Health system determinants of tuberculosis mortality in South Africa : a causal loop model
Date
2021-04-26
Journal Title
Journal ISSN
Volume Title
Publisher
BMC (part of Springer Nature)
Abstract
Background: Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains
unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider,
systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB
mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment
Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors
underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to
each other.
Results: Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of
guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and
utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socioeconomic
status). Through the development and refinement of the causal loop diagram, additional explanatory and linking
variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’
illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TBrelated
mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural
determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor
uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented
leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how
this negatively affects the demand for higher levels of stewardship.
Conclusions: Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system,
increasing health care worker support, and using windows of opportunity to target points of leverage within the South
African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this
model may allow for the identification of additional areas of intervention.
Description
CITATION: Osman, M., et al. 2021. Health system determinants of tuberculosis mortality in South Africa : a causal loop model. BMC Health Services Research, 21:388, doi:10.1186/s12913-021-06398-0.
The original publication is available at https://bmchealthservres.biomedcentral.com
The original publication is available at https://bmchealthservres.biomedcentral.com
Keywords
Tuberculosis -- Mortality, Health systems agencies, Loop model, Systems optimization, Tuberculosis -- Treatment
Citation
Osman, M., et al. 2021. Health system determinants of tuberculosis mortality in South Africa : a causal loop model. BMC Health Services Research, 21:388, doi:10.1186/s12913-021-06398-0