Learning from HIV: exploring migration and health in South Africa

Southern Africa is associated with high HIV prevalence and diverse population movements, including temporary, circular movements between rural and urban areas within countries (internal migration), and movements across borders (international migration). Whilst most migration in southern Africa is associated with the search for improved livelihood opportunities in urban areas a small--but significant--number of people are forced to migrate to escape persecution or civil war. This paper utilises recent empirical studies conducted in South Africa to explore linkages between migration into urban areas and health, focusing on HIV. It is shown that the relationship between migration and HIV is complex; that both internal and international migrants move to urban areas for reasons other than healthcare seeking; and that most migratory movements into urban areas involve the positive selection of healthy individuals. Whilst healthy migration has economic benefits for rural sending households, the data uncovers an important process of return migration (internally or across borders) in times of sickness, with the burden of care placed on the rural, sending household. There is an urgent need for a comprehensive response that maintains the health of migrants in urban areas, and provides support to rural areas in times of sickness.     

Learning from HIV: Exploring migration and health in South Africa

Abstract

Southern Africa is associated with high HIV prevalence and diverse population movements, including temporary, circular movements between rural and urban areas within countries (internal migration), and movements across borders (international migration). Whilst most migration in southern Africa is associated with the search for improved livelihood opportunities in urban areas a small – but significant – number of people are forced to migrate to escape persecution or civil war. This paper utilises recent empirical studies conducted in South Africa to explore linkages between migration into urban areas and health, focusing on HIV. It is shown that the relationship between migration and HIV is complex; that both internal and international migrants move to urban areas for reasons other than healthcare seeking; and that most migratory movements into urban areas involve the positive selection of healthy individuals. Whilst healthy migration has economic benefits for rural sending households, the data uncovers an important process of return migration (internally or across borders) in times of sickness, with the burden of care placed on the rural, sending household. There is an urgent need for a comprehensive response that maintains the health of migrants in urban areas, and provides support to rural areas in times of sickness.     

Free GP care and psychological health: Quasi-experimental evidence from Ireland

There is considerable ambiguity in the literature on the effect of health insurance on health. While the majority of previous analyses have examined physical health outcomes, analyses of the broader dimensions of health such as psychological health and wellbeing have been less frequent. Using data from the Irish Longitudinal Study on Ageing (TILDA) and a difference-in-differences research design, we examine the impact of free general practitioner (GP) care on psychological health among the older population and explore potential mechanisms. While we find no impact of public health insurance expansions on quality of life, life satisfaction, depression, and worry, the removal of GP fees for all those 70+ leads to a significantly lower level of perceived stress. The impact is mainly driven by poorer, sicker and single individuals. Further analyses show that removing GP fees leads to greater access to GP services and lower levels of financial stress.     

Regional prevalence of health worker absenteeism in Tanzania

Absenteeism of health workers in developing countries is common and can severely undermine the reliability of the health system. Therefore, it is important to understand where the prevalence of absenteeism is high. We develop a simple imputation method that combines a Service Delivery Indicators survey and a Service Provision Assessment survey to estimate the prevalence of absenteeism of health workers at the level of regions in Tanzania. The resulting estimates allow one to identify the regions in which the prevalence of absenteeism is significantly higher or lower than the national average and help policymakers determine priority areas for intervention.     

Socioeconomic-related health inequality in South Africa: evidence from General Household Surveys

Background  

Inequalities in health have received considerable attention from health scientists and economists. In South Africa, inequalities exist in socio-economic status (SES) and in access to basic social services and are exacerbated by inequalities in health. While health systems, together with the wider social determinants of health, are relevant in seeking to improve health status and health inequalities, those that need good quality health care too seldom get it. Studies on the burden of ill-health in South Africa have shown consistently that, relative to the wealthy, the poor suffer more from more disease and violence. However, these studies are based on selected disease conditions and only consider a single point in time. Trend analyses have yet to be produced. This paper specifically investigates socio-economic related health inequality in South Africa and seeks to understand how the burden of self-reported illness and disability is distributed and whether this has changed since the early 2000s.     

