Researching barriers to HIV treatment and maternal health

By Stephen Dale

More than 200 global health researchers gathered in Ottawa to discuss research results from the 7-year Teasdale-Corti Global Health Research Partnership. Canadian and South African researchers reported on the factors that make it difficult for poor people to take advantage of publicly funded health care.

South Africa’s commitment to funding universally accessible health care has led to some impressive improvements in its citizens’ health. Major gains include a huge expansion in the provision of Anti-Retro Viral Therapy (ART), a highly effective treatment for people living with HIV/AIDS.

But there are still people — particularly the poorest South Africans — who have benefited little from the country’s health services. For some, ART is rendered ineffective by their inability to maintain a regular treatment schedule. Child and maternal health outcomes have also remained disappointing.

A team of South African and Canadian researchers has been probing this paradox. With funding from the Teasdale-Corti Global Health Research Partnership, researchers from South Africa’s University of the Witwatersrand, University of the Western Cape and the University of Cape Town, as well as McMaster University in Canada, have been searching for the hidden factors that keep some citizens in poor health despite the formal government commitment to providing universal care.

The Teasdale-Corti partnership is funded through Canada’s Global Health Research Initiative, a partnership between IDRC, the Canadian International Development Agency, and the Canadian Institutes of Health Research.

Hard consequences of health care

The REACH (Researching Equity in Access to Health Care) program has been examining “the soft elements of health care that have hard consequences,” explains Professor Helen Schneider, a project team leader from South Africa’s University of the Western Cape.

“It’s not enough just to have the service available. It has to be of reasonable quality and people have to trust it. So we’re looking beyond the concrete elements, and asking whether other elements — the relationships, the rules of the game — act as barriers to access.”

To do this, the researchers surveyed a wide range of healthcare users in two poor districts, one rural and one urban.

Factors in maternal mortality

One study, based on interviews with women who used maternal services, found that women tended to delay going to hospital because of transportation costs. This is significant because 50% of South Africa’s maternal deaths are believed to arise from preventable problems such as arriving at hospital too late.

“Some women’s lives were so difficult that it was a struggle to access services,” says Loveday Penn Kekana of the Centre for Health Policy at University of the Witwatersrand in Johannesburg. Many women reported that a lack of public transit and the refusal of ambulance drivers to enter their neighbourhoods at night meant they had to hire a private car to get to hospital. Transportation is just one expense that forced many women to borrow money or sell possessions to cover pregnancy-related costs.

The survey also found that being treated disrespectfully by hospital staff was a disincentive to hospital use. In one extreme case, a woman who had been turned away from hospital and told to return the next day gave birth under a tree.

REACH’s findings have fed a lively public debate about how to reduce maternal mortality rates that exceed expectations for a middle-income country. While some suggest reforming the health system, others take aim at the country’s widening social inequality that underlies poor women’s struggle to access services. A proposed “pregnancy grant,” for example, would give women funding for the extra costs involved in having a baby.

Life-transforming therapy

Meanwhile, the delivery of medical care to people living with HIV/AIDS is also complicated by “soft elements” in the health system.

In general, the scaling-up of ART has been a resounding success in South Africa While in 2004 only 4% had access to the therapy that transforms the disease from a death sentence into a manageable, chronic condition, the proportion rose to 55% in 2010.

In a survey of ART patients, says Jana Fried of McMaster University in Hamilton, Canada, many reported that the drug regime was life transforming, allowing patients to live a normal life after having endured great hardship.

But there have been complications. The move from an entirely hospital-administered program to community clinics has proven convenient for patients but has prompted many to pay for additional doctor’s care, mostly because they feel uncertain about being seen only by nurses. That extra cost can create a crushing financial burden, says Mosha Moshabela of Johannesburg’s Witwatersrand University.

Making modest changes that lead patients to feel better about community care would take away that burden, says Helen Schneider. Loveday Penn Kekana adds that transitioning to nurse-led care is an increasingly global challenge, because stretched health systems around the world are looking to nurses to manage chronic conditions such as asthma and hypertension.

Stephen Dale is an Ottawa writer.

Click hereto read more about the REACH project, andherefor more on the IDRC and REACH.