Bibliography: leaves 302-333. / Health financing reforms, especially those aimed at improving equity, are prone to opposition. Those driving health reforms frequently find themselves pitted against vested interests. The thesis explores how best a reform driver might manage other actors in the reform process to achieve key goals. This involves creating and testing a conceptual framework. A review of the international health care reform literature identifies key gaps in knowledge. Additional bodies of theory, mainly from economics, are selected for review on the basis of their potential insight into relationships between reform drivers and actors. Their findings are compared and contrasted and taken forward into a conceptual framework. This is then tested against four case studies of health financing reform in South Africa: geographic resource allocation, health insurance and the removal of user fees, largely between 1994 and 1999, and the reform of the Conditional Grant for Tertiary hospitals, from 2000 to 2002. Two different approaches are used for testing the conceptual framework. First, key themes about managing actors are drawn from actor interviews in three case studies of health financing reform. With the second, more deductive, approach reform drivers in-- an additional case study were questioned on every element of the conceptual framework to see whether it provided an adequate description and understanding of how reform processes occurred. These two very different approaches acted as a check against each other but produced similar findings. The thesis suggests that an awareness of actor characteristics (such as resources, constraints, reputation and interests) can help a reform driver better manage reform development to achieve desired change. Reform drivers should build up teams of actors that can at the very least bring power, technical skills and specialist knowledge to the reform effort. Team building will also require careful consideration of the different forms of motivation appropriate to each actor. Ideally reform drivers should avoid opposing actors. Yet the prevailing context may indicate this is not possible. In such case reform drivers should limit information exchange, present and discuss reforms at a conceptual level, undermine technically any counter-reform design and choose carefully in which arena to fight.

Adolescent and young adult pregnancy is a major sexual health issue for vulnerable young women in South Africa. Beginning by examining the origins of adolescent pregnancy in South Africa, this paper then proceeds to examine the various sources of health information accessible to adolescent women, and how said information is used. Finally, it examines the disconnect between know ledge and use of health information, and the role this plays in high levels of adolescent pregnancy. This independent research examines how adolescent women in the South African township of Mitchells Plain, Cape Town (specifically the neighbourhood of Freedom Park) understand and engage with the limited health information at their disposal. Through a qualitative research process resulting in interview analysis, this article explores how vulnerable young women internalize, believe, and use health information, in order to better understand the causes of adolescent pregnancy and risky sexual behaviour. Participants were adolescent (18 -¬‐ 20) women, who were residents of Freedom Park, (a neighbourhood in Mitchells Plain) and were either pregnant or had a child. Demographic screening tools (n=31) were used to select participants for semi -¬‐ structured interviews (n=30). Interviews were later transcribed verbatim, and analyzed using NVIVO. In this Freedom Park sample, the ability of young women to internalize and act upon information about sexuality and health varied depending on who proffered that information and how those individuals were perceived by the recipient. In the research, three key factors emerged as impacting the internalization and later use of reproductive health information. First, for both sources of health information and for recipients, life experience s played a critical role in making information more relatable and therefore easier to internalize, believe and use. Second, the perceived trustworthiness of the source of information made the knowledge more believable and relevant to the recipient. Finally, high levels of comfort in discussing sexual health with the source of information made information more easily internalized, while fear of negative judgment from sources reduced comfort and discussions of sexual health. The research suggests that efforts to reduce instances of adolescent pregnancy in South Africa should pay close attention to who delivers information about health and sexuality. To be effective, young women should feel they share experiences with, trust in, and are comfort able with sources of information. Future research should pursue how improving adolescent's engagement with health information through feelings of belonging, self ‐ efficacy, and empowerment can improve understanding, trust, and utilization of health information.

