Doctoral Degrees (Family Medicine and Primary Care)

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    An evaluation of the quality of service delivery in private primary care facilities in Nairobi, Kenya
    (Stellenbosch : Stellenbosch University, 2021-12) Mohamoud, Gulnaz; Mash, Robert; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : Introduction: The World Health Organization (WHO) states that well-functioning primary health care (PHC) should be the foundation of effective health systems. Primary care (PC) is a subset of PHC, and is a “key process in the health system that supports first-contact, accessible, continued, comprehensive and coordinated patient-focused care.” In sub-Saharan Africa (SSA), health systems still face many challenges and PC remains poorly functioning in many countries. Measuring the quality of PC service delivery and identifying the strengths and weaknesses will help policy makers and implementers improve PC and achieve better health outcomes. Kenya’s Health Policy 2012-2030 aims to promote higher quality and better access to services, however, “quality” remains a major challenge. The private health care system provides 52% of all health care services and may have a bigger role to play in the future. In Kenya, most of the PC in the private sector is provided by general practitioners (GPs), the majority of whom do not have specialist postgraduate training. Due to diversity and fragmentation of the private PC system, there is little data on the strengths and weaknesses of key elements of PC service delivery. Hence, the new knowledge from our study is aimed at kick-starting future evaluations leading to a long term improvement in quality in service delivery in line with the existing and new health needs that are anticipated over the next few decades. The main aim of this study was to evaluate the quality of service delivery in PC facilities by GPs in the private sector in Nairobi, Kenya. Five studies were performed to measure the key elements of quality PC: first-contact access, coordination, continuity, comprehensiveness and person-centredness. The abstracts for the five articles are provided below. Article 1: Perceptions regarding the scope of practice of family doctors amongst patients in primary care settings in Nairobi. Background: Primary care is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by general practitioners. Little is known about how patients perceive their capability. The aim was to assess patients’ perceptions of the scope of practice of GPs working in private sector PC clinics in Nairobi and their awareness of the new discipline of family medicine. Methods: A descriptive survey using a structured, self-administered questionnaire in eight private sector PC clinics in Nairobi. Simple random sampling was used to recruit 162 patient participants. Results: Of the participants, only 30% knew the difference between FPs and GPs. There was a high to moderate confidence (>60%) that GPs could treat common illnesses, provide lifestyle advice, offer family planning and childhood immunisations. In adolescents and adults, low confidence (<60%) was expressed in their ability to manage tuberculosis, human immunodeficiency virus and cancer. In the elderly, there was low confidence in their ability to manage depression, anxiety, urinary incontinence and diabetes. There was low confidence in their ability to provide antenatal care and pap smears. Conclusion: Patients did not perceive that GPs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing family physicians. Article 2: Evaluation of the quality of service delivery in private sector, primary care clinics in Kenya. Background: The quality of PC service delivery is an important determinant of clinical outcomes. The patients’ perspective is one significant predictor of this quality. Little is known of the quality of such service delivery in the private sector in Kenya. The aim of the study was to evaluate the quality of service delivery from the patient’s perspective in private sector, PC clinics in Nairobi, Kenya. Methods: The study employed a descriptive cross-sectional survey by using the General Practice Assessment Questionnaire in 378 randomly selected patients from 13 PC clinics. Data were analysed using the Statistical Package for Social Sciences. Results: Overall, 76% were below 45 years, 74% employed and 73% without chronic diseases. Majority (97%) were happy to see the general practitioner (GP) again, 99% were satisfied with their consultation and 83% likely to recommend the GP to others. Participants found the receptionist helpful (97%) and the majority were happy with the opening hours (73%) and waiting times (85%). Although 84% thought appointments were important, only 48% felt this was easy to make, and only 44% were able to access a particular GP on the same day. Overall satisfaction was higher in employed (98%) versus those unemployed (95%), studying (93%) or retired (94%) (p < 0.001). Conclusion: Patients reported high satisfaction with the quality of service delivery. Utilisation was skewed towards younger, employed adults, without chronic conditions, suggesting that PC was not fully comprehensive. Services were easily accessible, although with little expectation of relational continuity. Further studies should continue to evaluate the quality of service delivery from other perspectives and tools. Article 3: Evaluation of the quality of communication in consultations by general practitioners in primary care settings, Nairobi, Kenya. Background: Primary care is the starting point for patients seeking health care. High quality PC requires effective communication to support person-centredness, continuity and coordination of care, and better health outcomes. In Kenya, there is very scanty knowledge about the quality of communication in consultations by GPs in the private sector. Hence, the aim was to evaluate the quality of communication in