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1.  From apartheid to integration: the role of the Witwatersrand Medical library in health care services in Johannesburg, South Africa. 
Adapting to change is always difficult; all the more so when changes in the administrative structure of health care are part of a national political transformation toward democracy. As South Africa moves from apartheid to integration in its health services, the Witwatersrand Medical Library (WML) will have to adopt innovative strategies to cope with increasing demands on its resources by sub-Saharan African medical libraries and with expected decreases in state funding for health and education. WML also will have to address the lack of hospital library services in the Johannesburg region by expanding its academic branches at University of the Witwatersrand Medical School's teaching hospitals to serve both hospital and academic health care staff. This article discusses these challenges in the context of rapidly changing academic health care services in Johannesburg.
PMCID: PMC226001  PMID: 7703943
2.  Scaling up the delivery of refractive error services within a district health system: the KwaZulu-Natal, South Africa experience 
Background
In South Africa, the health service is based on a Primary Health Care (PHC) philosophy with the District Health System (DHS) as the locus of delivery. However eye care services, particularly primary eye care, refractive error and low vision, have not been prioritised accordingly. Hence the aim of the Giving Sight to KwaZulu-Natal (GSKZN) project was to integrate the delivery of eye care services into the district health system, with emphasis on addressing the need for uncorrected refractive error and low vision services.
The project was implemented in the KwaZulu-Natal province, South Africa, to scale up the delivery of refractive error services utilising a four pronged approach; including advocacy, human resource development, equipment provision and research.
Methods
This paper is a description of the project and a retrospective analysis of data received through the course of the project from July 2007 to June 2011. Data were collected from training registers, equipment schedules and service delivery reports from institutions. Reports from the data base were then analysed and achievements in training and trends in service delivery were determined.
Results
Over a four year period (July 2007 and July 2011) 1004 persons received training in rendering eye health services appropriate to their level of deployment within the DHS. During the course of the project, these 1004 persons examined 1 064 087 patients. Furthermore, the total number of clinics offering primary eye care, refractive error and low vision services increased from 96 (10%) to 748 (76%). With increased numbers of PHC Nurses trained in primary eye care, a subsequent decrease of 51.08 percent was also observed in the number of patients seeking services at higher levels of care, thus streamlining eye health service delivery.
Conclusion
This project has shown that scaling up can occur in delivering eye health services within a health district, through a multi-faceted approach that encompasses focused training, advocacy, development of appropriate infrastructure and the development of referral criteria with clear guidelines for the management of patients.
doi:10.1186/1472-6963-13-361
PMCID: PMC3852626  PMID: 24074239
Public health; Primary eye health; Refractive error; Service delivery; District health system
3.  Health and Health Care in Post-Apartheid South Africa: A Future Vision 
This paper accepts the idea that patterns and distribution of health care and resources are determined by “realpolitik,” and that South Africa is at present in the throes of a political revolution, the outcome of which is bound to reflect a considerable degree of “self-determination” of the majority black (African, Asian, and mixed-race) people. It is postulated that the health services—and other pre-determinants of the health of the black people—will be shaped by a mixed socialist-capitalist economy and a socialized or nationalized form of health care service. This is because all the leading players in the revolutionary stakes, especially the exiled African National Congress of South Africa (ANC) and the above-ground United Democratic Front (UDF) and its affiliate, the National Alternative Medical and Dental Association (NAMDA), who are the front-runners, advocate these kind of changes for the future of South Africa, as exemplified in the ANC's Freedom Charter of 1955.
Powerful political forces, both inside South Africa and in the Western World, are resisting this outcome, despite it clearly being the democratic will of the people, as shown by all the polls. These reactionary strategies would leave the health of most blacks in South Africa and Namibia little improved over its present status.
PMCID: PMC2625628  PMID: 3280814
4.  Adverse or acceptable: negotiating access to a post-apartheid health care contract 
Background
As in many fragile and post-conflict countries, South Africa’s social contract has formally changed from authoritarianism to democracy, yet access to services, including health care, remains inequitable and contested. We examine access barriers to quality health services and draw on social contract theory to explore ways in which a post-apartheid health care contract is narrated, practiced and negotiated by patients and providers. We consider implications for conceptualizing and promoting more inclusive, equitable health services in a post-conflict setting.
Methods
Using in-depth interviews with 45 patients and 67 providers, and field observations from twelve health facilities in one rural and two urban sub-districts, we explore access narratives of those seeking and delivering – negotiating - maternal health, tuberculosis and antiretroviral services in South Africa.
