)21 532 1281 | Email: publishing@hmpg.co.za Creative Commons Attribution - Non Commercial Works License (CC BY-NC 4.0)

This journal, Strengthening Health Systems, is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the President’s Emergency Plan for AIDS Relief. The contents are the responsibility of Strengthening Health Systems and do not necessarily reflect the views of USAID or the United States Government

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

EDITORIAL

Can there really be a ‘science’ of health systems? Finding how to capture and learn from existing knowledge is a first step If there is one common feature among the diverse group of professionals who work with health systems, it is this: they know a lot about a lot of different things. Thanks to convoluted career paths, multidisciplinary interests and, more often than not, a load of international travel, they are highly qualified, highly experienced people who have seen it all – in many different places around the globe. They know how small changes can lead to big impacts. How illconceived reforms can cripple an entire system. And how a single supportive or antagonistic personality in a position of power can make or break any intervention. Each of these professionals is a walking library of knowledge, with a mass of transferable skills. How, then, can health systems interventions remain so resolutely unscientific? Whether it is a health minister trying to choose between policies to improve coverage and outcomes, a middle-manager looking to increase efficiency and reduce errors, or a service provider balancing business and compassion, no decision-maker at any level is able to review others’ experience to identify the ‘best’ options for achieving a desired result or avoiding failure. External technical advisors are similarly hamstrung, though may not admit it. Everyone has their opinion. But no one knows for sure. This gap is not for want of potential data. With close to 200 health systems in the world, with histories of change, improvement and failure stretching back decades, there is no shortage of material to draw on. The problem is, while the development effectiveness movement has led individual funders to look more closely at their own returns on investments, there has been no community-wide effort to consolidate health systems experience so that everyone can benefit – not least the countries that need to reform. What is more, even in this era of greater scrutiny, there remains no satisfactory approach to capturing the essence of why certain interventions have achieved success while others failed. Efforts to interrogate health systems interventions either draw too much on the biomedical approach, considering programmes as treatments with the potential to ‘cure’. They may be too selective, examining the technical aspects of a programme or reform in isolation, without recognition of the pivotal role of politics and personalities. Or they rigidly apply quasi-experimental techniques to turn ethnographic observations into something more familiar to scientists, losing much valuable information in the process. None of these approaches is a really good fit for the

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complex real-world settings in which health systems function and change. The simple truth is we still do not have the appropriate tools to examine and compare health system interventions. Nor do most of the field’s professionals – practitioners rather than academics – know where to start. That needs to change. But how? A crucial step is to go back to basics. To really consider the most appropriate techniques for this field. And to recognise that the common urge to mimic biomedicine is not always the best approach. We need to draw on the knowledge of anthropologists, psychologists, social scientists, historians, political scientists, and economists – and many more – to define the appropriate ways to study the complex systems that govern health. To define the experimental approaches that generate the most useful, generalisable findings. And to understand how to quantify uncertainty and address bias. The goal is nothing short of a complete transformation. But progress could be quick if there was some way to take stock of what we already know. Turning the information goldmine that is the combined experience of the profession into documented knowledge is the first crucial step. Systematically capturing the experience of practitioners will define the research agenda for a new, more relevant, more scientific field. In this context, journals have a crucial role to play. And it is with this rationale that Strengthening Health Systems has been conceived. Our aim is to capture the totality of knowledge about health systems: to support governments and development professionals to systematically document what they have seen; to link researchers with implementers to define research questions with practical relevance; and to provide policy-makers with a solid foundation of knowledge on which to base their decisions. We understand that health systems ‘evidence’ does not usually match academic ideals. But it has some value – and choosing to ignore it rather than tackle the challenge of imperfect information will hold this field back more than it would help. Strengthening Health Systems is ready for the challenge. Hannah Kikaya Former editor, Strengthening Health Systems hannah.kikaya@hmpg.co.za Originally published: Strengthen Health Syst 2014;1(1):3. DOI:10.7196/shs.3

EDITORIAL

Bridging the divides in health systems intervention and reform Strengthening Health Systems, an international open -access peer-reviewed journal, incorporates the Southern African Journal of Public Health. It is supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR) and published by the Health and Medical Publishing Group and South African Public Health Medicine Association. This journal will be an international, peer-reviewed, openaccess journal that will publish the best academic studies on practices of public health, preventive and community medicine that would strengthen health systems, capture the most significant field-based innovations and lessons, and build an interactive cohesive community of academics and service providers. We will publish four issues per year. The journal aims to bridge the divides between academia and service providers in health systems intervention and reform. We will endeavour to capture the totality of knowledge about health systems: to support governments and development professionals to systematically document what they have seen, to link researchers with implementers to define research questions with practical relevance and to provide policy makers with a solid foundation of knowledge on which to base their decisions. We would like to publish the most significant and widely applicable findings and experience from programme implementation and translational research, with recognisable policy impacts that draw on robust research and operational experience from both academic and non-academic authors and service

providers. We are committed to addressing the 5/95 publications gap for health systems research – a term coined by the WHO-based Alliance for Health Policy and Systems Research to describe the imbalance between the numbers of health systems research papers from developing countries compared with developed nations. The journal will also publish series of articles on health systems management, health technology assessment and evidence-based healthcare, as well as articles focusing on postgraduate studies in public health and preventive medicine. The first issue of the journal in 2017 covers these areas, as well as topical issues in the South African health system such as ‘wardbased outreach teams’. As such, we have pledged to maintain a policy of no author fees and open-access publication for all our content, to remove barriers to publication and to ensure the maximum dissemination and use of published work. To support all authors, no matter how inexperienced, and to capture their knowledge in the scientific record, we also offer a cluster of publishing support services, including protocol reviews, writing support, intensive author feedback/developmental editing, and mentoring arrangements. Deb Basu Editor Strengthen Health Syst 2017;2(1):3. DOI:10.7196/ SHS.2017.v2.i1.55

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CORRESPONDENCE

Stress in humanitarian workers: The case of the UNHCR office in Senegal To the Editor: In emerging countries, the consequences of stress remain undervalued. Stress in the workplace is increasingly recognised as one of the most serious occupational health hazards, reducing workers’ satisfaction and productivity, as well as increasing absenteeism and turnover.[1-3] A heavy workload, a lack of recognition of the work done and communication difficulties are things that can cause stress.[4] There is also the need to deal with situations where people feel disempowered (by the suffering of aid recipients, or war) or situations of waiting without the possibility of acting for security reasons.[5] We conducted a study to assess the prevalence of stress among the United Nations High Commission for Refugees (UNHCR) and its local partner (Office Africain pour le Développement et la Coopération, OFADEC) staff in Dakar, Senegal, and to determine the main stress factors. We conducted a descriptive cross-sectional study from 30 May to 30 December 2012. Sixty individuals were selected through random sampling. Using a self-administered questionnaire, we recorded the sociodemographic characteristics, lifestyle, working conditions, career plan and proposals for improvement, assessment of stress and relational problems of the staff. Data were entered and processed using Epi-Info 3.5.4 and Microsoft Excel (USA) software. Fifty-two employees responded, and participated in the study: 30 from OFADEC and 22 from UNHCR, with a predominance of males (sex ratio 1.73). It was a young population, with the majority being between 20 and 39 years of age (53.84%) (Table 1). Only 11.53% smoked, and 15.38% had sleep disorders. Over three-quarters (78.8%) of respondents had a fixed-term contract. The prevalence of stress was estimated to be 40.38% (n=21), predominantly within the male population (sex ratio 2). Almost all stressed people (92.9%) worked in a team, and 66.7% had been working continuously during the last 12 months. A total of 42.9% (n=25) felt exhausted, worried (23.8%, n=12), ill (19%, n=10) or had gone through several other feelings (14.3%, n=7). Nearly three-quarters (71.4%, n=37) of stressed individuals took an aggressive approach to stress and slightly more than half (56.7%, n=29) reported being verbally abused.

The prevalence of stress was high compared with some studies reported in the literature.[6,7] The type of renewable 1-year contract used in UN organisations and non-governmental organisations creates job insecurity, especially towards the end of the contract, and is therefore a source of stress among employees. The stressed people of our series encountered not only multiple relational problems with refugees, but also with colleagues and in the hierarchy. Effective management of stress at work requires organisational arrangements that are conducive to the physical and mental health of workers. Table 1. Distribution of workers by age group Age group (years)

OFADEC

UNHCR

Total

n, (%)

20 - 39

16 (53.33)

12 (54.55)

28 (53.84)

40 - 59

14 (46.67)

9 (40.90)

23 (44.23)

>60

0 (0)

1 (4.55)

1 (1.93)

Total

30 (100)

22 (100)

52 (100)

A S Mohamed Occupational Health Unit, Chaikh Anta Diop University of Dakar, Senegal azhar1er@gmail.com S A Dia Occupational Health Unit, Chaikh Anta Diop University of Dakar, Senegal N B Dieng Occupational Health Unit, Chaikh Anta Diop University of Dakar, Senegal M Ndiaye Occupational Health Unit, Chaikh Anta Diop University of Dakar, Senegal Strengthen Health Syst 2017;2(1):4-5. DOI:10.7196/ SHS.2017.v2.i1.51 1. Centers for Disease Control, National Institute for Occupational Safety and Health. Exposure to Stress: Occupational Hazards in Hospitals. Department of Health and Human Services Centers for Disease Control and Prevention National Institute. Atlanta: Department of Health and Human Services (National Institute for Occupational Safety and Health), 2008.

