Healthcare workers' perceptions and experiences of implementing voluntary medical male circumcision in KwaZulu-Natal, South Africa

Background: Voluntary Medical Male Circumcision (VMMC) is an effective HIV prevention strategy prioritized by the World Health Organisation (WHO) for regions of high HIV prevalence, South Africa (SA) and in particular KwaZulu-Natal (KZN) is one of such regions. Since the roll out of VMMC in 2010 there has been little research conducted on the implementation of this service. Existing studies on the uptake of VMMC have mainly focused on service users resulting in a paucity of data on health care workers perspectives on the intervention. Aim: To analyse health care workers' perceptions and experiences of implementing voluntary medical male circumcision in KZN, SA. Setting: The study took place at six different health districts and their six respective rural clinics in the KZN province of SA. Methods: A qualitative approach using a phenomenographic design was employed. Data were collected from a sample of 18 participants comprising of health care providers (n = 12) and health policy makers (n = 6). Individual, face-to-face interviews were conducted using a semi-structured interview guide. An audiotape was used to record the data, which were transcribed verbatim and then analysed using a step-wise phenomenographic data analysis procedure. Results: Participants reported that VMMC was implemented by the department of health with support from non-governmental organisations and private general practitioners. Negative perceptions and negative experiences regarding VMMC and implementation were reported. Conclusion: The implementation of VMMC is compromised due to poor preparation and training of healthcare workers for implementing the service. Addressing health care workers' needs for training and preparation is crucial for successful implementation of VMMC

From malaria control to elimination in South Africa: the researchers' perspectives

Background: Global decline in malaria episodes over the past decade gave rise to a debate to target malaria elimination in eligible countries. However; investigation regarding researchers' perspectives on barriers and facilitating factors to effective implementation of a malaria elimination policy in South Africa (SA) is lacking. Aim: The aim of this study was to investigate the malaria researchers' knowledge, understandings, perceived roles, and their perspectives on the factors influencing implementation of a malaria elimination policy in SA. Setting: Participants were drawn from the researchers who fulfilled the eligibility criteria as per the protocol, and the criteria were not setting-specific. Methods: The study was a descriptive cross-sectional survey conducted through an emailed self-administered semi-structured questionnaire amongst malaria researchers who met the set selection criteria and signed informed consent. Results: Most (92.3%) participants knew about SA's malaria elimination policy; but only 45.8% had fully read it. The majority held a strong view that SA's 2018 elimination target was not realistic; citing that the policy had neither been properly adapted to the country's operational setting nor sufficiently disseminated to all relevant healthcare workers. Key concerns raised were lack of new tools; resources; and capacity to fight malaria; poor cross-border collaborations; overreliance on partners to implement; poor community involvement; and poor surveillance.Conclusion: Malaria elimination is a noble idea; with sharp divisions. However; there is a general agreement that elimination requires: (a) strong cross-border initiatives; (b) deployment of adequate resources; (c) sustainable multistakeholder support and collaboration; (d) good surveillance systems; and (e) availability and use of all effective intervention tools

National Scale-Up of Integrated Community Case Management in Rural Ethiopia: Implementation and Early Lessons Learned

Background. Although under-five mortality in Ethiopia has decreased 67in the past two decades; many children still die from preventable or treatable conditions; mainly pneumonia; newborn problems; diarrhea; malaria and malnutrition. Most of these deaths can be avoided with timely and appropriate care; but access to and use of treatment remains inadequate. Community health workers appropriately trained; supervised; and supplied with essential equipment and medicines; can deliver case management or referral to most sick children. In 2010; Ethiopia added pneumonia to diarrhea; malaria and severe acute malnutrition; targeted for treatment in the integrated community case management (iCCM) strategy. Purpose. This article describes the national scale-up of iCCM implementation and early lessons learned. Methods. We reviewed data related to iCCM program inputs and processes from reports; minutes; and related documents from January 2010 through July 2013. We describe introduction and scale-up through eight health system components. Results.The government and partners trained and supplied 27;116 of the total 32;000 Health Extension Workers and mentored 80 of them to deliver iCCM services to over one million children. The government led a strong iCCM partnership that attracted development partners inimplementation; monitoring; evaluation; and research. Service utilization and weak supply chain remain major challenges. Conclusion:Strong MOH leadership; policy support; and national partnerships helped successful national iCCM scale-up and should help settle remaining challenges

The Implementation of Guidelines in a South African Population with Type 2 Diabetes