Access to a range of safe and effective modern contraceptive methods enables women to make free and informed choices about their reproductive lives and broadly improves maternal and child health outcomes. Successful avoidance of unintended pregnancy and the corresponding ability to plan for pregnancy are especially valuable in the context of Human Immunodeficiency Virus (HIV) infection. Revised South African national guidelines seeking to expand overall contraceptive access were released in 2012 and, in response to the severity of the domestic HIV epidemic, specifically detailed the sexual and reproductive health rights and needs of HIV-positive women. Six years later, evaluation of the implementation and impact of these guidelines, as well as of more recent policy responses in this area, is necessary. This need for evaluation is outlined in Part A of this mini-dissertation in the form of a research proposal. A literature review (Part B) assesses what is currently known about considerations surrounding contraceptive decision-making in the context of HIV and antiretroviral therapy (ART). The use of the subdermal Long Acting Reversible Contraceptive (LARC) implant in HIV-positive women is explored in depth, given that the 2012 guidelines introduced the method as an entirely new option for South African women, as well as in light of recent controversy surrounding the implant’s provision to women taking the first-line ART drug, efavirenz (EFV). A journal-style article structured for submission to BMC Public Health (Part C) then uses thematic qualitative methodology to explore primary family planning provider and other relevant stakeholder perspectives on the provision of implants to HIV-positive women clients attending Cape Town primary care facilities. The study adds to existing literature regarding implant provision in the context of HIV and ART, and offers new insight into the impact of a 2014 South African Department of Health decision to recommend against the then-newly introduced implant as an option for women taking EFV-based ART. This research finds that several converging factors may have lead primary providers to view the implant as broadly contraindicated in all HIV-positive clients regardless of their iii exposure to EFV, namely: insufficient provider training; provider and community unfamiliarity with and scepticism about the new method; structural pressures on providers to keep up to date with and provide wide-ranging integrated services in busy clinical environments; and inadequate stakeholder consultation surrounding the wording and overall appropriateness of the implant/EFV guidance itself. Recommendations are provided in the article, including the need for: the retraining of primary healthcare providers in rights and choice-based family planning (particularly in implant provision and counselling); simplified counselling messages and user-friendly decision-making tools to help providers facilitate informed contraceptive choice for HIV-positive women; generalized beneficiary and community sensitization/education about implants including in the context of HIV and ART; and more comprehensive stakeholder/beneficiary consultation in future contraceptive policy-related endeavors.

Includes bibliographical references (leaves 59-62). / Informed consent is an ethical and legal requirement for research involving human participants. However, there have been few studies that have evaluated the process, particularly in an African setting. In addition, standardized methods for assessing the quality of informed consent are not available in the literature. The aim of the study was to evaluate the quality of consent in a large tuberculosis vaccine immunology study and to identify factors associated with the quality of consent.

Introduction and background: South Africa continues to have the highest rates of HIV (prevalence and incidence) worldwide. Young women aged 15-24 appear to be at particular risk, with the rate of new infections in this age group estimated at 2.54% (over four times greater than that of men of the same age). Much research has focussed on trying to better understand the unique risk profile of young women: one such factor is the role of female education in reducing HIV risk. Increasingly evidence suggests that female education (specifically secondary school and improved school performance) reduce HIV risk, teenage pregnancy and risky sexual behaviours (encouraging condom use and delayed sexual debut). This study aims to build on this research considering household interest in education as an additional factor which might reduce HIV risk in adolescent females. Specifically this study proposes that household interest in education would lead to increased educational interest and success, reducing HIV risk, and in addition would build self-esteem and self-efficacy skills, enabling safer sexual practices and empowering young women in the negotiation of sexual relationships. This line of thinking also bridges a gap between research considering the role of female education in reducing sexual risk behaviours, and research focussing on the role of the home environment in promoting academic interest and success. Methods: This was a cross sectional study nested within the Swa Koteka Cash Transfer Trial located in Mpumalanga, South Africa. The study analyses baseline data collected in 2011 from 2533 young women aged 13-20 in grades 8-11. Biological outcomes of interest included HIV and HSV-2 status at baseline, and behavioural outcomes included having had vaginal sex, condom use at last sex and age of sexual debut. Multiple logistic regression was used to determine associations between both biological and behavioural outcomes and the different components of household educational support (as defined by supervision and assistance with homework, discussion of marks and studies, aspirations for further education and degree of disappointment at dropout). Ethical approval of this study was obtained from the UCT Human Research Ethics Committee, recognising approval for the Swa Koteka trial granted by the corresponding Wits committee. Results: HIV prevalence at baseline was 3.13%, increasing significantly with age. A similar pattern was noted in relation to HSV-2 prevalence, where baseline prevalence was 4.86%. 26.6% of young women reported having had vaginal sex: of those 59% reported having used a condom at last sexual act, with the median age of sexual debut being 16 years. Overall young women reported high rates of household educational support across all measures, though lower rates of parental involvement were noted in relation to assistance with homework and discussion of studies (possibly a marker of lower levels of parental education). No association was shown between household interest in education and either HIV or HSV-2 status. Supervision of homework, discussion of marks and greater educational aspirations were significant protective factors in reducing the risk of having had vaginal sex and delaying sexual debut, though not significantly associated with condom use. Greater disappointment at dropout acted as a significant risk factor for vaginal sex (OR=1.29 95%CI 1.14- 1.46, p<0.001) and early sexual debut (HR=1.15 95%CI 1.05-1.27, p=0.004), though again was not significantly associated with condom use. Greater self-efficacy was associated with greater likelihood of having had vaginal sex (OR= 1.14 95%CI 1.11-1.17 p<0.001), and earlier sexual debut (HR = 1.09 95%CI 1.07-1.12, P<0.001), but also with greater condom use (OR=1.08 95%CI 1.02-1.13, p=0.004). Conclusions: Although different elements of household educations support appear to exert variable effects on adolescent sexual risk behaviours, this study presents sufficient evidence that greater household educational support, at least in the form of checking homework, discussing marks and greater educational goals, is associated with lower sexual risk behaviours. As such, parental involvement in schooling should be formally encouraged even at higher levels. However such involvement may be limited by lower levels of education of the parental generation, a challenge which should be directly addressed by schools and communities to provide the necessary support for parents.

