The beginning of field research..Bloemfontein, South Africa

Rainbow Nation

Some of you have been requesting a blog post (thank you for the reminder) and I've been quite busy laying down the foundation of my research here in Bloemfontein but wanted to shoot off a post or two to share some of my journey with you. For my first post of the trip, I'll start what I'm actually doing....... This post is more academic than my usual stories so scroll down to the bottom if you just want to know specifics..first I'll give you a little idea of the problem.


South Africa and HIV

South Africa has the highest HIV prevalence in the world-- and to top it off has the highest tuberculosis (TB) rate and a human resources for health crisis (I'll blog about this another time, not glamorous but important). The prevalence of HIV is on average is 18.5% in this province (which is the 3rd highest in the country) but in specific populations it is as high as over 30%; Meaning 1 in 3 people are infected. Those with immune systems which are already vulnerable from the HIV are therefore more susceptible to opportunistic infections like TB- so a functioning health system is key.

Over 80% of the population accesses the public healthcare system (versus private) which is a nurse-led  (read: too few doctors). In 2004 the prices of medication finally came down from an interesting global battle with patents and many players and treatment was finally relatively affordable. In South Africa in 2004 when the rollout of antiretroviral treatmeant (ART) for HIV patients began, it was done with separate clinics and staff specifically for HIV patients (called a vertical programme). The process was very cumbersome for the patients as they had to go to a separate clinics for HIV-related care  (often not conveniently located- meaning they needed money for transportation, time off work etc.)  and another clinic to get any other care. Patients were stigmatized when seen going to HIV clinics (since people then knew they were HIV positive then) and also there was criticism that the health system was focusing too much on HIV and neglecting other priority diseases, infections and health needs of the population. The photo below shows the steps 1-2-3-4 that patients had to go through previously.

The cumbersome process previously to access treatment for HIV patients

This is not only a problem here in South Africa, but also in many other countries in Sub-Saharan Africa, especially when larger global health initiatives (i.e. The Global Fund, Bill and Melinda Gates Foundation, PEPFAR etc.) came in with wonderfully ambitious goals to test and treat tons of people for HIV. They  created a separate health system which paralleled the crumbling public sector system and drew resources away from it. The critics started asking, why can't these funds actually strengthen the health system for some long term, sustainable improvements?

The Solution?

Hence---drumroll----the concept of integration was re-birthed. In South Africa, that meant every public sector primary health care clinic should be able to provide ARTs to HIV patients (a.k.a. integrating Primary Care and HIV care). The people will then have a "one stop shop" for all their health needs. The Free State started this in 2010 and have been slowly rolling out this concept to all the 222 public sector clinics. Currently, they have reached about half of the clinics.

However, when you add all these patients who were seen at another clinic to a primary care clinic which is already struggling to cope with the needs of the patients, what happens? In some cases you may be adding an extra 1200 patients a month to a clinic without giving them too much more support. HIV patients have special needs and sometimes complex treatment regimens and the clinics are already under-resourced and understaffed.  Specifically, what happens to how the clinic functions and primary care. Are there aspects of it which are strengthened and aspects which are weakened? This hasn't been answered yet and is the question I am looking at.

My Research

My project has 2 main components: First, I'll use the data the government has collected on a select number of health indicators to see how they have/will change as integration progresses for each of the 222 clinics. Since I came, I have been sitting down with provincial program managers, assistant managers and data collectors to identify which indicators will tell me what I want to know for each program. Examples of things I am looking at are immunization rates, number of patients they see, diabetes and hypertension, tuberculosis--just to name a few.  I've narrowed it down to about 12 indicators and now and will analyze these from 2008/9 to 2013 on a monthly basis to pull out some trends.

The former homeland of QwaQwa

The second part is selecting 4 very different clinics in the province (based on urban/rural/former homeland, size of the clinic and when they integrated). The photo above is from a former homeland area where people were forcibly moved during the apartheid. I'll do a separate post on this. This week I went out to the 4 clinics across the province and  pitched my research to them. The largest clinic has about 10 nurses seeing over 400 patients a day and the smallest had 3-4 nurses seeing about 100 patients a day. I will do interviews with the staff and focus groups (group discussions) as well as my research assistant will administer a survey to patients and caregivers (In Sotho, the local language) to see what they think of the services they have received. I will repeat this part in one year (March/April 2013) to see how things have changed and compare it to the data I find this year.

What I hope to find is information that can help with recommendations for policy and support to the clinics to enable them to cope with handling this many patients within this resource-constrained setting. The number of patients needing treatment will hopefully grow and will not compromise the other services. Eventually, I would like to see all health systems be able to handle the needs of those with infectious diseases (like HIV and TB) and chronic diseases (like diabetes, heart diseases etc) and  balance prevention and treatment. I hope other countries can also learn a bit from what is happening here since South Africa has the largest public sector ART program in the world. This will be the largest study on this topic spanning the longest time period.

Thanks for sticking around and making it to the end of the post! I promise the next ones will be less academic and more stories.