Objective: The aim of this study was to identify the treatment gaps that pertain to risk factors in South African patients with type 2 diabetes mellitus; using national treatment guidelines.Design: Cross-sectional study.Setting and subjects: The study consisted of 666 patients with type 2 diabetes mellitus; attending a diabetes clinic at the Charlotte Maxeke Johannesburg Academic Hospital.Outcome measures: Using a public sector database; retrospective data were obtained on the treatment of type 2 diabetes mellitus participants. Patients were randomly selected on the basis of established type 2 diabetes mellitus diagnosis; and if they were receiving oral hypoglycaemic and/or insulin therapy. Age; gender; race; blood pressure; haemoglobin A1c (HbA1c) and fasting lipids were captured and measured. The history of patients' previous coronary artery disease; strokes; nephropathy; neuropathy and retinopathy was recorded.Results: The mean age of the patients was 63 years [standard deviation (SD) 11.9]; 55of whom were females. The HbA1c was 8.8 (SD 2.5). 26.2 of patients attained HbA1c levels of 7. Of the total patients; 45.8 met a 130/80 mmHg blood pressure target; and 53.8 a low-density lipoprotein (LDL) cholesterol of 2.5 mmol/l. Only 7.5 obtained the combined target for HbA1c ; blood pressure and LDL cholesterol.Conclusion: Traditionally; type 2 diabetes mellitus treatment has centred on correcting blood glucose levels. Yet; as many as 80

The Challenges Experienced by Nongovernmental Organisations with Regard to the Roll-Out of Antiretroviral Therapy in KwaZulu-Natal

Background: Successful administration of antiretroviral therapy (ART) requires full adherence to the regimen by the patient. The introduction of ART needs a well-functioning health system with adequately trained health professionals; laboratory support; a constant supply of drugs and social systems to assist with patients' adherence and to prevent future treatment failure. Objectives: The objective of this study was to explore and describe the challenges experienced by nongovernmental organisations with regard to the roll-out of antiretroviral therapy. Design: A qualitative; exploratory and descriptive study was conducted to determine the challenges experienced by nongovernmental organisations (NGOs) with regard to the roll-out of ART in KwaZulu-Natal. Nine participants were included purposefully from the NGOs that participated in this study. Data were collected through semi-structured individual interviews. Open coding for analysis was used. Results: The findings revealed four themes: challenges relating to sustainability; adherence; health infrastructure and behaviour. Conclusion: The results indicate a need for multisectoral collaboration in the roll-out of ART to ensure a concerted; comprehensive and sustainable programme

Proposed Guidelines for a Workplace Health Promotion Policy and Implementation Framework

Since workplace health promotion programmes are often not guided by a specific policy or health promotion framework; a study was conducted to develop guidelines for the implementation of health promotion in South African workplaces. A Delphi technique involving twelve health promotion experts was used to reach consensus about the proposed policy framework and guidelines. These guidelines are directed towards implementing a comprehensive workplace health promotion programme that aims to accommodate all employee health and safety needs. They can be used to develop relevant health promotion or wellness policies that are easy to implement; monitor and evaluate

Implementation of the National Programme for Prevention of Mother-To-Child Transmission of HIV: a Rapid Assessment in Cacadu District; South Africa

To conduct a rapid assessment of the prevention-of-mother-to-child-transmission-of-HIV (PMTCT) programme in two of the three local service areas in Cacadu district; Eastern Cape province; South Africa; we designed an exploratory study using a mixed-methods approach. Quantitative and qualitative data on PMTCT programme implementation were collected in 2008 through a structured assessment at the 44 health facilities implementing the programme in the province. This included in-depth interviews with 11 clinic supervisors; 31 clinic programme coordinators; and 8 hospital/maternity staff members in order to examine their perceived problems and suggestions regarding PMTCT programme implementation; an assessment of the clinic registers and recording systems; a meeting with stakeholders; and one feedback meeting with clinic managers; sub-district management and other stakeholders in regard to the results of the rapid assessment. Overall; most of the national criteria for PMTCT programme implementation were fulfilled across the health facilities. However; shortcomings were found relating to health policy; health services delivery and clients' health-seeking behaviour. The findings show the need for a well-functioning health system with adequate and trained staff; a reduced staff workload; proper case recording; an improved patient follow-up system; better support for staff; the empowerment of PMTCT clients; strong leadership; and coordination and collaboration between partners

From mental health policy development in Ghana to implementation: what are the barriers?

