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Implementation of universal health coverage in South Africa: formative effects, perceived quality of healthcare and modelling of health service utilisation indicators in a national health insurance pilot district
(University of the Witwatersrand, Johannesburg, 2023-01) Mukudu, Hillary; Igumbor, Jude; Otwombe, Kennedy; Fusheini, Adam
Background: According to the World Health Organisation, member countries should attain universal health coverage by 2030. To achieve this goal, South Africa introduced the National Health Insurance programme in 2012. Since then, the first phase of the pilot programme has been implemented in Tshwane and ten other country districts. Historically, no other health system reform in South Africa has generated more interest than the National Health Insurance. This 15-year preliminary plan and pilot received optimism and criticism depending on several factors. The pilot programme focusing on primary health care was implemented along with several other interventions. The components of the intervention included setting up: ward-based primary healthcare outreach teams, integrated school health programmes, district clinical specialist teams, centralised chronic medicine dispensing and distribution programmes, health patient registration systems, stock visibility systems, and contracting of private non-specialised (general) medical practitioners to provide services in public primary health care facilities. These interventions were envisaged to improve healthcare quality at the primary healthcare level and offset the burden of non-emergency (secondary) care at the hospital outpatient level. However, studies have yet to be done to determine population-level formative effects on primary and non-emergency secondary healthcare indicators, their relationships, and interdependencies. These data are needed to forecast and develop measures to meet the possible increase in health service utilisation. In addition, this information is essential to guide the possible scale-up of South Africa's National Health Insurance mechanism. Such guidance may be in setting benchmarks to monitor policy implementation, determine facility staffing, the package of health services, training needs, budget for medicines and consumables, and other resource allocation. Aim: Therefore, this study first aimed to determine the formative effects of implementing the Medical Practitioners' contracting of the National Health Insurance pilot program on primary healthcare utilisation indicators measured at both primary and non-emergency secondary levels of care. A comparison was made between Tshwane national health insurance pilot district and Ekurhuleni district, which is not a pilot district. Furthermore, the study aimed to determine the relationships between healthcare utilisation indicators and their interdependencies and then provide a forecast for 2025. Methods: This quasi-experimental and ecological study used selected primary health care and outpatient department indicators in the District Health Information System monthly reports between January 2010 and December 2019 for the Tshwane district and Ekurhuleni district. Thus, to determine the formative effects on primary healthcare utilisation indicators, the selected period was from June 2010 to May 2014. A total of 48-time periods (months), with 24 before (June 2010 to May 2012) and 24 after (June 2012 to May 2014) implementation of Medical Practitioners contracting of the National Health Insurance pilot programme. Similarly, June 2012 to May 2014 was the selected period to determine the effects on the perceived quality of care. A total of 24 months, with 12 before (June 2012 to May 2013) and 12 after (June 2013 to May 2014) implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. To determine the relationship and interdependence between Primary Health Care and Outpatient Department indicators and forecasts for 2025, 113 time periods (quarters) were selected. There were 28 quarters before and 84 quarters after implementing the National Health Insurance pilot programme. Similar methodological approaches were used to determine the effects of Medical Practitioners contracting in the National Health Insurance pilot programme on Primary Healthcare utilisation indicators and perceived healthcare quality. All study data types used in the thesis were continuous; thus, they were initially evaluated descriptively using means (standard deviations) and medians (interquartile ranges). The range was evaluated using minimum and maximum values. An Independent t-test assuming unequal variances was used to compare the means of Outpatient Department indicators in determining the effect of Medical Practitioners contracting in the National Health Insurance pilot programme on the perceived quality of healthcare. Single- and multiple-group (controlled) interrupted time series analysis was used to determine the effect of the National Health Insurance