consultations by GPs. Methods: Descriptive, observational cross-sectional study of 23 GPs consultations in 13 primary care facilities in Nairobi. One consenting adult patient was randomly selected from the GP’s list for an audio recording of their consultation. Audio recordings were assessed using the Stellenbosch University Observation Tool. The overall score for each consultation was obtained out of a maximum of 32. Data was analysed using the Statistical Package for Social Sciences version 25. Results: The median age of the GPs was 30.0 years (IQR: 29-32) with a median of 3-years’ experience after graduation (IQR=3-6). Median consultation time was 7.0 minutes (IQR=3-9). Median score of the consultations was 64.3% (IQR: 48.4-75.7). The GPs fully performed skills in gathering information, making a diagnosis and in its explanation and management. The GPs did not make an appropriate introduction, nor explore the family and social context or patient’s perspective. Patients were not fully involved in the shared decision making process. Safety netting and closure was not fully addressed. There was a significant positive correlation between the consultation scores and duration of the consultations (r=0.680, p=0.001). Conclusion: Consultations were brief, with low-to-moderate complexity and had a biomedical approach. Training in communication skills with the goal of providing person-centred care will result in higher quality consultations and PC. Article 4: The quality of primary care performance in private sector facilities in Nairobi, Kenya. Background: Integrated health services with an emphasis on PC are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality PC are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is little information on these key elements and such information is needed to improve service delivery. This study aimed to evaluate the quality of PC performance in a group of private sector clinics in Nairobi, Kenya. Methods: A cross-sectional descriptive study adapted the Primary Care Assessment Tool (PCAT) for the Kenyan context and surveyed 412 systematically sampled PC users, from 13 PC clinics. Data was analysed to measure 11 domains of PC performance and two aggregated PC scores using the Statistical Package for Social Sciences. Results: Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying poor overall performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact (access), coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate PC as acceptable to good. Conclusion: These private sector clinics in Nairobi had a poor overall performance. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, improving access after-hours and marketing the use of the clinics to the practice population. Article 5: General practitioners’ training and experience in the clinical skills required for comprehensive primary care, Nairobi, Kenya. Background: Quality service delivery in primary care requires availability of motivated and competent health professionals. There is a paucity of evidence on the ability of PC providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya. Therefore, the aim was to evaluate the GPs’ training and experience in the clinical skills required for comprehensive primary care. Methods: This was a cross-sectional descriptive survey using an adapted questionnaire, originally designed for a national survey of PC doctors in South Africa. The study evaluated self-reported clinical skills performance of all 25 GPs at the 13 PC clinics in Nairobi. Results: GPs were mostly under 40 years with less than 10 years of experience with an almost equal gender distribution. Categories with moderate performance included adult health, emergencies, communication and consultation, child health and clinical administration skills. Whilst, weak performance included surgery, ear-nose-and-throat, eyes, women’s health and orthopaedics. The GPs lacked training in specific skills related to proctoscopy, contraceptive devices, skin procedures, intra-articular injections, red reflex test and use of a genogram. Conclusion: Majority of the GPs were young with few years of clinical experience after graduation. GPs lacked training and performed poorly in some of the essential and basic skills required in PC. The gaps highlighted the need for training and broadening the model of care to offer a more comprehensive package. Training in family medicine can also be offered, which aims to deliver an expert generalist and attention should be given to health systems design and the necessary inputs required to support more comprehensive care. Final conclusions: The patients visiting these private clinics consisted mostly of young to middle-aged adults, who were well-educated and employed. Most of the patients did not have any chronic conditions and reported their health status as good to excellent. Overall ratings showed high satisfaction in relation to first-contact utilisation, services by the receptionists, the regular opening hours of the clinics and short waiting times. Even though patients expressed the desire to book appointments via the phone, access to this service was limited. Access to a particular GP by phone or for emergency consultations was also limited. Utilisation and long-term affiliation with the practice was reported as good, suggesting reasonable longitudinal continuity. Patients expressed high satisfaction with care enablement and had confidence in the GPs’ honesty and trustworthiness. Informational continuity was also strong, although relational continuity less so, as patients did not express a commitment to any particular GP. Patients had limited expectations of the comprehensiveness of services offered by the GPs. Patients also reported low confidence in the GPs’ ability to manage and provide care for many core aspects of PC. The clinics were not comprehensive in the range of services available and provided. The gaps were evident in areas such