BACKGROUND: Irrational medicine use is a global problem that may potentiate antimicrobial resistance AIM: This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators SETTING: The study was conducted in public-sector healthcare facilities in Eswatini METHODS: A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times RESULTS: At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up CONCLUSION: In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing CONTRIBUTION: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use

BACKGROUND: The participation of independent private general practitioners (GPs) is of fundamental importance to the successful implementation of key elements of the proposed National Health Insurance (NHI) reform, notably the contracting units for primary health care (CUPS). This study explored knowledge and perceptions of the NHI reforms of private GPs following the tabling of the NHI Bill in parliament in 2019 METHODS: An explorative qualitative research methodology was adopted. Using a semi-structured guide, nine solo private GPs, purposefully selected to represent the range of practices in the southern peninsula of Cape Town were interviewed in depth by B.L.P. over the period from January 2021 to March 2022 RESULTS: The GPs indicated support for the values of greater equity outlined in the NHI proposals. However, they had little engagement on or knowledge of their potential future roles in NHI. Concerns over financial viability and design were underpinned by an overall mistrust in the public sector to implement and manage NHI CONCLUSION: The study concurs with previous research that private GPs are broadly in support of the principles of, and are potential allies, in advancing NHI. General practitioners need a platform to share their concerns and contribute as co-designers of NHI reforms. In the interim, steps to increase collaboration between private and public sectors at local and provincial level through, for example, referral processes may help to build the trust that is necessary between the sectors CONTRIBUTION: This study foregrounds the role of trust relationships in advancing NHI

BACKGROUND: The progressive realisation of disability inclusion requires political will and commitment, and comprehensive monitoring is necessary to give a clear understanding of what needs to be addressed and to highlight the gaps and barriers to the achievement of social inclusion of people with disabilities. OBJECTIVES: This article uses an existing dataset to present a baseline assessment of inclusion for men and women with no, mild or moderate disability severity and with no or moderate affect difficulties in South Africa. METHODS: An existing dataset, capturing individual-level data for 8499 individuals, collected in 2019 across South Africa was analysed. Variables were utilised to represent aspects of nine domains of disability inclusion, and outcomes were compared using chi-squared tests (with Bonferroni adjustments) for groups categorised by disability severity and gender, and for affect severity and gender. RESULTS: Overall, inclusion levels declined with increasing disability severity, and there were fewer differences in inclusion levels between those with and without affect difficulties than for those with functioning difficulties (as measured using the Washington Group on Disability Statistics' Short Set of six questions on functioning. CONCLUSIONS: The article concludes by discussing several approaches to using the data to design policy responses, each of which results in a different range of domains that may initially be prioritised and targeted.

BACKGROUND: The current roles and capacity of community health workers (CHWs) in the management and control of non-communicable diseases (NCDs) remain poorly understood. OBJECTIVES: To assess CHWs' current roles, training and knowledge about diabetes and hypertension in Khayelitsha, Cape Town. METHODS: A cross-sectional study of 150 CHWs from two non-governmental organisations contracted to provide NCD care as part of a comprehensive package of services was conducted. An interviewer-administered closed-ended questionnaire was used to determine the roles, training, in-service support, knowledge and presence of NCDs. Descriptive analyses of these domains and multivariate analyses of the factors associated with CHWs' knowledge of hypertension and diabetes were conducted. RESULTS: The vast majority (96%) of CHWs were female, with a mean age of 35 years; 88% had some secondary schooling and 53% had been employed as CHWs for 4 years or more. Nearly half (47%) reported having an NCD. CHWs' roles in NCDs included the delivery of medication, providing advice and physical assessment. Only 52% of CHWs reported some formal NCD-related training, while less than half of the trained CHWs (n = 35; 44%) had received follow-up refresher training. CHWs' knowledge of diabetes and hypertension was poor. In the multivariate analyses, higher knowledge scores were associated with having an NCD and frequency of supervisory contact (≥1 per month). CONCLUSIONS: The roles performed by CHWs are broad, varied and essential for diabetes and hypertension management. However, basic knowledge about diabetes and hypertension remains poor while training is unstandardised and haphazard. These need to be improved if community-based NCD management is to be successful. The potential of peer education as a complementary mechanism to formal training needs as well as support and supervision in the workplace requires further exploration.

CONTEXTE: Les agents de santé communautaires (CHW) sont de plus en plus considérés comme un élément capital du personnel de santé en Afrique du Sud et dans d'autres parties du monde. Les CHW assument divers rôles, tels que l'autonomisation des communautés, la prestation de services et le lien entre les communautés et les services de santé. Leurs rôles sont mieux compris dans les domaines de la santé maternelle et infantile et les maladies infectieuses (infection par le VIH, le paludisme et la tuberculose. OBJECTIF: Cette étude examine les rôles actuels des CHW s'occupant des maladies non contagieuses (NCD). CADRE: L'étude a été menée dans un township urbain du Cap, en Afrique du Sud. MÉTHODE: On s'est servi d'une méthode de recherche qualitative et naturaliste qui utilise des observations et des entretiens approfondis avec les CHW et leurs superviseurs travaillant à Khayelitsha. RÉSULTATS: Les CHW ont des rôles multiples pour soigner les NCD. Ils sont éducateurs sanitaires, conseillers, personnel de rééducation et animateurs de groupes de soutien. Ils décèlent les complications de la maladie et aident les membres de la communauté à mieux naviguer dans le système de santé. Ces rôles sont déterminés selon les attentes du système de santé et les réponses aux besoins de la communauté. CONCLUSION: Cette étude indique les complexités des rôles des CHW travaillant avec les NCD. La compréhension des rôles des CHW donne une idée non seulement des compétences requises pour leur permettre de s'acquitter de leurs tâches quotidiennes, mais aussi du type de formation requis pour combler les lacunes actuelles.

