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Additional file 1:Table 3. The impoverishing effect of OOP health spending by region in Ethiopia, 2010/11. Table 4: The impoverishing effect of OOP health spending by residential areas and gender in Ethiopia 2010/11.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. Background: Universal health coverage (UHC) is critical to global poverty alleviation and equity of health systems. Many low-income and middle-income countries, including small island states in the Pacific, have committed to UHC and reforming their health financing systems to better align with UHC goals. This study provides the first comprehensive evidence on equity of the health financing system in Fiji, a small Pacific island state. The health systems of such states are poorly covered in the international literature. Methods: The study employs benefit and financing incidence analyses to evaluate the distribution of health financing benefits and burden across the public and private sectors. Primary data from a cross-sectional survey of 2000 households were used to assess healthcare benefits and secondary data from the 2008–2009 Fiji Household Income and Expenditure Survey to assess health financing contributions. These were analysed by socioeconomic groups to determine the relative benefit and financing incidence across these groups. Findings: The distribution of healthcare benefits in Fiji slightly favours the poor—around 61% of public spending for nursing stations and 26% of spending for government hospital inpatient care were directed to services provided to the poorest 20% of the population. The financing system is significantly progressive with wealthier groups bearing a higher share of the health financing burden. Conclusions: The healthcare system in Fiji achieves a degree of vertical equity in financing, with the poor receiving a higher share of benefits from government health spending and bearing a lower share of the financing burden than wealthier groups.

South Africa's colonial and apartheid inheritance is one of substantial social, economic, and health inequalities. Since the first democratic elections in 1994, the human development index has declined considerably, largely because of the HIV epidemic, which has reduced life expectancy. The South African government has committed to a universal health system, which is seen as critical to improve population health and redress inequalities.

Background Household contact with an index case of an infectious disease is a known risk factor for infection transmission. However, such contact may be underestimated due to the dynamic nature of households, particularly in longitudinal studies. Such studies generally begin with contact defined at a single point in time (‘snap-shot’), leading to contact misclassification for some individuals who actually experienced contact before and after the snapshot. Objective To quantify contact misclassification with index cases of disease in households. Methods Historical data of 112,026 individuals from 17,889 households from an epidemiological study on leprosy in northern Malawi were used. Individuals were interviewed in the early 1980s and followed up over 5 years. It was possible to trace whether individuals died, changed household within the area, or moved out of the area between the two surveys. Using a 10% sample of households as the starting population and parameters for demographic and household changes over 5 years, the extent of contact misclassification was estimated through a simulation model of household dynamics, which traced contact with index cases in households over time. The model thereafter compared initial contact status and ‘true’ contact status generated from simulations. Results The starting population had 11,401 individuals, 52% female, and 224 (2%) leprosy index cases. Eleven percent of the households had at least one index case resident and 10% (1, 177) of non-case individuals were initial contacts. Sensitivity of initial contact status ranged from 0.52 to 0.74 and varied by age and sex. Sensitivity was low in those aged 20–29 and under 5 years but high in 5- to 14-year-olds. By gender, there were no differences among those aged under 5; females had lower sensitivity among those aged under 20 and higher for those above 30, respectively. Sensitivity was also low in simulations of long incubation periods. Conclusion This work demonstrates the implications of changes in households on household contact-associated disease spread, particularly for long durations of follow-up and infections with long incubation periods where earlier unobserved contact is critical., Background Although there are significant numbers of people displaced by war in Africa, very little is known about long-term changes in the fertility of refugees. Refugees of the Mozambican civil war (1977–1992) settled in many neighbouring countries, including South Africa. A large number of Mozambican refugees settled within the Agincourt sub-district, underpinned by a Health and Socio-demographic Surveillance Site (AHDSS), established in 1992, and have remained there. The AHDSS data provide a unique opportunity