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CORRESPONDENCE

2. European Agency for Safety and Health at Work, Milczarek M, Rial-González E, Schneider E. Occupational safety and health in figures: Stress at work – facts and figures. Luxembourg: Office for Official Publications of the European Communities, 2009. 3. Al Mazrouei AM, Al Faisal W, Hussein HY, El Sawaf EM, Wasfy AS. Job-related stress among physicians at Dubai Health Authority hospitals – Dubai–UAE. Am J Psychol Cogn Sci 2015;1(3):83-88. 4. Aebischer Perone S, van Beerendonk H, Avril J, Bise G, Loutan L. Stress et santé mentale chez les expatriés. Rev Med Suisse 2008;4:1206-1211. 5. Bierens de Haan B, Van Beerendonk H, Michel N, Mulli JC. Le programme de soutien psychologique aux intervenants humanitaires du Comité International de la Croix-Rouge (CICR). Rev Fr Psychiatr

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Psychol Med 2002 https://www.icrc.org/fre/resources/documents/misc/5fzjgf.htm (accessed 22 November 2016). 6. Kan D, Yu X. Occupational stress, work-family conflict and depressive symptoms among Chinese bank employees: The role of psychological capital. Int J Environ Res Public Health 2016;13:134. https://doi.org/10.3390/ijerph13010134 7. Niedhammer I. Psychometric properties of the French version of the Karaseck Job Content Questionnaire: A study of the scales of decision latitude, psychological demands, social support, and physical demands in the GAZEL cohort. Int Arch Occup Environ Health 2002;75(3):129-144. https://doi.org/10.1007/s004200100270

ARTICLE

Health-technology assessment: Its role in strengthening health systems in developing countries D Mueller,1 MEngg; D Tivey, 2 PhD; D Croce,3 BEng, MBA Charlotte Maxeke Medical Research Cluster (CMeRC), University of the Witwatersrand, Johannesburg, South Africa ASERNIP-S, Royal Australasian College of Surgeons, Research and Evaluation, Adelaide, Australia 3 Centro di Ricerca in Economia e Management in SanitĂ e nel Sociale (CREMS) University Carlo Cattaneo (LIUC), Castellanza, Italy 1 2

Corresponding author: D Mueller (dbmueller7@yahoo.de)

Since the 1900s, there has been rapid generation, continuous innovation and incremental improvement of medical technologies. However, not all innovation and development result in overall health gains, nor does their implementation result in improved cost-efficient solutions. Health systems worldwide need to ensure efficiency and demonstrate value for investment, and when coupled with cost pressures and constrained resources they create a difficult decision-making environment for investing in health technology. To overcome these challenges there is a need to evaluate all technologies and eliminate those that are ineffective and not cost-effective, and that have been superseded. Evaluation should consider the availability of resources as well as the organisational, societal, legal and ethical issues pertaining to the country or the local setting. Starting in the 1950s, the concept of health-technology assessment (HTA) has been developed to generate evidence-based foundations to illustrate the relevant preconditions and consequences when using a health technology. It involves multidisciplinary teams applying a systematic approach that is grounded in the scientific method. The goal is to generate, or synthesise, the highest possible level of evidence to inform the decision-making process about health technologies. HTA offers a simple structure to unify the multiple dimensions (including clinical, patient-related, organisational, economic, ethical and legal aspects) in the consideration of complex problems/questions regarding technology deployment and reimbursement. However, its role has evolved to encompass technologies from inception to obsolescence as well as early awareness and alert systems, reassessment post introduction, evidence briefs and recommendation for disinvestment. HTA is increasingly seen as an innovative way to sustain and improve health systems. This process can contribute towards decision-making information at all levels of the healthcare system, including political, administrative and clinical. It is regarded as a â&#x20AC;&#x2DC;way of thinkingâ&#x20AC;&#x2122; to improve decision-making related to the planning, administration and management of healthcare interventions. Strengthen Health Syst 2017;2(1):6-11. DOI:10.7196/SHS.2017.v2.i1.50

Overview of health technology assessment According to the World Health Organization (WHO), healthcare technology is broadly defined as the practical application of scientific knowledge to disease prevention, diagnosis, treatment and rehabilitation care.[1] This includes drugs, devices, procedures and the organisational and support systems within which care is provided. Health technology assessment

(HTA) is the process, usually applied to the field of policy analysis, whereby healthcare technologies are subjected to a review by a multidisciplinary team. HTA studies the medical, social, ethical and economic implications of the development, diffusion and use of healthcare technology.[2] The objective is to provide a synthesis of the best available evidence to support policy decisions. In doing so, wide stakeholder

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engagement is required, including from patients, service users and providers, industry and academic groups. The goal is to substantially improve patient outcomes by supporting investment in effective and efficient technologies/services, which is ensured by HTA processes being grounded in rigorous research methods that are transparent and repeatable, and that account for bias. Based on Drummond et al.’s[3] framework, one of the key principles is the method of HTA. International organisations and networks, the WHO and individual agencies have developed frameworks and method ological tools to assess a health intervention. HTA guidelines differ among organisations, in areas such as the range of evidence accepted, the methods used and the scoping of topics to be addressed.[3] However, irrespective of methodology, it is important to clearly show and specify the use and interpretation of different data and their sources. In the context of HTA, multidisciplinary teams comprise experts from various medical disciplines, including clinicians, epidemiologists, information scientists, biostatisticians, biomedical engineers, public health specialists and health economists. Team structure will depend on the technology being reviewed and the point where the technologies are in their lifecycle. For these resources to produce quality information, they should have the capacity and support to find, collect and analyse information relevant to the specific context. In many Organisation for Economic Co-operation and Development member countries, agencies have been established to support the HTA teams, and all have the common goal of being key drivers for quality and safety, as well as facilitating and encouraging the best use of resources in health services.[4] However, an agency’s organisational structure and governance needs to reflect the cultural traditions, healthcare systems and fiscal climates of the region or country. Establishing such a structure requires an appropriate institutional and legislative framework, as well as financial resources. HTA bodies may: • receive public funding only and be established by ministries of health (at national, provincial or regional level) • receive a mixture of private and public funding • be independent of governments • be situated within academia or initiated by organisations of health professionals. Critical to establishing an HTA mechanism is securing a solid commitment from the decision-makers that HTA

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and the findings on clinical evidence, applicability, cost effectiveness and budgetary constraints are embedded in their decision-making process.

Health systems and HTA According to the WHO,[1] a health system consists of people, institutions, resources and activities whose main function is to promote, restore and/or maintain health. Acknowledging that not all countries can follow the above definition of a health system, it furthermore states that a modern health system should ideally: • endeavour to improve the health of the population it serves • respond to the public’s reasonable expectations • safeguard against the cost of an individual’s ill-health. There are large differences between countries in the way financial resources are obtained and distributed. This extends to differences in services provided by various healthcare professionals, and the organisational structure for their delivery. However, health technologies are common to all countries, and play an important role in achieving the goals of the health system.[5] HTA should directly influence policy- and decisionmaking processes at all levels, i.e. national, regional and local. Where HTA is placed will depend on whether a technology addresses a whole population issue (e.g. funding hepatitis C treatments) or a local issue of service delivery (e.g. imaging services). Key to HTA placement is the power to negotiate a price or authorise the allocation of funds for purchase. Kristensen et al.[6] propose a close relationship between HTA and policymaking (Fig. 1), and consider HTA as a bridge between research and decision-making. The ideal of HTA is to provide a comprehensive review of clinical evidence, and exhaustive economic, social and ethics analysis requires significant resources

Research evidence to practice

Planning/policy question

HTA questions/project recommendations

Policy issue to be addressed

Fig. 1. Adapted from HTA informing decision-making, Kristensen et al.[6]

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and time. The pace of technology development has required adaption in HTA methods to meet the needs of health systems. Increasingly, assessment is within a framework of potential, risk and cost. These three factors influence the evidence required to support decision-making within a health-system context.[7] Campbell et al.[7] argue that more evidence is required for high-promise interventions, irrespective of cost, if they are deemed high-risk. In contrast, a technology of similar promise but of low cost and judged to be low-risk requires less evidence. This framework allows the tailoring of HTA to be fit for purpose. This and other efforts to increase pragmatism within the HTA field will extend its utility in strengthening health systems. Such pragmatism has resulted in many HTA product types; however, all are based on adherence to protocol, transparency and being repeatable.[8] The products vary by scope, stage in technology lifecycle, promise and risk profile. Furthermore, the actual decision-making (appraisal) can be a part of the same or a separate process. In England and Wales, the National Institute for Health and Clinical Excellence conducts appraisals using the evidence coming from HTA, in a process that leads to guidance.[9] This is policy-making beyond HTA processes, and even involves a decision endpoint. Furthermore, HTA products can play a valuable role in transnational collaboration if the product has been appropriately conducted, clearly and precisely documented so that it can be assessed for transparency, timeliness, relevance and appropriate use of evidence.[10] Indeed, the pace of innovation requires efficient HTA generation and implementation, and this can only be achieved through collaboration both within and between health systems. The need for cooperation and sharing of information across cultures at a global level is evident from the many international networks and societies devoted to HTA. An example is the European network for Health Technology Assessment (EUnetHTA), established for HTA collaboration, which has developed models for sharing HTA reports between countries. This framework is based on nine domains:[10] • Current use of the technology (implementation level) • Description and technical characteristics of the technology • Safety • Effectiveness • Costs, economic evaluation • Ethical aspects • Legal aspects • Organisational aspects • Social aspects.