as chronic conditions, antenatal care, advice for lifestyle modifications, women’s and men’s health screening. The facilities did not offer a complete primary health care team such as access to a social worker, physiotherapist, counsellor or dietician. There was poor performance by the GPs in some of the essential and basic skills required to offer a more comprehensive package of care in areas such as women’s health, ear, nose and throat, ophthalmology and orthopaedics. The information system supported care coordination and was excellent due to an integrated electronic health record system and contributed to patient satisfaction. GPs conducted brief consultations of low-moderate complexity and showed a substantial commitment to parallel coordination of care within the clinic. However, the quality of sequential coordination was reported as borderline and patients were rarely referred to the hospital. Patients felt confident in and satisfied with brief bio-medical consultations. GPs were able to obtain sufficient biomedical information, make an appropriate diagnosis, as well as formulate and explain an appropriate management plan. However, there were gaps in the provision of whole-person medicine related to the patient’s perspectives and context, exploration of patient’s psychosocial and occupational history, shared decision making process, provision of safety netting and closure. Patients, however, felt that GPs were sufficiently family-centred and culturally competent. The combined observations of all these studies confirm that this private health care system is not offering fully accessible, continuous, coordinated, comprehensive and person-centred primary care. A number of recommendations are made to improve the quality of PC.
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    How to transform the workplace environment to prevent and control risk factors associated with non-communicable chronic diseases
    (Stellenbosch : Stellenbosch University, 2019-04) Schouw, Darcelle; Mash, Robert; Kolbe-Alexander, Tracy; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : The underlying causes of premature morbidity and mortality in South Africa (SA) are related to unhealthy lifestyle behaviours, which are modifiable. Chronic non-communicable diseases (cardiovascular disease, respiratory disease, diabetes and cancer) are partly attributed to behavioural risk factors such as tobacco smoking, harmful alcohol use, physical inactivity and unhealthy eating, which if not controlled, results in an increase in metabolic risk factors. The workplace is highlighted as an important setting for the prevention of non-communicable diseases (NCDs). The work environment directly shapes employee health, and health behaviours, and acts as an accelerator or preventer of chronic disease. Very little research in the African context has focused on how to transform the workplace environment to prevent and control the risk factors associated with NCDs. The aim of the research was to design, implement and evaluate a workplace health promotion program (WHPP) to prevent or reduce the risk factors for NCDs amongst the workforce at a commercial power plant in South Africa. The objectives were to monitor changes in NCD risk factors in the workforce, as well as monitor sick leave absenteeism and evaluate the costs and consequences of the workplace health promotion program. The abstracts for the four articles presented for the doctoral degree are provided here. Article 1 Title: Risk factors for non-communicable diseases in the workforce at a commercial power plant in South Africa. Background: Non-communicable diseases (NCDs) account for more than half of annual deaths globally and nearly 40% of deaths in South Africa. The workplace can be an important setting for the prevention of NCDs. Objectives: The objectives of this study were to describe the prevalence’s of reported NCDs and previously identified risk factors for NCDs, as well as to assess risky behaviour for NCDs, and the 10-year risk for cardiovascular disease, amongst the workforce at a commercial power plant in the Western Cape province of South Africa. Methods: A total of 156 employees was randomly selected from the workforce of 1 743. Questionnaires were administrated to elicit self-reported information about NCDs, tobacco smoking, alcohol use, diet, physical activity and psychosocial stress. Biometric health screening included measurements and calculations of blood pressure, total cholesterol, random glucose, body mass index (BMI), waist circumference and waist-to-hip ratio (WHR). The 10-year risk for cardiovascular disease was calculated using a chart-based validated non-laboratory algorithm. Results: The study participants had a mean age of 42.8 (25-64) years; 65.2% were male. A quarter (26.0%) smoked tobacco, 29.4% reported harmful or dependent alcohol use, 73.0% had inadequate fruit and vegetable intake, and 64.1% were physically inactive. Systolic and diastolic blood pressure was raised in 32.7% and 34.6% of the study participants, respectively, 62.2% had raised cholesterol, 76.9% were overweight or obese, and 27.1% had abdominal obesity. Overall, 17.4% were diagnosed with hypercholesterolaemia, 17.7% with hypertension, and 16.2% with depression. Around one third (34.1%) had a moderate-to-high 10-year cardiovascular disease risk. Conclusion: The prevalence’s of both behavioural and physical risk factors for NCDs amongst the power station study participants were high. There is a need for effective workplace interventions to reduce risk for NCDs. The workplace is ideally suited for targeted interventions. Article 2 Title: Transforming the workplace environment to prevent non-communicable chronic diseases: Participatory action research in a South African power plant. Background: The workplace is an important setting for the prevention of non-communicable diseases (NCDs). Policies for transformation of the workplace environment