Policy context, coherence and disjuncture in the implementation of the Ideal Clinic Realisation and Maintenance programme in the Gauteng and Mpumalanga provinces of South Africa

Suitability of paediatric legislation beyond the USA and Europe: a qualitative study on access to paediatric medicines

Background

Paediatric legislation has contributed to better access to appropriate treatments in the European Union and the USA by requiring paediatric research in return for financial incentives. This study explored whether similar policies could improve access to medicines in other countries.

Methods

We conducted 46 interviews with representatives from healthcare practice, patient organisations and health authorities from six countries (Australia, Brazil, Canada, Kenya, Russia and South Africa) as well as multinational pharmaceutical companies exploring their views regarding access barriers to paediatric medicines. Emphasis was placed on regulation-related barriers and the effect of the COVID-19 pandemic. Where participants were familiar with paediatric legislation, views regarding its relevance for domestic context were explored in depth.

Results

Insufficient paediatric research and development, regulatory hurdles and reimbursement constraints were reported to be relevant access barriers in all studied settings. In the absence of marketing registration or reimbursement, access to paediatric medicines was associated with increased legal, financial and informational barriers. Brazil, Kenya, Russia and South Africa additionally described overarching deficiencies in medicines provision systems, particularly in procurement and supply. The COVID-19 pandemic was said to have reduced regulatory hurdles while further heightening global access inequalities.Views regarding paediatric legislation were mixed. Concerns regarding the implementation of such policies focused on regulatory resource constraints, enforceability and potential reduction of industry activity.

Conclusions

The study findings suggest that paediatric legislation may be most impactful in mature health systems and should be accompanied by measures addressing access barriers beyond marketing registration. This could include strengthening domestic manufacturing capacities and technology transfer for medicines with high public health relevance. Ideally, legislative changes would build on global harmonisation of paediatric legislation, which could be achieved through existing WHO structures.

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.

Piercing the veil on the functioning and effectiveness of district health system governance structures: perspectives from a South African province

BACKGROUND

Leadership and governance are critical for achieving universal health coverage (UHC). In South Africa, aspirations for UHC are expressed through the proposed National Health Insurance (NHI) system, which underscores the importance of primary health care, delivered through the district health system (DHS). Consequently, the aim of this study was to determine the existence of legislated District Health Councils (DHCs) in Gauteng Province (GP), and the perceptions of council members on the functioning and effectiveness of these structures.

METHODS

This was a mixed-methods, cross-sectional study in GP's five districts. The population of interest was members of existing governance structures who completed an electronic-self-administered questionnaire (SAQ). Using a seven-point Likert scale, the SAQ focuses on members' perceptions on the functioning and effectiveness of the governance structures. In-depth interviews with the chairpersons of the DHCs and its technical committees complemented the survey. STATA® 13 and thematic analysis were used to analyze the survey data and interviews respectively.

RESULTS

Only three districts had constituted DHCs. The survey response rate was 73%. The mean score for perceived functioning of the structures was 4.5 (SD = 0.7) and 4.8. (SD = 0.7) for perceived effectiveness. The interviews found that a collaborative district health development approach facilitated governance. In contrast, fraught inter-governmental relations fueled by the complexity of governing across two spheres of government, political differences, and contestations over limited resources constrained DHS governance. Both the survey and interviews identified gaps in accountability to communities.

CONCLUSION

In light of South Africa's move toward NHI, strengthening DHS governance is imperative. The governance gaps identified need to be addressed to ensure support for the implementation of UHC reforms.

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.

Strategies to adapt and implement health system guidelines and recommendations: a scoping review

BACKGROUND

Evidence-based health system guidelines are pivotal tools to help outline the important financial, policy and service components recommended to achieve a sustainable and resilient health system. However, not all guidelines are readily translatable into practice and/or policy without effective and tailored implementation and adaptation techniques. This scoping review mapped the evidence related to the adaptation and implementation of health system guidelines in low- and middle-income countries.

METHODS

We conducted a scoping review following the Joanna Briggs Institute methodology for scoping reviews. A search strategy was implemented in MEDLINE (Ovid), Embase, CINAHL, LILACS (VHL Regional Portal), and Web of Science databases in late August 2020. We also searched sources of grey literature and reference lists of potentially relevant reviews. All findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

A total of 41 studies were included in the final set of papers. Common strategies were identified for adapting and implementing health system guidelines, related barriers and enablers, and indicators of success. The most common types of implementation strategies included education, clinical supervision, training and the formation of advisory groups. A paucity of reported information was also identified related to adaptation initiatives. Barriers to and enablers of implementation and adaptation were reported across studies, including the need for financial sustainability. Common approaches to evaluation were identified and included outcomes of interest at both the patient and health system level.

