Transcript An Analysis of the Uptake of Public Sector Socio-Economic Group:

An Analysis of the Uptake of Public Sector
Voluntary Counseling and Testing Services by
Socio-Economic Group:
A South African Case Study
Michael Thiede, Natasha Palmer, Sandi Mbatsha
Conference on Reaching the Poor
February 18, 2004
Washington, D.C.
Background
• 24 million people living with HIV/AIDS in sub-Saharan Africa
(UNAIDS 2000)
• HIV prevalence in South Africa 11.4 percent, in urban informal areas
21.3 percent (HSRC 2002)
• HIV/AIDS biggest threat to the health system
• Socio-economic status is the principal determinant for exposure
to HIV/AIDS, with poverty and social inequalities as leading cofactors in HIV transmission (Gilbert & Walker 2002, Farmer 2001)
• SA public sector covers 84% of population (53% of total health
expenditure)
• Do public sector HIV/AIDS prevention services reach the poor/
the target groups?
• What are the barriers to access?
• What are the valued benefits?
VCT for HIV/AIDS in South Africa
• Voluntary counseling and testing (VCT) prioritized as HIV
prevention strategy by many severely affected countries
• VCT increasingly offered as service in public sector clinics
throughout SA
• Routine element of antenatal care (excluded from study)
• Elements: Voluntary testing for HIV, pre-test counseling, posttest counseling (mostly by lay counselors from communities)
• Promoted as key motivating force for people to adopt safer
sexual behavior and as an entry point to care for HIV-infected
(UNAIDS 2002, Magongo et al. 2002)
The Sites
• Study focus on peri-urban areas/townships:
- diversity of socio-economic backgrounds among relatively
deprived segments of SA society
- particularly adequate to demonstrate differentials in services
uptake
- influx of migrants from rural areas into peri-urban settlements
poses additional risk factor for HIV (Lurie 2000)
• 3 different townships, each representative of its category:
a) Masiphumelele: small, relatively recent development,
approx. 20,000 people, 1 clinic
b) Khayelitsha: largest township in Western Cape,
approx. 500,000 people, several clinics
c) Langa: oldest township in Western cape, 60,000 people,
1 clinic
Methodology
• Waiting room survey to assess access to VCT services by
different socio-economic groups
- personal characteristics (age, gender, education,
employment status, …)
- household characteristics (no. of people, household
durables/ assets synchronized with SA-DHS)
- questions on sources of information, motivation etc. around
VCT, barriers to access
- clinic users, VCT patients
• In-depth interviews
• Focus group discussions
• Analysis of SA-DHS township EAs (Gauteng, Western Cape)
• Asset indices and wealth quintiles
The SA-DHS
• Conducted in 1998 as part of National Health Information
System of South Africa, only released in 2001
• PSUs correspond to EAs of SA Census 1996
• 10 households per EA: 12,860 households
• ‘Assets’:
- Main source of drinking water
- Electricity
- Household items (Radio, TV, telephone, bicycle, car, …)
- Floor material
- Roof material
• Township sample: 507 households
The Sample
• 540 waiting room interviews
(50 Masiphumelele, 270 Khayelitsha, 220 Langa)
• Clinic users above 14
• ‘Systematic’ sample selection
• Two sections (VCT and non-VCT patients)
• n=525 after data cleaning
• 208 VCT patients
DHS ‘Township’ Population
% Tow nship Population
60%
50.5%
50%
40%
30%
19.9%
20%
17.4%
8.9%
10%
3.4%
0%
Low est
asset score
Low asset
score
Medium
asset score
DHS Quintiles
High asset
score
Highest
asset score
Service Utilization in Western Cape Townships
60%
52.9%
% Service Users
50%
44.6%
40%
Clinic Utilisation
28.2%
30%
VCT Services
23.1%
20%
15.1%
13.0%
10%
7.6%
6.3%
4.6% 4.8%
0%
Low est
asset
score
Low
asset
score
Medium
asset
score
High
asset
score
Tow nship Quintiles
Highest
asset
score
Progressive Pattern
Cumul. % services utilisation
100%
80%
60%
Line of equality
Clinic attendance
VCT uptake
40%
20%
0%
0%
20%
40%
60%
Cumul. % wealth
80%
100%
… Compared at ‘National Level’
50%
% Service Users
43.8%
40%
38.1%
37.5%
28.9%
30%
Clinic Utilisation
19.7%
20%
VCT Services
16.6%
10%
0%
7.2% 7.2%
0.6% 0.5%
Low est
asset
score
Low
asset
score
Medium
asset
score
High
asset
score
Highest
asset
score
DHS Quintiles (National Sam ple)
Community views: Information
Positive people are not welcome in the family.
Woman, Langa
What makes people not come [to VCT services] is their
background. Sometimes you get that their family do not accept
a positive person. They see her as if she is someone who was
misbehaving outside and then got positive. One is afraid to tell
her husband because she is worried that the husband will
divorce her. A mother who is not working is afraid of being left
with the children to feed. … Some people think when you touch
them you going to make them positive.
Woman, Langa
People have a fear of knowing, they also say “Why must we
test if the government does not treat us?”
Woman, Langa
Community views: Stigma
If [the clinic counsellors] would go outside to the community, it
would be worse. People do not want that counsellors be seen
who come to their door. It is better if the counsellors stay
there, so they can counsel those who go to the clinic.
Woman, Khayelitsha
HIV/AIDS workshop is not very good because that name is
scary.
Man, Khayelitsha
We also don’t want [the counsellors] really to come to our
places.
Man, Khayelitsha
Community views: Confidentiality
… if my counsellor is my neighbour, I think that maybe she
can tell people about me and my status. Therefore I decide to
go and do the test in Salt River and not here in Langa, you
understand?
Woman, Langa
… sometimes people they go to another clinic. We fear each
other.
Woman, Langa
We don’t have any confidentiality here… for confidentiality we
go to Wynberg.
Woman, Khayelitsha
False Bay is not safe anymore because the health workers do
go there and come back and tell, so the only place I see is
Fishhoek clinic, and Wynberg. People prefer going to places
far away from here.
Woman, Masiphumelele
Limitations
• No data available on HIV/AIDS prevalence according to
socio-economic status
• Refusals
• Asset index may not capture full reality of socio-economic
differences in SA peri-urban township setting
• Resistance to discuss HIV/AIDS-related matters in in-depth
interviews
• Post-test interviews not possible
• Limited scope of study (excludes urban and rural)
 Need for this type of research at a broader level
Policy Implications
• Number of multiple test patients suggests that VCT services may
address limited share of population
• Relatively better-off groups within township communities
underrepresented due to persistent problems around stigma and
confidentiality
• General barriers to services uptake resulting from permanent
lack of information
• Foster culture of participatory health communication (‘health
enabling community’), make health information available (by
making it culturally secure
• Improve trust in communities (via community groups)
• Explore possibility of contracting out (voucher system for
private sector services)
• Introduce monitoring gauge (to keep track of patients’ socioeconomic backgrounds and evaluate against
community data)
Thank You
[email protected]
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[email protected]