Table 1. Characteristics of different kinds of HTA reports* Characteristics

Full HTA report

Mini-HTA

Rapid review

escribes characteristics and current use of D technology

Evaluates safety and effectiveness

Determines cost-effectiveness

Provides information on cost/financial impact

Discusses organisational considerations

OPT

ddresses ethical/social and legal A considerations Conducts comprehensive systematic literature review or a systematic review of a high level of evidence Critically appraises the quality of the evidence base onducts a review of only high-level evidence C or of recent evidence, and may restrict the literature search to one or two databases Y = yes; N = no; NA = not always; OPT = Optionally; O = often. *Adapted from Merlin et al.[8]

Key to collaboration are the common methodologies and central access to completed reports.[11] These domains define the ‘landscapes of HTA’ that should be considered when planning an HTA in Europe. According to EUnetHTA model, an HTA process can be based on different combinations of these domains, e.g. legal aspects may be important in some cases, while domains like effectiveness and safety issues of cost and economic evaluation should be covered in most HTAs. The EUnetHTA framework, although complex, is flexible, and provides clear guidance on the information needed to address each domain and, importantly, suggests resources to acquire the information. It also provides the scaffold to refine the scope of HTA processes to fit the needs of the health system, and it can be readily adapted to fulfil the definitions of HTA products proposed by Merlin et al.[8] (Table 1).

Decentralised HTA to support health systems The growing acceptance that medicine should be evidence-based has flowed on to the use of evidence within health policy decision-making.[12] Like clinical care, defining health policy to strengthen health systems should be the domain of those responsible for its implementation. This aligns with the World Bank position regarding investing in health.[13] The objective is decentralisation, to allow services and health expenditure to be guided by local need and user preferences, as well as increased awareness of fiscal responsibility, and greater accountability and equity

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through resource allocation to marginal regions and groups. However, the impact of decentralisation is yet to be fully realised,[14] partly owing to the complexity of decentralisation and the need to establish local governance systems and develop local capability.[15] For a local overview of health systems, the implementation of HTA processes can assist in addressing these challenges. However, this requires the training of personnel to conduct assessments and the provision of systems to support the HTA process as well as to facilitate the collaboration and commitment of all those responsible for service delivery. The drive for decentralisation has increased through advancements in health systems requiring the application of HTA methodologies at the regional and hospital levels. The main challenge to use HTA in hospital management relates to the decision-making arena and the need for rapid decisions. This has contributed to the so-called ‘hospital-based HTA’.[16] The purpose of these HTAs are to evaluate health technologies ‘in context’, in order to support decisions about the introduction of innovative and new technologies and to improve system efficiency by improving microeconomic efficiency. In 1982, CEDIT (Comité d’Evaluation et de Diffusion des Innovations Technologiques) was one of the first hospital-based agencies in Europe with the aim of supporting hospital managers in the management of technologies by assessing technologies on the principles of HTA.[16] In 1994, the Danish National Board of Health, a forerunner of the Danish Centre for Evaluation and Health Technology Assessment, issued a recommendation that a form capturing the HTA philosophy should be completed upon application for hospital devices and equipment. This form contained questions about the technology, the patient, the organisation and financial aspects, and is now recognised as the mini-HTA tool. This model is currently being applied in many hospitals in Denmark, and is also compulsory in the Regions of Denmark’s annual collection of early warnings. A study in 2006 by Ehlers et al.[17] to evaluate local decision support tools in Danish hospitals found that mini-HTA reports were already being used in most hospitals surveyed, and that local engagement in the HTA process was important for both the use of the reports and for implementation aspects.

HTA and public health challenges The WHO defines public health as an organised effort by a society to improve, promote and restore the health of its population.[1] Assessment of public health interventions poses additional challenges because of the engagement with a diverse stakeholder cohort, including public health professionals, clinicians,

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politicians and consumers. These challenges are exacerbated by a lack of standardised methodologies, and difficulties in measuring direct and indirect consequences of the intervention. Important trends, however, force us to consider assessment of public health interventions. One of these is the growing burden of chronic diseases that accompany the ageing population.[18] Due to the complexity of the intervention, one must consider the impact across individuals as well as community, organisational and policy levels, measure the effects on intermediate outcomes and examine the effects.[19] Such methodological challenges are tackled in European Union projects such as INTEGRATE -HTA.[20] The present trends and challenges in the public healthcare system call for the further development of scientifically based decision-making in public health, and the production of reports which address continuous developments in public health.[19]

HTA in developing countries HTA is recognised internationally as a valuable tool for supporting decision-making at all levels of a health service.[21] This in-depth, scientific, systematic multidisciplinary approach to evaluating health technology interventions has not been utilised generally in the South African (SA) public sector to inform decision-making.[22] Poorly made decisions at both macro- and microlevels in the health sector commit the institutions to current and future costs which they can ill afford. In countries like SA, with transitional economies, HTA is therefore needed especially when scarce resources demand smarter decisions to ensure efficient and effective outcomes and to understand the systemic implications of introducing technologies at all levels of the health system. As stated earlier, HTA is about bridging the gap between research and policy and planning. It is important that research is done locally to develop the best applicable information to be used in decisionmaking. Though HTA studies have been conducted in other countries, it is important to consider technologytransfer issues in this context. Health technologies, which include medical devices, are recognised as the main platform for healthcare delivery, and they pose complex challenges in their use. Research and development of these technologies are not as stringent as those for drugs, and the pace of technological advancement outstrips the evidence base, which further complicates their evaluation.[23] Health technology presents a serious challenge to public health, which faces inequalities, issues of equity and cost-effectiveness. Therefore, understanding the local environment is vital to develop

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policies around medical devices, to ensure they can be implemented. Although evidence of best practice can be obtained from international experience, ignoring the local setting could mean that these practices remain theoretical and not applicable. The majority of the medical devices being used in the SA context are purchased internationally (US, Europe, China and Japan). This has implications for the users in SA, as these devices are researched and developed in these respective countries with systems that benefit users in these countries. An HTA strategy that protects patients from unsafe and ineffective devices is post-market surveillance. This is a problem for users in SA, as these surveillance systems are not in place. The main hurdle is the lack of use of the HTA framework to support decision-making related to the procurement, use and disinvestment of health technologies in policy and planning in the SA healthcare system. A focus-group discussion with hospital CEOs has shown that HTA is not being uniformly used in the public decision-making process, and identified two main problems:[22] • Problem 1 is the lack of use of the HTA framework to evaluate health technologies in the SA public healthcare system. • Problem 2 is the lack of a health-technology decision support tool to guide decision-makers to ensure the best diagnostic, therapeutic and economic outcomes. The development and integration of a broad HTA frame work in policy and planning, to optimise the management of health technologies in public hospitals, should address these problems to ensure the safe and effective delivery of patient care.

Conclusion Limited resources raise the necessity of making decisions based upon evidence, and therefore the need to establish a system that supports decision makers. The process of HTA and its implementation will contribute to establishing a balance between equity, quality healthcare and efficiency in need prioritisation, investments decisions, organisational impacts of new and emerging technologies and reassessment of the value of existing interventions. Establishing a formal and institutionalised system of HTA will then result in effective implementation of the recommendations and findings, accompanied by close monitoring of the interventions. Setting up HTA units can be challenging and timeconsuming, and involves close collaboration between a variety of stakeholders, capacity in scientific research and financial resources. At a local level, immediate control over health spending can be achieved through establishing a hospital-based HTA capability. It can start off as a small

committee or unit, and evolve into larger organisational structures serving multiple hospitals. A smaller unit can build on the knowledge generated elsewhere and contextualise it to its own setting, while a large institution may solve complex multidimensional questions. The structure will thus depend upon the decision-making needs and ecosystem, the availability of qualified human resources and available financial resources. As depicted here, HTA has been widely embraced as a valuable multidisciplinary scientific approach to the evaluation of health technologies. Economics is only one component of technology assessment, and the broader HTA framework that incorporates social and ethical issues lends itself to wider applications, resulting in overall system benefits. HTA will yield valuable information to address deficiencies in our health system. In addition, it will encompass a wider understanding of the overall impact, requiring comprehensive policy considerations, identification of knowledge gaps and the need for research. The adopting and production of high-quality assessments is directly related to available expertise, experience and skill level, relevant capacity building, communication and implementation of recommendations. Ultimately, to adopt HTA is to embrace a culture of evaluation and accountability, and will contribute towards optimising the management and delivery of healthcare, with improved outcomes for patients, operators and institutions.