Trust and health worker performance: exploring a conceptual framework using South African evidence

Two relationships of particular importance to health care provision are those between patient and provider, and health worker and employer. This paper presents an analytical framework that establishes the key dimensions of trust within these relationships, and suggests how they may combine in influencing health system responsiveness. The paper then explores the relevance of the framework by using it to analyse case studies of primary care providers in South Africa. The analysis suggests that respectful treatment is the central demand of primary care service users, in terms of positive attitudes/behaviours, thoroughness, and technical competence, as well as institutions that support fair treatment. It is argued that such treatment is necessary for, and integral to, patient-provider trust. The findings also suggest that the notion of workplace trust (combining trust in colleagues, supervisor and employing organisation) has relevance to provider experiences of their workplaces, and so can provide important insights for strengthening management. Nonetheless, given the limitations of this preliminary analysis, further research is needed to develop the notion of workplace trust and to test what role it has, along with that of provider-community relations, in influencing health worker performance.     

The impact of health worker migration on development dynamics: evidence of wealth effects from Africa

This article examines three relevant hypotheses on the effect of health worker migration on human development and economic prosperity (at the macro- and micro-levels) in Africa. Owing to the lack of relevant data on health human resource (HHR) migration for the continent, the subject matter has remained empirically void over the last decades despite the acute concern about health professional emigration. Using quantile regression, the following findings have been established. (1) The effect of HHR emigration is positive (negative) at low (high) levels of economic growth. (2) HHR emigration improves (mitigates) human development (GDP per capita growth) in low (high) quantiles of the distribution. (3) Specific differences in effects are found in top quantiles of human development and low quantiles of GDP per capita growth where the physician (nurse) emigration elasticities of development are positive (negative) and negative (positive), respectively. As a policy implication, blanket health-worker emigration control policies are unlikely to succeed across countries with different levels of human development and economic prosperity. Hence, the policies should be contingent on the prevailing levels of development and tailored differently across the most and least developed African countries.     

Poverty,risky sexual behaviour,and vulnerability to HIV infection: evidence from South Africa

This paper explores the relationship among poverty, risky sexual behaviour, and vulnerability to HIV infection, using data from the 1998 South African Demographic and Health Survey. Asset index was employed as proxy of socioeconomic status. Inequalities in health were measured using concentration index. Women in poorer households were slightly less knowledgeable about HIV/AIDS, while the socioeconomic inequalities in risky sexual behaviour were negligible. These small health gradients may reflect the limitations of population-based surveys in collection of information on sexual behaviour. The results may also mean that women in general are equally at risk of HIV infection, which means that more work is required to establish how factors other than knowledge on HIV/ AIDS and socioeconomic status stand to enhance the vulnerability of women to HIV/AIDS.     

Physician's manual reporting underestimates mortality: evidence from a population-based HIV/AIDS treatment program

Background  

In clinical and cohort research, mortality estimates are often derived from manual reports generated by physicians or electronic reports from vital event registries. We examined the rate of underreporting of deaths by manual methods as compared with electronic reports from a vital event registry.     

Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey

Background  

Over 30% of women and men in the South African national HIV household of 2005 indicated that they had previously been tested for HIV (of which 91% were aware of their test results). This paper seeks to describe the associations between socio-demographic, behavioural and social characteristics and knowledge of HIV status among a nationally representative population in South Africa.     

In-kind incentives and health worker performance: Experimental evidence from El Salvador

We experimentally evaluated the effects of in-kind team incentives on health worker performance in El Salvador, with 38 out of 75 community health teams randomly assigned to performance incentives over a 12-month period. All teams received monitoring, performance feedback and recognition for their achievements allowing us to isolate the effect of the incentive. While both treatment and control groups exhibit improvements in performance measures over time, the in-kind incentives generated significant improvements in community outreach, quality of care, timeliness of care, and utilization of maternal and child health services after 12 months. Gains were largest for teams at the bottom and top of the baseline performance distribution. We find no evidence of results being driven by changes in reporting or by shifting away effort from non-contracted outcomes. These results suggest that in-kind team incentives may be a viable alternative to monetary or individual incentives in certain contexts.     

