Exploring demand and supply constraints on early TB detection in South Africa
| dc.contributor.advisor | Burger, Ronelle | en_ZA |
| dc.contributor.advisor | Van der Berg, Servaas | en_ZA |
| dc.contributor.advisor | Burger, Cobus | en_ZA |
| dc.contributor.author | Christian, Carmen | en_ZA |
| dc.contributor.other | Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics. | en_ZA |
| dc.date.accessioned | 2019-10-15T13:44:33Z | |
| dc.date.accessioned | 2019-12-11T06:43:05Z | |
| dc.date.available | 2019-10-15T13:44:33Z | |
| dc.date.available | 2019-12-11T06:43:05Z | |
| dc.date.issued | 2019-12 | |
| dc.description | Thesis (PhD)--Stellenbosch University, 2019. | en_ZA |
| dc.description.abstract | ENGLISH SUMMARY : The infectious nature of tuberculosis (TB) makes early TB detection an important public health objective. In the South African context, where the high TB burden remains concentrated among the poor and is exacerbated by the human immunodeficiency virus epidemic, TB control is a high priority for the National Department of Health. However, without an adequate grasp of the supply and demand issues underlying delays in TB detection, policies intended to improve detection, and ultimately TB outcomes, are unlikely to succeed. The overarching aim of the three chapters in this thesis is to consider the role of crucial demand-and supply-side constraints on early TB detection in South Africa. In this regard, three key factors are considered: The health-seeking behaviour of TB-symptomatic persons, the quality of TB care at the primary healthcare level and the role of nurse workloads in TB-detection protocol compliance. Early TB detection advances access to treatment, thereby preventing further transmission, in other words, demand prevention. Of great importance in determining whether a TB-symptomatic person seeks healthcare or not are the individual’s social and economic circumstances, as well as other generally unobservable factors such as TB stigma. Findings from Chapter 2 indicate that most persons with a chronic cough did not seek care for it. This is a perturbing finding considering that data were collected in high TB burden communities. Findings also provide evidence that in these communities, TB-control interventions may benefit from focusing on youth, those with lower levels of education, smokers and higher socioeconomic status sub-groups. Although no role for stigma in health-seeking behaviour was found, this finding underscores the need to improve methods to measure stigma. On the supply side, access to affordable, quality healthcare services with adequate capacity and the willingness to identify presumptive TB patients are essential prerequisites for the timely detection of TB. Chapters 3 and 4 explore supply-side weaknesses that place critical constraints on the effectiveness of TB detection at the primary healthcare level. Chapter 3 uses the unannounced Standardised Patient (SP) method to measure the quality of TB screening at primary healthcare facilities in urban South Africa. Findings from this chapter highlight the disconnect between the prescribed TB protocols and its implementation. Even though gaps and missed opportunities for early TB detection are identified (i.e. there is room for improvement), some findings are positive. These positive findings imply that there is a stronger than expected responsiveness to TB detection in South Africa than the current literature would suggest, although it is clear that weaknesses remain. Chapter 4 uses an SP fixed effects model to estimate primary healthcare facility correlates of TB-detection protocol compliance. The chapter provides evidence that human resource constraints at primary healthcare facilities are associated with suboptimal quality of TB detection. This chapter also recommends further investigation regarding the role of management in quality of care. The findings of this thesis contribute to the small but growing literature on the economics of infectious diseases and are intended to inform, guide and further enhance TB policies in South Africa. It also provides quantitative evidence for future quality-improvement research in this area. | en_ZA |
