Decision space and participation of primary healthcare facility managers in the Ideal Clinic Realisation and Maintenance programme in two South African provinces

The Meso-Level in Quality Improvement: Perspectives From a Maternal-Neonatal Health Partnership in South Africa

BACKGROUND

Sustained implementation of facility-level quality improvement (QI) processes, such as plan-do-study-act cycles, requires enabling meso-level environments and supportive macro-level policies and strategies. Although this is well recognised, there is little systematic empirical evidence on roles and capacities, especially at the immediate meso-level of the system, that sustain QI strategies at the frontline.

METHODS

In this paper we report on qualitative research to characterize the elements of a quality and outcome-oriented meso-level, focused on sub/district health systems (DHSs), conducted within a multi-level initiative to improve maternal-newborn health (MNH) in three provinces of South Africa. Drawing on the embedded experience and tacit knowledge of core project partners, obtained through in-depth interviews (39) and project documentation, we analysed thematically the roles, capacities and systems required at the meso-level for sustained QI, and experiences with strengthening the meso-level.

RESULTS

Meso-level QI roles identified included establishing and supporting QI systems and strengthening delivery networks. We propose three elements of system capacity as enabling these meso-level roles: (1) leadership stability and capacity, (2) the presence of formal mechanisms to coordinate service delivery processes at sub-district and district levels (including governance, referral and outreach systems), and (3) responsive district support systems (including quality oriented human resource, information, and emergency medical services [EMS] management), embedded within supportive relational eco-systems and appropriate decision-space. While respondents reported successes with system strengthening, overall, the meso-level was regarded as poorly oriented to and even disabling of quality at the frontline.

CONCLUSION

We argue for a more explicit orientation to quality and outcomes as an essential district and sub-district function (which we refer to as meso-level stewardship), requiring appropriate structures, processes, and capacities.

Nurse perceptions of practice environment, quality of care and patient safety across four hospital levels within the public health sector of South Africa

Improving the practice environment, quality of care and patient safety are global health priorities. In South Africa, quality of care and patient safety are among the top goals of the National Department of Health; nevertheless, empirical data regarding the condition of the nursing practice environment, quality of care and patient safety in public hospitals is lacking.AimThis study examined nurses' perceptions of the practice environment, quality of care and patient safety across four hospital levels (central, tertiary, provincial and district) within the public health sector of South Africa.MethodsThis was a cross-sectional survey design. We used multi-phase sampling to recruit all categories of nursing staff from central (n = 408), tertiary (n = 254), provincial (n = 401) and district (n = 244 [large n = 81; medium n = 83 and small n = 80]) public hospitals in all nine provinces of South Africa. After ethical approval, a self-reported questionnaire with subscales on the practice environment, quality of care and patient safety was administered. Data was collected from April 2021 to June 2022, with a response rate of 43.1%. ANOVA type Hierarchical Linear Modelling (HLM) was used to present the differences in nurses' perceptions across four hospital levels.ResultsNurses rated the overall practice environment as poor (M = 2.46; SD = 0.65), especially with regard to the subscales of nurse participation in hospital affairs (M = 2.22; SD = 0.76), staffing and resource adequacy (M = 2.23; SD = 0.80), and nurse leadership, management, and support of nurses (M = 2.39; SD = 0.81). One-fifth (19.59%; n = 248) of nurses rated the overall grade of patient safety in their units as poor or failing, and more than one third (38.45%; n = 486) reported that the quality of care delivered to patient was fair or poor. Statistical and practical significant results indicated that central hospitals most often presented more positive perceptions of the practice environment, quality of care and patient safety, while small district hospitals often presented the most negative. The practice environment was most highly correlated with quality of care and patient safety outcomes.ConclusionThere is a need to strengthen compliance with existing policies that enhance quality of care and patient safety. This includes the need to create positive practice environments in all public hospitals, but with an increased focus on smaller hospital settings.