have focused more on what to do and less on how to do it. The aim of this study was to learn how to transform the workplace environment in order to prevent and control the risk factors for NCDs amongst the workforce at a commercial power plant in Cape Town, South Africa. Methods: The study design utilized participatory action research (PAR) in the format of a cooperative inquiry group (CIG). The researcher and participants engaged in a cyclical process of planning, action, observation and reflection over a 2-year period. The group used outcome mapping to define the vision, mission, boundary partners, outcomes and strategies required. At the end of the inquiry the CIG reached a consensus on their key learning. Results: Substantial change was observed in the boundary partners: catering services (78% of progress markers achieved), sport and physical activities (75%), health and wellness services (66%), and managerial support (65%). Highlights from a 10-point consensus on key learning included the need for: authentic leadership; diverse composition and functioning of the CIG; value of outcome mapping; importance of managerial engagement in personal and organizational change; and making healthy lifestyle an easy choice. Conclusion: Transformation included a multifaceted approach and an engagement with the organization as a living system. Future studies will evaluate changes in the risk profile of the workforce as well as the costs and consequences for the organization. Article 3 Title: Changes in risk factors for non-communicable diseases associated with a Healthy Choices at Work program at a commercial power plant. Background: Globally, 71% of deaths are attributed to non-communicable diseases (NCD). The workplace is ideal for interventions aiming to prevent NCDs, however much of the current evidence is from high income countries. Objective: The aim of this study was to evaluate changes in NCD risk factors associated with a Healthy Choices at Work program (HCW) at a commercial power plant in South Africa. Methods: This was a before-and-after study in a randomly selected sample of 156 employees at baseline and 2-years. The HCW focused on catering, physical activity, health and wellness services and managerial support. Participants completed questionnaires on their participation in the HCW, tobacco smoking, harmful alcohol use, fruit and vegetable intake, physical activity, psychosocial stress and history of NCDs. Clinical measures included blood pressure, total cholesterol, random blood glucose, body mass index (BMI), waist circumference and waist-to-hip ratio. The 10-year cardiovascular risk was calculated using a validated algorithm. Data was analysed with the Statistical Package for the Social Sciences. Results: Paired data was obtained for 136 employees. Their mean age was 42.7 years (SD 9.7); 64% were male. The prevalence of sufficient fruit and vegetables increased from 27% to 64% (p<0.001), those meeting physical activity guidelines increased from 44% to 65% (p<0.001). Harmful alcohol use decreased from 21% to 5% (p=0.001). There were significant improvements in systolic and diastolic blood pressure (mean difference -10.2mmHg (95%CI: -7.3 to -13.2); and -3.9mmHg (95%CI: -1.8 to -5.8); p<0.001) and total cholesterol (mean difference -0.45mmol/l (-0.3 to -0.6)). There were no significant improvements in BMI. Psychosocial stress from relationships with colleagues, personal finances, and personal health significantly improved. There was a non-significant decrease of 4.5% in people with a high 10-year cardiovascular risk. Conclusion: The HCW was associated with significant reductions in behavioural, metabolic and psychosocial risk factors for NCDs. Article 4 Title: Cost and consequence analysis of Healthy Choices at Work (HCW) program to prevent non-communicable diseases in a commercial power plant. Abstract: The workplace is identified as an ideal setting for the implementation of a Healthy Choices at Work program (HCW) to prevent and control NCDs. However, given the limited resources assigned to workplace health promotion programs in LMIC, this study aimed to conduct a cost and consequence analysis using participatory action learning to improve the NCD risk profiles at low cost. Methods: Incremental costs were obtained from the activities of the Healthy Choices at Work program at the commercial power plant over a two-year period. A total of 156 employees participated in the intervention but the affect was experienced by all employees. An annual health risk assessment at baseline and follow up was included in the consequence of the study. Results: The total incremental costs over the two-year period accumulated to $3745 for 1743 employees. The cost per employee on an annual basis was $1 resulting in -10.2mmHg in systolic blood pressure, -3.87mmHg in diastolic blood pressure, -0.45mmol/l in total cholesterol, significant improvements (p=0.001) for harmful alcohol use, fruit and vegetable intake and physical inactivity. There was no improvement in correlation between sickness absenteeism and risk factors for non-communicable diseases. Conclusion: The cost to implement the multicomponent HCW programs was considerably low as was the significant consequences in transforming the workplace environment. Findings of this study will be useful for small, medium and large (SML) organisations, the national department of health, and similar settings in LMIC. Conclusion: The high prevalence of behavioral and metabolic risk factors for NCDs amongst participants at the power station resulted in the design of an effective WHPP to reduce risks. A Healthy Choice at Work program (HCW) included a multifaceted approach and was associated with significant reductions in risk factors for NCDs. The cost to implement the HCW program was low with significant consequences in transforming the workplace environment, which are useful findings for small, medium and large organizations.