to study changes in fertility over time and the role that the fertility of self-settled refugee populations plays in the overall fertility level of the host community, a highly relevant factor in many areas of sub-Saharan Africa. Objectives To examine the change in fertility of former Mozambican self-settled refugees over a period of 16 years and to compare the overall fertility and fertility patterns of Mozambicans to host South Africans. Methods Prospective data from the AHDSS on births from 1993 to 2009 were used to compare fertility trends and patterns and to examine socio-economic factors that may be associated with fertility change. Results There has been a sharp decline in fertility in the Mozambican population and convergence in fertility patterns of Mozambican and local South African women. The convergence of fertility patterns coincides with a convergence in other socio-economic factors. Conclusion The fertility of Mozambicans has decreased significantly and Mozambicans are adopting the childbearing patterns of South African women. The decline in Mozambican fertility has occurred alongside socio-economic gains. There remains, however, high unemployment and endemic poverty in the area and fertility is not likely to decrease further without increased delivery of family planning to adolescents and increased education and job opportunities for women., Background There is a lack of reliable data in developing countries to inform policy and optimise resource allocation. Health and socio-demographic surveillance sites (HDSS) have the potential to address this gap. Mortality levels and trends have previously been documented in rural South Africa. However, complex space–time clustering of mortality, determinants, and their impact has not been fully examined. Objectives To integrate advanced methods enhance the understanding of the dynamics of mortality in space–time, to identify mortality risk factors and population attributable impact, to relate disparities in risk factor distributions to spatial mortality risk, and thus, to improve policy planning and resource allocation. Methods Agincourt HDSS supplied data for the period 1992–2008. Advanced spatial techniques were used to identify significant age-specific mortality ‘hotspots’ in space–time. Multivariable Bayesian models were used to assess the effects of the most significant covariates on mortality. Disparities in risk factor profiles in identified hotspots were assessed. Results Increasing HIV-related mortality and a subsequent decrease possibly attributable to antiretroviral therapy introduction are evident in this rural population. Distinct space–time clustering and variation (even in a small geographic area) of mortality were observed. Several known and novel risk factors were identified, and population impact was quantified. Significant differences in the risk factor profiles of the identified ‘hotspots’ included ethnicity; maternal, partner, and household deaths; household head demographics; migrancy; education; and poverty. Conclusions A complex interaction of highly attributable multilevel factors continues to demonstrate differential space–time influences on mortality risk (especially for HIV). High-risk households and villages displayed differential risk factor profiles. This integrated approach could prove valuable to decision makers. Tailored interventions for specific child and adult high-risk mortality areas are needed, such as preventing vertical transmission, ensuring maternal survival, and improving water and sanitation infrastructure. This framework can be applied in other settings within the region., Background South Africa accounts for more than a sixth of the global population of people infected with HIV and TB, ranking her highest in HIV/TB co-infection worldwide. Remote areas often bear the greatest burden of morbidity and mortality, yet there are spatial differences within rural settings. Objectives The primary aim was to investigate HIV/TB mortality determinants and their spatial distribution in the rural Agincourt sub-district for children aged 1–5 years in 2004. Our secondary aim was to model how the associated factors were interrelated as either underlying or proximate factors of child mortality using pathway analysis based on a Mosley-Chen conceptual framework. Methods We conducted a secondary data analysis based on cross-sectional data collected in 2004 from the Agincourt sub-district in rural northeast South Africa. Child HIV/TB death was the outcome measure derived from physician assessed verbal autopsy. Modelling used multiple logit regression models with and without spatial household random effects. Structural equation models were used in modelling the complex relationships between multiple exposures and the outcome (child HIV/TB mortality) as relayed on a conceptual framework. Results Fifty-four of 6,692 children aged 1–5 years died of HIV/TB, from a total of 5,084 households. Maternal death had the greatest effect on child HIV/TB mortality (adjusted odds ratio=4.00; 95% confidence interval=1.01–15.80). A protective effect was found in households with better socio-economic status and when the child was