Local level inequalities in the use of hospital-based maternal delivery in rural South Africa

BACKGROUND: There is global concern with geographical and socio-economic inequalities in access to and use of maternal delivery services. Little is known, however, on how local-level socio-economic inequalities are related to the uptake of needed maternal health care. We conducted a study of relative socio-economic inequalities in use of hospital-based maternal delivery services within two rural sub-districts of South Africa. METHODS: We used both population-based surveillance and facility-based clinical record data to examine differences in the relative distribution of socio-economic status (SES), using a household assets index to measure wealth, among those needing maternal delivery services and those using them in the Bushbuckridge sub-district, Mpumalanga, and Hlabisa sub-district, Kwa-Zulu Natal. We compared the SES distributions in households with a birth in the previous year with the household SES distributions of representative samples of women who had delivered in hospitals in these two sub-districts. RESULTS: In both sub-districts, women in the lowest SES quintile were significantly under-represented in the hospital user population, relative to need for delivery services (8% in user population vs 21% in population in need; p < 0.001 in each sub-district). Exit interviews provided additional evidence on potential barriers to access, in particular the affordability constraints associated with hospital delivery. CONCLUSIONS: The findings highlight the need for alternative strategies to make maternal delivery services accessible to the poorest women within overall poor communities and, in doing so, decrease socioeconomic inequalities in utilisation of maternal delivery services. Keywords: Maternal health, Socio-economic inequalities, Access, Maternal delivery servicesWeb of Scienc

Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross sectional study

Background: In low-resource settings, patients’ use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. Methods: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant’s clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. Results: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. Conclusion: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients’ dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.Web of Scienc

Predicting the impact of border control on malaria transmission: a simulated focal screen and treat campaign

Background: South Africa is one of many countries committed to malaria elimination with a target of 2018 and all malaria-endemic provinces, including Mpumalanga, are increasing efforts towards this ambitious goal. The reduction of imported infections is a vital element of an elimination strategy, particularly if a country is already experiencing high levels of imported infections. Border control of malaria is one tool that may be considered. Methods: A metapopulation, non-linear stochastic ordinary differential equation model is used to simulate malaria transmission in Mpumalanga and Maputo province, Mozambique (the source of the majority of imported infections) to predict the impact of a focal screen and treat campaign at the Mpumalanga–Maputo border. This campaign is simulated by nesting an individual-based model for the focal screen and treat campaign within the metapopulation transmission model. Results: The model predicts that such a campaign, simulated for different levels of resources, coverage and take-up rates with a variety of screening tools, will not eliminate malaria on its own, but will reduce transmission substantially. Making the campaign mandatory decreases transmission further though sub-patent infections are likely to remain undetected if the diagnostic tool is not adequately sensitive. Replacing screening and treating with mass drug administration results in substantially larger decreases as all (including sub-patent) infections are treated before movement into Mpumalanga. Conclusions: The reduction of imported cases will be vital to any future malaria control or elimination strategy. This simulation predicts that FSAT at the Mpumalanga–Maputo border will be unable to eliminate local malaria on its own, but may still play a key role in detecting and treating imported infections before they enter the country. Thus FSAT may form part of an integrated elimination strategy where a variety of interventions are employed together to achieve malaria elimination

Modeling the relationship between precipitation and malaria incidence in Mpumalanga, South Africa

Climatic or weather-driven factors such as rainfall have considerable impact on vector abundance and the extrinsic cycles that parasites undergo in mosquitoes. Climate models therefore allow for a better understanding of the dynamics of malaria transmission. While malaria seasons occur regularly between October and May in Mpumalanga, there is considerable variation in the starting point, peak and magnitude of the season. The relationship between rainfall and malaria incidence may be used to better model the variation in the malaria season. As a first step, this study seeks to explore the complex association between rainfall and malaria incidence through time series methods

Assessing the effectiveness of malaria interventions at the regional level in Ghana using a mathematical modelling application