Results
Although South Africa’s right to access to health care is constitutionally guaranteed, in practice, a post-apartheid health care contract is not automatically or unconditionally inclusive. Access barriers, including poverty, an under-resourced, hierarchical health system, the nature of illness and treatment, and negative attitudes and actions, create conditions for insecure or adverse incorporation into this contract, or even exclusion (sometimes temporary) from health care services. Such barriers are exacerbated by differences in the expectations that patients and providers have of each other and the contract, leading to differing, potentially conflicting, identities of inclusion and exclusion: defaulting versus suffering patients, uncaring versus overstretched providers. Conversely, caring, respectful communication, individual acts of kindness, and institutional flexibility and leadership may mitigate key access barriers and limit threats to the contract, fostering more positive forms of inclusion and facilitating easier access to health care.
Conclusions
Building health in fragile and post-conflict societies requires the negotiation of a new social contract. Surfacing and engaging with differences in patient and provider expectations of this contract may contribute to more acceptable, accessible health care services. Additionally, the health system is well positioned to highlight and connect the political economy, institutions and social relationships that create and sustain identities of exclusion and inclusion – (re)politicise suffering - and co-ordinate and lead intersectoral action for overcoming affordability and availability barriers to inclusive and equitable health care services.
doi:10.1186/1744-8603-10-35
PMCID: PMC4036079  PMID: 24885882
Social contract theory; Health care access; Suffering; Defaulting; Post-apartheid South Africa
5.  The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis 
Social Science & Medicine (1982)  2010;71(6-3):1110-1118.
There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.
Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April 2008 with founders and CHWs from these earlier programmes. These data were triangulated with written primary sources and analysed using thematic content analysis. The study suggests that 1970s–1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today.
doi:10.1016/j.socscimed.2010.06.009
PMCID: PMC2941026  PMID: 20638169
Community health workers; Community health worker (CHW) policy; South Africa; Oral history; Apartheid; Task-shifting; Community participation
6.  Challenges to HIV prevention in psychiatric settings: Perceptions of South African mental health care providers 
Social science & medicine (1982)  2006;63(4):979-990.
Mental health services in South Africa increasingly feel the brunt of the AIDS epidemic. Despite the high prevalence of infection in the psychiatric setting, HIV risk reduction interventions targeting South Africans with psychiatric illness remain few and far between. The attitudes of mental health care providers about sexual relations and HIV among people with mental illness continue to influence the extent to which these issues are addressed in care settings. This study examines these attitudes through the use of a semi-structured interview administered to 46 mental health care providers in four provinces of South Africa. I found that personal, contextual and political factors in the clinic and the hospital create barriers to integrating prevention activities. In particular, providers face at least three challenges to intervening in the epidemic among their patients: their own views of psychiatric illness, the transitions occurring in the mental health care system, and shifting social attitudes toward sexuality. Barriers operate at the individual level, the institutional level, and the societal level. At the individual level providers’ perceptions of psychiatric symptoms shape their outlook on intervention with psychiatric patients. At the institutional level disruptive transitions in service delivery relegate HIV services to lesser importance. At the societal level, personal beliefs about sexuality and mental illness have remained slow to change despite major political changes. Minimizing barriers to implementing HIV prevention services requires institutional and health care policies that ensure adequate resources for treating people with mental illness and for staff development and support.
doi:10.1016/j.socscimed.2006.03.003
PMCID: PMC2800079  PMID: 16647793
Mental health care providers; HIV prevention; South Africa; Barriers
7.  Improving a Mother to Child HIV Transmission Programme through Health System Redesign: Quality Improvement, Protocol Adjustment and Resource Addition 
PLoS ONE  2010;5(11):e13891.
Background
Health systems that deliver prevention of mother to child transmission (PMTCT) services in low and middle income countries continue to underperform, resulting in thousands of unnecessary HIV infections of newborns each year. We used a combination of approaches to health systems strengthening to reduce transmission of HIV from mother to infant in a multi-facility public health system in South Africa.
