Browsing by Author "Hompashe, Dumisani MacDonald"
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- ItemEssays on accountability and service delivery in education and healthcare in South Africa(Stellenbosch : Stellenbosch University, 2021-03) Hompashe, Dumisani MacDonald; Smith, Anja; Van der Berg, Servaas; Stellenbosch University. Faculty of Economic and Management Sciences. Dept. of Economics.ENGLISH SUMMARY : South Africa’s public service is characterised by poor quality of services and a weak record of accountability and service delivery. Despite high investment of resources towards the poor, there has been no corresponding improvement in the quality of education enjoyed by the disadvantaged majority. In the health sector, South Africa has not managed to significantly improve health outcomes despite sizeable resource shifts in health expenditure since 1994. Most health indicators are at a lower level than other middle- and even low-income countries whose health expenditures are substantially lower than South Africa’s. This dissertation contains three chapters on the principal-agent problem and accountability in health and education, with a focus on primary healthcare facilities and primary schools in South Africa. The contribution of the dissertation, through the analysis of novel data, is to consider how informational asymmetries in public services such as health and education conspire with low expectations from clients to act as binding constraints for delivery of high-quality primary healthcare and basic education services. It also presents evidence on how clients are able to distinguish between high- and low-quality services, providing a potential lever for quality improvement. Chapter 2 considers the correlation of patient satisfaction with clinical quality of healthcare and what such correlation suggests about patients’ ability to read signals about the quality of care. The findings reveal that non-activated or RPs (uninformed clients) provide higher ratings than activated or SPs (informed clients) about the quality of care at facilities. Although positive and significant correlations between reported satisfaction and protocol adherence were found, there were fewer correlations for the RPs: in other words, RPs’ assessment of quality is less rooted in objective clinical measures than SPs who have been trained in assessing clinical quality of care. Chapter 3 provides a comparison between SP and RPs on the role of the non-clinical dimensions of care in patient satisfaction. More positive experiences of the non-clinical factors were positively and significantly associated with an overall more satisfactory experience of health services for both the SPs and RPs. However, among SPs, the non-clinical dimensions of healthcare were more often strongly related to patient satisfaction with overall care, while fewer of these dimensions were significant among RPs. Chapter 4 examines how school principals manage curriculum delivery and how their practices influence student performance. Many school principals and teachers indicated that curriculum Stellenbosch delivery monitoring was not conducted as expected. From this chapter’s findings, both from principals’ experiences and student performance data, it is clear that less informed parents and students are not able to effectively evaluate or monitor performance of their schools. These findings have important implications for the design of bottom-up monitoring and social accountability policies. Such policies may be in the form of participatory engagement of the community, including explicitly delegating some authority over monitoring activities to community structures. Insights into clients’ ability to discern quality provides potential to hold service providers accountable, given the right support from policymakers.
- ItemThe nurse did not even greet me : how informed versus non-informed patients evaluate health systems responsiveness in South Africa(BMJ Publishing Group, 2021) Hompashe, Dumisani MacDonald; Gerdtham, Ulf G.; Christian, Carmen S.; Smith, Anja; Burger, RonelleIntroduction: Universal Health Coverage is not only about access to health services but also about access to high-quality care, since poor experiences may deter patients from accessing care. Evidence shows that quality of care drives health outcomes, yet little is known about non-clinical dimensions of care, and patients’ experience thereof relative to satisfaction with visits. This paper investigates the role of non-clinical dimensions of care in patient satisfaction. Methods: Our study describes the interactions of informed and non-informed patients with primary healthcare workers at 39 public healthcare facilities in two metropolitan centres in two South African provinces. Our analysis included 1357 interactions using standardised patients (for informed patients) and patients’ exit interviews (for non-informed patients). The data were combined for three types of visits: contraception, hypertension and tuberculosis. We describe how satisfaction with care was related to patients’ experiences of non-clinical dimensions. Results: We show that when real patients (RPs) reported being satisfied (vs dissatisfied) with a visit, it was associated with a 30% increase in the probability that a patient is greeted at the facilities. Likewise, when the RPs reported being satisfied (vs dissatisfied) with the visit, it was correlated with a 15% increase in the prospect that patients are pleased with healthcare workers’ explanations of health conditions. Conclusion: Informed patients are better equipped to assess health-systems responsiveness in healthcare provision. Insights into responsiveness could guide broader efforts aimed at targeted education and empowerment of primary healthcare users to strengthen health systems and shape expectations for appropriate care and conduct.