Dr. Vera Scott (School of Public Health)
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| Position: | Senior researcher |
| Department: | School of Public Health |
| Faculty: | Faculty of Community and Health Sciences |
| Qualifications: | MBChB (UCT), DCH (UCT), MPH (UWC) |
| My publications in this repository | |
| More about me: | here , and here. |
| Tel: | + 27 21 959 2872 |
| Email: | verascott@mweb.co.za |
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Item How equitable is the scaling up of HIV service provision in South Africa?(Health and Medical Publishing Group, 2005) Scott, Vera; Chopra, Mickey; Conrad, Liz; Ntuli, AntoinetteOBJECTIVES. To assess the extent of inequalities in availability and utilisation of HIV services across South Africa. DESIGN. Cross-sectional descriptive study. Setting. Three districts reflecting different socio-economic conditions, but with similar levels of HIV infection, were purposively sampled. Outcome measures. Availability and utilisation of HIV services and management and support structures for programmes were assessed through the collection of secondary data supplemented by site visits. RESULTS. There were marked inequalities in service delivery between the three sites. Compared with two poorer sites, clinics at the urban site had greater availability of HIV services, including voluntary counselling and testing (100% v. 52% and 24% respectively), better uptake of this service (59 v. 9 and 5.5 clients per 1 000 adults respectively) and greater distribution of condoms (15.6 v. 8.2 condoms per adult male per year). Extra counsellors had also been employed at the urban site in contrast to the other 2 sites. The urban site also had far more intensive management support and monitoring, with 1 manager per 12 health facilities compared with 1 manager per more than 90 health facilities at the other 2 sites. CONCLUSION. The process of scaling up of HIV services seems to be accentuating inequalities. The urban site in this study was better able to utilise the extra resources. In contrast, the poorer sites have thus far been unable to scale up the response to HIV even with the availability of extra resources. Unless policy makers pay more attention to equity, efficacious interventions may prove to be of limited effectiveness.Item Research to action to address inequities: The experience of the Cape Town Equity Gauge(BioMed Central, 2008-01-04) Scott, Vera; Stern, Ruth; Sanders, David; Reagon, Gavin; Mathews, VeronaBACKGROUND: While the importance of promoting equity to achieve health is now recognised, the health gap continues to increase globally between and within countries. The description that follows looks at how the Cape Town Equity Gauge initiative, part of the Global Equity Gauge Alliance (GEGA) is endeavouring to tackle this problem. We give an overview of the first phase of our research in which we did an initial assessment of health status and the socio-economic determinants of health across the subdistrict health structures of Cape Town. We then describe two projects from the second phase of our research in which we move from research to action. The first project, the Equity Tools for Managers Project, engages with health managers to develop two tools to address inequity: an Equity Measurement Tool which quantifies inequity in health service provision in financial terms, and a Equity Resource Allocation Tool which advocates for and guides action to rectify inequity in health service provision. The second project, the Water and Sanitation Project, engages with community structures and other sectors to address the problem of diarrhoea in one of the poorest areas in Cape Town through the establishment of a community forum and a pilot study into the acceptability of dry sanitation toilets. METHODS: A participatory approach was adopted. Both quantitative and qualitative methods were used. The first phase, the collection of measurements across the health subdistricts of Cape Town, used quantitative secondary data to demonstrate the inequities. In the Equity Tools for Managers Project further quantitative work was done, supplemented by qualitative policy analysis to study the constraints to implementing equity. The Water and Sanitation Project was primarily qualitative, using in-depth interviews and focus group discussions. These were used to gain an understanding of the impact of the inequities, in this instance, inadequate sanitation provision. RESULTS: The studies both demonstrate the value of adopting the GEGA approach of research to action, adopting three pillars of assessment and monitoring; advocacy; and community empowerment. In the Equity Tools for Managers Project study, the participation of managers meant that their support for implementation was increased, although the failure to include nurses and communities in the study was noted as a limitation. The development of a community Water and Sanitation Forum to support the Project had some notable successes, but also experienced some difficulties due to lack of capacity in both the community and the municipality. CONCLUSION: The two very different, but connected projects, demonstrate the value of adopting the GEGA approach, and the