Methodology/Principal Findings
All primary care sites and specialized birthing centers in a resource constrained sub-district of Cape Metro District, South Africa, were enrolled in a quality improvement (QI) programme. All pregnant women receiving antenatal, intrapartum and postnatal infant care in the sub-district between January 2006 and March 2009 were included in the intervention that had a prototype-innovation phase and a rapid spread phase. System changes were introduced to help frontline healthcare workers to identify and improve performance gaps at each step of the PMTCT pathway. Improvement was facilitated and spread through the use of a Breakthrough Series Collaborative that accelerated learning and the spread of successful changes. Protocol changes and additional resources were introduced by provincial and municipal government. The proportion of HIV-exposed infants testing positive declined from 7.6% to 5%. Key intermediate PMTCT processes improved (antenatal AZT increased from 74% to 86%, PMTCT clients on HAART at the time of labour increased from 10% to 25%, intrapartum AZT increased from 43% to 84%, and postnatal HIV testing from 79% to 95%) compared to baseline.
Conclusions/Significance
System improvement methods, protocol changes and addition/reallocation of resources contributed to improved PMTCT processes and outcomes in a resource constrained setting. The intervention requires a clear design, leadership buy-in, building local capacity to use systems improvement methods, and a reliable data system. A systems improvement approach offers a much needed approach to rapidly improve under-performing PMTCT implementation programmes at scale in sub-Saharan Africa.
doi:10.1371/journal.pone.0013891
PMCID: PMC2976693  PMID: 21085479
8.  Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries 
PLoS ONE  2014;9(2):e88437.
Background
Little is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.
Methods
A situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.
Results
The PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.
Conclusions
The low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.
doi:10.1371/journal.pone.0088437
PMCID: PMC3928234  PMID: 24558389
9.  An e-Health Decision Support System for Improving Compliance of Health Workers to the Maternity Care Protocols in South Africa 
Applied Clinical Informatics  2013;4(1):25-36.
Background
There are problems of quality in maternity services at primary health care level in South Africa. Many of these problems can be traced to non-adherence to the maternity care guidelines and lack of tools to support clinic staff and managers in their roles. Objective: The aim of this research was to investigate the utility of e-health (computerized) decision support systems at addressing the problem of compliance of health workers to the maternity care guidelines at primary health care in South Africa. At present there are no documented studies on e-health clinical decision support systems for primary health care in South Africa, though clinical decision support systems for primary health care are listed as part of the e-health strategy of the National Department of Health. Methods: An e-health decision support system named the Bacis (Basic Antenatal Care Information System) Program was developed, then implemented and evaluated at a primary health care clinic. The duration of the study was two years: this includes development, implementation and evaluation.
Results and Conclusion
There was an overall improvement in compliance from 85.1 % to 89.3%. This result was not statistically significant. However when results were stratified into specific categories, the Bacis Program showed statistically significant improvement in compliance over the checklist system in three out of nine important categories. These are compliance at booking, patients younger than 18 years and patients booking after week 20. Further, insights and experience were also gained on development and implementation of clinical information systems at resource strained environments such as primary health care in South Africa. These results, insights and experience are invaluable for the implementation of the proposed e-health strategy in South Africa.
doi:10.4338/ACI-2012-10-RA-0044
PMCID: PMC3644812  PMID: 23650485
Clinical decision support systems; maternal health care; guideline adherence; primary health care
10.  Teaching medical ethics to undergraduate students in post‐apartheid South Africa, 2003–2006 
Journal of Medical Ethics  2007;33(11):673-677.
The apartheid ideology in South Africa had a pervasive influence on all levels of education including medical undergraduate training. The role of the health sector in human rights abuses during the apartheid era was highlighted in 1997 during the Truth and Reconciliation Commission hearings. The Health Professions Council of South Africa (HPCSA) subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country. Curricular reform at the University of Stellenbosch in 1999 presented an unparalleled opportunity to formally introduce ethics teaching to undergraduate students. This paper outlines the introduction of a medical ethics programme at the Faculty of Health Sciences from 2003 to 2006, with special emphasis on the challenges encountered. It remains one of the most comprehensive undergraduate medical ethics programmes in South Africa. However, there is scope for expanding the curricular time allocated to medical ethics. Integrating the curriculum both horizontally and vertically is imperative. Implementing a core curriculum for all medical schools in South Africa would significantly enhance the goals of medical education in the country.
doi:10.1136/jme.2006.018432
PMCID: PMC2598089  PMID: 17971474
11.  Effect of an innovative community based health program on maternal health service utilization in north and south central Ethiopia: a community based cross sectional study 
Reproductive Health  2014;11:28.