older. Spatial models disclosed that the areas which experienced the greatest child HIV/TB mortality were those without any health facility. Conclusion Low socio-economic status and maternal deaths impacted indirectly and directly on child mortality, respectively. These factors are major concerns locally and should be used in formulating interventions to reduce child mortality. Spatial prediction maps can guide policy makers to target interventions where they are most needed., Background Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants. Objectives The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania. Methods This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan–Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders. Results Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7–30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [−0.16; 95% CI (−0.24, −0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30–0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22–0.88)]. Conclusion Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania., Background Alcohol is a risk factor for the leading causes of mortality and morbidity among young people globally. Youth drinking, initiated in early adolescence and continued into early adulthood, is influenced by maternal socio-demographic factors and maternal education. Limited prospective data exists in South Africa on the prevalence of alcohol use during adolescence and adolescent and maternal socio-demographic correlates. Objective To examine the prevalence of lifetime alcohol use during early (13 years) and late (18 years) adolescence in Soweto, South Africa, and its association with child and maternal socio-demographic factors. Methods Data on alcohol use in early adolescence (age 13 years) and late adolescence (age 18 years) were collected using self-completed pen and paper and self-completed computer-based questionnaires, respectively. Univariate analyses were conducted on child (gender and number of school years repeated by grade 7), maternal socio-demographic correlates (education, marital status, and age), and household socioeconomic status (SES). Bivariate logistic regression analyses examined associations between alcohol use and all child and maternal socio-demographic factors. Multivariate logistic regression analyses were conducted on all the variables found to be significantly (p, Globally, communication plays an integral role in public health strategies, from infectious diseases to diseases related to lifestyles. The evolution of the field of social and behaviour change communication (SBCC), combined with the need for evidence based practice and multi-level interventions to promote health, and human resource gaps in sub-Saharan Africa have led to the imperative to standardise and formalise the field. Moreover, current practitioners come from different disciplinary backgrounds underlining the need to define common core skills and competencies. This paper describes the partnership between the Wits School of Public Health and the Soul City Institute for Health and Development Communication and how the partners responded to this need. It highlights the factors influencing sustainable institutional capacity to provide quality assured, accredited training. We describe an unexpected positive response from a number of practitioner organisations that have chosen to send multiple staff members for training, specifically to build a critical mass within their organisations. Finally, we note the interest from (mostly) southern-based academic institutions in setting up similar programmes and postulate that south–south collaborations can contribute to building sustainable context specific and evidence-informed SBCC programmes in the global south., Introduction In light of global concerns about insufficient numbers of doctors, midwives, and nurses, the World Health Organization (WHO) has identified the scale-up of the production of medical professionals who are competent and responsive to community needs as urgent and necessary. Coincident with this imperative, South African medical schools have also had to consider redressing apartheid-era inequities in access to medical education and changing the racial and gender profile of medical graduates to be representative of the population. In this article, we explore progress and challenges with regard to transformation, defined as intentional and planned changes aimed at addressing historical disadvantages, in the Gauteng Province of South Africa. Methods A cross-sectional, descriptive analysis was conducted using data on medical school admissions and graduations from the Health and Education Departments for the period 1999–2011. Admission and graduation statistics of 1999, 2005, 2008, and 2011 were analysed according to race and gender. Results The results show that there has been progress in transforming the race and gender composition of medical students and graduates, in line with the transformation strategies of the South African government. In 1999, black African enrolments and graduates were conspicuously low in two of the three medical schools in the Gauteng province. By 