pilot project implementation on the utilisation of selected primary and non-emergency outpatient department indicators and perceived healthcare quality. A different methodological approach was used to determine the interdependencies and relationships between selected primary healthcare and non-emergency outpatient department indicators and their forecasts for 2025. Initially, data were evaluated descriptively using means (standard deviations) and medians (interquartile ranges) and the range was evaluated using minimum and maximum values. Prior to the development of the vector error correction model, several steps were taken. Firstly, a natural log transformation of all time series data was done to enhance additivity, linearity, and validity. Additionally, the level of lags at which variables were interconnected or endogenously obtained was determined due to the sensitivity of causality. Furthermore, the stationarity of time series data was determined using both graphical means and the Augmented Dick Fuller test to confirm the stability of each time series. Finally, cointegration was determined using the Johansen cointegration test to check for the correlation between two or more nonstationary series. After developing the Vector Error Correction Model, the Granger causality test was done to determine whether one series is helpful for forecasting another. Then the Vector Error Correction Model relationships between variables of selected primary healthcare and non-emergency outpatient department indicators were used to forecast the utilisation of both levels of services by 2025. Results: The findings showed changes in primary healthcare indicators measured at primary and non-emergency secondary levels before and after contracting private medical practitioners of the National Health Insurance pilot programme. The study also confirmed the influence of selected primary health care and outpatient department headcounts on each other by finding four cointegration relationships between the variables. There were differences between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the utilisation of primary health care services. Thus, the positive impact observed in primary healthcare utilisation post-June 2012 is not attributable to the implementation of the Medical Practitioners' contracting of the National Health Insurance pilot programme. Conversely, there were similarities between single-group and controlled interrupted time series analysis findings for Tshwane district and Ekurhuleni district considered independently and collectively on the perceived quality of primary healthcare. In the interpretation of this finding, the similarities indicated that implementing the Medical Practitioners' contracting of the National Health Insurance pilot programme positively influenced the perception of a better quality of primary healthcare in the Tshwane district. Regarding primary healthcare indicators, there were differences between single-group and controlled interrupted time series analysis. Single-group interrupted time series analysis showed a 65% and 32% increase in the number of adults remaining on anti-retroviral therapy in Tshwane and Ekurhuleni districts, respectively (relative risk [RR]: 1.65; 95% confidence interval [CI]: 1.64–1.66; p < 0.0001 and RR: 1.32; 95% CI: 1.32–1.33; p < 0.0001, respectively). However, controlled interrupted time series analysis did not reveal any differences in any of the post-intervention parameters. Furthermore, single-group interrupted time series analysis showed a 2% and 6% increase in the number of clients seen by a professional nurse in the Tshwane and Ekurhuleni districts, respectively (RR: 1.02; 95% CI: 1.01–1.02; p < 0.0001 and RR: 1.06; 95% CI: 1.05–1.07; p < 0.0001, respectively). However, controlled interrupted time series analysis did not show any differences in any of the post-intervention parameters. In addition, single-group interrupted time series analysis revealed that there was a 2% decrease and 1% increase in the primary healthcare headcounts for clients aged ≥5 years in Tshwane and Ekurhuleni district (RR: 0.98; 95% CI: 0.97–0.98; p < 0.0001 and RR: 1.01; 95% CI: 1.01–1.02; p < 0.0001, respectively). Similarly, there was a 2% decrease and a 5% increase in the total primary healthcare headcounts in the Tshwane district and Ekurhuleni districts, respectively (RR: 0.98; 95% CI: 0.97–0.98; p < 0.001 and RR: 1.05; 95% CI: 1.04–1.06, p < 0.0001, respectively). However, controlled interrupted time-series analysis revealed no difference in all parameters before and after intervention in terms of total primary healthcare headcounts and primary healthcare headcounts for clients aged ≥5 years. Regarding secondary non-emergency outpatient department headcounts, single-group and controlled interrupted time series analyses revealed similar findings. Despite these similarities, single-group interrupted time series analysis showed a disparate increase in the outpatient department