Background
Among Millennium Development Goals, achieving the fifth goal (MDG-5) of reducing maternal mortality poses the greatest challenge in Sub-Saharan Africa. Ethiopia has one of the highest maternal mortality ratios in the world with unacceptably low maternal health service utilization. The Government of Ethiopia introduced an innovative community-based intervention as a national strategy under the Health Sector Development Program. This new approach, known as the Health Extension Program, aims to improve access to and equity in essential health services through community based Health Extension Workers.
Objective
The objective of the study is to assess the role of Health Extension Workers in improving women’s utilization of antenatal care, delivery at health facility and postnatal care services.
Methods
A cross sectional household survey was conducted in early 2012 in two districts of northern and south central parts of Ethiopia. Data were collected from 4949 women who had delivered in the two years preceding the survey. Logistic regression analysis was performed to determine the association between visit by Health Extension Workers during pregnancy and use of maternal health services, controlling for the effect of other confounding factors.
Results
The non–adjusted analysis showed that antenatal care attendance at least four times during pregnancy was significantly associated with visit by Health Extension Workers [Odds Ratio 3.46(95% CI 3.07,3.91)], whereas health facility delivery (skilled attendance at birth) was not significantly associated with visit by Health Extension Workers during pregnancy [Odds Ratio 0.87(95% CI 0.25,2.96)]. When adjusted for other factors the association of HEWs visit during pregnancy was weaker for antenatal care attendance [Adjusted Odds Ratio: 1.35(95% CI: 1.05, 1.72)] but positively and significantly associated with health facility delivery [Adjusted Odds Ratio 1.96(1.25,3.06)].
Conclusion
In general HEWs visit during pregnancy improved utilization of maternal health services. Health facility delivery is heavily affected by other factors. Meaningful improvement in skilled attendance at birth (health facility delivery) should include addressing other factors on top of visits by HEWs during pregnancy and specific target oriented interventions during visits by HEWs to support skilled attendance at birth.
doi:10.1186/1742-4755-11-28
PMCID: PMC4041359  PMID: 24708848
Skilled attendance at birth; Community based health programs; Health facility delivery; Antenatal care; Health Extension Worker; Ethiopia
12.  Public funding of health at the district level in Indonesia after decentralization – sources, flows and contradictions 
Background
During the Suharto era public funding of health in Indonesia was low and the health services were tightly controlled by the central government; district health staff had practically no discretion over expenditure. Following the downfall of President Suharto there was a radical political, administrative and fiscal decentralization with delivery of services becoming the responsibility of district governments. In addition, public funding for health services more than doubled between 2001 and 2006. It was widely expected that services would improve as district governments now had both more adequate funds and the responsibility for services. To date there has been little improvement in services. Understanding why services have not improved requires careful study of what is happening at the district level.
Methods
We collected information on public expenditure on health services for the fiscal year 2006 in 15 districts in Java, Indonesia from the district health offices and district hospitals. Data obtained in the districts were collected by three teams, one for each province. Information on district government revenues were obtained from district public expenditure databases maintained by the World Bank using data from the Ministry of Finance.
Results
The public expenditure information collected in 15 districts as part of this study indicates district governments are reliant on the central government for as much as 90% of their revenue; that approximately half public expenditure on health is at the district level; that at least 40% of district level public expenditure on health is for personnel, almost all of them permanent civil servants; and that districts may have discretion over less than one-third of district public expenditure on health; the extent of discretion over spending is much higher in district hospitals than in the district health office and health centers. There is considerable variation between districts.
Conclusion
In contrast to the promise of decentralization there has been little increase in the potential for discretion at the district level in managing public funds for health – this is likely to be an important reason for the lack of improvement in publicly funded health services. Key decisions about money are still made by the central government, and no one is held accountable for the performance of the sector – the district blames the center and the central ministries (and their ministers) are not accountable to district populations.
doi:10.1186/1478-4505-7-5
PMCID: PMC2678112  PMID: 19371410
13.  Migration, settlement change and health in post-apartheid South Africa: Triangulating health and demographic surveillance with national census data1 
Background
World population growth will be increasingly concentrated in the urban areas of the developing world; however, some scholars caution against the oversimplification of African urbanization noting that there may be “counter-urbanization” and a prevailing pattern of circular rural–urban migration. The aim of the paper is to examine the ongoing urban transition in South Africa in the post-apartheid period, and to consider the health and social policy implications of prevailing migration patterns.
Methods
Two data sets were analysed, namely the South African national census of 2001 and the Agincourt health and demographic surveillance system. A settlement-type transition matrix was constructed on the national data to show how patterns of settlement have changed in a five-year period. Using the sub-district data, permanent and temporary migration was characterized, providing migration rates by age and sex, and showing the distribution of origins and destinations.
