Translating research for policy makers and the broader public is a key step in getting research into policy and practice (GRIPP), and is increasingly important for donors.
The Centre for Health Policy in the School of Public Health recently co-hosted a mini-symposium for health service providers and researchers on researching equity in access to health care (REACH) in South Africa.
Nearly 50 delegates from all levels of the Department of Health and local and international academics attended the meeting which aimed to stimulate engagement with district-level health teams to share research findings, discuss and identify research questions, and explore ways for getting more evidence into policy.
Seven presenters showcased results of the five-year REACH project which used maternal deliveries, tuberculosis (TB) and antiretroviral (ARV) services at sub-district level to trace health system equity and access. About 4 000 adults using these tracer services at two rural sites – Hlabisa (KwaZulu-Natal) and Bushbuckridge (Mpumalanga) – and two urban sites – Mitchell’s Plain (Western Cape) and Soweto Region D of Johannesburg (Gauteng) – were involved in the studies which explored socio-economic, race, gender and citizenship factors.
Examining access to TB services, one study found that patients requiring daily, rather than weekly or monthly, clinic treatment collection experienced greater access barriers. This impacted substantially on costs and exhaustion levels due to lengthy distances to clinics. These daily clinic-based patients were twice as likely to report missing a dose in comparison to their counterparts collecting their treatment less frequently, raising challenges for how South Africa’s directly observed treatment (DOTS) policy is implemented.
A study in Bushbuckridge found access to ARV therapy largely improved when patients were down-referred from hospital- to clinic-care. However, clinic-based patients were five times as likely to practice complementary and self healthcare, which impacted on costs: over a quarter spent 15% or more than hospital-based patients on their healthcare, although they reported less stigma and more respect from communities and providers.
Regarding maternal health services, research showed that women overcame considerable affordability, accessibility and acceptability barriers to deliver at facilities. The poorest women were disproportionately not delivering in facilities and strategies are needed to target and include them. For women who do deliver in facilities, “it is where you deliver – and not who you are – that seems to decide the level of clinical care you receive,” said CHP researcher, Loveday Penn-Kekana.
A study in Hlabisa, which uses a decentralised, integrated approach for TB and HIV services, found there was almost universal coverage of HIV testing among TB patients with 94% being offered an HIV test. Those using the closest clinic to their homes were most likely to be offered an HIV test, indicating reduced perception of stigma. However, a higher proportion of ART patients experienced insufficient respect compared to TB patients.
Issues emerging during the discussion included: the importance of social determinants of health, such as the financial burden of accessing care; quality of care at facility-level, including cleanliness, respect and waiting times; and the need for mechanisms to narrow the gap between provider actions and patient expectations of care. The system was seen to fail providers, who in turn, failed patients.
Modise Makhudu, Acting Chief Director for the Johannesburg Health District, commented: “I would like this dialogue to be intensified, and our invitation to these processes be formalised with the Department so that we can engage easily. What most impressed me is that South Africa shows that it is a caring country – if we didn’t care, we wouldn’t have spoken about access to the services. With the coming National Health Insurance, we need to deal with these access issues, and managers including staff need to feel the importance of access as part of the responsiveness to community needs.”
He asked the researchers to examine enabling factors for improving performance at facility level, including norms and standards, and leadership.
The REACH partners are the Centre for Health Policy at Wits University, the Health Economics Unit at the University of Cape Town, McMaster University in Canada, the University of the Western Cape School of Public Health, RADAR at Wits; and the Africa Centre for Health and Population Studies at the University of Kwa-Zulu Natal.