importance of involvement of all stakeholders at all stages. The studies also illustrate the potential of a research institution as informed 'outsiders', in influencing policy and practice.Item Scaling up integration: Development and results of a participatory assessment of HIV/TB services, South Africa(BioMed Central Ltd, 2010) Scott, Vera; Chopra, Mickey; Azevedo, Virginia; Caldwell, Judy; Naidoo, Pren; Smuts, BrendaBACKGROUND: In South Africa the need to integrate HIV, TB and STI programmes has been recognised at a policy and organisation level; the challenge is now one of translating policies into relevant actions and monitoring implementation to ensure that the anticipated benefits of integration are achieved. In this research, set in public primary care services in Cape Town, South Africa, we set out to determine how middle level managers could be empowered to monitor the implementation of an effective, integrated HIV/TB/STI service. METHODS: A team of managers and researchers designed an evaluation tool to measure implementation of key components of an integrated HIV/TB/STI package with a focus on integration. They used a comprehensive health systems framework based on conditions for programme effectiveness and then identified and collected tracer indicators. The tool was extensively piloted in two rounds involving 49 clinics in 2003 and 2004 to identify data necessary for effective facility-level management. A subsequent evaluation of 16 clinics (2 per health sub district, 12% of all public primary care facilities) was done in February 2006. RESULTS: 16 clinics were reviewed and 635 records sampled. Client access to HIV/TB/STI programmes was limited in that 50% of facilities routinely deferred clients. Whilst the physical infrastructure and staff were available, there was problem with capacity in that there was insufficient staff training (for example, only 40% of clinical staff trained in HIV care). Weaknesses were identified in quality of care (for example, only 57% of HIV clients were staged in accordance with protocols) and continuity of care (for example, only 24% of VCT clients diagnosed with HIV were followed up for medical assessment). Facility and programme managers felt that the evaluation tool generated information that was useful to manage the programmes at facility and district level. On the basis of the results facility managers drew up action plans to address three areas of weakness within their own facility. CONCLUSIONS: This use of the tool which is designed to empower programme and facility managers demonstrates how engaging middle managers is crucial in translating policies into relevant actions.Item Assessing and improving care for patients with TB/HIV/STIs in a rural district in KwaZulu-Natal South Africa(Health and Medical Publishing Group (HMPG), 2011) Loveday, Marion; Scott, Vera; McLaughlin, Jennifer; Amien, Feroza; Virgina, ZweigenthalSetting: Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate. Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal. Methods: A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified. Results: We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days. Conclusion: Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.Item Between HIV diagnosis and initiation of antiretroviral therapy: Assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town, South Africa(Wiley-Blackwell, 2011) Scott, Vera; Zweigenthal, Virginia; Jennings, KarenBACKGROUND: While much is written about the scale up of HIV counselling and testing (HCT) and antiretroviral therapy (ART), little research has been done on the expansion of routine preART HIV care. OBJECTIVE: To assess the quality of preART care in Cape Town and its continuity with HCT and ART. METHODS: The scale up of the HCT, preART and ART service platform and programmatic support in Cape Town is described. Data from the August 2010 routine annual HIV/TB/STI evaluation, from interviews with 133 facility managers and a folder review of 634 HCT s who tested positive and 1115 clients receiving preART HIV care are analysed. RESULTS: Historically the implementation and management of preART care has been relatively neglected compared with the scale-up of HCT and ART. The CD4 count was done on 77.5% positive HCT clients and 46.6% were clinically staged - crucial steps that determine the care path. There were: gaps in quality of care - 32.2% of women had a PAP smear; missed opportunities for integrated care - 67% were symptomatically screened for tuberculosis; and positive prevention - 48.3% had contraceptive needs assessed. Breaks in the continuity of care of preART clients occurred with only 47.2% of eligible clients referred appropriately to the ARV service. CONCLUSION: While a package of preART care has been clearly defined in Cape Town, it has not been fully implemented. There are weaknesses in the continuity and quality service delivered that undermine the programme objectives of provision of positive prevention and timeous access to ART.Item Knowledge, attitude and practice study of HIV in female adolescents presenting for contraceptive services in a rural health district in the north-east of Namibia(OpenJournals Publishing, 