Browsing by Person "Nicol, Mark P."

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Decentralising DR-TB care: the trade-off between quality of care and service coverage in the early phase of implementation
(International Union Against Tuberculosis and Lung Disease, 2025-09-03) Jassat, Waasila; Moshabela, Mosa; Nicol, Mark P.; Dickson, Laurie; Cox, Helen; Mlisana, Koleka; Black, John; Loveday, Marian; Grant, Alison D.; Kielmann, Karina; Schneider, Hans G.
A policy of decentralised care for drug-resistant TB (DR-TB) was introduced in South Africa in 2011. We describe a trade-off between increasing coverage of services and poor quality of care, in the early phase of policy implementation. This was a mixed methods case study, comparing implementation in KwaZulu-Natal and Western Cape provinces; with interviews and quantitative analysis of routine DR-TB programme data. We analysed qualitative data, thematically organizing findings into inputs, processes, and outputs to explore how decentralisation influenced quality of DR-TB care. Decentralisation of DR-TB care expanded access across provinces but there was wide variation in pace, planning and structural readiness. Where rapid scale-up outpaced capacity-building, weaknesses in resourcing, workforce, and clinical governance compromised quality of care. Two illustrative examples highlight that decentralisation to inadequately resourced sites resulted in morbidity to patients who did not receive effective monitoring for adverse events; and decentralising services to inadequately capacitated clinicians resulted in incorrect initiation in more complex cases and late referral of clinical complications. Attempts to decentralise DR-TB treatment in the context of complex treatment algorithms and limited health system capacity resulted in trade-offs of care quality. We argue that quality of care should be an essential consideration in early implementation of health programmes.
Diverse clinical and social circumstances: Developing patient-centred care for DR-TB patients in South Africa
(The Union, 2021-09-21) Mitrani, Leila; Dickson-Hall, Lindy; Le Roux, Sacha; Grant, Alison D.; Kielmann, Karina; Mlisana, Koleka; Moshabela, Mosa; Nicol, Mark P.; Black, John; Cox, Helen
Objective: To describe the medical, socio-economic and geographical profiles of patients with rifampicin-resistant TB (RR-TB) and the implications for the provision of patient-centred care.
"We had to manage what we had on hand, in whatever way we could": Adaptive responses in policy for decentralised drug-resistant tuberculosis care in South Africa
(Oxford University Press, 2021-02-13) Kielmann, Karina; Dickson-Hall, Lindy; Jassat, Waasila; Le Roux, Sacha; Moshabela, Mosa; Cox, Helen; Grant, Alison D.; Loveday, Marian; Hill, Jeremy; Nicol, Mark P.; Mlisana, Koleka; Black, John
In 2011, the South African National TB Programme launched a policy of decentralized management of drug-resistant tuberculosis (DR-TB) in order to expand the capacity of facilities to treat patients with DR-TB, minimize delays to access care and improve patient outcomes. This policy directive was implemented to varying degrees within a rapidly evolving diagnostic and treatment landscape for DR-TB, placing new demands on already-stressed health systems. The variable readiness of district-level systems to implement the policy prompted questions not only about differences in health systems resources but also front-line actors’ capacity to implement change in resource-constrained facilities. Using a grounded theory approach, we analysed data from indepth interviews and small group discussions conducted between 2016 and 2018 with managers (n = 9), co-ordinators (n = 15), doctors (n = 7) and nurses (n = 18) providing DR-TB care. Data were collected over two phases in district-level decentralized sites of three South African provinces. While health systems readiness assessments conventionally map the availability of ‘hardware’, i.e. resources and skills to deliver an intervention, a notable absence of systems ‘hardware’ meant that systems ‘software’, i.e. health care workers (HCWs) agency, behaviours and interactions provided the basis of locally relevant strategies for decentralized DR-TB care. ‘Software readiness’ was manifest in four areas of DR-TB care: re-organization of service delivery, redressal of resource shortages, creation of treatment adherence support systems and extension of care parameters for vulnerable patients. These strategies demonstrate adaptive capacity and everyday resilience among HCW to withstand the demands of policy change and innovation in stressed systems. Our work suggests that a useful extension of health systems ‘readiness’ assessments would include definition and evaluation of HCW ‘software’ and adaptive capacities in the face of systems hardware gaps.