Ensuring leadership at the operational level of a health system in protracted crisis context: a cross-sectional qualitative study covering 8 health districts in Eastern Democratic Republic of Congo

BACKGROUND

This study examines how leadership is provided at the operational level of a health system in a protracted crisis context. Despite advances in medical science and technology, health systems in low- and middle-income countries struggle to deliver quality care to all their citizens. The role of leadership in fostering resilience and positive transformation of a health system is established. However, there is little literature on this issue in Democratic Republic of the Congo (DRC). This study describes leadership as experienced and perceived by health managers in crisis affected health districts in Eastern DRC.

METHODS

A qualitative cross-sectional study was conducted in eight rural health districts (corresponding to health zones, in DRC's health system organization), in 2021. Data were collected through in-depth interviews and non-participatory observations. Participants were key health actors in each district. The study deductively explored six themes related to leadership, using an adapted version of the Leadership Framework conceptual approach to leadership from the United Kingdom National Health Service's Leadership Academy. From these themes, a secondary analysis extracted emerging subthemes.

RESULTS

The study has revealed deficiencies regarding management and organization of the health zones, internal collaboration within their management teams as well as collaboration between these teams and the health zone's external partners. Communication and clinical and managerial capacities were identified as key factors to be strengthened in improving leadership within the districts. The findings have also highlighted the detrimental influence of vertical interventions from external partners and hierarchical supervisors in health zones on planning, human resource management and decision-making autonomy of district leaders, weakening their leadership.

CONCLUSIONS

Despite their decentralized basic operating structure, which has withstood decades of crisis and insufficient government investment in healthcare, the districts still struggle to assert their leadership and autonomy. The authors suggest greater support for personal and professional development of the health workforce, coupled with increased government investment, to further strengthen health system capacities in these settings.

Hospital managers’ views on the state of patient safety culture across three regions in Ghana

Background

Improving patient safety culture in healthcare organisations contributes positively to the quality of care and patients’ attitudes toward care. While hospital managers undoubtedly play critical roles in creating a patient safety culture, in Ghana, qualitative studies focussing on hospital managers’ views on the state of patient safety culture in their hospitals remain scanty.

Objective

This study aimed to explore the views of hospital managers regarding compliance to patient safety culture dimensions in the selected hospitals in the Bono, Greater Accra, and Upper East regions of Ghana.

Methodology

This was a qualitative exploratory study. A purposive sampling of all hospital managers involved in patient safety practices was conducted. The sampled managers were then invited to a focus group discussion. Twelve focus group discussions with each consisting of a maximum of twelve participants were conducted. The ten patient safety culture dimensions adapted from the Agency for Healthcare Research and Quality’s patient safety culture composite measures framed the interview guide. Deductive thematic content analysis was done. Lincoln and Guba’s methods of trustworthiness were applied to ensure that the findings are valid and reliable.

Findings

Positive patient safety culture behaviours such as open communication, organisational learning, and strong teamwork within units, were an established practice in the selected facilities across Ghana. Lack of teamwork across units, fear of reporting adverse events, the existence of a blame culture, inconsistent response to errors, extreme shortage of staff, sub-standard handover, lack of management support with resources constrained the patient safety culture. The lack of standardised policies on reporting adverse events and response to errors encouraged managers to use various approaches, some resulting in a blame culture. Staff shortage contributed to poor quality of safety practices including poor handover which was also influenced by lateness to duty.

Conclusion

Prompt and appropriate responses by managers to medical errors require improvements in staffing and material resources as well as the enactment of standard policies across health facilities in the country. By so doing, hospital managers would contribute significantly to patient safety, and help build a patient safety culture in the selected hospitals.

Newborn and infant hearing screening at primary healthcare clinics in South Africa designated as National Health Insurance pilot sites: An exploratory study

Background

Primary healthcare (PHC) is the first point of entry, providing basic services to individuals. South Africa is in the process of re-engineering its PHC as part of National Health Insurance (NHI) plans to ensure universal healthcare coverage.