2012) Ntumba, Alexis; Scott, Vera; Igumbor, Ehimario U.Background: Namibia bears a large burden of Human Immunodeficiency Virus (HIV), and the youth are disproportionately affected. Objectives: To explore the current knowledge, attitudes and behaviour of female adolescents attending family planning to HIV prevention. Methods: A cross-sectional study design was used on a sample 251 unmarried female adolescents aged from 13 years to 19 years accessing primary care services for contraception using an interviewer-administered questionnaire. Data were analysed using Epi Info 2002. Crude associations were assessed using cross-tabulations of knowledge, attitude and behaviour scores against demographic variables. Chi-square tests and odds ratios were used to assess associations from the cross-tabulations. All p-values < 0.05 were considered statistically significant. Results: A quarter of sexually active teenagers attending the family-planning services did not have adequate knowledge of HIV prevention strategies. Less than a quarter (23.9%) always used a condom. Most respondents (83.3%) started sexual intercourse when older than 16 years, but only 38.6% used a condom at their sexual debut. The older the girls were at sexual debut, the more likely they were to use a condom for the event (8% did so at age 13 years and 100% at age 19 years). Conclusions: Knowledge of condom use as an HIV prevention strategy did not translate into consistent condom use. One alternate approach in family-planning facilities may be to encourage condom use as a dual protection method. Delayed onset of sexual activity and consistent use of condoms should be encouraged amongst schoolchildren, in the school setting.Item Constraints to implementing an equity-promoting staff allocation policy: understanding key actors perspectives affecting implementation in South Africa(Oxford University Press, 2012) Scott, Vera; Mathews, Verona; Gilson, LucyMuch of current research on issues of equity in low- and middle-income countries focuses on uncovering and describing the extent of inequities in health status and health service provision. In terms of policy responses to inequity, there is a growing body of work on resource reallocation strategies. However, little published work exists on the challenges of implementing new policies intended to improve equity in health status or health service delivery. While the appropriateness of the technical content of policies clearly influences whether or not they promote equity, policy analysis theory suggests that it is important to consider how the processes of policy development and implementation influence policy achievements. Drawing on actor analysis and implementation theory, we seek to understand some of the dynamics surrounding the proposed implementation of one set of South African staff allocation strategies responding to broader equity-oriented policy mandates. These proposals were developed by a team of researchers and mid-level managers in 2003 and called for the reallocation of staff between better- and lesser-resourced districts in the Cape Town Metropolitan region to reduce broader resource allocation inequities. This was felt necessary because up to 70% of public health expenditure was on staff, and new financing for health care was unavailable. We focus on the views and reactions of the two sets of implementing actors most directly influenced by the proposed staff reallocation strategies: district health managers and clinic nurses. One strength of this analysis is that it gives voice to the experience of the district level—the key but much neglected implementation arena in a decentralized health system. The paper’s findings unpack differences in these actors’ positions on the proposed strategies, and explore the factors influencing their positions. Ultimately, we show how a lack of trust in the relationships between mid-level managers and nurse service providers influenced the potential to implement a specific set of equity-oriented strategiesItem Is there room for improvement? Intervening at facility and district level to improve access and quality of care in a well-performing TB Control Programme: the Cape Town experience(Health and Medical Publishing Group, 2012) Scott, Vera; Caldwell, Judy; Azevedo, VirginiaObjectives. To use a quality improvement approach to improve access to and quality of tuberculosis (TB) diagnosis and care in Cape Town. Methods. Five HIV/AIDS/sexually transmitted infections/TB (HAST) evaluations were conducted from 2008 to 2010, with interviews with 99 facility managers and a folder review of over 850 client records per evaluation cycle. The data were used in a local quality improvement process: sub-district workshops identified key weaknesses and facility managers drew up action plans. Lessons learnt and successful strategies were shared at quarterly districtwide HIV/TB meetings. Results. Geographical access was good, but there were delays in treatment commencement times. Access for high-risk clients improved significantly with intensified TB case finding made routine in both the HIV counselling and testing and antiretroviral treatment (ART) services (p<0.01 for both). Access for children in contact with an