Browsing by Author "Cleary, Susan"

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    Enabling relational leadership in primary healthcare settings: lessons from the DIALHS collaboration
    (Oxford University Press, 2018) Cleary, Susan; du Toit, Alison; Scott, Vera; Gilson, Lucy
    Strong management and leadership competencies have been identified as critical in enhancing health system performance. While the need for strong health system leadership has been raised, an important undertaking for health policy and systems researchers is to generate lessons about how to support leadership development (LD), particularly within the crisis-prone, resource poor contexts that are characteristic of Low- and Middle-Income health systems. As part of the broader DIALHS (District Innovation and Action Learning for Health Systems Development) collaboration, this article reflects on 5 years of action learning and engagement around leadership and LD within primary healthcare (PHC) services. Working in one sub-district in Cape Town, we cocreated LD processes with managers from nine PHC facilities and with the six members of the sub-district management team. Within this article, we seek to provide insights into how leadership is currently practiced and to highlight lessons about whether and how our approach to LD enabled a strengthening of leadership within this setting. Findings suggest that the sub-district is located within a hierarchical governance context, with performance monitored through the use of multiple accountability mechanisms including standard operating procedures, facility audits and target setting processes. This context presents an important constraint to the development of a more distributed, relational leadership. While our data suggest that gains in leadership were emerging, our experience is of a system struggling to shift from a hierarchical to a more relational understanding of how to enable improvements in performance, and to implement these changes in practice.
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    Factors associated with patterns of plural healthcare utilization among patients taking antiretroviral therapy in rural and urban South Africa: a cross sectional study
    (BioMed Central, 2012) Moshabela, Mosa; Schneider, Helen; Silal, Sheetal; Cleary, Susan
    Background: In low-resource settings, patients’ use of multiple healthcare sources may complicate chronic care and clinical outcomes as antiretroviral therapy (ART) continues to expand. However, little is known regarding patterns, drivers and consequences of using multiple healthcare sources. We therefore investigated factors associated with patterns of plural healthcare usage among patients taking ART in diverse South African settings. Methods: A cross-sectional study of patients taking ART was conducted in two rural and two urban sub-districts, involving 13 accredited facilities and 1266 participants selected through systematic random sampling. Structured questionnaires were used in interviews, and participant’s clinic records were reviewed. Data collected included household assets, healthcare access dimensions (availability, affordability and acceptability), healthcare utilization and pluralism, and laboratory-based outcomes. Multiple logistic regression models were fitted to identify predictors of healthcare pluralism and associations with treatment outcomes. Prior ethical approval and informed consent were obtained. Results: Nineteen percent of respondents reported use of additional healthcare providers over and above their regular ART visits in the prior month. A further 15% of respondents reported additional expenditure on self-care (e.g. special foods). Access to health insurance (Adjusted odds ratio [aOR] 6.15) and disability grants (aOR 1.35) increased plural healthcare use. However, plural healthcare users were more likely to borrow money to finance healthcare (aOR 2.68), and incur catastrophic levels of healthcare expenditure (27%) than non-plural users (7%). Quality of care factors, such as perceived disrespect by staff (aOR 2.07) and lack of privacy (aOR 1.50) increased plural healthcare utilization. Plural healthcare utilization was associated with rural residence (aOR 1.97). Healthcare pluralism was not associated with missed visits or biological outcomes. Conclusion: Increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher socioeconomic status, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Plural healthcare utilization may be an indication of patients’ dissatisfaction with perceived quality of ART care provided. Healthcare expenditure of a catastrophic nature remained a persistent complication. Plural healthcare utilization did not appear to influence clinical outcomes. However, there were potential negative impacts on the livelihoods of patients and their households.
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    Gender differences in experiences of ART services in South Africa: a mixed methods study
    (Blackwell Publishing Ltd, 2012) Schneider, Helen; Govender, Veloshnee; Harris, Bronwyn; Cleary, Susan; Moshabela, Mosa; Birch, Stephen
    Objectives: A mixed methods study exploring gender differences in patient profiles and experiences of ART services, along the access dimensions of availability, affordability and acceptability, in two rural and two urban areas of South Africa. methods Structured exit interviews (n = 1266) combined with in-depth interviews (n = 20) of women and men enrolled in ART care. results Men attending ART services were more likely to be employed (29% vs. 20%, P = 0.001) and were twice as likely to be married ⁄ co-habiting as women (42% vs. 22% P = 0.001). Men had known their HIV status for a shorter time (mean 32 vs. 36 months, P = 0.021) and were also less likely to disclose their status to non-family members (17% vs. 26%, P = 0.001). From both forms of data collection, a key finding was the role of female partners in providing social support and facilitating use of services by men. The converse was true for women who relied more on extended families and friends than on partners for support. Young, unmarried and unemployed men faced the greatest social isolation and difficulty. There were no major gender differences in the health system (supply side) dimensions of access. conclusions Gender differences in experiences of HIV services relate more to social than health system factors. However, the health system could be more responsive by designing services in ways that enable earlier and easier use by men.
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    Unequal access to ART: exploratory results from rural and urban case studies of ART use
    (BMJ Publishing Group, 2012) Cleary, Susan; Birch, Stephen; Moshabela, Mosa; Schneider, Helen
    INTRODUCTION: South Africa has the world's largest antiretroviral treatment (ART) programme. While services in the public sector are free at the point of use, little is known about overall access barriers. This paper explores these barriers from the perspective of ART users enrolled in services in two rural and two urban settings. METHODS: Using a comprehensive framework of access, interviews were conducted with over 1200 ART users to assess barriers along three dimensions: availability, affordability and acceptability. Summary statistics were computed and comparisons of access barriers between sites were explored using multivariate linear and logistic regressions. RESULTS: While availability access barriers in rural settings were found to be mitigated through a more decentralised model of service provision in one site, affordability barriers were considerably higher in rural versus urban settings. 50% of respondents incurred catastrophic healthcare expenditure and 36% borrowed money to cover these expenses in one rural site. On acceptability, rural users were less likely to report feeling respected by health workers. Stigma was reported to be lowest in the two sites with the most decentralised services and the highest coverage of those in need. CONCLUSIONS: While results suggest inequitable access to ART for rural relative to urban users, nurse-led services offered through primary healthcare facilities mitigated these barriers in one rural site. This is an important finding given current policy emphasis on decentralised and nurse-led ART in South Africa. This study is one of the first to present comprehensive evidence on access barriers to assist in the design of policy solutions.