This MPH dissertation is a systematic review of the factors contributing to vaccine hesitancy in Africa. The dissertation comprises of the following three parts: The research protocol (Part A) outlines the background and proposed methods of the research. The protocol outlines the search strategy used to identify research eligible for this review according to defined criteria. The objective of this research was to identify determinants of vaccine hesitancy in Africa. The protocol describes data collection methods and the analysis plan of this research in order to address the objective. The literature review (Part B) provides a summary and interpretation of the current literature on barriers to vaccination, specifically vaccine hesitancy and its impacts on immunisation programs. The literature review identifies discord among literature in defining vaccine hesitancy and evaluating its presence and impact on varying populations, and reviews the attempts for standardisation by the Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy. Lastly, the literature review identifies gaps in the literature, and suggests filling them ideally with a standardised metric. The manuscript (Part C) is presented in a format suitable for Vaccine journal submission. The manuscript includes a background, a description of the methods used, and a presentation and discussion of the results of the systematic review.

Includes bibliographical references. / South Africa has the most people living with HIV (PLWH) in the world. With increased access to HIV Counselling and Testing (HCT) as well as expanded Antiretroviral Therapy (ART) treatment guidelines; there is a large and increasing number of people who need access to HIV care. Limited data and few studies have evaluated access to HIV care. A cross sectional survey with stratified random sampling was conductedfrom January – April 2011 to determine the proportion of PLWH in urban areas in thegreater Cape Town area who are accessing appropriate HIV care and factors associatedwith accessing care. The sampling frame for this study was the Zambia South Africa TBand AIDS Reduction (ZAMSTAR) Study. Self reported HIV positive adults were randomly selected. Self reported HIV negative adults or adults of unknown HIV status were also randomly selected in order to decrease possible stigmatisation. Consenting participants were interviewed and completed a questionnaire detailing their access to HIV testing and care. Participants who disclosed that they were HIV positive were included in the analysis. Access to appropriate HIV care was defined as one of three scenarios: 1. Receiving ART and having attended an ART clinic or collected ART medication within the last three months. 2. Undergoing ART work up and having attended an ART clinic within the last three months. 3. In PreART care having had a CD4 count in the last 6 months. 1257 participants were interviewed. 627(50%) reported being HIV positive, 487(39%) HIV negative and 143(11%) did not know or wish to disclose their status. Of the 627 HIV positive participants: 392 (63%) reported taking ART of whom 369 (94%) accessed appropriate HIV care. 25 (4 %) were being worked up for ART of whom 16 (64%) accessed appropriate HIV care. 210 (33%) were in PreART care, 81 (39%) having accessed appropriate HIV care. Females were 3.78 times more likely to be in appropriate care than males (p <0.001), and a person in the age category greater than 45 years was 4.63 times more likely to be in appropriate care than someone in the age category 15-24 (p= 0.002).