2011, an almost six-fold increase in black African student enrolments was seen in one medical school that was previously designated as a white institution. In contrast, at the historically black medical school, whites only represented 0.40% of enrolments in 1999 and 7.4% in 2011. Since 1999, the number and proportion of female medical enrolments and graduates has also increased substantially. Conclusion While there has been progress with redressing historical disparities and inequities in terms of race and gender, further efforts are needed to ensure that student intakes and graduations are in line with the South African population profile., Background Environmentally acquired asbestos-related diseases (ARDs) are of concern globally. In South Africa, there is widespread contamination of the environment due to historical asbestos mining operations that were poorly regulated. Although the law makes provision for the compensation of occupationally acquired ARDs, compensation for environmentally acquired ARDs is only available through the Asbestos Relief Trust (ART) and Kgalagadi Relief Trust, both of which are administered by the ART. This study assessed ARDs and compensation outcomes of environmental claims submitted to the Trusts. Methods The personal details, medical diagnoses, and exposure information of all environmental claims considered by the Trusts from their inception in 2003 to April 2010 were used to calculate the numbers and proportions of ARDs and compensation awards. Results There were 146 environmental claimants of whom 35 (23.9%) had fibrotic pleural disease, 1 (0.7%) had lung cancer, and 77 (52.7%) had malignant mesothelioma. 53 (36.3%) claimants were compensated: 20 with fibrotic pleural disease and 33 with mesothelioma. Of the 93 (63.7%) claimants who were not compensated, 33 had no ARDs, 18 had fibrotic pleural disease, 1 had lung cancer, and 44 had mesothelioma. In addition to having ARDs, those that were compensated had qualifying domestic (33; 62.2%) or neighbourhood (20; 37.8%) exposures to asbestos. Most of the claimants who were not compensated had ARDs but their exposures did not meet the Trusts’ exposure criteria. Conclusions This study demonstrates the environmental impact of asbestos mining on the burden of ARDs. Mesothelioma was the most common disease diagnosed, but most cases were not compensated. This highlights that there is little redress for individuals with environmentally acquired ARDs in South Africa. To stop this ARD epidemic, there is a need for the rehabilitation of abandoned asbestos mines and the environment. These issues may not be unique to South Africa as many countries continue to mine and use asbestos., Background Crystalline silica and asbestos are common minerals that occur throughout South Africa, exposure to either causes respiratory disease. Most studies on silicosis in South Africa have been cross-sectional and long-term trends have not been reported. Although much research has been conducted on the health effects of silica dust and asbestos fibre in the gold-mining and asbestos-mining sectors, little is known about their health effects in other mining sectors. Objective The aims of this thesis were to describe silicosis trends in gold miners over three decades, and to explore the potential for diamond mine workers to develop asbestos-related diseases and platinum mine workers to develop silicosis. Methods Mine workers for the three sub-studies were identified from a mine worker autopsy database at the National Institute for Occupational Health. Results From 1975 to 2007, the proportions of white and black gold mine workers with silicosis increased from 18 to 22% and from 3 to 32% respectively. Cases of diamond and platinum mine workers with asbestos-related diseases and silicosis, respectively, were also identified. Conclusion The trends in silicosis in gold miners at autopsy clearly demonstrate the failure of the gold mines to adequately control dust and prevent occupational respiratory disease. The two case series of diamond and platinum mine workers contribute to the evidence for the risk of asbestos-related diseases in diamond mine workers and silicosis in platinum mine workers, respectively. The absence of reliable environmental dust measurements and incomplete work history records impedes occupational health research in South Africa because it is difficult to identify and/or validate sources of dust exposure that may be associated with occupational respiratory disease., Context In the South African mining sector, cardiorespiratory-specific autopsies are conducted under the Occupational Diseases in Mines and Works Act (ODMWA) on deceased mineworkers to determine eligibility for compensation. However, low levels of autopsy utilisation undermine the value of the service. Objective To explore enablers and barriers to consent that impact on ODMWA autopsy utilisation for posthumous monetary compensation. Methods In-depth interviews were conducted with mineworkers, widows and relatives of deceased mineworkers as well as traditional healers and mine occupational health practitioners. Results A range of socio-cultural barriers to consent for an