Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system.

BACKGROUND: South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. METHODS: As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system's realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. RESULTS: The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients' narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. CONCLUSIONS: Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.

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.

Developing excellence in biostatistics leadership, training and science in Africa: How the Sub-Saharan Africa Consortium for Advanced Biostatistics (SSACAB) training unites expertise to deliver excellence.

The increase in health research in sub-Saharan Africa (SSA) has generated large amounts of data and led to a high demand for biostatisticians to analyse these data locally and quickly.  Donor-funded initiatives exist to address the dearth in statistical capacity, but few initiatives have been led by African institutions. The Sub-Saharan African Consortium for Advanced Biostatistics (SSACAB) aims to improve biostatistical capacity in Africa according to the needs identified by African institutions, through (collaborative) masters and doctoral training in biostatistics. We describe the SSACAB Consortium, which comprises 11 universities and four research institutions- supported by four European universities. SSACAB builds on existing resources to strengthen biostatistics for health research with a focus on supporting biostatisticians to become research leaders; building a critical mass of biostatisticians, and networking institutions and biostatisticians across SSA.  In 2015 only four institutions had established Masters programmes in biostatistics and SSACAB supported the remaining institutions to develop Masters programmes. In 2019 the University of the Witwatersrand became the first African institution to gain Royal Statistical Society accreditation for a Biostatistics MSc programme. A total of 150 fellows have been awarded scholarships to date of which 123 are Masters fellowships (41 female) of which with 58 have already graduated. Graduates have been employed in African academic (19) and research (15) institutions and 10 have enrolled for PhD studies. A total of 27 (10 female) PhD fellowships have been awarded; 4 of them are due to graduate by 2020. To date, SSACAB Masters and PhD students have published 17 and 31 peer-reviewed articles, respectively. SSACAB has also facilitated well-attended conferences, face-to-face and online short courses. Pooling the limited biostatistics resources in SSA, and combining with co-funding from external partners is an effective strategy for the development and teaching of advanced biostatistics methods, supervision and mentoring of PhD candidates.

Patient satisfaction with nurse-delivery primary health care services in Free State and Gauteng provinces, South Africa: A comparative study.

BACKGROUND: The majority of health care users in South Africa utilise primary health care (PHC) services where these services are free at the point of entry. There is a dearth of knowledge on the factors influencing patient satisfaction with PHC clinic services. AIM: This study compared patient satisfaction with PHC services in the Free State (FS) and Gauteng (GP) provincesSetting: Secondary data analysis was conducted on a cross-sectional survey obtained from the Research on the State of Nursing Project run by the Centre for Health Policy in 2012. METHODS: A pre-tested satisfaction survey questionnaire with questions on facility evaluation, experience with providers and receipt of medication was administered to 1110 systematically randomly sampled adult patients attending antiretroviral, hypertension, diabetes and tuberculosis services. RESULTS: Of 1110 respondents, 1096 responded to the patient satisfaction survey signifying a 98.8% response rate. Over 60% of respondents were women in both provinces. Over 90% of patients were satisfied with PHC services in both provinces. Factors associated with satisfaction in GP and FS were time spent waiting for consultation, nurses listened, being given information on condition and being treated politely. Having privacy respected came out as a significant factor in FS. CONCLUSIONS: High levels of satisfaction with PHC services were experienced by study participants in both provinces. Satisfied patients adhere to treatment plans and have better health-seeking behaviour, which translates to improved clinical outcomes. Therefore, nurses should continue listening, respecting and treating their patients with politeness, and also implement efficient work schedules to reduce patient waiting times.

An evaluation of the competencies of primary health care clinic nursing managers in two South African provinces.