Findings
The comparison of national and sub-district data highlight the following features: urban population growth, particularly in metropolitan areas, resulting from permanent and temporary migration; prevailing patterns of temporary, circular migration, and a changing gender balance in this form of migration; stepwise urbanization; and return migration from urban to rural areas.
Conclusions
Policy concerns include: rural poverty exacerbated by labour migration; explosive conditions for the transmission of HIV; labour migrants returning to die in rural areas; and the challenges for health information created by chronically ill migrants returning to rural areas to convalesce. Lastly, suggestions are made on how to address the dearth of relevant population information for policy-making in the fields of migration, settlement change and health.
doi:10.1080/14034950701356401
PMCID: PMC2830108  PMID: 17676507
South Africa; Agincourt; urbanisation; migration; temporary migration; permanent migration; rural-urban links; health policy
14.  Positive practice environments influence job satisfaction of primary health care clinic nursing managers in two South African provinces 
Background
Nurses constitute the majority of the health workforce in South Africa and they play a major role in providing primary health care (PHC) services. Job satisfaction influences nurse retention and successful implementation of health system reforms. This study was conducted in light of renewed government commitment to reforms at the PHC level, and to contribute to the development of solutions to the challenges faced by the South African nursing workforce. The objective of the study was to determine overall job satisfaction of PHC clinic nursing managers and the predictors of their job satisfaction in two South African provinces.
Methods
During 2012, a cross-sectional study was conducted in two South African provinces. Stratified random sampling was used to survey a total of 111 nursing managers working in PHC clinics. These managers completed a pre-tested Measure of Job Satisfaction questionnaire with subscales on personal satisfaction, workload, professional support, training, pay, career prospects and standards of care. Mean scores were used to measure overall job satisfaction and various subscales. Predictors of job satisfaction were determined through multiple logistic regression analysis.
Results
A total of 108 nursing managers completed the survey representing a 97% response rate. The mean age of respondents was 49 years (SD = 7.9) and the majority of them (92%) were female. Seventy-six percent had a PHC clinical training qualification. Overall mean job satisfaction scores were 142.80 (SD = 24.3) and 143.41 (SD = 25.6) for Gauteng and Free State provinces respectively out of a maximum possible score of 215. Predictors of job satisfaction were: working in a clinic of choice (RRR = 3.10 (95% CI: 1.11 to 8.62, P = 0.030)), being tired at work (RRR = 0.19 (95% CI: 0.08 to 0.50, P = 0.001)) and experience of verbal abuse (RRR = 0.18 (95% CI: 0.06 to 0.55, P = 0.001).
Conclusion
Allowing nurses greater choice of clinic to work in, the prevention of violence and addressing workloads could improve the practice environment and job satisfaction of PHC clinic nursing managers.
doi:10.1186/1478-4491-12-27
PMCID: PMC4024627  PMID: 24885785
Job satisfaction; Primary health care; Nursing managers; Health workforce; South Africa
15.  Outreach services to improve access to health care in South Africa: lessons from three community health worker programmes 
Global Health Action  2013;6:10.3402/gha.v6i0.19283.
Introduction
In South Africa, there are renewed efforts to strengthen primary health care and community health worker (CHW) programmes. This article examines three South African CHW programmes, a small local non-governmental organisation (NGO), a local satellite of a national NGO, and a government-initiated service, that provide a range of services from home-based care, childcare, and health promotion to assist clients in overcoming poverty-related barriers to health care.
Methods
The comparative case studies, located in Eastern Cape and Gauteng, were investigated using qualitative methods. Thematic analysis was used to identify factors that constrain and enable outreach services to improve access to care.
Results
The local satellite (of a national NGO), successful in addressing multi-dimensional barriers to care, provided CHWs with continuous training focused on the social determinants of ill-health, regular context-related supervision, and resources such as travel and cell-phone allowances. These workers engaged with, and linked their clients to, agencies in a wide range of sectors. Relationships with participatory structures at community level stimulated coordinated responses from service providers. In contrast, an absence of these elements curtailed the ability of CHWs in the small NGO and government-initiated service to provide effective outreach services or to improve access to care.