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    Evaluating the impact of family physicians within the district health system of South Africa
    (Stellenbosch : Stellenbosch University, 2017-12) Von Pressentin, Klaus Botho; Mash, Robert J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY: The majority of the South African population are dependent on the public health sector in helping them deal with the quadruple burden of disease, consisting of HIV/AIDS and tuberculosis, maternal and child health problems, non-communicable diseases as well as trauma and violence-related injuries. The post-1994 South African government has embraced the global shift towards primary health care (PHC) as the vehicle for delivering quality health care to all. The health of communities is better in countries with strong PHC-centred health systems. Global evidence supports PHC delivered by primary care teams that include doctors with postgraduate training in family medicine (family physicians). However, the evidence on the contribution of family physicians (FPs) to strengthening health systems is mainly derived from high income countries. African leaders and policy makers are looking for local evidence on the potential role of FPs, as investment in the training and development of a new cadre of specialists in family medicine represents a significant financial commitment within the health system. According to a 2015 national consensus paper, South African FPs have six roles in the PHC team: care provider to patients, consultant to the PHC team (mainly nurses and doctors), champion of community-oriented PHC, clinical governance leader (focus on quality improvement), clinical trainer of students and registrars, and capacity building of the PHC team members. FPs are working in various aspects of the South African district health system (DHS), namely district hospitals, primary care facilities (health centres and clinics) and community based PHC teams (community health workers). The DHS consists of all health services relating to the health and wellbeing of a community within a defined geographic area (the health district). The discipline of family medicine was made a specialty in 2007 by the South African health professions council and resulted in re-structured training of FPs in keeping with the training model of other medical specialities. Graduates from this new training model have entered the DHS since 2011. These graduates are deployed in a heterogeneous manner in the different provinces, which reflect the uncertainty among policy makers and health managers on how best to use FPs in their districts. FPs represent a costly human resource investment in an environment dominated by vertical disease programmes and nurse-driven PHC services. This uncertainty together with the paucity of local evidence paved the way for anational study that was conceptualised in response to a joint funding call of the National Department of Health and EuropeAid in 2013, titled: “Strengthening primary health care through primary care doctors and family physicians”. This PhD research project represents one component of the overall project that aimed to evaluate the contribution of FPs to the DHS in South Africa. The study aimed to evaluate the impact of FPs within the DHS of South Africa. The study objectives are shown below: A. To describe the perceived impact of FPs in terms of their six roles within the DHS. B. To describe co-health workers’ perception of the impact of FPs compared to medical officers who had received no postgraduate training. C. To compare the perceived impact of FPs between metropolitan and rural districts, between facility types (district hospitals vs. primary care facilities), as well as by training programme model (graduation before and after 2011). D. To explore the perceptions of district managers regarding the impact of FPs in the following three domains: health system performance, clinical processes and health outcomes. E. To assess the influence of FPs at primary care facilities and district hospitals. The influence of FPs was evaluated in terms of two domains: health system performance, and quality of clinical processes across the burden of disease. F. To evaluate the impact of an increase in FP supply in each district (number per 10 000 population) on key health system performance indicators, key clinical processes and key health outcomes.