infectious case has improved but is still low (42% investigated and treated). Quality of care was mostly high at baseline (adherence to treatment protocols 95%). Measurement of body mass index improved from 20% to 62%. The assessment of contraception improved from 27% to 58%. Care for co-infected clients showed improved use of customised HIV stationery and increased assessment for ART eligibility. Conclusions. The HAST audit contributed to the improved TB cure rates by supplementing routine information and involving sub-district managers, facility managers and facility staff in a quality improvement process that identified local opportunities for programme strengthening.Item Evaluation of how integrated HIV and TB programs are implemented in South Africa and the implications for rural-urban equity(James Cook University, 2013) Scott, Vera; Sanders, DavidIntroduction: In countries such as South Africa with a high prevalence of HIV and TB policy directives support program integration. Operational research suggests this is desirable, at least for increasing coverage of HIV and TB services, but warns that implementation models must take local health service infrastructure into account. Methods: A program evaluation of HIV and TB prevention and therapeutic services was performed at facility level in two purposefully selected districts in South Africa – one deep rural and an urban district – in order to describe integration and how it is implemented. Twenty-six rural and 146 urban public primary-care facilities were evaluated using secondary data generated from two large evaluations of HIV/TB/Sexually Transmitted Infections (STI) programs conducted in December 2008 and May 2009. The data collection tools consisted of a review of data in the routine health information system, a facility manager interview, a checklist for equipment and supplies, register reviews and a series of patient folder (health record) reviews. Data were collected on extent to which clients receive integrated services, as well as the quality of care, and the availability of key resources and system capacity to support quality care. Data were entered into MS Excel spreadsheets and proportions calculated for all indicators, and confidence intervals for proportions. Results: Evidence of integration was found across two dimensions - disease programs and the prevention–therapeutic axis. Integration was enabled in both the rural and urban districts because HIV and TB services were co-located in the extensive network of general primary-care services. Smaller rural facilities did not always have staff trained in all the required services, nurses worked without the support of a doctor and supervision was weaker, threatening quality of care. In the rural district there were instances of clients receiving more integrated services. The quality of care in the TB program was high in both districts. Conclusions: In both the districts evaluated, integration across programs and the prevention-care-rehabilitation axis of services was achieved through co-location at primary-care level. Coupled with health system strengthening, this has the potential to improve access across the HIV/TB/STI cluster of services. The benefit is likely to be greater in rural areas. Quality of care was maintained in the long established TB programs in both settings.Item Integration of HIV prevention into sexual and reproductive health services in an urban setting in South Africa(AOSIS OpenJournals, 2013) Parker, Shireen; Scott, VeraBackground: The United Nations Political Declaration on HIV and AIDS of 2006 stressed the need to strengthen policy and programme linkages between HIV and Sexual and Reproductive Health (SRH). However, the effectiveness and best practices for strengthening SRH and HIV linkages are poorly researched in the context of family-planning services. In Cape Town, HIV-prevention services have been integrated into family-planning services. There are two models of service configuration: dedicated stand-alone reproductive health clinics and familyplanning services located in comprehensive primary-care facilities. Objective: To describe how reproductive health services are integrating HIV prevention and care strategies and to measure the coverage and quality of these integrated services. Methods: A cross-sectional study was conducted using structured interviews with facility managers; a facility-based checklist; and a patient record review to assess the availability of resources, training, access, quality and integration. Results: Facilities in Cape Town are equipped adequately to offer integrated HIV-prevention and SRH services. Overall there was poor coverage of integrated services with 54% of familyplanning clients having a known HIV status; 47% being screened for a sexually transmitted infection and 55% being offered HIV counselling and testing and receiving condoms. Quality and continuity of care seemed better at the dedicated clinics than at the comprehensive facilities, supported by better training coverage. Conclusion: Engaging middle-level management is crucial with regard to improving integration within a well-resourced setting.Item Critiquing the response to the Ebola epidemic through a