Conclusion
Significant investment in resources, training, and support can enable CHWs to address barriers to care by negotiating with poorly functioning government services and community participation structures.
doi:10.3402/gha.v6i0.19283
PMCID: PMC3556683  PMID: 23364101
primary health care; access to care; community health workers; social determinants of health; accountability; South Africa
16.  A model for the integration of primary healthcare services in the province of KwaZulu-Natal, South Africa 
Introduction
In South Africa, Integration of Services Policy was enacted in 1996 with the aim of increasing health service utilization by increasing the accessibility of all services at primary healthcare level. However, the problem with the policy arises in the implementation of integrated primary healthcare as there is no agreed upon understanding of what this phenomenon means in the South African context.
Aims
Analyse integration of primary healthcare services and ultimately develop a model for the integration of primary healthcare services.
Results
It emerged that there were three core categories that were used by the participants as discriminatory dimensions of integrated primary healthcare in South Africa. These core categories were (a) comprehensive health care, (b) supermarket approach and (c) one stop shop.
Conclusion
The phenomenon, integrated primary healthcare meant different things in different contexts.
PMCID: PMC3031840
primary healthcare; integrated primary healthcare; grounded theory; South Africa
17.  Study protocol: Audit and Best Practice for Chronic Disease Extension (ABCDE) Project 
Background
A growing body of international literature points to the importance of a system approach to improve the quality of care in primary health care settings. Continuous Quality Improvement (CQI) concepts and techniques provide a theoretically coherent and practical way for primary care organisations to identify, address, and overcome the barriers to improvements. The Audit and Best Practice for Chronic Disease (ABCD) study, a CQI-based quality improvement project conducted in Australia's Northern Territory, has demonstrated significant improvements in primary care service systems, in the quality of clinical service delivery and in patient outcomes related to chronic illness care. The aims of the extension phase of this study are to examine factors that influence uptake and sustainability of this type of CQI activity in a variety of Indigenous primary health care organisations in Australia, and to assess the impact of collaborative CQI approaches on prevention and management of chronic illness and health outcomes in Indigenous communities.
Methods/design
The study will be conducted in 40–50 Indigenous community health centres from 4 States/Territories (Northern Territory, Western Australia, New South Wales and Queensland) over a five year period. The project will adopt a participatory, quality improvement approach that features annual cycles of: 1) organisational system assessment and audits of clinical records; 2) feedback to and interpretation of results with participating health centre staff; 3) action planning and goal setting by health centre staff to achieve system changes; and 4) implementation of strategies for change. System assessment will be carried out using a System Assessment Tool and in-depth interviews of key informants. Clinical audit tools include two essential tools that focus on diabetes care audit and preventive service audit, and several optional tools focusing on audits of hypertension, heart disease, renal disease, primary mental health care and health promotion.
The project will be carried out in a form of collaborative characterised by a sequence of annual learning cycles with action periods for CQI activities between each learning cycle.
Key outcome measures include uptake and integration of CQI activities into routine service activity, state of system development, delivery of evidence-based services, intermediate patient outcomes (e.g. blood pressure and glucose control), and health outcomes (complications, hospitalisations and mortality).
Conclusion
The ABCD Extension project will contribute directly to the evidence base on effectiveness of collaborative CQI approaches on prevention and management of chronic disease in Australia's Indigenous communities, and to inform the operational and policy environments that are required to incorporate CQI activities into routine practice.
doi:10.1186/1472-6963-8-184
PMCID: PMC2556328  PMID: 18799011
18.  Apartheid: Focus on Health 
This paper focuses on health in the Republic of South Africa and calls not only for technical warfare against disease, poverty, and bigotry but also for attention to predisposing causes of disease and ill health among the African majority.
PMCID: PMC2537449  PMID: 522192
19.  Utilization of the Primary Health Care Services in the Tshwane Region of Gauteng Province, South Africa 
PLoS ONE  2010;5(11):e13909.
Background
In South Africa, the provision of primary health care is a basic service designed to be cost effective and bring healthcare as close as possible to the population, particularly to those people of low economic status. It is a service which is provided free of charge by the South African government and as part of the millennium health goals, it is intended that the service should be accessible to the populace and be effectively utilized.
Objective
This study was designed to investigate the accessibility and utilization of the primary health care services in three community health care centres in the Tshwane of the Gauteng Province, South Africa.
Methodology
Data were obtained from participants attending three Community Health Care Centres in the Tshwane Region using self-administered structured questionnaires. A document review of the Community Health Care Centres records was conducted to investigate the utilization trends of the services provided and descriptive statistics were used to analyze the data obtained.