Background: The 2015 edition of the Global Burden of Diseases Study identified elevated systolic blood pressure─ defined as systolic blood pressure greater than the minimum risk category of 110–115 mm Hg ─ as the largest single contributor to the global burden of disease, responsible for 211.8 million disability adjusted life years lost, up 8.8% in the last decade. Middle‐income countries are currently bearing the highest share of this burden, and, because of the rapid demographic transition towards larger and older populations, the burden is bound to increase rapidly in the coming years, unless age‐specific values of blood pressure are substantially reduced to compensate for the unfavourable demographic changes. Achieving this more favourable blood pressure distribution in populations undergoing rapid changes in their socioeconomic structure requires knowledge of the mechanisms underlying temporal variations of blood pressure and the relationships of such variations with socioeconomic variables.However, evidence on these mechanisms and reliable information on the temporal trends of blood pressure themselves are scant outside high‐income countries. Given the large gain in health that would result in low‐ and middle‐income countries if an optimal blood pressure were to be achieved in large sectors of the population, there is little doubt that temporal trends in the distribution of blood pressure in these populations and their possible determinants are an open and important area for investigation. Objectives: Objectives of the study were: 1. To assess the level of quality and comparability of blood pressure data collected in a series of large‐scale surveys carried out between 1998 and 2015 in South Africa, a middle‐income country undergoing rapid demographic and epidemiological transition; 2. To explore the possibility of applying a series of latent variables techniques to improve the comparability of data from the different sources and to minimise the effect of measurement and representation error on the estimation of cross‐sectional relationships and temporal trends; 3. To estimate changes in the distribution of blood pressure and derived quantities ‐‐‐ such as prevalence of uncontrolled hypertension ‐‐‐ in the South African adult population between 1998 and 2015, taking into account between‐surveys differences and measurement and representation error that could lead to artefactual conclusions; 4. To estimate the extent to which the estimated changes in the blood pressure distribution during the study period could be explained by concurrent changes in the distribution of a series of biological, behavioural and socioeconomic risk factors. Methods: A series of techniques within the general framework of structural equation modelling were applied to jointly analyse the data and estimate the temporal trends and relationships of interest. Results: The average systolic and diastolic blood pressure of South African adult women has progressively decreased since 2003‐2004, reversing the previous rising trend. Among men, the reversal happened only for the systolic blood pressure, while the average diastolic blood pressure continued rising, although at a lower pace than previously.In both genders, this pattern resulted in a reduction of the prevalence of uncontrolled hypertension between 2003‐2004 and 2014‐2015, by 8 percentage points among women and by 4.5 percentage points among men. This consistent and rapid decrease cannot be explained by changes in the age structure of the population, smoking and alcohol consumption habits, distribution of body mass index or urbanization. The diffusion of antihypertensive treatment and, among women, cohort effects and rapidly increasing educational level partly explain the recent trend, but a substantial part of the observed decrease remains unexplained by the factors available in our analyses. Large seasonal variations in both systolic and diastolic blood pressure are present in the South African population, and their magnitude is greater among population strata with low socioeconomic status. From a methodological point of view, there were two further results of this study. First, estimates of blood pressure and related quantities from the eight large‐scale population surveys carried out in South Africa between 1998 and 2015are not directly comparable, because of methodological differences and overall data quality. Second, structural equation modelling (and, within this general framework, multiple group modelling, normal‐censored regression, mixture analysis with skew‐normal distributions and the use of additional parameters and phantom variables) represent a viable and advantageous alternative to current methods of comparative analysis of blood pressure data. Conclusions: Encouraging signs regarding the future development of the burden of diseases related to elevated blood pressure in the South African population emerge from this study. Age‐specific prevalence of uncontrolled hypertension seems to be decreasing, especially among women, and this decrease is accompanied by declining mortality for cardiovascular disease, particularly for stroke, recorded in burden of mortality studies. The reasons of this decrease are largely unexplained and warrant further investigation. However, among the possible drivers analysed in this study, increased accessibility and efficacy of antihypertensive treatment are likely to be playing a role in the observed decrease in blood pressure. The growing obesity epidemic, on the contrary, is likely to be limiting the achievable benefits. Both of these factors can be targeted to maintain and improve the current decline in population values of blood pressure and prevalence of hypertension. The large seasonal variations of blood pressure and their unequal distribution across socioeconomic strata also suggest that interventions to reduce exposure to low temperatures might have public health benefit. From the point of view of the epidemiological investigation, the results of this study suggest that the current methods for the analysis of survey data on blood pressure and the measurement protocols for future data collections should be improved to increase between‐surveys comparabilityand gather more reliable information on temporal changes in BP and gain better understanding of their drivers. Specifically, analytical methods should take explicitly into account known sources of measurement and representation error to reduce their biasing effects, especially when inter‐survey comparisons are involved. Protocols for future studies should routinely include collection of auxiliary information and/or explicit validation of devices and procedures in the specific population.