Aim

This study aimed to establish whether newborn and infant hearing screening (NIHS) could be integrated into the re-engineering process of the PHC as part of the NHI framework.

Setting

The NHI pilot clinics in five provinces in South Africa.

Methods

A non-experimental, descriptive, cross-sectional survey research design was adopted. Questionnaires were sent to nursing managers, unit managers or acting managers at PHC facilities. Nineteen of these self-administered questionnaires were completed. Data were analysed using descriptive statistics.

Results

Immunisation services were the most common type of service offered at the clinics. Over a quarter of the respondents indicated that NIHS services were offered at their facility in the form of universal NIHS. Equipment was limited with a lack of valid and reliable screening measures. Only 2 (11%) respondents indicated budgetary resources. Follow-up and referral pathways were reported by 10 (53%) respondents, which did not include an audiologist.

Conclusions

There is a need for careful and systematic planning in terms of early hearing detection programmes at PHC level. Planning needs to commence with considerations of who will perform NIHS, training of these personnel by audiologists and the role of the audiologist within the teams outlined in the NHI Bill.

Leveraging HIV Care Infrastructures for Integrated Chronic Disease and Pandemic Management in Sub-Saharan Africa

In Sub-Saharan Africa, communicable and other tropical infectious diseases remain major challenges apart from the continuing HIV/AIDS epidemic. Recognition and prevalence of non-communicable diseases have risen throughout Africa, and the reimagining of healthcare delivery is needed to support communities coping with not only with HIV, tuberculosis, and COVID-19, but also cancer, cardiovascular disease, diabetes, and depression. Many non-communicable diseases can be prevented or treated with low-cost interventions, yet implementation of such care has been limited in the region. In this Perspective piece, we argue that deployment of an integrated service delivery model is an urgent next step, propose a South African model for integration, and conclude with recommendations for next steps in research and implementation. An approach that is inspired by South African experience would build on existing HIV-focused infrastructure that has been developed by Ministries of Health with strong support from the U.S. President’s Emergency Response for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. An integrated chronic healthcare model holds promise to sustainably deliver infectious disease and non-communicable disease care. Integrated care will be especially critical as health systems seek to cope with the unprecedented challenges associated with COVID-19 and future pandemic threats.

Implementing the Ideal Clinic Program at Selected Primary Healthcare Facilities in South Africa

Background: Primary healthcare (PHC) in South Africa often experiences crucial challenges that lead to patients’ negative experiences regarding their care, compromising the significant role that PHC services could play in health promotion and disease prevention. The primary purpose of implementing the Ideal Clinic (IC) in South Africa was to improve patients’ care quality at the clinics. There seems to be a paucity of studies determining professional nurses’ experiences when implementing the IC. Purpose: This study aimed to explore and describe professional nurses’ experiences regarding implementing the IC at three selected clinics in the Makhado local area. Study method: A qualitative phenomenological research design was used to explore professional nurses’ experiences regarding IC implementation. Purposive sampling was used to select 15 professional nurses working at the three selected clinics. Data were collected using semi-structured one-on-one interviews. Interviews were conducted until saturation was reached. Trustworthiness was ensured by applying Lincoln and Guba’s four criteria, i.e., credibility, transferability, dependability, and confirmability. Ethical clearance was obtained from the University of Limpopo Turfloop Research and Ethics Committee, and permission to conduct the study was obtained from Limpopo Province Department of Health Research and Ethics Committee. Thematic analysis was used to analyze data. Results: The following themes emerged from the study findings: perceived benefits of the IC on the primary healthcare services provided to the community, challenges experienced by professional nurses when implementing the IC program, and challenges related to the supply of resources for implementing the IC. The study results revealed that, although the IC aimed to improve the overburdened PHC facilities in SA, the professional nurses still experienced some challenges when implementing the IC program. Some of the challenges faced were a lack of knowledge and training in the IC program, poor infrastructure and the shortage of equipment, and inadequate provision of support by line managers, all of which resulted in poor-quality patient care. Conclusion: This study revealed that the introduction and implementation of the IC can have potential benefits to the community and the primary healthcare system. However, it was not introduced and appropriately implemented, which resulted in professional nurses experiencing several challenges. The national department of health needs to strengthen the program’s implementation through proper training, consultation, and continuous support of the nurses. Provision of quality equipment and supplies is also recommended.