Results
The results showed that the Community Health Care Centres in the Tshwane Region are accessible to most participants who lived within 5 km of such centres and who traveled 30 minutes or less to the clinic. Using a taxi or walking were found to be the most common means of transport used to gain access to such a clinic. The findings showed that generally, participants were satisfied with the services provided.
Conclusion
Participants of this study have access to the community health care centres in the Tshwane Region and there seems to be effective utilization by patients attending them.
doi:10.1371/journal.pone.0013909
PMCID: PMC2976689  PMID: 21085475
20.  Is chiropractic care primary health care? 
The following paper sets out to examine three issues: primary health care, chiropractic care, and the challenges to both in the next decade. The current crisis of primary health within the health care system provides chiropractic with an opportunity to choose between functioning as primary care or primary contact care. Chiropractic has seldom met its potential, or its own rhetoric, with regard to holistic health care which would make the case for being primary health care much stronger. There have been numerous social and political factors that have influenced this but part of the problem is that chiropractic has failed to clearly articulate itself as primary health care, and in some instances, has denied that it was. New opportunities and challenges will force chiropractors to resolve the issue of whether chiropractic is a general model of health care, or a form of health specialty (the neuromusculoskeletal practitioner verses the primary health practitioner).
PMCID: PMC2484820
chiropractic; manipulation; health care
21.  HIV/AIDS mitigation strategies and the State in sub-Saharan Africa – the missing link? 
Background
The HIV/AIDS pandemic in sub-Saharan Africa is widely recognised as a development disaster threatening poverty reduction, economic growth and not merely a health issue. Its mitigation includes the societal-wide adoption and implementation of specific health technologies, many of which depend on functional institutions and State.
Discussion
Donor and International Institutions' strategies to mitigate HIV/AIDS in sub-Saharan Africa are premised on a single optimal model of the State, one which focuses on the decentralised delivery of public goods alone (such as healthcare) – the service delivery state. The empirical evidence, though sparse, of "successful" and "unsuccessful" sub-Saharan Africa states' performance in mitigating HIV/AIDS does not support this model. Rather, the evidence suggests an alternative model that takes a country context specific approach – encompassing political power, institutional structures and the level of health technology needed. This model draws on the historical experience of East Asian countries' rapid development.
Summary
For international public health policies to be effective, they must consider a country tailored approach, one that advocates a coordinated strategy designed and led by the State with involvement of wider society specific to each country's particular history, culture, and level of development.
doi:10.1186/1744-8603-2-1
PMCID: PMC1382207  PMID: 16417625
22.  Quality of life among tuberculosis (TB), TB retreatment and/or TB-HIV co-infected primary public health care patients in three districts in South Africa 
Introduction
TB and HIV co-morbidity amount to a massive burden on healthcare systems in many countries. This study investigates health related quality of life among tuberculosis (TB), TB retreatment and TB-HIV co-infected public primary health care patients in three districts in South Africa.
Methods
A cross sectional study was conducted among 4900 TB patients who were in the first month of anti-TB treatment in primary public health care clinics in three districts in South Africa. Quality of life was assessed using the social functioning (SF)-12 Health Survey through face to face interviews. Associations of physical health (Physical health Component Summary = PCS) and mental health (Mental health Component Summary = MCS) were identified using logistic regression analyses.
Results
The overall physical and mental health scores were 42.5 and 40.7, respectively. Emotional role, general health and bodily pain had the lowest sub-scale scores, while energy and fatigue and mental health had the highest domain scores. Independent Kruskal–Wallis tests found significant positive effects of being TB-HIV co-infected on the domains of mental health functioning, emotional role, energy and fatigue, social function and physical role, while significant negative effects were observed on general health, bodily pain and physical function. In multivariable analysis higher educational, lower psychological distress, having fewer chronic conditions and being HIV negative were significantly positively associated with PCS, and low poverty, low psychological distress and being HIV positive were positively significantly associated with MCS.
Conclusion
TB and HIV weaken patients’ physical functioning and impair their quality of life. It is imperative that TB control programmes at public health clinics design strategies to improve the quality of health of TB and HIV co-infected patients.
doi:10.1186/1477-7525-10-77
PMCID: PMC3422995  PMID: 22742511
Social functioning; Tuberculosis patients; HIV and AIDS; Quality of life; South Africa
23.  Patient experiences and health system responsiveness in South Africa 
Background
Patients' views are being given more and more importance in policy-making. Understanding populations' perceptions of quality of care is critical to developing measures to increase the utilization of primary health care services. Using the data from the South African World Health Survey (WHS), the current study aims to evaluate the degree of health care service responsiveness (both out-patient and in-patient) and comparing experiences of individuals who used public and private services in South Africa.