autopsy was identified. These barriers were largely related to gendered power relations, traditional and religious beliefs, and communication and trust. Understanding these barriers presents opportunities to intervene so as to increase autopsy utilisation. Conclusions Effective interventions could include engagement with healthy mine-workers and their families and re-evaluating the permanent removal of organs. The study adds to our understanding of utilisation of the autopsy services., Background In 2005, the South African government introduced a voluntary, subsidised health insurance scheme for civil servants. In light of the global emphasis on universal coverage, empirical evidence is needed to understand the relationship between new health financing strategies and health care access thereby improving global understanding of these issues. Objectives This study analysed coverage of the South African government health insurance scheme, the population groups with low uptake, and the individual-level factors, as well as characteristics of the scheme, that influenced enrolment. Methods Multi-stage random sampling was used to select 1,329 civil servants from the health and education sectors in four of South Africa's nine provinces. They were interviewed to determine factors associated with enrolment in the scheme. The analysis included both descriptive statistics and multivariate logistic regression. Results Notwithstanding the availability of a non-contributory option within the insurance scheme and access to privately-provided primary care, a considerable portion of socio-economically vulnerable groups remained uninsured (57.7% of the lowest salary category). Non-insurance was highest among men, black African or coloured ethnic groups, less educated and lower-income employees, and those living in informal-housing. The relatively poor uptake of the contributory and non-contributory insurance options was mostly attributed to insufficient information, perceived administrative challenges of taking up membership, and payment costs. Conclusion Barriers to enrolment include insufficient information, unaffordability of payments and perceived administrative complexity. Achieving universal coverage requires good physical access to service providers and appropriate benefit options within pre-payment health financing mechanisms., Background South Africa is currently undergoing major health system restructuring in an attempt to improve health outcomes and reduce inequities in access. Such inequities exist between private and public health care and within the public health system itself. Experience shows that rural health care can be disadvantaged in policy formulation despite good intentions. The objective of this study was to identify the major challenges and priority interventions for rural health care provision in South Africa thereby contributing to pro-rural health policy dialogue. Methods The Delphi technique was used to develop consensus on a list of statements that was generated through interviews and literature review. A panel of rural health practitioners and other stakeholders was asked to indicate their level of agreement with these statements and to rank the top challenges in and interventions required for rural health care. Results Response rates ranged from 83% in the first round (n=44) to 64% in the final round (n=34). The top five priorities were aligned to three of the WHO health system building blocks: human resources for health (HRH), governance, and finance. Specifically, the panel identified a need to focus on recruitment and support of rural health professionals, the employment of managers with sufficient and appropriate skills, a rural-friendly national HRH plan, and equitable funding formulae. Conclusion Specific policies and strategies are required to address the greatest rural health care challenges and to ensure improved access to quality health care in rural South Africa. In addition, a change in organisational climate and a concerted effort to make a career in rural health appealing to health care workers and adequate funding for rural health care provision are essential., Background Job satisfaction is an important determinant of health worker motivation, retention, and performance, all of which are critical to improving the functioning of health systems in low- and middle-income countries. A number of small-scale surveys have measured the job satisfaction and intention to leave of individual health worker cadres in different settings, but there are few multi-country and multi-cadre comparative studies. Objective The objective of this study was to compare the job satisfaction and intention to leave of different categories of health workers in Tanzania, Malawi, and South Africa. Methods We undertook a cross-sectional survey of a stratified cluster sample of 2,220 health workers, 564 from Tanzania, 939 from Malawi, and 717 from South Africa. Participants completed a self-administered questionnaire, which included demographic information, a 10-item job satisfaction scale, and one question on intention to leave. Multiple regression was used to identify significant predictors of job