Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

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Abstract

In 2011, South Africa implemented a policy to decentralize treatment for rifampin-resistant tuberculosis (TB) to reduce durations of hospitalization and enable local treatment. We assessed policy implementation in Western Cape Province, where services expanded from 6 specialized TB hospitals to 406 facilities, by analyzing National Health Laboratory Service data on TB during 2012–2015. We calculated the percentage of patients who visited a TB hospital <1 year after rifampin-resistant TB diagnosis, the median duration of their hospitalizations, and the total distance between facilities visited. We assessed temporal changes with linear regression and stratified results by location. Of 2,878 patients, 65% were from Cape Town. In Cape Town, 29% visited a TB hospital; elsewhere, 68% visited a TB hospital. We found that hospitalizations and travel distances were shorter in Cape Town than in the surrounding areas.

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The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges

Pren Naidoo, Grant Theron, Molebogeng Rangaka … (2017)

Abstract Background While tuberculosis incidence and mortality are declining in South Africa, meeting the goals of the End TB Strategy requires an invigorated programmatic response informed by accurate data. Enumerating the losses at each step in the care cascade enables appropriate targeting of interventions and resources. Methods We estimated the tuberculosis burden; the number and proportion of individuals with tuberculosis who accessed tests, had tuberculosis diagnosed, initiated treatment, and successfully completed treatment for all tuberculosis cases, for those with drug-susceptible tuberculosis (including human immunodeficiency virus (HIV)–coinfected cases) and rifampicin-resistant tuberculosis. Estimates were derived from national electronic tuberculosis register data, laboratory data, and published studies. Results The overall tuberculosis burden was estimated to be 532005 cases (range, 333760–764480 cases), with successful completion of treatment in 53% of cases. Losses occurred at multiple steps: 5% at test access, 13% at diagnosis, 12% at treatment initiation, and 17% at successful treatment completion. Overall losses were similar among all drug-susceptible cases and those with HIV coinfection (54% and 52%, respectively, successfully completed treatment). Losses were substantially higher among rifampicin- resistant cases, with only 22% successfully completing treatment. Conclusion Although the vast majority of individuals with tuberculosis engaged the public health system, just over half were successfully treated. Urgent efforts are required to improve implementation of existing policies and protocols to close gaps in tuberculosis diagnosis, treatment initiation, and successful treatment completion.

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South Africa’s protracted struggle for equal distribution and equitable access – still not there

Hendrik CJ van Rensburg (2014)

The purpose of this contribution is to analyse and explain the South African HRH case, its historical evolution, and post-apartheid reform initiatives aimed at addressing deficiencies and shortfalls. HRH in South Africa not only mirrors the nature and diversity of challenges globally, but also the strategies pursued by countries to address these challenges. Although South Africa has strongly developed health professions, large numbers of professional and mid-level workers, and also well-established training institutions, it is experiencing serious workforce shortages and access constraints. This results from the unequal distribution of health workers between the well-resourced private sector over the poorly-resourced public sector, as well as from distributional disparities between urban and rural areas. During colonial and apartheid times, disparities were aggravated by policies of racial segregation and exclusion, remnants of which are today still visible in health-professional backlogs, unequal provincial HRH distribution, and differential access to health services for specific race and class groups. Since 1994, South Africa’s transition to democracy deeply transformed the health system, health professions and HRH establishments. The introduction of free-health policies, the district health system and the prioritisation of PHC ensured more equal distribution of the workforce, as well as greater access to services for deprived groups. However, the HIV/AIDS epidemic brought about huge demands for care and massive patient loads in the public-sector. The emigration of health professionals to developed countries and to the private sector also undermines the strength and effectiveness of the public health sector. For the poor, access to care thus remains constrained and in perpetual shortfall. The post-1994 government has introduced several HRH-specific strategies to recruit, distribute, motivate and retain health professionals to strengthen the public sector and to expand access and coverage. Of great significance among these is the NHI Plan that aims to bridge the structural divide and to redistribute material and human resources more equally. Its success largely hinges on HRH and the balanced deployment of the national workforce. Low- and middle-income countries have much to learn from South African HRH experiences. In turn, South Africa has much to learn from other countries, as this case study shows.

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Inequities in access to health care in South Africa.

John E Ataguba, Nonhlanhla Nxumalo, Jane Goudge … (2010)

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. In South Africa, little is known about access barriers to health care for the general population. We explore affordability, availability, and acceptability of services through a nationally representative household survey (n = 4668), covering utilization, health status, reasons for delaying care, perceptions and experiences of services, and health-care expenditure. Socio-economic status, race, insurance status, and urban-rural location were associated with access to care, with black Africans, poor, uninsured and rural respondents, experiencing greatest barriers. Understanding access barriers from the user perspective is important for expanding health-care coverage, both in South Africa and in other low- and middle-income countries.

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Author and article information

Journal

Journal ID (nlm-ta): Emerg Infect Dis

Journal ID (iso-abbrev): Emerg Infect Dis

Journal ID (publisher-id): EID

Title: Emerging Infectious Diseases

Publisher: Centers for Disease Control and Prevention

ISSN (Print): 1080-6040

ISSN (Electronic): 1080-6059

Publication date (Print): March 2021

Volume: 27

Issue: 3

Pages: 728-739

Affiliations

[1]Boston University, Boston, Massachusetts, USA (S.V. Leavitt, K.R. Jacobson, E.J. Ragan, J. Bor, T.C. Bouton, H.E. Jenkins);

[2]Boston Medical Center, Boston (K.R. Jacobson, E.J. Ragan, T.C. Bouton);

[3]University of the Witwatersrand, Johannesburg, South Africa (J. Bor);

[4]Stellenbosch University, Stellenbosch, South Africa (J. Hughes, R.M. Warren);

[5]Brown University, Providence, Rhode Island, USA (T.C. Bouton);

[6]Green Point Tuberculosis Laboratory, Cape Town, South Africa (T. Dolby);

[7]South African Medical Research Council Centre for Tuberculosis Research, Cape Town (R.M. Warren);

[8]Department of Science and Technology–National Research Foundation Centre of Excellence for Biomedical Tuberculosis Research, Cape Town (R.M. Warren)

Author notes

Address for correspondence: Sarah V. Leavitt, Boston University School of Public Health, Department of Biostatistics, Crosstown Bldg, 801 Massachusetts Ave, 3rd Fl, Boston, MA 02118, USA; email: sv1205@ 123456bu.edu

Article

Publisher ID: 20-3204

DOI: 10.3201/eid2703.203204

PMC ID: 7920662

PubMed ID: 33622466

SO-VID: ccc55c93-b1b4-47b2-8786-1374006dfa78

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Decentralized Care for Rifampin-Resistant Tuberculosis, Western Cape, South Africa

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Point-Of-Care Testing for Tuberculosis

Most cited references 24

The South African Tuberculosis Care Cascade: Estimated Losses and Methodological Challenges

South Africa’s protracted struggle for equal distribution and equitable access – still not there

Inequities in access to health care in South Africa.

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