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Decisive and strong leadership and intersectoral action from South Africa in response to the COVID-19 virus
Fonn, Sharon,Nkonki, Lungiswa
- , 2020, DOI: 10.7196/SAMJ.2020.v110i5.14739
Abstract:
Aligning vertical interventions to health systems: a case study of the HIV monitoring and evaluation system in South Africa
Mary Kawonga, Duane Blaauw, Sharon Fonn
Health Research Policy and Systems , 2012, DOI: 10.1186/1478-4505-10-2
Abstract: The study was conducted in one health district in South Africa. Data were collected through key informant interviews with programme and health facility managers and review of M&E records at health facilities providing HIV services. Data analysis assessed the extent to which processes for HIV data collection, collation, analysis and reporting were integrated with the DHIS.The HIV M&E system is top-down, over-sized, and captures a significant amount of energy and resources to primarily generate antiretroviral treatment (ART) indicators. Processes for producing HIV prevention indicators are integrated with the DHIS. However processes for the production of HIV treatment indicators by-pass the DHIS and ART indicators are not disseminated to district health managers. Specific reporting requirements linked to ear-marked funding, politically-driven imperatives, and mistrust of DHIS capacity are key drivers of this silo approach.Parallel systems that bypass the DHIS represent a missed opportunity to strengthen system-wide M&E capacity. Integrating HIV M&E (staff, systems and process) into the health system M&E function would mobilise ear-marked HIV funding towards improving DHIS capacity to produce quality and timely HIV indicators that would benefit both programme and health system M&E functions. This offers a practical way of maximising programme-system synergies and translating the health system strengthening intents of existing HIV policies into tangible action.The purpose of monitoring and evaluation (M&E) is to produce reliable and timely health information and use it to evaluate policy, set priorities, plan, and monitor the effectiveness and impacts of interventions [1,2]. In recent years, many low- and middle-income countries have established dedicated (or vertical) M&E systems for their HIV programmes [3,4]. The anticipated aims of such M&E systems have however not been realised in many countries due to low financial investment in M&E infrastructure, weak or ill-def
Administrative integration of vertical HIV monitoring and evaluation into health systems: a case study from South Africa
Mary Kawonga,Sharon Fonn,Duane Blaauw
Global Health Action , 2013, DOI: 10.3402/gha.v6i0.19252
Abstract: Background: In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes. Objective: To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority. Methods: This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of ‘exercised decision-space’ – traditionally used to measure local level managers’ exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority – classified as ‘low’, ‘medium’ or ‘high’ – over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge. Results: Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority. Conclusions: This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers.
Infant mortality in South Africa - distribution, associations and policy implications, 2007: an ecological spatial analysis
Benn KD Sartorius, Kurt Sartorius, Tobias F Chirwa, Sharon Fonn
International Journal of Health Geographics , 2011, DOI: 10.1186/1476-072x-10-61
Abstract: Infant mortality remains high in South Africa with seemingly little reduction since previous estimates in the early 2000's. Results showed marked geographical differences in infant mortality risk between provinces as well as within provinces as well as significantly higher risk in specific sub-districts and provinces. A number of determinants were found to have a significant adverse influence on infant mortality at the sub-district level. Following multivariable adjustment increasing maternal mortality, antenatal HIV prevalence, previous sibling mortality and male infant gender remained significantly associated with increased infant mortality risk. Of these antenatal HIV sero-prevalence, previous sibling mortality and maternal mortality were found to be the most attributable respectively.This study demonstrates the usefulness of advanced spatial analysis to both quantify excess infant mortality risk at the lowest administrative unit, as well as the use of Bayesian modelling to quantify determinant significance given spatial correlation. The "novel" integration of determinant prevalence at the sub-district and coefficient estimates to estimate attributable fractions further elucidates the "high impact" factors in particular areas and has considerable potential to be applied in other locations. The usefulness of the paper, therefore, not only suggests where to intervene geographically, but also what specific interventions policy makers should prioritize in order to reduce the infant mortality burden in specific administration areas.Despite the Millennium Development Project's aims to reduce infant and child mortality, this problem remains a challenge in sub-Saharan Africa. The infant mortality rate (IMR), moreover, has worsened in many of these countries reversing the gains achieved in the previous century [1][2][3][4][5]. In 1990, for example, there was a 20-fold difference (180 versus 9 deaths per 1000 live births) in IMR between sub-Saharan African and industrializ
Developing a new mid-level health worker: lessons from South Africa's experience with clinical associates
Jane Doherty,Daphney Conco,Ian Couper,Sharon Fonn
Global Health Action , 2013, DOI: 10.3402/gha.v6i0.19282
Abstract: Background: Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008. Objective: We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker. Methods: We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed. Results: Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards. Conclusions: This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives.