not referred headcounts, which were lower in the Tshwane district (3 387 [95%CI 901, 5 873] [p = 0.010]) than in Ekurhuleni district (5 399 [95% CI: 1 889, 8 909] [p = 0.004]). Conversely, while there was no change in outpatient department referred headcounts in the Tshwane district, there was an increase in headcounts in the Ekurhuleni district (21 010 [95% CI: 5 407, 36 611] [p = 0.011]). Regarding the outpatient department not referred rate, there was a decrease in the Tshwane district (-1.7 [95% CI: -2.1 to -1.2] [p < 0.0001]), but not in the Ekurhuleni district. Controlled interrupted time series analysis showed differences in headcounts for outpatient department follow-up (24 382 [95% CI: 14 643, 34 121] [p < 0.0001]), the outpatient department not referred (529 [95% CI: 29, 1 029 [p = 0.038]), and outpatient department not referred rate (-1.8 [95% CI: -2.2 to -1.1] [p < 0.0001]) between Tshwane the reference district and Ekurhuleni district. Four common long-run trends were found in the relationships and dependencies between primary healthcare indicators measured at the primary healthcare level and the non-emergency secondary level of care needed to forecast future utilisation. First, a 10% increase in outpatient departments not referred headcounts resulted in a 42% (95% CI: 28-56, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, 231% (95% CI: 156-307, p < 0.0001) increase in primary healthcare clients seen by a public medical practitioner, 37% (95% CI: 28-46, p < 0.0001) increase in primary healthcare clients on ART, and 615% (95% CI: 486-742, p < 0.0001) increase in primary healthcare clients seen by a professional nurse. Second, a 10% increase in outpatient department referrals resulted in an 8% (95% CI: 3-12, p < 0.0001) increase in new primary healthcare diabetes mellitus clients, a 73% (95% CI: 51-95, p < 0.0001) increase in primary healthcare headcounts for clients seen by a medical professional, a 25% (95% CI: 23-28, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and a 44% (95% CI: 4-71, p = 0.026) increase in primary healthcare headcounts for clients seen by a professional nurse. Third, a 10% increase in outpatient department follow-up headcounts resulted in a 12% (95% CI: 8-16, p < 0.0001) increase in primary healthcare headcounts for new diabetes mellitus, 67% (95% CI: 45-89, p < 0.0001) increase in primary healthcare headcounts for clients seen by public medical practitioners, 22% (95% CI: 19-24, p < 0.0001) increase in primary healthcare headcounts for clients on ART, and 155% (95% CI: 118-192, p < 0.0001) increase in primary healthcare headcounts for clients seen by a professional nurse. Fourth, a 10% increase in headcounts for total primary healthcare clients resulted in a 0.4% (95% CI: 0.1-0.8, p < 0.0001) decrease in primary healthcare headcounts for new diabetes clients. Based on these relationships and dependencies, the outpatient department follow-up headcounts would increase from 337 945 in the fourth quarter of 2019 to 534 412 (95% CI: 327 682–741 142) in the fourth quarter of 2025, while the total primary healthcare headcounts would only marginally decrease from 1 345 360 in the fourth quarter of 2019 to 1 166 619 (95% CI: 633 650–1 699 588) in the fourth quarter of 2025. Conclusion: The study findings suggested that improvements in primary health care indicators in National Health Insurance pilot districts could not be attributed to the implementation of contracting private medical practitioners but were likely a result of other co-interventions and transitions in the district. However, it might have resulted in an improved perception of quality of care at primary health care facilities, evidenced by a reduction in the self-referral rate for non-emergency hospital outpatient departments. The study also confirmed the influence of selected primary healthcare and non-emergency outpatient department headcounts on each other by finding four common long-run trends of relationships. Based on these relationships and trends, outpatient department follow-up headcounts are forecasted to increase by two-thirds. Conversely, the total headcount for primary healthcare clients seen by a professional nurse will marginally decrease. Recommendations: Based on the study findings, the bidirectional referral between primary and non-emergency secondary levels of care in the Tshwane district should be strengthened to offset the burden of care at outpatient departments of district hospitals. Thus, the district health information system should include a down-referral indicator to monitor this activity. With the implementation of National Health Insurance, there is a need to improve the perception of quality of care at the primary healthcare level through appropriate training, recruitment, and placement of medical practitioners. Similarly, professional nurses, the core providers of primary healthcare services, should be supported and capacitated in line with the epidemiological transition.