Testing as a measure of worker health and safety training: perspectives from a hazardous materials program

BACKGROUND: Health and safety training for hazardous materials workers is among OSHA's major policies. A large and growing workforce in this area, and the resulting risks for these workers and the public, make quality training critical. Measuring trainees' individual knowledge following training is a common but controversial practice. METHODS: Technical issues and benefits in testing, strategies for mitigating the limitations of testing, and the relevance of testing at a broader policy level were examined from the perspective of a large and diverse program. RESULTS: Knowledge data from individuals greatly aided in evaluating program effectiveness at the time of training and in assessing workplace impact later. Use of sound testing principles and creative examination methods and materials, and collaboration across programs, all helped to address concerns for individual programs and the field generally. CONCLUSIONS: Programs would benefit from fully considering the benefits and options related to knowledge assessment in training. Those who choose to assess individual knowledge could move the process forward through added rigor, collaboration, and documentation of efforts.     

HIV and AIDS in South Africa: what is an appropriate public health response?

Ninety-eight cases of acquired immune deficiency syndrome (AIDS)were reported in the Republic of South Africa by the end of1987, and 166 by mid-December 1988. By 12 February 1990, 353cases of AIDS had been reported: 326 in South Africans and 27in people from either elsewhere in southern Africa or abroad.The South African patients comprised two main groups: whitemen with the pattern of infection typical of homosexual andbisexual men; and heterosexuals exhibiting the pattern commonin much of central and southern Africa. There have been a smallnumber of people with haemophilia affected with AIDS, but onlyone injecting drug user with AIDS to date. There is evidenceof considerable spread of the epidemic into the South Africanblack population; migrant labour, the high prevalence of sexuallytransmitted diseases and suspicion of government-directed familyplanning programmes have all contributed to this. Seropositivityrates in South African blacks are noted to be rising rapidlyand the doubling time is considered to be about 8.5 months.The government and some employers have adopted discriminatorymeasures to control the disease, including the screening ofmigrant workers and the repatriation of those found to be seropositive.Public health leadership from the state authorities has beeninappropriate. We argue for greater involvement of homosexual,worker, community and public health personnel in developingpolicies of control for human immunodeficiency virus (HIV) infectionin South Africa, if the response is to be ethical, non-discriminatory,sensitive, prevention-orientated and effective.     

Comparative health systems research in a context of HIV/AIDS: lessons from a multi-country study in South Africa, Tanzania and Zambia

Comparative, multi-country research has been underutilised as a means to inform health system development. South-south collaboration has been particularly poor, even though there have been clearly identified benefits of such endeavours. This commentary argues that in a context of HIV/AIDS, the need for regional learning has become even greater. This is because of the regional nature of the problem and the unique challenges that it creates for health systems. We draw on the experience of doing comparative research in South Africa, Tanzania and Zambia, to demonstrate that it can be useful for determining preconditions for the success of health care reforms, for affirming common issues faced by countries in the region, and for developing research capacity. Furthermore, these benefits can be derived by all countries participating in such research, irrespective of differences in capacity or socio-economic development.     

Claims on health care: a decision-making framework for equity, with application to treatment for HIV/AIDS in South Africa

Trying to determine how best to allocate resources in health care is especially difficult when resources are severely constrained, as is the case in all developing countries. This is particularly true in South Africa currently where the HIV epidemic adds significantly to a health service already overstretched by the demands made upon it. This paper proposes a framework for determining how best to allocate scarce health care resources in such circumstances. This is based on communitarian claims. The basis of possible claims considered include: the need for health care, specified both as illness and capacity to benefit; whether or not claimants have personal responsibility in the conditions that have generated their health care need; relative deprivation or disadvantage; and the impact of services on the health of society and on the social fabric. Ways of determining these different claims in practice and the weights to be attached to them are also discussed. The implications for the treatment of HIV/AIDS in South Africa are spelt out.     

The effects of paid sick leave on worker absenteeism and health care utilization

We estimate the short‐term effects of paid sick leave on worker absenteeism and health care utilization in the United States using data from the 2000–2013 Medical Expenditure Panel Survey. We use both parametric and matching‐based difference‐in‐differences methods to account for nonrandom selection into jobs that offer paid sick leave and estimate the treatment effect separately for workers who gained and lost sick leave benefits. We find consistent evidence of increased absenteeism among female workers who gained paid sick leave but not for other groups. Estimates for office‐based visits are mostly statistically insignificant and may not have a causal interpretation due to preexisting trends.