| dc.description.abstract | AFRIKAANSE OPSOMMING : Die aansteeklike aard van tuberkulose (TB) maak die vroeë opsporing van gevalle ʼn belangrike doel van openbare gesondsheidsbeleid. In Suid-Afrika, waar die hoë TB-las onder armes gekonsentreerd bly en vererger word deur die menslike immuniteidsgebreksvirus epidemie, is die beheer van TB ʼn groot prioriteit vir die Nasionale Departement van Gesondheid. Maar sonder ʼn voldoende begrip van die vraag- en aanbodfaktore wat die opsporing van TB gevalle vertraag sal beleid moeilik kan slaag. Die oorkoepelende doel van die drie hoofstukke in hierdie proefskrif is om die rol van vraag- en aanbodbeperkings op die vroeë opsporing van TB gevalle in Suid-Afrika te beskou. In hierdie verband word drie faktore ondersoek: Die gesondheidsoekende optrede van TB-simptomatiese persone, die gehalte van TB sorg op primêre gesondheidsvlak, en die rol van die werklading van verpleegsters in die toepassing van die protokol vir die opsporing van TB gevalle. Vroeë opsporing van TB gevalle verbeter toegang tot behandeling, waardeur verdere oordrag verhinder word, d.w.s. dit verhinder die groei van die vraag na sorg. Iemand met TB simptome se sosiale en ekonomiese omstandighede, sowel as faktore soos stigma (wat moeilik waargeneem word), beïnvloed tot ‘n belangrike mate of die persoon stappe neem om gesondheidsorg te bekom. Bevindinge uit Hoofstuk 2 dui daarop dat die meeste mense met ʼn kroniese hoes nie gesondheidsorg bekom het nie. Dit is ʼn onrusbarende bevinding, gegewe dat die data afkomstig is uit gemeenskappe met hoë TB-voorkoms. Die bevindinge dui ook daarop dat ingrypings om TB beter te beheer in sulke gebiede liefs moet konsentreer op die jeug, mense met laer opvoedingsvlakke, rokers en hoë sosio-ekonomiese statusgroepe. Al kon daar geen statistiese aanduidings gevind word dat stigma die soeke na gesondheidsorg beïnvloed nie, is dit tog noodsaaklik om die rol van beter meting van stigma te beklemtoon. Aan die aanbodkant is toegang tot bekostigbare gesondheidsdienste van gehalte met voldoende kapasiteit en die bereidheid om moontlike TB pasiënte te identifiseer ʼn belangrike voorvereiste vir die tydige opsporing van TB gevalle. Hoofstukke 3 en 4 verken aanbodkant-gebreke wat belangrike beperkings plaas op die effektiewe opsporing van TB op primêre gesondheidsvlak. Hoofstuk 3 gebruik die onaangekondigde “Standaard-pasiënt”-(SP) metode om die gehalte van TB diagnose by primêre gesondheidsfasiliteite in stedelike Suid-Afrikaanse gebiede te meet. Bevindinge van hierdie hoofstuk beklemtoon die groot verskil tussen voorgeskrewe TB-riglyne en hulle implementering. Ten spyte van die identifikasie van gapings en verspilde geleenthede vir vroeë opsporing van TB, is van die bevindinge positief. Die positiewe bevindinge impliseer dat daar beter as verwagte TB identifikasie in Suid-Afrika bestaan as wat die bestaande literatuur voorstel, alhoewel dit duidelik is dat daar steeds tekortominge bestaan. Hoofstuk 4 gebruik ʼn SP vaste-effek model om die korrelasies tussen primêre gesondheidsfasiliteite en korrekte toepassing van TB-riglyne te beraam. Die hoofstuk toon dat beperkte menslike hulpbronne by primêre gesondheidsfasiliteite verband hou met sub-optimale opsporing van TB. In hierdie hoofstuk ord daar ook aanbevelings gemaak oor die nodgiheid van verdere ondersoek in rol van bestuur in kwaliteit van gesondheidsorg. Die bevindinge van hierdie proefskrif dra by tot die beperkte maar groeiende literatuur oor die ekonomie van aansteeklike siektes en is bedoel om as inligting en as gids vir die versterking van TB-beleid in Suid-Afrika te dien. Die kwantitatiewe bevindinge dien as ‘n kennis basis vir toekomstige navorsing oor gehalte-verbetering op hierdie gebied. | af_ZA |
| dc.description.version | Doctoral | |
| dc.format.extent | xxiii, 166 pages ; illustrations, includes annexures | |
| dc.identifier.uri | http://hdl.handle.net/10019.1/107008 | |
| dc.language.iso | en_ZA | en_ZA |
| dc.publisher | Stellenbosch : Stellenbosch University | |
| dc.rights.holder | Stellenbosch University | |
| dc.subject | Tuberculosis -- Diagnosis -- South Africa | en_ZA |
| dc.subject | Tuberculosis -- Medical care -- South Africa | en_ZA |
| dc.subject | Communicable diseases -- Economic aspects -- South Africa | en_ZA |
| dc.subject | UCTD | |
| dc.title | Exploring demand and supply constraints on early TB detection in South Africa | en_ZA |
| dc.type | Thesis | en_ZA |