Facility standards and the quality of public sector primary care: Evidence from South Africa's "Ideal Clinics" program

Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes-a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators.

Providers' definitions of quality and barriers to providing quality care: a qualitative study in rural Mpumalanga Province, South Africa

Background:

South Africa requires high-quality primary health care (PHC) to retain patients and optimize outcomes. While prior research has identified implementation challenges within the PHC system, there is less understanding of how providers define quality, their perceptions of barriers to providing quality care, and how they overcome these barriers. This study assesses provider views on quality at primary care clinics in a rural sub-district of Mpumalanga Province.

Methods:

We conducted in-depth interviews with providers in early 2019 on the value of quality metrics for providers and patients, what indicators they would use to assess clinic performance, and barriers and facilitators of delivering care. Interviews were conducted in Shangaan, audio-recorded, and translated into English. A deductive approach was used to develop a provisional coding schema, which was then refined using an inductive approach in response to patterns and themes emerging from the data.

Results:

Twenty-three providers were interviewed (83% female, 65% professional nurses). Providers did not give a single standard definition of quality care. Clinic structure and resources emerged as a key issue, as providers linked deficiencies in infrastructure and support to deficits in care delivery. Providers identified mitigating strategies including informal coordination across clinics to address medication and equipment shortages. Common across the providers’ discussion was poor communication between the district, PHC supervisors, and implementers at the facility level.

Conclusion:

Providers connected deficits in quality of care to inadequate infrastructure and insufficient support from district and provincial authorities; mitigating strategies across clinics could only partially address these deficits. The existence of a national quality measurement program was not broadly reflected in providers’ views on quality care. These findings underscore the need for effective district and national approaches to support individual facilities, accompanied by feedback methods designed with input from frontline service providers.

Using social network analysis to examine inter-governmental relations in the implementation of the Ideal Clinic Realisation and Maintenance programme in two South African provinces

BACKGROUND

Within the context of universal health coverage (UHC), South Africa has embarked on a series of health sector reforms. The implementation of the Ideal Clinic Realisation and Maintenance (ICRM) programme is a major UHC reform. Cooperative governance is enshrined in South Africa's Constitution, with health a concurrent competency of national and provincial government. Hence, effective inter-governmental relations (IGR) are essential for the ICRM programme implementation.

AIM

The aim of the study was to measure the cohesion of IGR, specifically consultation, support and information sharing, across national, provincial and local government health departments in the ICRM programme implementation.

MATERIALS AND METHODS

Using Provan and Milward's theory on network effectiveness, this study was a whole network design social network analysis (SNA). The study was conducted in two districts in Gauteng (GP) and Mpumalanga (MP) provinces of South Africa. Following informed consent, we used both an interview schedule and a network matrix to collect the social network data from health policy actors in national, provincial and local government. We used UCINET version 6.619 to analyse the SNA data for the overall network cohesion and cohesion within and between the government spheres.

RESULTS

The social network analysis revealed non-cohesive relationships between the different spheres of government. In both provinces, there was poor consultation in the ICRM programme implementation, illustrated by the low densities of seeking advice (GP = 15.6%; MP = 24.4%) and providing advice (GP = 14.1%; MP = 25.1%). The most cohesive relationships existed within the National Department of Health (density = 66.7%), suggesting that national policy actors sought advice from one another, rather than from the provincial health departments. A density of 2.1% in GP, and 12.5% in MP illustrated the latter.

CONCLUSION

The non-cohesive relationships amongst policy actors across government spheres should be addressed in order to realise the benefits of cooperative governance in implementing the ICRM programme.