satisfaction and intention to leave. Results There were statistically significant differences in job satisfaction and intention to leave between the three countries. Approximately 52.1% of health workers in South Africa were satisfied with their jobs compared to 71% from Malawi and 82.6% from Tanzania (χ2=140.3, p, Background In 2007, the South African government introduced the occupation-specific dispensation (OSD), a financial incentive strategy, to attract, motivate, and retain health professionals in the public sector. Implementation commenced with the nursing sector, but there have been unintended negative consequences. Objective First, to examine implementation of the OSD for nurses using Hogwood and Gunn's framework that outlines ‘perfect implementation’ pre-conditions. Second, to highlight the conditions for the successful implementation of financial incentives. Methods A qualitative case study design using a combination of a document review and in-depth interviews with 42 key informants. Results The study found that there were several implementation weaknesses. Only a few of the pre-conditions were met for OSD policy implementation. The information systems required for successful policy implementation, such as the public sector human resource data base and the South African Nursing Council register of specialised nurses were incomplete and inaccurate, thus undermining the process. Insufficient attention was paid to time and resources, dependency relationships, task specification, and communication and coordination. Conclusion The implementation of financial incentives requires careful planning and management in order to avoid loss of morale and staff grievances., Background Mid-level medical workers play an important role in health systems and hold great potential for addressing the human resource shortage, especially in low- and middle-income countries. South Africa began the production of its first mid-level medical workers – known as clinical associates – in small numbers in 2008. Objective We describe the way in which scopes of practice and course design were negotiated and assess progress during the early years. We derive lessons for other countries wishing to introduce new types of mid-level worker. Methods We conducted a rapid assessment in 2010 consisting of a review of 19 documents and 11 semi-structured interviews with a variety of stakeholders. A thematic analysis was performed. Results Central to the success of the clinical associate training programme was a clear definition and understanding of the interests of various stakeholders. Stakeholder sensitivities were taken into account in the conceptualisation of the role and scope of practice of the clinical associate. This was achieved by dealing with quality of care concerns through service-based training and doctor supervision, and using a national curriculum framework to set uniform standards. Conclusions This new mid-level medical worker can contribute to the quality of district hospital care and address human resource shortages. However, a number of significant challenges lie ahead. To sustain and expand on early achievements, clinical associates must be produced in greater numbers and the required funding, training capacity, public sector posts, and supervision must be made available. Retaining the new cadre will depend on the public system becoming an employer of choice. Nonetheless, the South African experience yields positive lessons that could be of use to other countries contemplating similar initiatives., Background In light of an increasing global focus on health system strengthening and integration of vertical programmes within health systems, methods and tools are required to examine whether general health service managers exercise administrative authority over vertical programmes. Objective To measure the extent to which general health service (horizontal) managers, exercise authority over the HIV programme's monitoring and evaluation (M&E) function, and to explore factors that may influence this exercise of authority. Methods This cross-sectional survey involved interviews with 51 managers. We drew ideas from the concept of ‘exercised decision-space’ – traditionally used to measure local level managers’ exercise of authority over health system functions following decentralisation. Our main outcome measure was the degree of exercised authority – classified as ‘low’, ‘medium’ or ‘high’ – over four M&E domains (HIV data collection, collation, analysis, and use). We applied ordinal logistic regression to assess whether actor type (horizontal or vertical) was predictive of a higher degree of exercised authority, independent of management capacity (training and experience), and M&E knowledge. Results Relative to vertical managers, horizontal managers had lower HIV M&E knowledge, were more likely to exercise a higher degree of authority over HIV data collation (OR 7.26; CI: 1.9, 27.4), and less likely to do so over HIV data use (OR 0.19; CI: 0.05, 0.84). A higher HIV M&E knowledge score was predictive of a higher exercised authority over HIV data use (OR 1.22; CI: 0.99, 1.49). There was no association between management