Health system determinants of tuberculosis mortality in South Africa: a causal loop model

Abstract Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thi...

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Main Authors: Muhammad Osman, Aaron S Karat, Munira Khan, Sue-Ann Meehan, Arne von Delft, Zameer Brey, Salome Charalambous, Anneke C Hesseling, Pren Naidoo, Marian Loveday
Format: Article
Language:English
Published: BMC 2021-04-01
Series:BMC Health Services Research
Subjects:
Online Access:https://doi.org/10.1186/s12913-021-06398-0
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spelling doaj-6bbda2807b234d56b3f0c14a2630cd912021-05-02T11:09:28ZengBMCBMC Health Services Research1472-69632021-04-0121111110.1186/s12913-021-06398-0Health system determinants of tuberculosis mortality in South Africa: a causal loop modelMuhammad Osman0Aaron S Karat1Munira Khan2Sue-Ann Meehan3Arne von Delft4Zameer Brey5Salome Charalambous6Anneke C Hesseling7Pren Naidoo8Marian Loveday9Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch UniversityTB Centre, London School of Hygiene & Tropical MedicineTuberculosis and HIV Investigative Network (THINK)Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch UniversitySchool of Public Health and Family Medicine, University of Cape TownBill and Melinda Gates FoundationThe Aurum InstituteDesmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch UniversityDesmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch UniversityHIV Prevention Research Unit, South African Medical Research Council, KwaZulu-NatalAbstract Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.https://doi.org/10.1186/s12913-021-06398-0Tuberculosis mortalityHealth systems
collection DOAJ
language English
format Article
sources DOAJ
author Muhammad Osman
Aaron S Karat
Munira Khan
Sue-Ann Meehan
Arne von Delft
Zameer Brey
Salome Charalambous
Anneke C Hesseling
Pren Naidoo
Marian Loveday
spellingShingle Muhammad Osman
Aaron S Karat
Munira Khan
Sue-Ann Meehan
Arne von Delft
Zameer Brey
Salome Charalambous
Anneke C Hesseling
Pren Naidoo
Marian Loveday
Health system determinants of tuberculosis mortality in South Africa: a causal loop model
BMC Health Services Research
Tuberculosis mortality
Health systems
author_facet Muhammad Osman
Aaron S Karat
Munira Khan
Sue-Ann Meehan
Arne von Delft
Zameer Brey
Salome Charalambous
Anneke C Hesseling
Pren Naidoo
Marian Loveday
author_sort Muhammad Osman
title Health system determinants of tuberculosis mortality in South Africa: a causal loop model
title_short Health system determinants of tuberculosis mortality in South Africa: a causal loop model
title_full Health system determinants of tuberculosis mortality in South Africa: a causal loop model
title_fullStr Health system determinants of tuberculosis mortality in South Africa: a causal loop model
title_full_unstemmed Health system determinants of tuberculosis mortality in South Africa: a causal loop model
title_sort health system determinants of tuberculosis mortality in south africa: a causal loop model
publisher BMC
series BMC Health Services Research
issn 1472-6963
publishDate 2021-04-01
description Abstract Background Tuberculosis (TB) is a major public health concern in South Africa and TB-related mortality remains unacceptably high. Numerous clinical studies have examined the direct causes of TB-related mortality, but its wider, systemic drivers are less well understood. Applying systems thinking, we aimed to identify factors underlying TB mortality in South Africa and describe their relationships. At a meeting organised by the ‘Optimising TB Treatment Outcomes’ task team of the National TB Think Tank, we drew on the wide expertise of attendees to identify factors underlying TB mortality in South Africa. We generated a causal loop diagram to illustrate how these factors relate to each other. Results Meeting attendees identified nine key variables: three ‘drivers’ (adequacy & availability of tools, implementation of guidelines, and the burden of bureaucracy); three ‘links’ (integration of health services, integration of data systems, and utilisation of prevention strategies); and three ‘outcomes’ (accessibility of services, patient empowerment, and socio-economic status). Through the development and refinement of the causal loop diagram, additional explanatory and linking variables were added and three important reinforcing loops identified. Loop 1, ‘Leadership and management for outcomes’ illustrated that poor leadership led to increased bureaucracy and reduced the accessibility of TB services, which increased TB-related mortality and reinforced poor leadership through patient empowerment. Loop 2, ‘Prevention and structural determinants’ describes the complex reinforcing loop between socio-economic status, patient empowerment, the poor uptake of TB and HIV prevention strategies and increasing TB mortality. Loop 3, ‘System capacity’ describes how fragmented leadership and limited resources compromise the workforce and the performance and accessibility of TB services, and how this negatively affects the demand for higher levels of stewardship. Conclusions Strengthening leadership, reducing bureaucracy, improving integration across all levels of the system, increasing health care worker support, and using windows of opportunity to target points of leverage within the South African health system are needed to both strengthen the system and reduce TB mortality. Further refinement of this model may allow for the identification of additional areas of intervention.
topic Tuberculosis mortality
Health systems
url https://doi.org/10.1186/s12913-021-06398-0
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