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    Determining the causes for the shortage of human resources for primary health care in Botswana and developing a pilot intervention to address the problem
    (Stellenbosch : Stellenbosch University, 2017-12) Nkomazana, Oathokwa; Mash, Robert; Phaladze, Nthabiseng; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : The global policy on universal health coverage is a commitment to ensuring that all people have access to comprehensive health services without suffering financial hardship. Furthermore, primary healthcare has been recognised as a vehicle to achieving equitable access to comprehensive and cost effective health services. Effective primary healthcare services in many low– and middle-income countries, however, have been hampered by severe shortages and inequitable distribution of the health workforce. Internal migration of health workers from rural to urban areas and from public to private or non-governmental organisations, coupled with regional and international migrations, have exacerbated the shortage and inequity in many of these countries. Multiple strategies have been employed to address the shortage of healthcare workers with varying degrees of success. These include training, fiscal, regulatory and professional or personal support. Thse strategies concur with the World Health Organisation’s policy recommedations for the retention of healthcare workers in rural and remote areas. The causes of shortages in human resources for health are many and complex and effective mitigating strategies should therefore be comprehensive and context-specific and derived from an adequate understanding of the context. Although Botswana is reported to have a shortage of human resources for health, which is worse in rural areas and primary health care, there is a paucity of readily-accessible, integrated and comprehensive information on human resources for health. Moreover, there has not been any research to determine the cause(s) of the shortage which negates evidence based interventions. A situational analysis of the human resources for primary health care in Botswana was conducted using an analysis of the existing databases as well as conducting focus group discussions with health care workers, the community and policy makers in three health districts. The findings of the situational analysis then informed the subsequent intervention: creating more supportive health management for primary healthcare workers using a cooperative inquiry group method. The cooperative inquiry group, based on what they learnt from the inquiry, developed a consensus on the prerequisites for effective supportive supervision. This thesis has quantified the numbers of healthcare workers in the primary and hospital care as well as rural and urban areas. It has elucidated the perceived causes of the shortage of healthcare workers as well as potential solutions. It has also highlighted the need for Botswana to explore how to implement the World Health Organisation’s policy recommendations for retention of healthcare workers which were deemed to be inadequately addressed. This is a thesis by publication. The abstracts of the four articles are given below: Article number 1: Human resources for health in Botswana: the results of in-country database and reports analysis Background: Botswana is a large middle-income country in Southern Africa with a population of just over two million. Shortage of human resources for health is blamed for the inability to provide high quality accessible health services. There is however a lack of integrated, comprehensive and readily-accessible data on the health workforce. Aim: The aim of this study was to analyse the existing databases on health workforce in Botswana in order to quantify the human resources for health. Method: The Department of Policy, Planning, Monitoring and Evaluation at the Ministry of Health, Ministry of Education and Skills Development, the Botswana Health Professions Council, the Nursing and Midwifery Council of Botswana and the in-country World Health Organization office provided raw data on human resources for health in Botswana. Results: The densities of doctors and nurses per 10 000 population were four and 42, respectively; three and 26 for rural districts; and nine and 77 for urban districts. The average vacancy rate in 2007/2008 was 5% and 13% in primary and hospital care, respectively, but this is projected to increase to 53% and 43%, respectively, in 2016. Only 21% of the doctors registered with the Botswana Health Professions Council were from Botswana, the rest being mainly from other African countries. Before 2009 doctors were trained at regional and international medical schools. Nonetheless Botswana trained 77% of its health workforce locally. Conclusion: Although the density of health workers is relatively high compared to the region, they are concentrated in urban areas, insufficient to meet the projected requirements and reliant on migrant professionals. Article number 2: Stakeholders’ perceptions on shortage of healthcare workers in primary healthcare in Botswana: focus group discussions Background: An adequate health workforce force is central to universal health coverage and positive public health outcomes. However many African countries, including Botswana, have critical shortages of healthcare workers, which are worse in primary healthcare. The aim of this study was to explore the perceptions of healthcare workers, policy makers and the community on the shortage of healthcare workers in Botswana. Method: Fifteen focus group discussions were conducted with three groups of policy makers, six groups of healthcare workers and six groups of community members in rural, urban and remote rural health districts of Botswana. All the participants were 18 years and older. Recruitment was purposive and the framework method was used to inductively analyse the data. Results: There was a perceived shortage of healthcare workers in primary healthcare, which was believed to result from an increased need for health services, inequitable distribution of healthcare workers, migration and too few such workers being trained. Migration was mainly the result of unfavourable personal and family factors, weak and ineffective healthcare and human resources management, low salaries and inadequate incentives for rural and remote area service. Conclusions: Botswana has a perceived shortage of healthcare workers, which is worse in primary healthcare and rural areas, as a result of multiple complex factors. To address the scarcity the country should train adequate numbers of healthcare workers and distribute them equitably to sufficiently resourced healthcare facilities. Article number 3: Understanding the organisational culture of district health services: Mahalapye and Ngamiland Health Districts of Botswana Background: Botswana has a shortage of healthcare workers, especially in primary health care. Retention and high performance of employees however is closely linked to job satisfaction and motivation which are both highest where employees’ personal values and goals are realised. Aim: The aim of the study was to evaluate the organisational culture of the district health services as experienced by the primary healthcare workers. Setting: The study was conducted in the Ngamiland and Mahalapye health districts Method: This was a cross-sectional survey. The participants were asked to select ten values that best described their personal, current organisational and desired organisational values from a predetermined list. Results: 60 and 67 healthcare workers completed the survey in Mahalapye and Ngamiland districts, respectively. Eight of the top ten prevalent organisational values were common to both districts: teamwork, blame, patient satisfaction, blame, confusion, job insecurity, not sharing information and manipulation. When all the current values were assessed 32% (Mahalapye) and 36% (Ngamiland) selected by healthcare workers, were potentially limiting organisational effectiveness. The organisational values desired by healthcare workers in both districts were: transparency, professional growth, staff recognition, shared decision-making, accountability, productivity, leadership development and teamwork. Conclusions: The experience of the primary healthcare workers in the two health districts were overwhelmingly negative which is likely to contribute to low levels of motivation, job satisfaction, productivity and high attrition rates. There is an urgent need for organisational transformation with a focus on staff experience and leadership development at all levels of the health system in Botswana. Article number 4: How to create more supportive supervision for primary healthcare: lessons from Ngamiland district of Botswana: Co-operative inquiry group Background: Supportive supervision is a way to foster performance, productivity, motivation and retention of health workforce. Nevertheless there is a dearth of evidence of the impact and acceptability of supportive supervision in low- and middle-income countries. This article describes a participatory process of transforming the supervisory practice of district health managers to create a supportive environment for primary healthcare workers. Objective: The objective of the study was to explore how district health managers can change their practice to create a more supportive environment for primary healthcare providers. Methods: A facilitated cooperative inquiry group was formed with Ngamiland health district managers. Cooperative inquiry group belongs to the participatory action research paradigm and is characterised by a cyclic process of observation, reflection, planning and action. The cooperative inquiry group went through three cycles between March 2013 and March 2014. Results: 12 district health managers participated in the inquiry group. The major insights and learning that emerged from the inquiry process included inadequate supervisory practice, perceptions of healthcare workers’ experiences; change in the managers’ supervision paradigm, recognition of the supervisors’ inadequate supervisory skills and barriers to supportive supervision. Finally, the group developed a 10-point consensus on what they had learnt regarding supportive supervision. Conclusion: Ngamiland health district managers have come to appreciate the value of supportive supervision and changed their management style to be more supportive of their subordinates. They also developed a consensus on supportive supervision that could be adapted for use nationally. Supportive supervision should be prioritised at all levels of the health system and it should be adequately resourced.
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    The experiences of HIV positive patients on antiretroviral drugs attending the public service health institutions in the Eastern Cape Province : a qualitative study
    (Stellenbosch : Stellenbosch University, 2017-03) Chandia, J.; Mash, R. J. (Bob); Stellenbosch University. Faculty of Medicine and Health Sciences. Department of Family & Emergency Medicine. Family Medicine & Primary Care.