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Integration of Cultural Heritage when teaching and learning about the kidney in Grade 11 Life Sciences classrooms in SA: A Self Study
(University of the Witwatersrand, Johannesburg, 2024) Nkabinde, Nonkululeko; Mandikonza, Caleb
In this research I was researching my own practice in the classroom; therefore, the research is focused on my practice. However, my practice cannot happen without my learners. I am conscious that my learners are indirect participants because it is their reaction to my teaching that determines how I will teach. This study seeks to establish how use of knowledge from my culture and the learners’ cultural heritage as a methodology can be conducted meaningfully to teach the concept of the kidney in my Grade 11 class of Life Sciences. This is because learners often feel that there are major differences that exist between their culture and the culture of the science they come to learn at school (Aikenhead & Jegede, 1999). The use of cultural heritage in a classroom has the potential to help move learners from one level of cognitive development to another (Mandikonza, 2019). Furthermore, the National Curriculum and Assessment Policy Statement (CAPS) grades R-12 that stipulates policy on curriculum and assessment in the schooling sector in South Africa suggests that all learners be given the expression of what is regarded as knowledge, skills and values that are worth learning (CAPS, 2012). It emphasizes that children need to acquire and apply knowledge and skills in ways that are meaningful to their lives (lived experience); as such, the curriculum promotes the idea of grounding knowledge in local contexts (realities) while being sensitive to global imperatives (CAPS, 2011). This study used a qualitative research design and followed an interpretivist approach. The theoretical frameworks that guided this study was the social constructivism theory -Vygotsky’s social development theory, Zone of Proximal Development (ZPD) and More Knowledgeable Other (MKO). Learners in my Grade 11 class were purposively selected to participate in the study. Data collecting techniques included journaling that I used as a way of reporting observations, reflection 4 | P a g e and reactions to classroom occurrences as well as observation by critical friend who observed and can asked questions that were provocative which provided data to be studied through another lens (Noor & Shafee, 2020). Multiple data collecting tools were used which included semi- structured interviews, audio and video recordings. A narrative enquiry was used to analyze my data. Findings from this study suggest that CH contributes meaningfully in the learning of science concepts, there are challenges that are associated with integrating CH in the science classrooms that need to be addressed lastly, there is a need for teachers to constantly improve their practice in the classroom. Findings from this study may in some way contribute in assisting the production of culturally appropriate learning material for curriculum developers
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Investigating practising teachers’ willingness to teach genetics with the use of ICT
(University of the Witwatersrand, Johannesburg, 2024) Khanye, Mapaseka; Kavai, Portia
This study aimed to investigate practising teachers’ willingness to teach the topic of genetics with the use of ICT. I wanted to find out if teachers consider themselves sufficiently prepared to use ICT in the classroom. The motivation for investigating practising teachers’ willingness to teach the topic of genetics with the use of ICT was to determine whether teachers appreciate the value of ICT and its relevance in the classroom. If teachers do not see the value and relevance of ICT in education, hopefully, this study will help the Department of Education in facilitating a better alignment between research and practice and provide training that will adequately train and prepare teachers for the use of ICT. The Department of Education supports the use of ICT in classrooms and this is also part of the current international drive for education. Data was collected through interviews and classroom observations. There were four participant teachers within the age range of 25- 50 years category; two participants were female and the other two were males. Participants had to teach grade 12 Life Sciences as a subject for them to be part of this study. Findings show that teachers in my study, both males and females, were willing to teach the topic of genetics with the use of ICT. However, only one teacher considered himself sufficiently prepared to teach with ICT. The study showed that although the other three teachers valued and appreciated ICT in the classroom, they still needed further training on how to incorporate ICT in their lessons. Findings also showed that teachers faced several challenges when using ICT. Issues such as load shedding and the internet either being slow or expensive are some of the cited challenges. The study recommends that during in-service workshops, teachers need to be provided with proper and adequate information about the function, usage and benefits of ICT. In addition, there is a need for the Department of Education to start investing and providing schools with backup generators so that lessons are not disturbed due to load shedding. Finally, free data or the internet needs to be made available and accessible so that teachers and learners may be able to view pre-recorded video lessons and access learning materials such as past question papers from various reputable websites.
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From the onset: Impact of Nutrition and Lifestyle during the Preconception period in Urban South African Young Adults
(University of the Witwatersrand, Johannesburg, 2023-03) Mukoma, Gudani Goodman; Norris, Shane A.