CONCLUSIONS

The findings from this review suggest several themes in the literature and identify a need for future research to strengthen the evidence base for improving the implementation and adaptation of health system guidelines in low- and middle-income countries. The findings can serve as a future resource for researchers seeking to evaluate implementation and adaptation of health system guidelines. Our findings also suggest that more effort may be required across research, policy and practice sectors to support the adaptation and implementation of health system guidelines to local contexts and health system arrangements in low- and middle-income countries.

Innovations, contestations and fragilities of the health system response to COVID-19 in the Gauteng Province of South Africa

Background

Gauteng province, with 26.3% of South Africa’s population, is the commercial and industrial powerhouse of the country. During the first epidemic wave in 2020, Gauteng accounted for 32.0% of South Africa’s reported COVID-19 cases.

Aim

The aim of this study was to describe the health system response to the COVID-19 pandemic during the first epidemic wave in Gauteng province and to explore the perspectives of key informants on the provincial response.

Material and methods

Using an adapted Pandemic Emergency Response Conceptual Framework, this was a qualitative case study design consisting of 36 key informant interviews and a document analysis. We used thematic analysis to identify themes and sub-themes from the qualitative data.

Results

Our case study found that Gauteng developed an innovative, multi-sectoral and comprehensive provincial COVID-19 response that aimed to address the dual challenge of saving lives and the economy. However, the interviews revealed multiple perspectives, experiences, contestations and contradictions in the pandemic response. The COVID-19 pandemic exposed and amplified the fragilities of existing systems, reflected in the corruption on personal protective equipment, poor data quality and inappropriate decisions on self-standing field hospitals. Rooted in a chronic under-investment and insufficient focus on the health workforce, the response failed to take into account or deal with their fears, and to incorporate strategies for psychosocial support, and safe working environments. The single-minded focus on COVID-19 exacerbated these fragilities, resulting in a de facto health system lockdown and reported collateral damage. The key informants identified missed opportunities to invest in primary health care, partner with communities and to include the private health sector in the pandemic response.

Conclusion

Gauteng province should build on the innovations of the multi-sectoral response to the COVID-19 pandemic, while addressing the contested areas and health system fragilities.

Reorganisation of primary care services during COVID-19 in the Western Cape, South Africa: Perspectives of primary care nurses

BACKGROUND

Primary care nurses play a pivotal role in the response to disasters and pandemics. The coronavirus diseases 2019 (COVID-19) pandemic required preventative, diagnostic, and curative measures for persons presenting with symptoms of COVID-19 by healthcare providers, whilst continuing other essential services. We aimed to investigate the reorganisation of primary care services during COVID-19 from the perspectives of primary care nurses in the Western Cape province of South Africa.

METHODS

We administered an online survey with closed and open-ended questions to professional nurses enrolled for a Postgraduate Diploma in Primary Care Nursing at Stellenbosch University (2020) and alumni (2017-2019) working in the Western Cape. Eighty-three participants completed the questionnaire.

RESULTS

The majority of the participants (74.4%) reported that they were reorganising services using a multitude of initiatives in response to the diverse infrastructure, logistics and services of the various healthcare facilities. Despite this, 48.2% of the participants expressed concerns, which mainly related to possible non-adherence of patients with chronic conditions, the lack of promotive and preventative services, challenges with facility infrastructure, and staff time devoted to triage and screening. More than half of the participants (57.8%) indicated that other services were affected by COVID-19, whilst 44.6% indicated that these services were worse than before.

CONCLUSION

Our findings suggest that the very necessary reorganisation of services that took place at the start of the COVID-19 pandemic in South Africa enabled effective management of patients infected with COVID-19. However, the reorganisation of services may have longer-term consequences for primary care services in terms of lack of care for patients with other conditions, as well as preventive and promotive care.

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.

Acceptability and feasibility of inter-related activities to improve agency among African district health managers: A four-country study

District health managers (DHMs) lead and manage Ministry of Health programmes and system performance. We report on the acceptability and feasibility of inter-related activities to increase the agency of DHMs in Kenya, Nigeria, South Africa and Uganda using a cross-sectional rapid appraisal with 372 DHMs employing structured questionnaires. We found differences and similarities between the countries, in particular, who becomes a DHM. The opportunity to provide leadership and effect change and being part of a team were reported as rewarding aspects of DHMs' work. Demotivating factors included limited resources, bureaucracy, staff shortages, lack of support from leadership and inadequate delegation of authority. District managers ranked the acceptability of the inter-related activities similarly despite differences between contexts. Activities highly ranked by DHMs were to employ someone to support primary care staff to compile and analyse district-level data; to undertake study tours to well-functioning districts; and joining an African Regional DHM Association. DHMs rated these activities as feasible to implement. This study confirms that DHMs are in support of a process to promote bottom-up, data-driven, context-specific actions that can promote self-actualisation, recognises the roles DHMs play, provides opportunities for peer learning and can potentially improve quality of care.

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.