1. World Health Organization. A Glossary of Terms for Community Health Care and Services for older persons. Geneva: WHO, 2004. http://whqlibdoc.who. int/wkc/2004/WHO_WKC_Tech.Ser._04.2.pdf (accessed 16 January 2017). 2. International Network of Agencies for Health Technology Assessment. A Checklist for Health Technology Assessment Reports, 2014. http://www. inahta.org/wp-content/uploads/2014/04/INAHTA_HTA_Checklist_English. pdf (accessed 16 January 2017). 3. Drummond MF, Schwartz JS, Jönsson B, et al. Key principles for the improved conduct of health technology assessments for resource allocation decisions. Int J Technol Assess Health Care 2008;24(3):244-258. https://doi.org/10.1017/S0266462308080343 4. Health Technology Assessment International, International Network of Agencies for Health Technology Assessment. Resources for Health Technology Assessment. http://www.inahta.org/wp-content/themes/ inahta/img/AboutHTA_Resources_for_HTA.pdf (accessed 16 January 2017). 5. Velasco Garrido M, Kristensen FB, Nielsen CP, Busse R, eds. Health Technology Assessment and Health Policy-Making in Europe – Current Status, Challenges and Potential. Copenhagen: World Health Organization, 2008. 6. Kristensen FB, Matzen P, Madsen PB. Health technology assessment of the diagnosis of colorectal cancer in a public health service system. Seminars Colon Rectal Surg 2002;13:96-102. http://www.seminarscolonrectalsurgery. com/ 7. Campbell B, Knox P. Promise and plausibility: Health technology adoption decisions with limited evidence. Int J Technol Assess Health Care 2016;32(3):122-125. http://doi.org/10.1017/S0266462316000234 8. Merlin T, Tamblyn D, Ellery B; INAHTA Quality Assurance Group. What’s in a name? Developing definitions for common health technology assessment product types of the International Network of Agencies for Health Technology Assessment (INAHTA). Int J Technol Assess Health Care 2014;30:430-437. https://doi.org/S0266462314000543

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9. Walley T. Health technology assessment in England: Assessment and appraisal. Med J Aust 2007;187:283-285. https://www.mja.com.au/system/ files/issues/187_05_030907/wal10714_fm.pdf (accessed 20 February 2017) 10. EUnetHTA Joint Action 2, Work Package 8. HTA Core Model version 2.0, 2013. http://www.corehta.info/BrowseModel.aspx (accessed 20 February 2017). 11. Woodford Guegan E, Cook A. European network for Health Technology Assessment Joint Action (EUnetHTA JA): A process evaluation performed by questionnaires and documentary analysis. Southampton: National Institute for Health Research Journals Library, 2014 (Health Technology Assessment No. 18.37. https://doi.org/10.3310/hta18370 12. Bossert TJ, Beauvais JC. Decentralization of health systems in Ghana, Zambia, Uganda and the Philippines: A comparative analysis of decision space. Health Policy Plan 2002;17(1):14-31. https://doi.org /10.1093/heapol/17.1.14 13. World Bank. World Development Report 1993: Investing in Health. New York: Oxford University Press, 1993. 14. Channa A, Faguet JP. Decentralization of health and education in developing countries: A quality-adjusted review of the empirical literature. World Bank Res Obs 2016;31(2):199-241. https://doi.org /10.1093/wbro/lkw001 15. Litvack J, Ahmad J, Bird R. Rethinking Decentralization in Developing Countries. The International Bank for Reconstruction and Development. World Bank, Washington, D.C., 1998. 16. Cicchetti A, Marchetti M, Dibidino R, Corio M. HTAiâ&#x20AC;&#x2122;s Hospital-Based Sub-Interest Group. Hospital-based health technology assessment. World-wide survey. http://www.htai.org/fileadmin/HTAi_Files/ISG/

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HospitalBasedHTA/2008Files/HospitalBasedHTAISGSurveyReport.pdf (accessed 20 April 2017). 17. Ehlers L, Vestergaard M, Kidholm K, et al. Doing the mini-health technology assessments in hospitals: A new concept of decision support in health care? Int J Technol Assess Health Care 2006:22(3):295-301. https://doi. org/10.1017/S0266462306051178 18. National Institute on Aging, World Health Organization. Global Health and Aging Publication 11-7737. Bethesda, USA: National Institute on Aging, 2011. 19. Battista RN, Lafortune L. Health technology assessment and public health: A time for convergence. Eur J Public Health 2009;19(3):227. https://doi.org /10.1093/eurpub/ckp054 20. Rehfuess EA, Gerhardus A. INTEGRATE-HTA. INTEGRATE-HTA: Adopting and implementing an integrated perspective on complex interventions. J Public Health 2017;39(1):209-212. http://dx.doi.org/10.1093/pubmed/fdw119 21. Velasco-Garrido M, Busse R. Health technology assessment. An introduction to objectives, role of evidence, and structure in Europe. Copenhagen, Denmark: World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2005. 22. Mueller D, Govender M, Basu D. Health technology assessment in South Africa â&#x20AC;&#x201C; future promise. S Afr Med J 2011;101(5):286-287. https://doi.org /10.7196/SAMJ.4867 23. Tarricone R, Torbica A, Drummond M. Challenges in the assessment of medical devices: The MedtecHTA Project. Health Econ 2017;26:5-12. https://doi.org/10.1002/hec.3469

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Training needs for primary healthcare clinics in National Health Insurance pilot districts E Holland,1 MB ChB, FCP, PhD; D Olivier,2 BA (Hons) Psych, MA Psych (Research Consultation), CAHM; C Louwrens,3 BA Psych Counselling, BA (Hons) (Appl Psych) Special Projects Unit, Foundation for Professional Development, Pretoria, South Africa Research Unit, Foundation for Professional Development, Pretoria, South Africa 3 Programme Evaluation Unit, Foundation for Professional Development, Pretoria, South Africa 1 2

Corresponding author: E Holland (ErrolH@foundation.co.za)

Background. The Foundation for Professional Development is providing services to the National Department of Health (NDoH) to recruit and manage the performance of 142 medical practitioners who provide clinical services in the primary healthcare (PHC) clinics in the pilot districts of the National Health Insurance (NHI) initiative. Objectives. To review the training requirements of recruited medical practitioners in order to identify gaps in competencies and to contribute to the success of the NHI initiative to improve the quality of healthcare services for all South Africans. Methods. The NDoHâ&#x20AC;&#x2122;s priority clinical conditions were used to inform the design of a self-reported training-needs questionnaire. Respondents had to rate their personal competency in 11 priority clinical conditions, and provide their reasons for not acquiring the necessary competency in each condition. A personal competency score for each priority clinical condition and an overall score on self-reported personal competency were calculated. Results. The immediate care for, investigation and management of sexual assault and the management of drugresistant tuberculosis and depression in adults were identified as the clinical conditions with the lowest personalcompetency ratings. The overall reasons identified for not acquiring the necessary competencies were insufficient exposure, insufficient training or a combination thereof. Conclusion. Training in the priority conditions in PHC services should be constantly evaluated and addressed to ensure optimal service delivery. These conditions should receive specific focus in the training at medical schools and during internship, and competencies should be consolidated by targeted education programmes at PHC facilities. Strengthen Health Syst 2017;2(1):12-17. DOI:10.7196/SHS.2017.v2.i1.27

One of the key requirements for the oversight of the functioning of the recruited medical practitioners is to ensure that they are equipped with the required competencies to deal with the most common conditions they see at the clinics. The National Health Plan for South Africa (SA) was tabled in 1994, and was the first major initiative to provide comprehensive healthcare services that were accessible to all South Africans, close to where they lived, through a wellco-ordinated district health system.[1] Despite these efforts to improve health outcomes by rationalising access to the health system, child and adult mortality rates

remain unacceptable. Infectious diseases, particularly HIV/AIDS and the associated TB complications, are the main causes. SA has the third highest TB incidence rate and the second highest multiple-drug-resistant TB incidence in the world.[2] The escalation of the ARV-therapy rollout, efforts to strengthen voluntary counselling and testing services and the prevention strategies to combat mother-to-child transmission of HIV have made significant inroads in the HIV/AIDS pandemic. Non-communicable diseases such as stroke, heart disease, hypertension, diabetes and cancers are the other key contributors to the high mortality rates.