Objective: This paper identifies the key barriers to mental health policy implementation in Ghana and suggests ways of overcoming them. Method: The study used both quantitative and qualitative methods. Quantitatively; the WHO Mental Health Policy and Plan Checklist and the WHO Mental Health Legislation Checklist were employed to analyse the content of mental health policy; plans and legislation in Ghana. Qualitative data was gathered using in-depth interviews and focus group discussions with key stakeholders in mental health at the macro; meso and micro levels. These were used to identify barriers to the implementation of mental health policy; and steps to overcoming these. Results: Barriers to mental health policy implementation identified by participants include: low priority and lack of political commitment to mental health; limited human and financial resources; lack of intersectoral collaboration and consultation; inadequate policy dissemination; and an absence of research-based evidence to inform mental health policy. Suggested steps to overcoming the barriers include: revision of mental health policy and legislation; training and capacity development and wider consultation. Conclusion: These results call for well-articulated plans to address the barriers to the implementation of mental health policy in Ghana to reduce the burden associated with mental disorders

Evaluation of the Integrated Management of Childhood Illness Strategy Implementation in Bulawayo City; Zimbabwe; 2006

Introduction. Bulawayo City reported an age-specific death rate for under-5s of 5.9/1 000 in 2004; and this figure rose to 6.8/ 1 000 in 2005. Nurses were trained in implementation of the Integrated Management of Childhood Illness (IMCI) strategy in 2005. We evaluated the programme in order to establish the level of implementation and the quality of care given to children aged under 5 years. Methods. We conducted a cross-sectional study on a population of sick children aged between 2 months and 5 years; health care workers and caregivers. Data were collected using a structured observation checklist of the case management of sick children; exit interviews with caregivers; and a structured inventory checklist for equipment; drugs and supplies at each health facility. Results. Nine facilities; 17 nurses and 72 children were observed during the study. Seventeen children (24) were assessed for the three general danger signs (failure to drink or breastfeed; vomiting everything ingested; and convulsions); 31 (43) were correctly prescribed an oral antibiotic; and 11received the first dose of treatment at the health facility. Thirty-two per cent of caregivers who received a prescription for an oral medication were able to report correctly how to give the treatment. Drugs were below minimum stock levels in all 9 facilities. Only 19 (20) of the 94 nurses were trained in IMCI. Conclusion. IMCI implementation in Bulawayo failed to meet the accepted standard protocol requirements. The main deficiencies noted were the low number of IMCI-trained health workers and the lack of availability of essential drugs at health facilities. However; it was noteworthy that only two case assessment parameters differed statistically between IMCI-trained and non-trained nurses. Larger studies are needed to confirm or refute these findings

Status of Health Sector Strategic Plans in Five Countries of the WHO African Region

Objectives: To assess the adequacy of the existing strategic plans and compare the format and content of health sector strategic plans with the guidelines in selected countries of the African region. Data source: The health strategic plans for Gambia; Liberia; Malawi; Tanzania and Uganda; which are kept at the WHO/AFRO; were reviewed. Data extraction: All health strategic plans among the Anglophone countries (Gambia; Ghana; Kenya; Liberia; Malawi; Mauritius; Tanzania; Uganda; Zambia and Zimbabwe) that were developed after the year 2000 were eligible for inclusion. Fifty percent of these countries that fitted this criterion were randomly selected. They included Gambia; Liberia; Malawi; Tanzania and Uganda. The analysis framework used in the review included situation analysis; an assessment of appropriateness of strategies that are selected; well developed indicators for each strategy; the match between the service and outcomes targets with available resources; and existence of a clear framework for partnership engagement for implementation. Data synthesis: Most of the strategic plans identify key ill health conditions and their contributing factors. Health service and resource gaps are described but not quantified in the Botswana; Gambia; Malawi; Tanzania strategic documents. Most of the plans selected strategies that related to the situational analysis. Generally; countries' plans had clear indicators. Matching service and outcome targets to available resources was the least addressed area in majority of the plans. Most of the strategic plans identified stakeholders and acknowledged their participation in the implementation; providing different levels of comprehensiveness. Conclusion: Some of the areas that are well addressed according to the analysis framework included: addressing the strategic concerns of the health policies; identifying key partners for implementation; and selection of appropriate strategies. The following areas needed more emphasis: quantification of health system gaps; setting targets that are cognisant of the local resource base; and being more explicit in what stakeholders' roles are during the implementation period

Implementation of the Mental Health Care Act (2002) at District Hospitals in South Africa : Translating Principles into Practice