Background: In South Africa, 22% of adolescents are overweight or obese, the onset of tobacco smoking is shown to peak between the ages of 15 and 22, 1 in 3 adolescents watch more than 3 hours of television per day, and nearly half of all adults are insufficiently active. Physical inactivity, poor diet, risky alcohol use, illicit drug use are among the behavioural risk factors associated with obesity and mental health problems, all of which have morbidity and mortality implications for adult health. Risks in later life include premature death, long-term disability, childbirth complications, gestational diabetes, diabetes and cardiovascular diseases. However, there is data paucity showing the personal, social, and environmental factors that are determinants of health, especially diet, physical activity (PA), obesity, and associated NCDs in South African adolescents and young adults. Aim: To investigate the individual, household, and environmental factors that influence adolescents' dietary and physical activity habits and to identify ways in which these factors can be leveraged for interventions to better ensure the health of future generations, especially during the crucial preconception years. Methods: This thesis was purposely designed to use a sequential mixed-methods approach that integrates quantitative (Chapter 3 paper 1: cross-sectional and Chapter 6 paper 4: longitudinal) and qualitative (Chapter 4 paper 2: longitudinal and Chapter 5 paper 3: cross-sectional) analyses in order to meet the four specific objectives of my research. The methods selected for this series of investigations were primarily influenced by the substantive research questions that arose, as opposed to methodological and epistemological concerns alone. I utilized three pre-existing data sources, including the "Birth-to-Twenty Cohort," the "Determinants of Type 2 Diabetes Mellitus (T2D)" study, and the "Soweto household enumeration survey." I have gathered new prospective data that is quantitatively and qualitatively longitudinal and cross-sectional. Results: The findings of this thesis in the context of Soweto show that the relationship between dietary patterns and nutritional status (BMI) is independent of socioeconomic status (SES). Adolescents and young adults face a variety of intersecting barriers resulting from personal preferences and their living conditions, which influence their dietary and physical activity habits while occurring at the time; this is important to consider when designing interventions to promote healthy behaviour change. Unexpected stressors, such as the outbreak of the COVID-19 pandemic, contributed to exacerbating adolescents' and young adults' poor health conditions, and as a result, the prevalence of poor nutrition intake, a lack of physical activity, and mental health issues increased. Although the nutrient patterns of adolescents and adults were comparable over time, their associations with BMI were not. The associations with BMI of the "plant-driven nutrient pattern," "fat-driven nutrient pattern," and "animal-driven nutrient pattern" revealed sex differences. Conclusion: Adolescent diet and lifestyle continue to be important research areas in the intent to enhance preconception health and reducing maternal and infant mortality.
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Examining Lecturers’ Use of ICT in an Introductory Economics Course During the Covid-19 Pandemic
(University of the Witwatersrand, Johannesburg, 2024) Pratt, Juanita Renee; Makda, Fatima
This study investigated how lecturers in the economics department at an urban university in South Africa used information communication technology to teach an introductory economics course during the Covid-19 pandemic. Many lecturers who teach introductory economics do not integrate ICT in their teaching and this can impact the quality of teaching and learning. It has become more critical to examine this challenge because most higher education institutions now integrate some form of online learning and teaching in their courses. Therefore, it is important to examine lecturers’ response to online teaching during emergency remote teaching in order to learn from their experience and identify the competencies needed to teach introductory economics. The purpose of the study was to examine lecturers’ use of ICT in an introductory economics course and to consider the competencies that support teaching with ICT in the subject. The main research question was How do lecturers use ICT to teach introductory economics during the Covid-19 pandemic? To better understand lecturers’ ICT practices, this qualitative study adopted an interpretivist approach and used content analysis to examine participant interviews and learning materials embedded in the learning management system for the introductory economics course. In addition to content analysis, the data were analysed and interpreted through the theoretical framework of the Teacher Response Model and Teaching Quality Framework. Several themes emerged about the nature of economics lecturers’ pedagogy namely: (a) they adapted their teaching practice by deploying all assessments through the learning management system and developing video lectures for students to download; (4) they developed new practices to encourage formative assessment and they acquired technical skills to manage the transition to emergency remote teaching; and (c) they used existing technologies in new ways to manage the change in teaching mode. Despite their inexperience with online teaching, lecturers were motivated to integrate ICT into their economics teaching practice in order to (d@) maintain the continuity of the course and to ensure academic standards were upheld. Furthermore, they (e) acknowledged the fact that the majority of economics students had limited resources and they accommodated for this inequity by responding to students’ academic, social and emotional needs. Although many lecturers lacked the experience of teaching online, they displayed flexibility, innovation and commitment to the academic project by utilising ICT to facilitate learning and teaching to the best of their ability during the challenging conditions of emergency remote teaching.