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The maternal mortality ratio remains unacceptably high at 197 per 100 000 live births, even though this has decreased from 281 per 100 000 live births in 2011.[2] It is clear that the district health system has made major strides in rationalising the healthcare provided for the majority of citizens of the country; however, the burden of disease remains formidable, particularly in the rural and remote areas of the country. It is thus imperative that health personnel are fully competent in dealing with these common causes of disease morbidity and mortality. The strategic plan of the NDoH provides guidelines for service provision in district health services, and outlines the priorities for PHC services in programme 4 of the plan.[3] Non-communicable diseases, particularly cardiovascular diseases, cancers, chronic respiratory diseases and diabetes contribute to 40% of all deaths. Another matter of concern is that only 25% of adults with mental disorders are assessed and receiving treatment. The need for maintenance of the norms and standards for the management of violence, trauma and emergency medical services is highlighted, which more recently includes those for the management of sexual assault. The strategic plan also identifies the priority areas in communicable disease control, including diarrhoeal diseases, influenza prevention and control programmes and the elimination of malaria.

Methods An important responsibility of the Foundation for Professional Development in meeting the service requirements rendered at the PHC clinics by the contracted medical practitioners was to establish their level of competency to provide efficient services in the priority PHC conditions identified in the strategic plan. Part of this responsibility was to call on the practitioners to complete a self-evaluation questionnaire aimed at identifying the training needs of the recruited medical practitioners. These practitioners were placed at 260 PHC clinics in eight NHI pilot districts across SA. A message of invitation to participate in the questionnaire was sent to them in an email. Participation in the survey was voluntary, without any form of coercion, and no incentive for participation was offered. The questionnaire was hosted on LimeSurvey (https://www. limesurvey.org) The questionnaire covered a selection of 11 clinical health priorities including: the prevention, investigation and management of HIV and sexually transmitted infections (STIs); the reduction of mother-to-child transmission of HIV; the immediate care, investigation and management of sexual assault; the management of drug-resistant TB; the investigation and management of diarrhoea in children; the comprehensive management

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of asthma; the comprehensive management of hypertension and its complications; the comprehensive management of Type I and Type II diabetes mellitus; the management of depression in adults; the pharmaceutical management of epilepsy; and the approach to and management of high blood pressure and pre-eclampsia in pregnancy. For each of these priorities, the respondents were asked to rate on a scale of 1 - 5 their personal competency. The scale was coded as 1 = uncomfortable in dealing with the clinical condition and I need to be fully trained; 2 = not fully comfortable in dealing with the clinical condition and I need training; 3 = can deal with the clinical condition reasonably well but I would value full training on the condition; 4 = competent but I would like to improve my knowledge; and 5 = fully competent – no additional training required. Respondents were also asked to indicate where they were trained for each priority clinical condition, including medical school, during internship, during community service or in practice after community service. Openended questions provided the respondents with the opportunity to comment on their reasons for not acquiring the necessary competence. The questions referring to the district where the medical practitioners were placed were quantified. Other data that were quantified were the respondents’ reasons for not acquiring the necessary competence. The quantitative data were analysed using the Statistical Package for Social Sciences (SPSS) version 22.0 (IBM Corp., USA). Mean scores were calculated for each self-reported competency rating. Respondents could attain a minimum mean score of 1 and a maximum mean score of 5 for their competence regarding each clinical condition. An item analysis was conducted to assess the reliability of the self-reported personal competencyrating subscales. An item analysis is useful in providing researchers with information about the overall and individual reliability of questions, and in the improve ment of questionnaires. It was necessary to determine the reliability of the self-reported personal competencyrating subscales because it was the first time that this specific questionnaire was used in practice. An additional regression analysis was conducted to test the hypothesis that an increase in the number of years of practical experience after community service will lead to an increase in the mean self-reported personal competency score (H0: p>0.05; H1: p<0.05).

Results The questionnaire had 72 respondents (Table 1). The analyst counted each district mentioned in the openended question about the name of the district where

ARTICLE Table 2. Place where trained/mentored (N=67)

the medical practitioners had been placed. It was found that the respondents were representative of all eight districts (Table 1). The majority of respondents worked in the Gert Sibande district. The variable for the number of years working after community service was collapsed into three categories: 0 - 2 years, 3 - 5 years and â&#x2030;Ľ6 years. There were 71 respondents to this question. It was found that an equal number of respondents had either 3 - 5 years or â&#x2030;Ľ6 years of experience practising as a medical practitioner after community service (Table 1). The minority of respondents had 0 - 2 years of experience (Table 1). The respondents were asked to indicate where they received training/mentorship for each of the 11 priority clinical conditions. A total of 67 responses were received. For the prevention, investigation and management of HIV and STIs, the reduction of motherto-child HIV transmission and the management of drug-resistant TB, it was found that the majority of the respondents received training/mentorship in practice after community service (Table 2). For the immediate care for, investigation and management of sexual assault, the majority of respondents received training/ mentorship during community service (Table 2). The majority of the respondents indicated that they had received their training/mentorship at medical school for the pharmaceutical management of epilepsy, the management of depression in adults, the comprehensive management of hypertension and its complications, the comprehensive management of asthma and the investigation and management of diarrhoea in children (Table 2). For the approach and management of high blood pressure and pre-eclampsia in pregnancy, and the comprehensive management of Type I and Type II diabetes mellitus, the majority of the respondents indicated that they received training/ mentorship during their internships (Table 2). There were more respondents who completed their Table 1. District and number of years practising District Thabo Mofutsanyana Tshwane uMgungundlovu OR Tambo Gert Sibande Dr Kenneth Kaunda Vhembe UMzinyathi Total Number of years working after CS 0 - 2 years 3 - 5 years â&#x2030;Ľ6 Total

n (%) 9 (12.5) 10 (13.9) 10 (13.9) 7 (9.7) 15 (20.8) 6 (8.3) 12 (16.7) 3 (4.2) 72 n (%) 19 (26.8) 26 (36.6) 26 (36.6) 71

Prevention, investigation and management of HIV and STIs Medical school During internship During community service In practice after community service Reduction of mother-to-child HIV transmission Medical school During internship During community service In practice after community service Immediate care, investigation and management of sexual assault Medical school During internship During community service In practice after community service Management of drug-resistant TB Medical school During internship During community service In practice after community service Investigation and management of diarrhoea in children Medical school During internship During community service In practice after community service Comprehensive management of asthma Medical school During internship During community service In practice after community service Comprehensive management of hypertension and its complications Medical school During internship During community service In practice after community service Comprehensive management of Type I and Type II diabetes mellitus Medical school During internship During community service In practice after community service Management of depression in adults Medical school During internship During community service In practice after community service Pharmaceutical management of epilepsy Medical school During internship During community service In practice after community service Approach and management of high blood pressure and preeclampsia in pregnancy Medical school During internship During community service In practice after community service

n (%) 12 (17.9) 13 (19.4) 12 (17.9) 30 (44.8) 5 (7.5) 16 (23.9) 10 (14.9) 36 (53.7) 12 (17.9) 10 (14.9) 29 (43.3) 16 (23.9) 6 (9.0) 12 (17.9) 16 (23.9) 33 (49.3) 21 (31.3) 19 (28.4) 13 (19.4) 14 (20.9) 21 (31.3) 18 (26.9) 17 (25.4) 11 (16.4) 19 (28.4) 17 (25.4) 18 (26.9) 13 (19.4) 17 (25.4) 21 (31.3) 16 (23.9) 13 (19.4) 25 (37.3) 17 (25.4) 16 (23.9) 9 (13.4) 23 (34.3) 21 (31.3) 14 (20.9) 9 (13.4)

19 (28.4) 21 (31.3) 13 (19.4) 14 (20.9)

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2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

5 4 3.94

Comprehensive management of Type I and Type II diabetes mellitus

3.39

3.60

3.61

Approach to and management of high blood pressure and pre-eclampsia in pregnancy

3.93

Pharmaceutical management of epilepsy

3.96

Management of depression in adults

3.79

Comprehensive management of hypertension and its complications

2.94

Comprehensive management of asthma

3.19

Investigation and management of diarrhoea in children

3.31

Reduction of HIV mother-to-child transmission

3.94

Management of drug-resistant TB

Prevention, investigation and management of HIV and STIs

Mean self-reported personal competency score per priority clinical condition

1981

2004

2003

2002

Immediate care for, investigation and management of sexual assault

1994

2000

1988

Frequency, n

1995

community service between 2010 and 2014 than those who completed their community service between 1981 and 2009 (Fig. 1). The 11 self-reported personal competency subscales all had high reliabilities and all Cronbach’s α=0.908. For the prevention, investigation and management of HIV and STIs, the mean score was 3.94, meaning that the majority of the respondents felt that they were competent, but also open to improve their knowledge about these clinical conditions (Fig. 2). Similarly, the mean score for the reduction of mother-to-child HIV transmission was 3.81, and for the investigation and management of diarrhoea in children it was 3.79, meaning that the majority of the respondents also felt that they were competent but willing to improve their knowledge for these two clinical conditions (Fig. 2). Also, the mean scores for the comprehensive management of hypertension and its complications, asthma, Type I and Type II diabetes mellitus, high blood pressure and pre-eclampsia in pregnancy were 3.93, 3.96, 3.94, 3.60, and 3.61, respectively (Fig. 2). This indicates that the majority of respondents perceive themselves as competent in these five clinical conditions, but would value further knowledge. 9 9 Low mean scores were recorded 8 for the immediate 8 7 care, investigation and management of sexual assault 6 (3.19) and for the management5 of depression in adults (3.39) (Fig. 2). These scores indicate that the majority 3 of the respondents feel that they can deal with these 2 2 2 2 2 clinical conditions but would value further training. 1 1 The lowest mean score of all the clinical conditions was for the management of drug-resistant TB, with a score of 2.94 (Fig. 2). This indicates that the majority of Year in which community was completed respondents feel service that they can deal with the clinical

l competency score

Fig. 1. Mean self-reported competency scores. Rating: 5 = fully competent; 4 = competent; 3 = can deal with condition; 2 = not fully comfortable; 1 = uncomfortable