Includes bibliographical references (leaves 369-414). / This study aims to examine the existing enabling and regulatory interventions in Cameroon, and to explore their impact on the performance of private providers of malaria services. It makes recommendations to decision-makers on the best strategies for influencing the performance of private providers of public health services in low income countries. The study’s framework involves the Ministry of Health as a principal who authorises the private sector as an agent to provide malaria services to populations, in exchange for mutually agreed rewards and in the context of specified rules. Data were collected using both qualitative and quantitative research methods. This study found that the private sector provides a substantial portion of malaria services in Cameroon. There is evidence that enabling and regulatory interventions can enhance the private sector's quantity and quality of inputs which are used for expanding coverage, improving quality of care and affordability of malaria services. These interventions can approximate the objectives of multiple stakeholders including the Ministry of Health, Medical Council, managers, clinical staff and patients, thereby addressing the principal- agent problems in the health sector. Areas of private sector activity that are particularly difficult, but critical to influence are those of overcharging, unnecessary self-referral and issues of informal providers. Enabling interventions neither compete with nor negate traditional regulations in the health sector but seek to complement regulatory mechanisms by adding value from the perspective of influencing private sector providers’ behaviour. Government needs to invest in its ability - improving capacities and governance, providing resources and logistics - to oversee the ongoing development, implementation, monitoring and revision of enabling and regulatory interventions for the private health sector. The performance of private providers appears to be more positively influenced by enabling interventions than by regulatory mechanisms. In the absence of enabling interventions it may be inappropriate to try to influence the performance of private providers through regulatory mechanisms alone. While the resources needed for enforcement of regulations are limited, enabling and regulatory interventions can be integrated in such a way that it is in the interests of the private sector to comply with regulation of health service delivery. This can reduce the level of resources needed for effective enforcement of regulation amongst private providers. This study concludes that the integration of enabling and regulatory interventions appear to be a strategic policy option for influencing the performance of private providers of malaria services in low income countries.

Includes bibliographical references. / Financial risk protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". The study (the first of kind in Ghana) measured the relative progressivity of health care financing mechanisms, the catastrophic and impoverishment effect of direct health care payments, as well as evaluating the factors affecting enrolment in the national health insurance scheme (NHIS), which is the intended means for achieving equitable health financing and universal coverage in Ghana. To achieve the purpose of the study, secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other ministries and departments, and further complemented with primary household data collected in six districts. In addition 44 focus group discussions with different groups of people and communities were conducted. In-depth interviews were also conducted with six managers of District NHI schemes as well as the NHIS headquarters. The study found that generally Ghana's health care financing system is progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes which account for over 50% of health care funding. The national health insurance levy is mildly progressive as indicated by a Kakwani index of 0.045. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are associated with significant catastrophic and impoverishment effects on households. The results also indicate that high premiums, ineffective exemptions, fragmented funding pools and perceived poor quality of care affect the expansion of the NHIS. For Ghana to attain adequate financial protection and ultimately achieve universal coverage, it needs to extend cover to the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the NHI. Furthermore, the funding pool for health care needs to grow and this can be achieved by improving the efficiency of tax collection and increasing the budgetary allocation to the health sector.