BACKGROUND: Managerial competencies to enhance individual and organisational performance have gained currency in global efforts to strengthen health systems. Competent managers are essential in the implementation of primary health care (PHC) reforms that aim to achieve universal health coverage. OBJECTIVE: To evaluate the competencies of PHC clinic nursing managers in two South African provinces. DESIGN: A cross-sectional study was conducted in two South African provinces. Using stratified random sampling, 111 PHC clinic nursing managers were selected. All supervisors (n=104) and subordinate nurses (n=383) were invited to participate in the survey on the day of data collection. Following informed consent, the nursing managers, their supervisors, and subordinate nurses completed a 40-item, 360-degree competency assessment questionnaire, with six domains: communication, leadership and management, staff management, financial management, planning and priority setting, and problem-solving. Standard deviations, medians, and inter-quartile ranges (IQRs) were computed separately for PHC nursing managers, supervisors, and subordinate nurses for competencies in the six domains. The Tinsley and Weiss index was used to assess agreement between each of the three possible pairs of raters. RESULTS: A 95.4% response rate was obtained, with 105 nursing managers in Gauteng and Free State completing the questionnaires. There was a lack of agreement about nursing managers' competencies among the three groups of raters. Overall, clinic nursing managers rated themselves high on the five domains of communication (8.6), leadership and management (8.67), staff management (8.75), planning and priority setting (8.6), and problem-solving (8.83). The exception was financial management with a median score of 7.94 (IQR 6.33-9.11). Compared to the PHC clinic managers, the supervisors and subordinate nurses gave PHC nursing managers lower ratings on all six competency domains, with the lowest rating for financial management (supervisor median rating 6.56; subordinate median rating 7.31). CONCLUSION: The financial management competencies of PHC clinic nursing managers need to be prioritised in continuing professional development programmes.

Using diaries to explore the work experiences of primary health care nursing managers in two South African provinces.

BACKGROUND: South Africa is on the brink of another wave of major health system reforms that underscore the centrality of primary health care (PHC). Nursing managers will play a critical role in these reforms. OBJECTIVE: The aim of the study was to explore the work experiences of PHC clinic nursing managers through the use of reflective diaries, a method hitherto under-utilised in health systems research in low- and middle-income countries. DESIGN: During 2012, a sub-set of 22 PHC nursing managers was selected randomly from a larger nurses' survey in two South African provinces. After informed consent, participants were requested to keep individual diaries for a period of 6 weeks, using a clear set of diary entry guidelines. Reminders consisted of weekly short message service reminders and telephone calls. Diary entries were analysed using thematic content analysis. A diary feedback meeting was held with all the participants to validate the findings. RESULTS: Fifteen diaries were received, representing a 68% response rate. The majority of respondents (14/15) were female, each with between 5 and 15 years of nursing experience. Most participants made their diary entries at home. Diaries proved to be cathartic for individual nursing managers. Although inter-related and not mutually exclusive, the main themes that emerged from the diary analysis were health system deficiencies; human resource challenges; unsupportive management environment; leadership and governance; and the emotional impact of clinic management. CONCLUSIONS: Diaries are an innovative method of capturing the work experiences of managers at the PHC level, as they allow for confidentiality and anonymity, often not possible with other qualitative research methods. The expressed concerns of nursing managers must be addressed to ensure the success of South Africa's health sector reforms, particularly at the PHC level.

Exploring perceptions of HIV risk and health service access among Zimbabwean migrant women in Johannesburg: a gap in health policy in South Africa?

We present qualitative data from a 2005 exploratory study, recently published studies, and an analysis of the Department of Health's strategic plan to highlight the need for a broader policy debate on health-care access for migrants in South Africa. We conducted in-depth interviews with 15 Zimbabwean women living in inner-city Johannesburg to document the special characteristics of this group of migrants, enquiring about their perceptions of HIV risk, and experiences of health services in South Africa. We identified access barriers, namely perceptions of relatively low HIV risk, severely constrained financial circumstances, uncertain legal status, and experiences of unresponsive health workers. We recommend that migrant-health rights be placed on South Africa's policy agenda, migrants be included in HIV prevention programs and that health workers be sensitized to the needs of migrants.