TY - JOUR
T1 - Organisation of care for people receiving drug-resistant tuberculosis treatment in South Africa
T2 - a mixed methods study
AU - Dickson, Lindy
AU - Le Roux, Sacha Roxanne
AU - Mitrani, Leila
AU - Hill, Jeremy
AU - Jassat, Waasila
AU - Cox, Helen
AU - Mlisana, Koleka
AU - Black, John
AU - Loveday, Marian
AU - Grant, Alison
AU - Kielmann, Karina
AU - Ndjeka, Norbert
AU - Moshabela, Mosa
AU - Nicol, Mark
N1 - This study was supported by a Health Systems Research Initiative award
from the Medical Research Council of the United Kingdom and the Wellcome
Trust (MR/N015924/1). This UK funded award is part of the EDCTP2 programme
supported by the European Union. HC is supported by a Wellcome Trust Fellowship.
MN is supported by an Australian National Health and Medical Research Council
Award (APP1174455). No conflicts of interest were reported
Publisher Copyright:
© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.
PY - 2023/11/17
Y1 - 2023/11/17
N2 - OBJECTIVES: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. DESIGN: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. PARTICIPANTS AND SETTING: People identified with MDR/RR-TB from 13 high-burden districts within South Africa. OUTCOME MEASURES: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. RESULTS: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. CONCLUSIONS: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.
AB - OBJECTIVES: Treatment for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) is increasingly transitioning from hospital-centred to community-based care. A national policy for decentralised programmatic MDR/RR-TB care was adopted in South Africa in 2011. We explored variations in the implementation of care models in response to this change in policy, and the implications of these variations for people affected by MDR/RR-TB. DESIGN: A mixed methods study was done of patient movements between healthcare facilities, reconstructed from laboratory records. Facility visits and staff interviews were used to determine reasons for movements. PARTICIPANTS AND SETTING: People identified with MDR/RR-TB from 13 high-burden districts within South Africa. OUTCOME MEASURES: Geospatial movement patterns were used to identify organisational models. Reasons for patient movement and implications of different organisational models for people affected by MDR/RR-TB and the health system were determined. RESULTS: Among 191 participants, six dominant geospatial movement patterns were identified, which varied in average hospital stay (0-281 days), average patient distance travelled (12-198 km) and number of health facilities involved in care (1-5 facilities). More centralised models were associated with longer delays to treatment initiation and lengthy hospitalisation. Decentralised models facilitated family-centred care and were associated with reduced time to treatment and hospitalisation duration. Responsiveness to the needs of people affected by MDR/RR-TB and health system constraints was achieved through implementation of flexible models, or the implementation of multiple models in a district. CONCLUSIONS: Understanding how models for organising care have evolved may assist policy implementers to tailor implementation to promote particular patterns of care organisation or encourage flexibility, based on patient needs and local health system resources. Our approach can contribute towards the development of a health systems typology for understanding how policy-driven models of service delivery are implemented in the context of variable resources.
KW - Health policy
KW - Organisation of health services
KW - Patient-Centered Care
KW - PUBLIC HEALTH
KW - QUALITATIVE RESEARCH
KW - Tuberculosis
UR - http://www.scopus.com/inward/record.url?scp=85177982068&partnerID=8YFLogxK
U2 - 10.1136/bmjopen-2022-067121
DO - 10.1136/bmjopen-2022-067121
M3 - Article
C2 - 37977868
AN - SCOPUS:85177982068
SN - 2044-6055
VL - 13
JO - BMJ Open
JF - BMJ Open
M1 - e067121
ER -