Supporting malaria control with interfaced applications of mathematical models that enables investigating effectiveness of various interventions as well as their cost implications could be useful. Through their usage for planning, these applications may improve the prospects of attaining various set targets such as those of the National Strategic Plan policies for malaria control in Ghana. A malaria model was adapted and used for simulating the incidence of malaria in various regions of Ghana. The model and its application were developed by the Modelling and Simulation Hub Africa and calibrated using district level data in Ghana from 2012 to 2018. Average monthly rainfall at the zonal level was fitted to trigonometric functions for each ecological zone using least squares approach. These zonal functions were then used as forcing functions. Subsequently, various intervention packages were investigated to observe their impact on averting malaria incidence by 2030. Increased usage of bednets but not only coverage levels, predicted a significant proportion of cases of malaria averted in all regions. Whereas, improvements in the health system by way of health seeking, testing and treatment predicted a decline in incidence largely in all regions. With an increased coverage of SMC, to include higher age groups, a modest proportion of cases could be averted in populations of the Guinea savannah. Indoor residual spraying could also benefit populations of the Transitional forest and Coastal savannah as its impact is significant in averting incidence. Enhancing bednet usage to at least a doubling of the current usage levels and deployed in combination with various interventions across regions predicted significant reductions, in malaria incidence. Regions of the Transitional forest and Coastal savannah could also benefit from a drastic decline in incidence following a gradual introduction of indoor residual spraying on a sustained basis

Advancing malaria reactive case detection in a Zambia-like setting: A modeling study

In Zambia-like settings, asymptomatic and clinical carriers not seeking treatment further complicate malaria elimination, making reactive case detection (RCD) essential for identifying undetected infections. However, RCD faces operational hurdles, including resource shortages, logistical challenges, limited community health workers (CHWs), and limitations in availability and sensitive rapid diagnostic tests (RDTs). Prioritizing specific improvement measures is critical to enhance intervention outcomes. A mathematical model of malaria transmission for low-transmission areas (fewer than 200 cases per 1,000 annually) was developed using published data to simulate RCD. This model assessed the impact of potential improvement measures designed to address the identified operational challenges affecting RCD. Improvement measures included increasing CHWs, adjusting response times, improving RDT sensitivity, and incorporating focal mass drug administration (fMDA). A shortage of CHWs and limited availability of RDTs have the most negative impact on RCD’s ability to reduce cases. In scenarios where CHWs or RDT availability for RCD were reduced by 50%, annual cases increased by approximately 22%. Only the incorporation of fMDA as an improvement measure succeeded countering the situation, resulting in a 43% reduction. Increasing CHWs to offset RCD inefficiencies caused by limited RDT sensitivity and difficulties finding individuals reduced cases by approximately 13 and 14%, respectively, reducing more cases than improving reaction time or increasing the screening radius. Although RCD is prone to challenges, the manipulation of improvement measures such as CHWs and fMDA provides promise for RCD to contribute towards malaria elimination. However, the participation of CHWs is voluntary and primarily motivated by informal incentives, often provided by donors. Finding sustainable means to ensure the sufficient availability of CHWs may guarantee continued RCD contributions toward maintaining stable malaria prevalence. More research is required to explore the application of RCD in archetypical transmission areas suitable for RCD as improvement measures to the identified challenges hindering RCD

Operational research (ers) in development: Growing a new generation of operational researchers

This paper explores the theme of training operational research (OR) practitioners in South Africa by critically evaluating a Masters program in Operational Research in Development (ORD), launched in 2005 at the University of Cape Town. This program was specifically focused on applying OR to the problems of the developing world in general and Africa in particular. We describe the program and review the practical work undertaken by students participating in the program. Topics range widely across domains including health (anti-malarial drug resistance); poverty (food banking); governance (NGO management structures and monitoring of local government performance) and sustainable livelihoods (spaza shop operations). We use the review to highlight strengths and weaknesses of the program, as well as challenges faced in the OR education in South Africa at a postgraduate level

Hitting a moving target: a model for malaria elimination in the presence of population movement

Abstract South Africa is committed to eliminating malaria with a goal of zero local transmission by 2018. Malaria elimination strategies may be unsuccessful if they focus only on vector biology, and ignore the mobility patterns of humans, particularly where the majority of infections are imported. In the first study in Mpumalanga Province in South Africa designed for this purpose, a metapopulation model is developed to assess the impact of their proposed elimination-focused policy interventions. A stochastic, non-linear, ordinary-differential equation model is fitted to malaria data from Mpumalanga and neighbouring Maputo Province in Mozambique. Further scaling-up of vector control is predicted to lead to a minimal reduction in local infections, while mass drug administration and focal screening and treatment at the Mpumalanga-Maputo border are predicted to have only a short-lived impact. Source reduction in Maputo Province is predicted to generate large reductions in local infections through stemming imported infections. The mathematical model predicts malaria elimination to be possible only when imported infections are treated before entry or eliminated at the source suggesting that a regionally focused strategy appears needed, for achieving malaria elimination in Mpumalanga and South Africa