BACKGROUND: Community health workers (CHWs) are increasingly being recognised as a crucial part of the health workforce in South Africa and other parts of the world. CHWs have taken on a variety of roles, including community empowerment, provision of services and linking communities with health facilities. Their roles are better understood in the areas of maternal and child health and infectious diseases (HIV infection, malaria and tuberculosis. AIM: This study seeks to explore the current roles of CHWs working with non-communicable diseases (NCDs). SETTING: The study was conducted in an urban townshipin Cape Town, South Africa. METHOD: A qualitative naturalistic research design utilising observations and in-depth interviews with CHWs and their supervisors working in Khayelitsha was used. RESULTS: CHWs have multiple roles in the care of NCDs. They act as health educators, advisors, rehabilitation workers and support group facilitators. They further screen for complications of illness and assist community members to navigate the health system. These roles are shaped both by expectations of the health system and in response to community needs. CONCLUSION: This study indicates the complexities of the roles of CHWs working with NCDs. Understanding the actual roles of CHWs provides insights into not only the competencies required to enable them to fulfil their daily functions, but also the type of training required to fill the present gaps.

The use of private health care providers in low- and middle-income countries (LMICs) is widespread and is the subject of considerable debate. We review here a new model of private primary care provision emerging in South Africa, in which commercial companies provide standardized primary care services at relatively low cost. The structure and operation of one such company is described, and features of service delivery are compared with the most probable alternatives: a private general practitioner or a public sector clinic. In a case study of cost and quality of services, the clinics were popular with service users and run at a cost per visit comparable to public sector primary care clinics. However, their current role in tackling important public health problems was limited. The implications for public health policy of the emergence of this new model of private provider are discussed. It is argued that encouraging the use of such clinics by those who can afford to pay for them might not help to improve care available for the poorest population groups, which are an important priority for the government. Encouraging such providers to compete for government funding could, however, be desirable if the range of services presently offered, and those able to access them, could be broadened. However, the constraints to implementing such a system successfully are notable, and these are acknowledged. Even without such contractual arrangements, these companies provide an important lesson to the public sector that acceptability of services to users and low-cost service delivery are not incompatible objectives.

En los países de ingresos bajos y medianos el recurso a proveedores de asistencia sanitaria privados constituye una práctica generalizada, que es objeto de amplio debate. Examinamos aquí un nuevo modelo de suministro de atención primaria privada surgido en Sudáfrica, en el que empresas comerciales prestan servicios normalizados de atención primaria a un costo relativamente bajo. Se describe la estructura y el funcionamiento de una de dichas empresas, comparando las características de la prestación de servicios con las alternativas más probables: un médico general privado o un dispensario del sector público. Un estudio práctico sobre el costo y la calidad de los servicios reveló que los dispensarios eran populares entre los usuarios de los servicios y tenían un costo por visita comparable al de los dispensarios de atención primaria del sector público. Sin embargo, su contribución al control de problemas importantes de salud pública era limitada. Se examinan las implicaciones para las políticas de salud pública de la aparición de este nuevo modelo de proveedor privado. Se alega que la promoción del uso de tales dispensarios por quienes pueden pagar por ellos quizá no ayude a mejorar la atención disponible para los grupos de población más pobres, que constituyen una prioridad importante para el gobierno. No obstante, si lograra ampliarse el abanico de servicios actualmente ofrecido y el número de personas con acceso a ellos, sería deseable quizá que se alentara a tales proveedores a competir para conseguir financiamiento del gobierno. Sin embargo, las dificultades existentes para implantar con éxito esos sistemas son considerables y reconocidas. Aun sin tales arreglos contractuales, estas empresas suponen una importante lección para el sector público, a saber, que la aceptación de los servicios por los usuarios y la prestación de servicios de bajo costo no son objetivos incompatibles.

Le recours à des dispensateurs de soins de santé privés dans les pays à revenu faible ou intermédiaire est largement répandu et fait l'objet de nombreux débats. Nous examinons ici un nouveau type de dispensation des soins de santé primaire par des prestataires privés, qui fait son apparition en Afrique du Sud, où des sociétés commerciales proposent des services standardisés de soins de santé primaires à un coût relativement bas. L'article décrit la structure et le fonctionnement d'une de ces sociétés et compare les divers aspects des services offerts avec ceux des alternatives les plus probables, à savoir un médecin généraliste du secteur privé ou un dispensaire public. Lors d'une étude de cas portant sur le coût et la qualité des services, les dispensaires privés jouissaient de la faveur des usagers et fonctionnaient avec un coût par visite comparable à celui des dispensaires de soins de santé primaires du secteur public. Le rôle actuel de ces dispensaires dans la prise en charge de problèmes de santé publique importants est cependant limité. Les conséquences de l'émergence de ce nouveau type de prestataires sur les politiques de santé publique sont examinées. Il est souligné qu'en encourageant les personnes qui en ont les moyens à utiliser de tels services, on ne contribue pas nécessairement à améliorer les soins accessibles aux groupes de population les plus pauvres, qui constituent une priorité majeure pour le gouvernement. Il pourrait cependant être souhaitable d'encourager les prestataires privés à solliciter une aide gouvernementale si l'éventail des services offerts, ainsi que la population qui y aurait accès, étaient élargis. On sait toutefois que la réussite de la mise en œuvre d'un tel système se heurte à d'importantes contraintes. Mais, même en l'absence d'accords contractuels, ces sociétés démontrent clairement au secteur public que l'acceptabilité des services par les usagers et la fourniture de services à faible coût ne sont pas des objectifs incompatibles.