capacity and degree of authority. Conclusions This study demonstrates a HIV M&E model that is neither fully vertical nor integrated. The HIV M&E is characterised by horizontal managers producing HIV information while vertical managers use it. This may undermine policies to strengthen integrated health system planning and management under the leadership of horizontal managers., Background Ninety percent of the world's 2.1 million HIV-infected children live in sub-Saharan Africa, and 2.5% of South African children live with HIV. As HIV care and treatment programmes are scaled-up, a rise in loss to follow-up (LTFU) has been observed. Objective The aim of the study was to determine the rate of LTFU in children receiving antiretroviral treatment (ART) and to identify baseline characteristics associated with LTFU in the first year of treatment. We also explored the effect of patient characteristics at 12 months treatment on LTFU in the second year. Methods The study is an analysis of prospectively collected routine data of HIV-infected children at the Harriet Shezi Children's Clinic (HSCC) in Soweto, Johannesburg. Cox proportional hazards models were fitted to investigate associations between baseline characteristics and 12-month characteristics with LTFU in the first and second year on ART, respectively. Results The cumulative probability of LTFU at 12 months was 7.3% (95% CI 7.1–8.8). In the first 12 months on ART, independent predictors of LTFU were age, Background South Africa is experiencing a demographic and epidemiological transition with an increase in population aged 50 years and older and rising prevalence of non-communicable diseases. This, coupled with high HIV and tuberculosis prevalence, puts an already weak health service under greater strain. Objective To measure self-reported chronic health conditions and chronic disease risk factors, including smoking and alcohol use, and to establish their association with health care use in a rural South African population aged 50 years or older. Methods The Study on Global Ageing and Adult Health (SAGE), in collaboration with the INDEPTH Network and the World Health Organization, was implemented in the Agincourt sub-district in rural northeast South Africa where there is a long-standing health and socio-demographic surveillance system. Household-based interviews were conducted in a random sample of people aged 50 years and older. The interview included questions on self-reported health and health care use, and some physical measurements, including blood pressure and anthropometry. Results Four hundred and twenty-five individuals aged 50 years or older participated in the study. Musculoskeletal pain was the most prevalent self-reported condition (41.7%; 95% Confidence Interval [CI] 37.0–46.6) followed by hypertension (31.2%; 95% CI 26.8–35.9) and diabetes (6.1%; 95% CI 4.1–8.9). All self-reported conditions were significantly associated with low self-reported functionality and quality of life, 57% of participants had hypertension, including 44% of those who reported normal blood pressure. A large waist circumference and current alcohol consumption were associated with high risk of hypertension in men, whereas in women, old age, high waist–hip ratio, and less than 6 years of formal education were associated with high risk of hypertension. Only 45% of all participants reported accessing health care in the last 12 months. Those who reported higher use of the health facilities also reported lower levels of functioning and quality of life. Conclusion Self-reported chronic health conditions, especially hypertension, had a high prevalence in this population and were strongly associated with higher levels of health care use. The primary health care system in South Africa will need to provide care for people with non-communicable diseases., Background This article is a review of the PhD thesis by Elizabeth Kimani-Murage that explores the double burden of malnutrition in rural South Africa. This is in the context of a worryingly rapid increase in obesity and obesity-related diseases in low- and middle-income countries (LMICs) including South Africa, and in the wake of on-going nutrition transition and lifestyle changes in these countries. Objective To understand the profiles of malnutrition among children and adolescents in a poor, high HIV prevalent, transitional society in a middle-income country. Methods A cross-sectional growth survey was conducted in 2007 targeting 4,000 children and adolescents aged 1–20 years. In addition, HIV testing was carried out on children aged 1–5 years and Tanner pubertal assessment among adolescents aged 9–20 years. Results The study shows stunting at an early age and adolescent obesity, particularly among girls, that co-exists in the same socio-geographic population. The study also shows that HIV is an independent modifiable risk factor for poor nutritional outcomes in children and makes a significant contribution to nutritional outcomes at the individual level. Significant predictors of undernutrition at an early age, documented at individual, household, and community levels, include child's HIV status, age and birth