5 4.5

July 2017 4 3.5

y = –0.0079x + 3.6873 2

condition, but would value further training in the management of drug-resistant TB. An overall score was calculated for all the respondents who answered this section of the questionnaire (n=68). The overall score was 3.64 out of a maximum of 5. This score indicates that the average respondent felt that he/she was competent in all of the priority clinical conditions but was also open to improving his/her knowledge. A regression analysis between the number of years practising after community service and the mean self-reported competency rating score indicated that no significant relationship exists between these two variables, as the number of years practising after community service only accounts for 0.45% of the variation in the mean self-reported competency rating score, F(1, 66)=0.293, p=0.59 for a confidence level of 95% and an R2 of 0.0045 (Fig. 3). It was found under each priority clinical condition that the respondents’ reasons for not acquiring full competency were insufficient exposure to the clinical condition, insufficient training, or a combination of both.

Conclusion The fact that the regression analysis revealed that 99.6% of the variation in the mean self-reported competency rating score cannot be explained by the number of years practising after community service means that there must be other variables that have a greater influence on the respondents’ self-reported competencies. This finding is partly supported by the qualitative accounts of the medical practitioners; not all of them felt that they were sufficiently exposed to the clinical conditions, and therefore the number of years of experience as an independent variable has a negligible influence on their self-perceived competencies. It is recommended that an objective assessment of the medical practitioners’ competencies should be conducted and compared with the subjective self-reported competencies. Such an assessment should provide a more accurate indication of knowledge or competency. It is imperative that health-science training at both undergraduate and postgraduate levels that ensures the acquisition of high levels of competence in dealing with the core elements contributing to the high burden of disease is strengthened. However, as expected, the greatest experience in dealing with the above core diseases is acquired in the work-based learning experiences of medical prac titioners, particularly during and following community service. This is suggested for two of the disease entities with the lowest mean scores, which fell below the

1981

1988

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2 2

2014

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5 4 3 3.94

3.94

3.39 8

9 3.60 93.61 8

Year in which community service was completed

2013 to and management of Approach high blood pressure and pre-eclampsia 2014 in pregnancy

2011 Pharmaceutical management 2012 of epilepsy

Management of depression in adults

2010

3.93

2007 Comprehensive management of hypertension and its complications 2008 Comprehensive management of Type 2009 I and Type II diabetes mellitus

Investigation and management 2004 of diarrhoea in children 2005 Comprehensive management 2006 of asthma

3.96

3.79

2.94

Immediate care for, investigation 2000 and management of sexual assault 2002 Management of drug-resistant TB 2003

1981 Prevention, investigation and 1988 management of HIV and STIs

3.19

Reduction of HIV mother-to-child transmission 1995

3.31

1994

1.5

3.93

3.94

3.39

3.60

3.61

Approach to and management of high blood pressure and pre-eclampsia in pregnancy

3.96

Pharmaceutical management of epilepsy

2.5

3.79

Management of depression in adults

2.94

Comprehensive management of Type I and Type II diabetes mellitus

3.5

3.19

Comprehensive management of hypertension and its complications

3.31

Comprehensive management of asthma

3.94

Investigation and management of diarrhoea in children

Management of drug-resistant TB

4.5

Reduction of HIV mother-to-child transmission

Immediate care for, investigation and management of sexual assault

Prevention, investigation and management of HIV and STIs

Mean self-reported personal competency score Mean self-reported personal competency score per priority clinical condition

Fig. 2. Mean self-reported personal competency score per priority clinical condition.

y = â&#x20AC;&#x201C;0.0079x + 3.6873 R2 = 0.0045

10 11 12 13 14 15 16 17 18 19 20

Years practising after community service, n

Fig. 3. Scatterplot with regression line. Acknowledgements. The Evaluation Unit of the Foundation for Professional Development was instrumental in crafting the web5 based questionnaire and its hosting by the LimeSurvey. 4.5 Author contributions. Dr E A Holland, as co-ordinator of 4 the project, was responsible for the conceptualisation of the y = â&#x20AC;&#x201C;0.0079x + 3.6873 3.5 competency assessment. Mr C P Louwrens was responsible for R2 = 0.0045 the analysis of data and the interpretation and write-up of the 3 results. Mr D H Olivier assisted with the development of the 2.5 electronic data-collection tool, preliminary data analysis and 2 interpretation of results. 1.5 Funding. Funding for the evaluation of the competencies of the1 medical practitioners, as well as the publication of 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 the findings, was provided by the Foundation for ProfesYears practising after community service, n sional Development. Mean self-reported personal competency score

average score of 3.64 for all the conditions surveyed. These were the immediate care for, investigation and management of sexual assault, with a mean score of 3.19, where 77.2% of respondents indicated that they had received their training during community service and in practice after community service, and the management of drug-resistant TB, with a mean score of 2.94, and where only 26.9% indicated that they had received their training at medical school or during internship. This indicates a need for a special focus on these conditions by medical schools, so that medical practitioners are well-grounded in the management of these conditions of national importance in healthcare. This is in contrast to the third clinical condition with a mean score below the mean overall score of 3.64: the management of depression in adults. Unlike the first two conditions mentioned above, here 62.75% of respondents indicated that they received their training in medical school and during their internship, with only 36% indicating that they acquired their training during community service or in practice after community service. This uncertainty is probably related to the finding that less than 50% of patients with major depression are recognised by the primary-care physician and given an appropriate diagnosis.[4] The above finding suggests that continuity of training is essential for practitioners involved in primary healthcare, and that the role of the district clinical management teams as indicated in Section 4.2.4 of the NDoH humanresources strategy is paramount in ensuring that the gaps in knowledge and competencies are identified and effectively addressed.[1] This will also facilitate the safety and efficiency of the functioning of the referral mechanisms between the various levels of the health service. The efficient organisation of the functioning teams will be an essential feature for the success of the much-anticipated full rollout of the NHI initiative.[2] Effective monitoring of the participation of all medical professionals in continuous professional development remains a high priority for the maintenance of satisfactory levels of knowledge and competencies of medical practitioners. The content of all these programmes should keep abreast with recent developments in the field, including the value and cost-effectiveness of new technologies, as well as with any revisions to national health policy priorities and protocols of care.

Frequency, n Mean self-reported personal competency score per priority clinical condition

Year in which community service was completed

1. National Department of Health, South Africa. Human Resources for Health South Africa. HRH Strategy for the Health Sector: 2012/2013 - 2016/2017. 2011.

Study limitations The study focused specifically on the self-reported training needs of the medical practitioners, and no objective assessments were conducted to test their competencies or knowledge.

http://www.gov.za/sites/www.gov.za/files/hrh_strategy_0.pdf (accessed 30 March 2016). 2. National Department of Health. National Health Insurance for South Africa. Towards Universal Health Coverage. Government Gazette Number 39506. 2015. https://www.gov.za/sites/www.gov.za/files/39506_gon1230.pdf (accessed 29 March 2016).

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3. National Department of Health. Strategic plan 2014/2015 - 2018/2019.

4. Simon GE, Goldberg D, Tiemens BG, Ustun TB. Outcomes of recognized and

2014. https://www.health-e.org.za/wp-content/uploads/2014/08/SA-DoH-

unrecognized depression in an international primary care study. Gen Hosp

Strategic-Plan-2014-to-2019.pdf (accessed 30 March 2016).