Workforce Resources for Health in Developing Countries
Bangdiwala Shrikant,Fonn Sharon,Okoye Osegbeaghe,Tollman Stephen
Public Health Reviews , 2010,
Abstract: With increased globalization and interdependence among countries, sustained health worker migration and the complex threats of rapidly spreading infectious diseases, as well as changing lifestyles, a strong health workforce is essential. Building the human resources for health should not only include healthcare professionals like physicians and nurses, but must take into consideration community health workers, mid-level workers and strengthened primary healthcare systems to increase coverage and address the basic health needs of societies. This is especially true in low and middle-income countries where healthcare access is a critical challenge.There is a global crisis in the health workforce, expressed in acute shortages and maldistribution of health workers, geographically and professionally. This massive global shortage, though imprecise quantitatively, is estimated at more than 4 million workers. To respond to this crisis, policies and actions are needed to address the dynamics of the health labour market and the production and management of the health workforce, and to strengthen the performance of existing health systems. Schools of public health need to develop the range of capacity and leadership in addition to the traditional training of healthcare managers and researchers. Countries should first identify their health problems in order to properly address their health worker needs, retention, recruitment and training, if they are to come close to reaching the Millennium Development Goals (MDGs) for health.
Investing in African research training institutions creates sustainable capacity for Africa: the case of the University of the Witwatersrand School of Public Health masters programme in epidemiology and biostatistics
Ronel Kellerman, Kerstin Klipstein-Grobusch, Renay Weiner, Steven Wayling, Sharon Fonn
Health Research Policy and Systems , 2012, DOI: 10.1186/1478-4505-10-11
Abstract: A descriptive cross-sectional survey of the 70 students registered for the masters programme in epidemiology & biostatistics from 2000-2005 was conducted. Data were collected from self-administered questionnaires.Sixty percent (42/70) of students responded. At the time of the survey 19% of respondents changed their country of residence after completion of the masters course, 14% migrated within Africa and 5% migrated out of Africa. Approximately half (47%) were employed as researchers and 38% worked in research institutions. Sixty percent reported research output, and four graduates were pursuing PhD studies. Government subsidy to higher education institutions, investments of the University of the Witwatersrand in successful programmes and ongoing bursaries for students to cover tuition fees were important for sustainability.Investing in African institutions to improve research training capacity resulted in the retention of graduates in Africa in research positions and produced research output. Training programmes can be sustained when national governments invest in higher education and where that funding is judiciously applied. Challenges remain if funding for students bursaries is not available.The African region carries a high and disproportionate burden of the world's health problems but finding appropriate solutions to them is complex [1]. One of the contributing factors is a lack of African research capacity to conduct local, relevant research [2,3]. Africa demonstrates an uneven geographical spread of research capacity, and there is a dearth of published research done in Africa for Africa [4]. Only 0.1-0.2% of research articles published in the top 50 biomedical journals between 1995 and 2002 had an African first author [5] and only 1.7 - 7.7% of articles published in the six highest ranking journals on tropical medicine from 2000-2002 were generated exclusively by scientists from countries with a low human development index [6]. Strengthening the research ca
Building capacity for public and population health research in Africa: the consortium for advanced research training in Africa (CARTA) model
Alex C. Ezeh,Chimaraoke O. Izugbara,Caroline W. Kabiru,Sharon Fonn
Global Health Action , 2010, DOI: 10.3402/gha.v3i0.5693