    ENGLISH SUMMARY : Introduction: In August 2003, a landmark decision was made by the South African government to include the use of antiretroviral drugs in the public health service as part of the comprehensive response to the HIV pandemic. The Eastern Cape Province implemented the decision in May 2004.The aim of this study was to explore the experiences of patients taking antiretroviral (ARV) medication in the public sector of the Eastern Cape Province. The main objective was to explore the personal, health service and contextual related experiences of HIV positive patients on antiretroviral drugs attending the public service health institutions in the Eastern Cape Province with the following specific objectives: - To explore how patients incorporate the taking of ARVs into their lifestyle. - To explore the beliefs and feelings of patients regarding their ARVs. - To explore the positive and negative experiences of patients attending the ARV clinic. - To explore how others such as family and friends react to their taking of ARVs. - To explore what they expect of the ARVs. - To explore what motivates them to take the ARVs. - To explore the positive and negative forces that affect the patient’s ability to adhere to the treatment. - To understand the social, cultural and contextual issues that impact on the patient’s ability to take ARVs. - To elicit any other unanticipated issues that arise in the patient’s context or experience that are important to their ability to take ARVs. The results of the study will inform the strategies for implementing the antiretroviral programme in the Eastern Cape Province. Methods: Study design: A qualitative study design was used. A purposive sample of HIV positive patients on antiretroviral drugs who met the inclusion criteria were selected from HIV Clinics at Lusikisiki, Mthatha, East London and Port Elizabeth. Data on the experiences of the participants were collected via interviews, from daily narratives in the medicine diaries compiled by the patients,focus groups of patients and patient’s treatment supporters/care givers, and participant observation. Data from the individual and focus group interviews were collected until a point of saturation was reached. Analysis: The data analysis was done using ATLAS-t.i Version 6.2 computer programme for the analysis of qualitative data. Ethical considerations Informed consent was obtained from all participants and confidentiality ensured. Ethics Committee approval was obtained from the University of Stellenbosch and Walter Sisulu University. Permission was obtained from the Heads of Clinical Governance of the participating hospitals. Results: The personal experiences of participants highlighted the importance of the knowledge of one’s HIV status through testing, as a gateway to accessingcare, although the decision to test was not an easy one due to the fear of stigma and discrimination. Disclosure of HIV status was selective for the same reason. Acceptance of HIV status; use of technology, especially mobile phones; andtreatment supporters facilitated adherence to the ARVs.The health benefits of ARVs motivated adherence and outweighed the challenges of the side effects. Save for a few positive experiences related to the health service, patients had challenging experiences. These included negative health provider attitudes, stigma and discrimination, long waiting times, inadvertent disclosure, lack of person centred care, inequity in access to care, poor infrastructure, overcrowding and unhygienic practices and environment. The positive contextual experiences related to support from the family and others the participants interacted with. Some family members and others were also responsible for the negative experiences the participants were subjected to, particularly stigma and discrimination. Challenging experiences related to food insecurity and poor socio-economic status featured quite prominently. The socio-cultural experiences mainly related to the effects of traditional medicine in relation to the ARVs, especially when taken concurrently. The healthcare providers discouraged the practice as it could affect the efficacy of the ARVs. Conclusions: The conclusions were based on the objectives of the study. The incorporation of ARVs into the lifestyle of the patients was facilitated by the treatment supporters and the use of technology, mainly mobile phones. The patients believed that ARVs saved their life and gave them hope to live long enough to fulfil their aspirations in life, e.g., bringing up of their children. Lack of acceptance of HIV status, and drug and alcohol abuse were considered to be some of the serious challenges to adherence and the health benefits of ARVs.A few but inconsistent positive experiences related to the HIV clinic included some practice of person centred care,availability of ARVs,patient education and sharing of experiences with peers. The negative experiences dominated the experiences at the HIV clinic. These included lack of person centred care, the practice of stigma and discrimination by the health care providers, poor unhygienic infrastructure, and fears about the sustainability of the supply of ARVs in the public service. The positive reaction of the family and others in the form of support contributed to improvement in the health of the patients while the negative reactions, especially stigma and discrimination, compromised support and fuelled ill health for the patients. Socio-cultural and other contextual challenges related to the taking of ARVs were the rampant practice of stigma and discrimination against people living with HIV by families and the society at large, leading to lack of support. Poverty, food insecurity and the use of traditional medicine concurrently with ARVs were also highlighted. Other unanticipated issues raised were the importance of the role of the treatment supporters in the care of the people living with HIV and the need to consider those who have no source of income for some form of remuneration. The emerging rising challenge of drug and alcohol abuse in relation to patients on ARVs was highlighted and is a concern. For all the issues raised above, specific recommendations have been made.