Psychiat 1999;21(2):97-105. https://doi.org/10.1016/S0163-8343(98)00072-3

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Progress of the municipal ward-based primary healthcare outreach teams in Vhembe, Limpopo Province P Sodo, BDT, Comm Dent, MPH; A Bosman, BComm (Fin Man), HED, BCom Hons (Acc), ACHM Programme Evaluation Unit, Foundation for Professional Development, Pretoria, South Africa Corresponding author: P Sodo (pumlasodo5@gmail.com)

Background. The primary healthcare (PHC) re-engineering strategy aims to strengthen the delivery of PHC services in the context of the National Health Insurance system. It repositions a curative, individually orientated system towards a proactive, integrated and population-based approach to service delivery, based on municipal wardbased primary healthcare outreach teams (MWBPHCOTs). Objectives. To determine the progress and effectiveness of MWBPHCOTs in Vhembe, Limpopo Province, in the financial year 2014/2015. Methods. Using a mixed-methods approach, document review and analysis of the existing district health information system (DHIS), MWBPHCOTs data were collected from all the four subdistricts of Vhembe. Results. The results of the rapid assessment reported that a total of 151 MWBPHCOTs were operational in the 4 sub-districts of Vhembe. A total of 75 team leaders and 554 community health workers have been trained since the inception of the programme. The results of the assessment also reported that 71Â 413 household visits were conducted in the financial year 2014/2015. The evidence showed that the programme contributed to strengthening linkages to other sectors and departments through a referral system. Conclusion. Overall, the DHIS data analysis provided evidence that the programme is achieving its set target, although there are still some problems in implementation, such as the dual roles played by the outreach team leaders and community health workers. Strengthen Health Syst 2017;2(1):18-22. DOI: 10.7196/SHS.2017.v2.i1.34

South Africa (SA) is plagued by four clear health problems that have been described as the quadruple burden of disease:[1] HIV/AIDS and TB; maternal, infant and child mortality; non-communicable diseases; and injury and violence. Rates of death and disability remain unacceptably high across the country and especially in more deprived zones, such as Limpopo Province in general and Vhembe District in particular. Access to healthcare is a major concern in SA, particularly in rural communities where there is poverty. There is still inequality in access to healthcare despite post-apartheid health policy to increase the number of health facilities. Although health services are provided free of charge, monetary and time costs of travel to a local clinic may pose a significant barrier for vulnerable segments of the population, leading to overall poorer

health outcomes.[2] Most poor communities reside far from health facilities, and are therefore faced with challenges when it comes to travel costs to the health facilities. This results is low utilisation of healthcare facilities in poorer communities. Although different strategies have been implemented to address this particular challenge in SA, there is still a need for more new approaches to achieve equitable access to healthcare, especially in rural communities. Achieving equitable universal health coverage requires the provision of accessible, necessary services for the entire population, without imposing an unaffordable burden on individuals or households. Following a visit to Brazil by the minister of health and MECs in 2010, the vision of re-engineering primary healthcare (PHC) was discussed. This was the lesson

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learnt from the Brazilian health system, where they were able to improve health outcomes through wardbased outreach teams. Following the discussions, the three-stream approach to PHC re-engineering was adopted by the Department of Health (DOH). The PHC re-engineering strategy aims to strengthen the delivery of PHC services, in the context of the National Health Insurance (NHI) system. PHC re-engineering repositions a curative, vertical, individually orientated system to a proactive, integrated, and population-based approach to service delivery, based on municipal ward-based primary healthcare outreach teams (WBPHCOTs) that include community health workers (CHWs) and homebased carers (HBCs).[3] In 2011, the PHC re-engineering model was launched in SA as a response to the government’s commitment to ‘strengthening the effectiveness of the health system’ by promoting cost-effective PHC services that are delivered close to communities and households and that encourage health promotion, prevention and community involvement.[4] The PHC re-engineering model is divided into three streams: WBPHCOTs, school health teams and district-based clinical specialist teams. The WBPHCOT stream in the PHC re-engineered model denotes the level of the health service that provides services to communities, families and individuals in a ward. In order to improve access and health outcomes, and to take health services to the community, the national policy has outlined that communities (wards) should have at least one PHC outreach team comprising a professional nurse, an environmental health officer, health promoters and 6 - 10 CHWs.[3] The nurse who is the team leader is a staff member at a PHC clinic. The Vhembe health district operates within SA's district health system (DHS), which is based on the PHC approach, aimed at keeping people healthy and caring for them when they become unwell. Positive outcomes such as increased life expectancy have been observed, but intervention efforts and the significant allocation of resources over the past 20 years through the DHS have not succeeded in strengthening PHC as much as is needed.[5] Vhembe district started implementing WBPHCOTs towards the end of 2011, when the training of outreach team leaders and CHWs was conducted. The roadshows were also conducted to sensitise communities to the intervention. This was followed by the establishment of wards where WBPHCOTs were implemented. The rapid assessment of the Vhembe WBPHCOTs set out the progress of WBPHCOTs, and also Fig.to1.determine Geographical location

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to determine which aspects of the programme need to be improved.

Methodology Study design The cross-sectional rapid assessment used quantitative methods. The data sources included a document review of quarterly reports and a district health information system (DHIS) data analysis. The rapid assessment focused on the four Vhembe subdistricts (Fig. 1).

Data collection An initial stakeholder planning meeting was held where topics such as the implementation of the WBPHCOT programme, the purpose of the assessment and possible data sources were discussed. The rapid assessment started on 15 February 2016 and ended on 15 April 2016. The Vhembe department of health (DoH) supplied the Foundation for Professional Development (FPD) with WBPHCOT paper-based data that were collected from households in Makhado, Mutale, Musina and Thulamela, quarterly reports and access to DHIS data. The assessment team then extracted the ward-based outreach teams (WBOT) indicators from the DHIS data.

Data analysis The quantitative data obtained from the DHIS dataset were analysed descriptively using SPSS version

A Fig. 1. Geographical location

B Fig. 1. Geographical location of Limpopo Province, South Africa (A) and the four Vhembe subdistricts (B).

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16 to produce frequencies and percentages of the implementation indicators and outcome indicators where possible.

Ethics approval Ethical clearance was obtained from the FPD research ethics committee (ref. no. 1/2016) and the assessment initiation document, and the final scope of assessment was signed by both FPD and the Limpopo provincial DoH.

Results Document review According to the draft WBPHCOT policy framework and strategy (2015), each ward-based outreach team has a target of reaching 1 500 households per annum. All the team members are delegated; however, they are not fully employed for WBOT purposes. The duty of outreach team leaders (OTLs) is delegated to professional nurses who are fulltime nurses in the facilities, while the duties of CHWs are delegated to HBCs, who are employed fulltime by the non-profit organisations (NPOs) to perform HBCs’ duties. The results of the assessment reported challenges in terms of resources such as stationery, equipment batteries and transport to conduct household visits. As of February 2016, there were a total of 804 538 households registered in Vhembe district, and a total of 151 teams across 97 wards within the district (Table 1). A total of 554 community health workers were trained, and a total of 75 OTLs had been trained since the inception of the programme in Vhembe (Table 1). Table 1. Vhembe ward-based outreach teams Households Subdistrict Wards, n registered, n Makhado A Makhado B Thulamela A Thulamela B Mutale Musina TOTAL

DHIS data Secondary data that were analysed looked at WBOT indicators that were extracted from the DHIS for the financial year 2014/2015, which was being assessed. A total of 71 413 households were visited in the year 2014/2015, of which 36 796 were follow-up visits. Out of 71 413 households visited, only 2 158 households visits were supervised by outreach team leaders. (Table 2). A total of 23 539 visits were conducted to households with children <5 years old, while 20 038 visits were conducted to households with clients who needed adherence support and 9 337 visits were conducted to households of clients with home-based care. A total of 3 095 household members were referred to facilities, social services or home-based care. A total of 1 354 clients were referred to the facility while 1 119 were referred to home-based care, and 623 were referred to the social services. A total of 181 421 headcount household visits were conducted, of which 29 457 were of children <5 years old, while the rest were of children ≥5 years. A total of 412 campaigns were conducted between the financial years 2014 and 2015.

Discussion The use of delegated human resources is unrealistic because it affects the supervision of the programme. The results of the assessment reported that the professional nurses who work full time in the facilities are delegated to perform the OTL’s duties, but they do not have enough time to go out and support the teams due to gross staff shortages in the facilities.

220 340 277 498 76 231 197 114 31 331 2 024

18 20 16 24 13 6

Functional teams, n 29 19 42 42 17 2

804 538

151

CHWs trained, n 119 101 126 117 82 9

Team leaders trained, n

554

22 19 2 19 11 2

CHWs = community health workers.

Table 2. Household visits Indicator HH CHW supervised by team leaders O OHH follow-up visit OHH supervised visit OHH visits total

2014 total 1 209 10 311 782 30 083

2015 total 2 140 26 485 1 376 41 330

2014 & 2015 total 3 349 36 796 2 158 71 413

OHH = outreach household.

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Table 3. Types of household visited Indicator OHH with pregnancy care OHH with postnatal care OHH with child under 5 years care OHH with adherence support OHH with home based care

2014 Total 928 778 9 953 8 015 3 993

2015 Total 1 321 1 777 13 586 12 023 5 344

2014 & 2015 Total 2 249 2 555 23 539 20 038 9 337

OHH = outreach household.

Table 4. Referrals Indicator

2014 Total

2015 Total

2014 & 2015 Total

OHH client refer to facility

748

606

1Â 354

OHH client refer to social services

259

364

623

OHH client refer to home-based care

471

648

1 119

OHH back-referral form

439

500

939

Indicator

2014 Total

2015 Total

2014 & 2015 Total

OHH headcount under 5 years

11 669

17 788

29 457

OHH headcount 5 years and older

72 205

79 759

151 964

OHH head count total

83 874

97 547

181 421

OHH = outreach household.