Abstract: Background: Globally, sub-Saharan Africa bears the greatest burden of disease. Strengthened research capacity to understand the social determinants of health among different African populations is key to addressing the drivers of poor health and developing interventions to improve health outcomes and health systems in the region. Yet, the continent clearly lacks centers of research excellence that can generate a strong evidence base to address the region's socio-economic and health problems. Objective and program overview: We describe the recently launched Consortium for Advanced Research Training in Africa (CARTA), which brings together a network of nine academic and four research institutions from West, East, Central, and Southern Africa, and select northern universities and training institutes. CARTA's program of activities comprises two primary, interrelated, and mutually reinforcing objectives: to strengthen research infrastructure and capacity at African universities; and to support doctoral training through the creation of a collaborative doctoral training program in population and public health. The ultimate goal of CARTA is to build local research capacity to understand the determinants of population health and effectively intervene to improve health outcomes and health systems. Conclusions: CARTA's focus on the local production of networked and high-skilled researchers committed to working in sub-Saharan Africa, and on the concomitant increase in local research and training capacity of African universities and research institutes addresses the inability of existing programs to create a critical mass of well-trained and networked researchers across the continent. The initiative's goal of strengthening human resources and university-wide systems critical to the success and sustainability of research productivity in public and population health will rejuvenate institutional teaching, research, and administrative systems.
Gender responsive multidisciplinary doctoral training program: the Consortium for Advanced Research Training in Africa (CARTA) experience
Alex Ezeh,Anne M. Khisa,Catherine Kyobutungi,Emmanuel Otukpa,Eunice Kilonzo,Evelyn Gitau,Justus Musasiah,Marta Vicente-Crespo,Peter Ngure,Sharon Fonn
- , 2019, DOI: https://doi.org/10.1080/16549716.2019.1670002
Abstract: ABSTRACT Doctoral training has increasingly become the requirement for faculty in institutions of higher learning in Africa. Africa, however, still lacks sufficient capacity to conduct research, with just 1.4% of all published research authored by African researchers. Similarly, women in Sub-Saharan Africa only constitute 30% of the continent’s researchers, and correspondingly publish little research. Challenging these gendered inequities requires a gender responsive doctoral program that caters for women’s gender roles that likely affect their enrollment in, and completion of, doctoral programs. In this article, we describe a public and population health multidisciplinary doctoral training program – CARTA and its approach to supporting women. This has resulted in women’s enrollment in the program equaling men’s and similar throughput rates. CARTA has achieved this by meeting women’s practical needs around childbearing and childrearing and we argue that this has produced some outcomes that challenge gender norms, such as fathers being child minders in support of their wives and creating visible female role models
ISSUES IN MEDICINE: Will clinical associates be effective for South Africa?
J Doherty, I Couper, S Fonn
South African Medical Journal , 2012,
Abstract: South Africa has developed an innovative mid-level medical worker model that can contribute substantively to the development of quality district-level health care. These clinical associates entered the South African job market in 2011 and have reportedly been received favourably. The first cohorts performed well on local and national examinations, with pass rates >95%. They have demonstrated confidence and competence in the common procedures and conditions encountered in district hospitals; reportedly fitted in well at most of the sites where they commenced working; and made a significant contribution to the health team, resulting in a demand for more clinical associates. Universities and provinces involved in producing clinical associates are enthusiastic and committed. However, priorities are to establish sustainable funding sources for training and deployment, provide adequate supervision and support, monitor the initial impact of the new cadre on health services, and manage the sensitivities of the medical and nursing professions around scopes of practice and post levels. Longer-term concerns are national leadership and support, scaling up of training, the development of career pathways, and the improvement of working conditions at district hospitals.
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