primary health care approach(BMC Public Health, 2016) Scott, Vera; Sarah, Crawford-Browne; David, SandersBACKGROUND: The 2014/2015 West Africa Ebola epidemic has caused the global public health community to engage in difficult self-reflection. First, it must consider the part it played in relation to an important public health question: why did this epidemic take hold and spread in this unprecedented manner? Second, it must use the lessons learnt to answer the subsequent question: what can be done now to prevent further such outbreaks in the future? These questions remain relevant, even as scientists announce that the Guinea Phase III efficacy vaccine trial shows that rVSV-EBOV (Merck, Sharp & Dohme) is highly efficacious in individuals. This is a major breakthrough in the fight against Ebola virus disease (EVD). It does not replace but may be a powerful adjunct to current strategies of EVD management and control. DISCUSSION: We contribute to the current self-reflection by presenting an analysis using a Primary Health Care (PHC) approach. This approach is appropriate as African countries in the region affected by EVD have recommitted themselves to PHC as a framework for organising health systems and the delivery of health services. The approach suggests that, in an epidemic made complex by weak pre-existing health systems, lack of trust in authorities and mobile populations, a broader approach is required to engage affected communities. In the medium-term health system development with attention to primary level services and community-based programmes to address the major disease burden of malaria, diarrhoeal disease, meningitis, tuberculosis and malnutrition is needed. This requires the development of local management and an investment in human resources for health. Crucially this has to be developed ahead of, and not in parallel with, future outbreaks. In the longer-term a commitment is required to address the underlying social determinants which make these countries so vulnerable, and limit their capacity to respond effectively to, epidemics such as EVD. CONCLUSION: The PHC approach offers an insightful critique of the global and regional factors which have compromised the response of health systems in Guinea, Liberia and Sierra Leone as well as suggesting what a strengthened EVD response might involve in the short, medium and long-term.Item Exploring how different modes of governance act across health system levels to influence primary healthcare facility managers' use of information in decisionmaking: experience from Cape Town, South Africa(BioMed Central, 2017) Scott, Vera; Gilson, LucyBACKGROUND: Governance, which includes decision-making at all levels of the health system, and information have been identified as key, interacting levers of health system strengthening. However there is an extensive literature detailing the challenges of supporting health managers to use formal information from health information systems (HISs) in their decision-making. While health information needs differ across levels of the health system there has been surprisingly little empirical work considering what information is actually used by primary healthcare facility managers in managing, and making decisions about, service delivery. This paper, therefore, specifically examines experience from Cape Town, South Africa, asking the question: How is primary healthcare facility managers’ use of information for decision-making influenced by governance across levels of the health system? The research is novel in that it both explores what information these facility managers actually use in decision-making, and considers how wider governance processes influence this information use. METHODS: An academic researcher and four facility managers worked as co-researchers in a multi-case study in which three areas of management were served as the cases. There were iterative cycles of data collection and collaborative analysis with individual and peer reflective learning over a period of three years. RESULTS: Central governance shaped what information and knowledge was valued – and, therefore, generated and used at lower system levels. The central level valued formal health information generated in the district-based HIS which therefore attracted management attention across the levels of the health system in terms of design, funding and implementation. This information was useful in the top-down practices of planning and management of the public health system. However, in facilities at the frontline of service delivery, there was a strong requirement for local, disaggregated information and experiential knowledge to make locally-appropriate and responsive decisions, and to perform the people management tasks required. Despite central level influences, modes of governance operating at the subdistrict level had influence over what information was valued, generated and used locally. CONCLUSIONS: Strengthening local level managers’ ability to create enabling environments is an important leverage point in supporting informed local decision-making, and, in turn, translating national policies and priorities, including equity goals, into appropriate service delivery practices.