Methods
A population-based survey of 2352 participants (1116 men and 1236 women) was conducted in South Africa in 2003, the WHS – as part of a World Health Organization (WHO) project focused on health system performance assessment in member countries.
Results
Health care utilization was among those who attended in-patient care 72.2% attended a public and 24.3% a private facility, and of those who attended out-patient care 58.7% attended a public and 35.7% a private facility. Major components identified for out-patient care responsiveness in this survey were highly correlated with health care access, communication and autonomy, secondarily to dignity, confidentiality and quality of basic amenities, and thirdly to health problem solution. The degree of responsiveness with publicly provided care was in this study significantly lower than in private health care. Overall patient non-responsiveness for the public out-patient service was 16.8% and 3.2% for private care. Discrimination was also one of the principal reasons for non-responsiveness in all aspects of provided health care.
Conclusion
Health care access, communication, autonomy, and discriminatory experiences were identified as priority areas for actions to improve responsiveness of health care services in South Africa.
doi:10.1186/1472-6963-9-117
PMCID: PMC2716320  PMID: 19602290
24.  The Greater Sekhukhune-CAPABILITY outreach project 
Journal of Community Genetics  2013;4(3):335-341.
The Greater Sekhukhune-CAPABILITY Outreach Project was undertaken in a rural district in Limpopo, South Africa, as part of the European Union-funded CAPABILITY programme to investigate approaches for capacity building for the translation of genetic knowledge into care and prevention of congenital disorders. Based on previous experience of a clinical genetic outreach programme in Limpopo, it aimed to initiate a district clinical genetic service in Greater Sekhukhune to gain knowledge and experience to assist in the implementation and development of medical genetic services in South Africa. Implementing the service in Greater Sekhukhune was impeded by a developing staff shortage in the province and pressure on the health service from the existing HIV/AIDS and TB epidemics. This situation underscores the need for health needs assessment for developing services for the care and prevention of congenital disorders in middle- and low-income countries. However, these impediments stimulated the pioneering of innovate ways to offer medical genetic services in these circumstances, including tele-teaching of nurses and doctors, using cellular phones to enhance clinical care and adapting and assessing the clinical utility of a laboratory test, QF-PCR, for use in the local circumstances.
doi:10.1007/s12687-013-0149-x
PMCID: PMC3739856  PMID: 23842823
Medical genetic services; Congenital disorders; South Africa
25.  Maternal health care professionals' perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam 
BMC Public Health  2010;10:608.
Background
High quality maternal health care is an important tool to reduce maternal and neonatal mortality. Services offered should be evidence based and adapted to the local setting. This qualitative descriptive study explored the perspectives and experiences of midwives, assistant physicians and medical doctors on the content and quality of maternal health care in rural Vietnam.
Method
The study was performed in a rural district in northern Vietnam. Four focus group discussions with health care professionals at primary health care level were conducted. The data was analysed using qualitative manifest and latent content analysis.
Result
Two main themes emerged: "Contextual conditions for maternal health care" and "Balancing between possibilities and constraints". Contextual conditions influenced both pregnant women's use of maternal health care and health care professionals' performance. The study participants stated that women's uses of maternal health care were influenced by economical constraints and cultural norms that impeded their autonomy in relation to childbearing. Structural constraints within the health care system included inadequate financing of the primary health care, resulting in lack of human resources, professional re-training and adequate equipment.
Conclusion
Contextual conditions strongly influenced the performance and interaction between pregnant women and health care professionals within antenatal care and delivery care in a rural district of Vietnam. Although Vietnam is performing comparatively well in terms of low maternal and child mortality figures, this study revealed midwives' and other health care professionals' perceived difficulties in their daily work. It seemed maternal health care was under-resourced in terms of staff, equipment and continuing education activities. The cultural setting in Vietnam constituting a strong patriarchal society and prevailing Confucian norms limits women's autonomy and reduce their possibility to make independent decisions about their own reproductive health. This issue should be further addressed by policy-makers. Strategies to reduce inequities in maternal health care for pregnant women are needed. The quality of client-provider interaction and management of pregnancy may be strengthened by education, human resources, re-training and provision of essential equipment.
doi:10.1186/1471-2458-10-608
PMCID: PMC3091560  PMID: 20946681

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