Table 5. Headcount

OHH = outreach household.

Table 6. Support groups and campaigns Indicator

2014 Total

2015 Total

2014 & 2015 Total

OHH support group

1 078

773

1 851

OHH campaign

298

114

412

OHH = outreach household.

Jinabhai et al.[6] reported that retired nurses and/ or enrolled nurses were often appointed to provide leadership of the WBOTs. In some cases, available staff members in facilities were also allocated double tasks. This strategy is not sustainable even in the short term. Nxumalo and Choonara[7] reported that in the Emfuleni subdistrict of Sedibeng, the DoH team managers often did not have control over the CHWs working in the WBOTs, as the CHWs are employed by NGOs. The fact that the CHWs are employed by NGOs also limits the DoH in allocating CHWs to teams. Whyte[8] further reported that WBOTs in Ekurhuleni often lacked sufficient knowledge to conduct household visits. In the case of unimmunised children, only 29% were followed up appropriately. Lack of supervision and poor knowledge were identified as some of the challenges experienced by WBOTs in Ekurhuleni.

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The results of the assessment further reported challenges in resources used for household visits. These include stationery, equipment batteries, and transport. This indicates poor planning and the lack of a budget for WBOTs. It affects the proper implementation of the programme and might result in poor outcomes. The report by Jinabhai et al.[6] also confirmed that the required infrastructure and office equipment are often not available to support the WBOTs in performing their duties. The results of the analysis of DHIS indicators for WBOTs showed evidence of the effectiveness of WBOTs in the implemented wards, although it did not show the impact of the programme. The impact can only be seen when these indicators are combined with facility-based indicators such as early antenatal bookings, retention in care and immunisation coverage. Paper-based forms and lists are used in all the districts, except for the Northern Cape and Tshwane.[6] This restricts the WBOTs in their service delivery and the distribution of data. If such data could be combined with other indicators, it would strengthen planning and decision-making processes. Padayachee et al.[9] state that the assessment of WBOTs in the North West Province will only be possible in combination with the assessment of facility-based indicators, which are sensitive to community-based action. The indicators should be reviewed regularly at subdistrict and district level. Pillay and Baron[10] confirmed the lack of a link between community-based services and the services offered by fixed health facilities. The integration of data and services would increase the quality of care provided at these facilities. The results of the assessment displayed openness to partnerships, although there was resistance in some sectors. This is based on the referral-form completion rate of 30%, which is very low in comparison to the referrals done. Â This calls for more engagement of all stakeholders to strengthen partnerships and referral linkages. The Centre for Health Policy at the University of the Witwatersrand did, however, report on the difficulties in ensuring collaboration between provincial and local government,[10] and claimed that such difficulties could affect implementation and service delivery.

Study limitations The assessment had to be conducted in a short period of time, and therefore the impact of the project could not be measured.

Conclusion The DHIS data have shown evidence that the WBPHCOTs are reaching households in the communities, despite

ARTICLE the reported challenges in terms of human resources, transport and supplies. A total of 804 538 households were reached by 151 teams in 97 wards since the inception of the intervention. Besides the profiling of the households, a total of 3 095 household members were identified and referred to facilities, social services or home-based care during the financial year 2014/2015. The service provided by the WBPHCOTs could be improved even further if co-operation between the various partners and sectors were optimised. This should in turn solve the problems related to infrastructure and consumables. Acknowledgements. We thank the Limpopo Department of Health for giving us the opportunity to conduct this assessment. We also thank the Vhembe department of health personnel for their participation and assistance throughout the assessment. Disclaimer. The findings and conclusions in this paper are those of the authors and do not represent the official position of the Foundation for Professional Development. Author contributions. Both authors made substantial contributions to conception and design, and/or the acquisition of data, and/or the analysis and interpretation of data. Funding. The assessment was funded by the Department of Health. Conflict of interest. None.

1. Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: Historical roots of current public health challenges. Lancet 2009;374:817-834. https://doi.org/10.1016/s0140-6736(09)60951-x 2. McLaren Z, Ardington C, Leibbrandt M. Distance as a barrier to health care access in South Africa. June 2013. A Southern Africa Labour and Development Research Unit Working Paper Number 97, Cape Town: SALDRU, University of Cape Town. 3. National Department of Health. An Investment Case for Ward-Based Primary Health Care Outreach Teams: Draft document. Pretoria: National Department of Health, 2016. 4. National Department of Health. Re-engeneering Primary Health Care in South Africa Discussion Document. Pretoria: National Department of Health, 2010. 5. Massyn N, English R, McCracken P, Ndlovu N, Gerritsen A. Disease profile for Vhembe Health District, Limpopo. Health Systems Trust, 2015. 6. Jinabhai CC, Marcus TS, Chaponda A. Rapid appraisal of ward-based outreach teams. http://www.up.ac.za/media/shared/62/COPC/COPC%20 Reports%20Publications/wbot-report-epub-lr-2.zp86437.pdf (accessed 15 November 2016). 7. Nxumalo N, Choonara S. A rapid assessment of ward based PHC outreach teams in Gauteng Sedibeng District â&#x20AC;&#x201C; Emfuleni sub-district. University of the Witwatersrand, 2014. 8. Whyte C. Implementation of the ward based primary health care outreach teams in the Ekurhuleni health district: A process evaluation. PhD thesis. Johannesburg: University of the Witwatersrand, 2015. 9. Padayachee T, Chetty N, Matse M, Mampe T, Schneider H. Progress in the establishment of Ward-based Outreach Teams: Experience in the North West Province. North West: Health Systems Trust, 2013. 10. Pillay Y, Baron P. The implementation of PHC re-engineering in South Africa. Public Health Association of South Africa (PHASA) Conference, Bloemfontein, South Africa, 2011. http://www.phasa.org.za/articles/theimplementation-of-phc-re-engineering-in-southafrica.html. (accessed 14 November 2016).

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PUBLIC HEALTH NOTEBOOK

Public health biostatistics notebook B V Girdler-Brown, FCPHM (SA), FFPH (UK), MMed (Community Health), MB ChB, MBA, Hons BCom (Econ) School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria, South Africa Corresponding author: B V Girdler-Brown (brendangirdlerbrown@gmail.com) Strengthen Health Syst 2017;2(1):23. DOI:10.7196/SHS.2017.v2.i1.53

The intention for this section is to make a space available for peer-reviewed articles that contribute to biostatistical awareness and skilling for public health practitioners. It is directed at a range of different levels. The idea is not to publish research articles under this heading, but rather to print notes, comments, tutorials, news etc. to do with applied biostatistical practice among public health practitioners. Articles may vary in length between 1 000 and 10 000 words. A single edition may include one longer article, or it may include a number of shorter articles (from the same author(s) or from different contributors). There is a growing number of experienced biostat isticians in southern Africa who would be able to assist the journal with occasional articles that would be suitable for this section. In addition, it is planned to invite local as well as international experts (especially those who have been involved with assisting southern African researchers in the past) to contribute on specific topics. If a reader is planning an article, please contact the editor of the journal to ensure that the topic planned is not already being addressed by someone else. In addition, the editor would welcome suggestions for future topics, as well as suggestions as to who would be a good person to approach for an article about the suggested topic. The idea is not to ‘plod’ through the MPH or MMed syllabus, but to provide a range of clear, well-written and authoritative informative articles. Ultimately, after there have been many editions of the journal, these articles, collectively, will provide a resource for the nonstatisticians (and perhaps some statisticians as well) tasked with the analysis of their own data sets, as well as for students preparing for the MPH MMed or College exams. It is anticipated that the journal’s readership will be made up of people with a wide range of statistical

abilities, all the way from those MPH and MMed students who might not have any past exposure to statistics learning to those with higher degrees in statistics. Therefore, the range of articles that will be accepted for publication will be wide as well. Since the intention is to offer skilling opportunities through the articles that are published, it would be useful if articles also include statistical software commands to assist readers with applying the content. The following list contains some suggestions for articles that might be considered appropriate for this section of the journal. The list is provided in order to give potential authors an idea of just how wide the scope might be, as well as the range of sophistication that would be acceptable. It is obviously not complete, and is not intended as a shopping list. • Moving data efficiently between software packages • Setting up a questionnaire in EpiData • Getting started with R • Using different statistical packages to switch between wide and long data formats • A tutorial on the principles of hypothesis testing • Estimating Bayesian credible intervals • Examples of free sample-size estimation software packages • Determination of sample size for logistic regression • Sample-size determination for ANOVA (or a Bland and Altman plot etc…) • A tutorial on methods of imputation for missing data • A tutorial on analysis of data obtained from a survey with complex sampling • Introduction to graphics with Stata (or with R) • A tutorial on propensity score-matching. Suggestions and contributions will be welcome. The first contribution will be an overview of hypothesis testing for the difference between two population means, along with Stata commands.

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