BackgroundPoverty undermines adherence to tuberculosis treatment. Economic support may both encourage and enable patients to complete treatment. In South Africa, which carries a high burden of tuberculosis, such support may improve the currently poor outcomes of patients on tuberculosis treatment. The aim of this study was to test the feasibility and effectiveness of delivering economic support to patients with pulmonary tuberculosis in a high-burden province of South Africa.MethodsThis was a pragmatic, unblinded, two-arm cluster-randomized controlled trial, where 20 public sector clinics acted as clusters. Patients with pulmonary tuberculosis in intervention clinics (n = 2,107) were offered a monthly voucher of ZAR120.00 (approximately US$15) until the completion of their treatment. Vouchers were redeemed at local shops for foodstuffs. Patients in control clinics (n = 1,984) received usual tuberculosis care.ResultsIntention to treat analysis showed a small but non-significant improvement in treatment success rates in intervention clinics (intervention 76.2%; control 70.7%; risk difference 5.6% (95% confidence interval: -1.2%, 12.3%), P = 0.107). Low fidelity to the intervention meant that 36.2% of eligible patients did not receive a voucher at all, 32.3% received a voucher for between one and three months and 31.5% received a voucher for four to eight months of treatment. There was a strong dose–response relationship between frequency of receipt of the voucher and treatment success (P <0.001).ConclusionsOur pragmatic trial has shown that, in the real world setting of public sector clinics in South Africa, economic support to patients with tuberculosis does not significantly improve outcomes on treatment. However, the low fidelity to the delivery of our voucher meant that a third of eligible patients did not receive it. Among patients in intervention clinics who received the voucher at least once, treatment success rates were significantly improved. Further operational research is needed to explore how best to ensure the consistent and appropriate delivery of such support to those eligible to receive it.Trial registrationCurrent Controlled Trials ISRCTN50689131

BackgroundIn an attempt to address a complex disease burden, including improving progress towards MDGs 4 and 5, South Africa recently introduced a re-engineered Primary Health Care (PHC) strategy, which has led to the development of a national community health worker (CHW) programme. The present study explored the development of a cell phone-based and paper-based monitoring and evaluation (M&E) system to support the work of the CHWs.MethodsOne sub-district in the North West province was identified for the evaluation. One outreach team comprising ten CHWs maintained both the paper forms and mHealth system to record household data on community-based services. A comparative analysis was done to calculate the correspondence between the paper and phone records. A focus group discussion was conducted with the CHWs. Clinical referrals, data accuracy and supervised visits were compared and analysed for the paper and phone systems.ResultsCompared to the mHealth system where data accuracy was assured, 40% of the CHWs showed a consistently high level (>90% correspondence) of data transfer accuracy on paper. Overall, there was an improvement over time, and by the fifth month, all CHWs achieved a correspondence of 90% or above between phone and paper data. The most common error that occurred was summing the total number of visits and/or activities across the five household activity indicators. Few supervised home visits were recorded in either system and there was no evidence of the team leader following up on the automatic notifications received on their cell phones.ConclusionsThe evaluation emphasizes the need for regular supervision for both systems and rigorous and ongoing assessments of data quality for the paper system. Formalization of a mHealth M&E system for PHC outreach teams delivering community based services could offer greater accuracy of M&E and enhance supervision systems for CHWs.

The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors, was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure.

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