weight, maternal age, age of household head, and area of residence. Significant predictors of overweight/obesity and risk for metabolic disease during adolescence, documented at individual and household levels include child's age, sex, and pubertal development, household-level food security, socio-economic status, and household head's highest education level. Conclusions The combination of early stunting and adolescent obesity raises critical concerns in the wake of the rising public health importance of metabolic diseases in LMICs. This is because, both paediatric obesity and adult short stature are risk factors for metabolic syndrome and metabolic diseases in adulthood. Clearly, policies and interventions to address malnutrition in this and other transitional societies need to be double-pronged and gender-sensitive., Background Increasing urbanisation and rising unhealthy lifestyle risk factors are contributing to a growing diabetes epidemic in South Africa. In 2000, a study estimated diabetes prevalence to be 5.5% in those aged over 30. Accurate, up-to-date information on the epidemiology and burden of disease due to diabetes and its sequelae is essential in the planning of health services for diabetes management. Objective To calculate the non-fatal burden of disease in Years Lost due to Disability (YLD) due to diabetes and selected sequelae in South Africa in 2009. YLD measures the equivalent loss of life due to ill-health. Methods A series of systematic literature reviews identified data on the epidemiology of diabetes and its sequelae in South Africa. The data identified were then applied to Global Burden of Disease (GBD) methodology to calculate the burden attributable to diabetes. Results Prevalence of type 2 diabetes in South Africa in 2009 is estimated at 9.0% in people aged 30 and older, representing approximately 2 million cases of diabetes. We modelled 8,000 new cases of blindness and 2,000 new amputations annually caused by diabetes. There are 78,900 YLD attributed to diabetes, with 64% coming from diabetes alone, 24% from retinopathy, 6% from amputations, 9% from attributable stroke disability, and 7% from attributable ischemic heart disease disability. Conclusion We estimate that the prevalence of diabetes is increasing in South Africa. Significant disability associated with diabetes is demonstrated. Some of the attributed burden can be prevented through early detection and treatment., Background Non-communicable diseases (NCD) and infectious chronic illnesses are recognised as significant contributing factors to the burden of disease globally, specifically in South Africa, yet clinical management is often poor. The involvement of community health workers (CHWs) in TB and HIV care in South Africa, and other low- and middle-income settings, suggests that they could make an important contribution in the management of NCDs. Objectives Using a rapid assessment, this study examines the outcomes of a pilot CHW programme to improve the management of hypertension and diabetes in Gauteng province, South Africa. Methods A record review compared outcomes of patients receiving home visits (n56) with a control group (n168) attending the clinic, matched, as far as possible, on age, gender, and condition. Focus group discussions and semi-structured interviews with CHWs, patients, district, clinic, and NGO staff were used to obtain descriptions of the functioning of the programme and patient experiences. Results Despite the greater age and co-morbidity among those in the pilot programme, the findings suggest that control of hypertension was improved by CHW home visits in comparison to usual clinic care. However, too few doctor visits, insufficient monitoring of patient outcomes by clinic staff, and a poor procurement process for supplies required by the CHWs hampered the programme's activities. Conclusion The role of CHWs in the management of hypertension should be given greater consideration, with larger studies being conducted to provide more robust evidence. Adequate training, supervision, and operational support will be required to ensure success of any CHW programme., Introduction In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care. Methods The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care. Results The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care. Conclusion Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.

Includes bibliographical references., In South Africa, health care is financed through different mechanisms - allocations from general taxes, private health insurance contributions and direct out-of-pocket payments. These mechanisms impact differently on different households. While there are empirical evidence in developed countries, the distributional impact of such payments and methodological challenges in such assessments in the context of Africa are scarce. Borrowing from the tax literature, the thesis aims to assess the relative impact of health care financing on households' welfare and standards of living. Methodological issues around the assessment of income redistributive impact of health care payments in the context of South Africa are also explored.