Legislation prior to 2002 tended to reinforce the alienation; stigmatisation and disempowerment of mentally ill patients in South Africa. In line with international develop- ments in mental health legislation; the Mental Health Care Act (2002) was promulgated in South Africa. Its core principles - human rights for users; decentralisation and integration of mental health care at primary; secondary and tertiary levels of care; and a focus on care; treatment and rehabilitation - are progressive and laudable. However; the task of implementing the requirements of the Act at community and district hospital levels is fraught with problems. Lack of infrastructure; inadequate skills and poor support and training undermine its successful implementation.Health workers already burdened with enormous workloads and inadequate resources struggle to manage mentally ill patients at district hospitals. The 72- hour observation is a particular area of difficulty throughout the country. This paper outlines the rationale and sense behind this legislation; discusses the problems encountered at the 'rock face'; and offers solutions to the problem of translating principles into practice

Implementation of the International Health Regulations (2005) in the African Region

The International Health Regulations (IRH; 2005) are a legally binding international instrument for preventing and controlling the spread of diseases internationally while avoiding unnecessary interference with international travel and trade. Under the IHRs that were adopted on 23 May 2005 and entered into force on 15 June 2007; Member States have agreed to comply with the rules therein in order to contribute to regional and international public health security. Obligations also include the establishment of IHR National Focal Points (NFP) defined as a national centre designated by each Member State; and accessible at all times for communication with WHO IHR Contact Points. Furthermore; Member States were requested to designate experts for the IHR roster; enact appropriate legal and administrative instruments and mobilize resources through collaboration and partnership building. The Fifty-sixth session of the WHO Regional Committee for Africa called for the implementation of the IHR in the context of the regional Integrated Disease Surveillance and Response (IDSR) strategy considering the commonalities and synergies between IHR (2005) and the IDSR. They both aim at preventing and responding to public health threats and/or events of national and international concern. This document discusses the issues and challenges and proposes actions that Member States should take to ensure the required IHR core capacities are acquired in the WHO African Region

Progress Report on Implementation of Regional Committee Resolution AFR/RC59/R3 on Accelerated Malaria Control

Several resolutions have been adopted and commitments made to scale up malaria control towards elimination in the African Region. These include United Nations; African Union; regional economic communities; World Health Assembly and Regional Committee resolutions. WHO AFRO provides support to countries; regional economic communities and the African Union in planning; implementing monitoring and evaluating their malaria control and elimination strategies. WHO also provides guidance and support for capacity building and resource mobilization towards reduction of the burden of malaria. As a result of scaling up evidence-based and high- impact malaria interventions; the overall estimated incidence of malaria in the African Region fell by 33 from 2000 to 2010 and the upward trend of the disease was reversed. Furthermore; 12 countries in the African Region are on track to reduce malaria incidence by at least 50-75 by 2015. The action points of Resolution RC 59/R3 on Accelerated Malaria Control: Towards Elimination in the African Region remain relevant and should continue to guide countries in the context of their broader health; development and poverty reduction agenda

Primary health care and the medical practitioners

The principles of primary health care were readily adopted in Seychelles because these same principles had already been accepted in the programme of the Seychelles People's Progressive Front since its foundation in the early 1964. The declaration of AlmaAta of 1978; coming one year after the SPPF formed a new government; provided an added stimulus to the development of a new health system based on principles such as equity and universal access to comprehensive health services; people's participation in a health; and emphasis on health as part of community and national development

Training of health personnel in Sierra Leone for primary health care

Sierra Leone; like many African countries; has experienced considerable delay in implementing programmes geared towards the achievement of health for all by the year 2000 through primary health care. There is widespread dissatisfaction towards health care delivery not only as a result of inadequate financing but also due to the general incompetence of health personnel to meet new challenges. A primary health care policy calls for the the training of health personnel of all types and in numbers to meet the needs of the entire country. Training is thus regarded as a priority intervention to meet these challenge. A guideline to relate education and training innovations to the elements of primary care is presented

The need for a training programme in community-oriented education for health personnel in Sierra Leone

There is a pressing need for a community-oriented medical training in Sierra Leone to cope with the country's health problems. To enable a community-oriented training programme to be succesfully implemented; it is first necessary to clarify the basic concepts of a community-oriented training programme in order to remove some misconceptions. The following is therefore an attempt aimed at clarifying the situation by giving a brief backgroung to the health needs of Sierra Leone followed by a definition of community-oriented medical education