Health System In South Africa Research Articles

Coverage of vitamin A supplementation, deworming and immunisations: Associations with nutritional status among urban children younger than 5 years in Nelson Mandela Bay, Eastern Cape Province, South Africa

Background. Even though immunisation coverage is tracked through the district health system in South Africa (SA), limited information is available regarding interventions linked to the Expanded Programme on Immunisation (EPI) and the impact on the nutritional status of children <5 years of age. 
 Objectives. To describe coverage of immunisations, vitamin A supplementation and deworming among children <5 years old in an urban area of Nelson Mandela Bay, Eastern Cape Province, SA. A secondary objective was to investigate whether a history of missed immunisations, vitamin A supplementation or deworming was associated with wasting or stunting in children. 
 Methods. A descriptive study was conducted between September 2015 and February 2016, where cross-sectional anthropometrical data were collected from 1 513 children in 32 pre-schools, together with a retrospective analysis of the participants’ Road-to-Health/clinic cards to collect data on immunisation, vitamin A and deworming. Participants were categorised into 3-month age intervals to facilitate data analysis. Ethical approval was obtained from the Nelson Mandela University Research Ethics Committee (Human). 
 Results. Data of 1 496 children were included in the analysis. The prevalence of underweight was 2.5% (n=37), while 11.2% (n=167) were stunted and 1.1% (n=16) were wasted. There were associations between age category and delayed vitamin A supplementation (χ2=32.105; df=19; n=836; p=0.03) and deworming (χ2= 45.257; df=17; n=558; p<0.001), but there was no association between delayed vaccinations and age category. There were no significant differences in anthropometrical indicators for children with delayed vitamin A supplementation, deworming and vaccinations compared with children in this sample who were up to date regarding the relevant indicators. However, weight-for-age, height-for-age and weight-for-height z-scores and stunting risk were associated with low birthweight (LBW) (odds ratio (OR) 4.658; p<0.001). 
 Conclusion. Coverage of vitamin A supplementation and deworming but not immunisations was poorer among children in older age categories. A history of delayed vitamin A, deworming and vaccinations was not associated with the anthropometrical status of children. Children with LBW should be considered for more rigorous follow-up, as they are at higher risk of stunting. 

Digital Health Ecosystem Framework to Address Fragmentation of the Health System in South Africa

Globally, the healthcare industry is plagued by fragmentation, and this fragmentation of the health system has become one of the major problems facing especially low- and middle-income countries. Likewise, the current health system in South Africa is highly fragmented and segmented, with two-tiered systems characterised by a multiplicity of health information systems. This fragmentation has inhibited the efficient delivery of healthcare services and resulted in limited access to integrated health data across healthcare providers. This paper proposes a Digital Health Ecosystem framework to address fragmentation of the health system in South Africa. A qualitative approach was employed, using desktop-based research. A literature review was conducted to elucidate the need for a framework to address fragmentation of the health system in South Africa. It emerged from the literature that the coexistence of subsystems operating independently contributes to health system fragmentation in South Africa. The proposed framework aims to address the ubiquitous problem of health system fragmentation and to enhance data-sharing capabilities across healthcare facilities. A Digital Health Ecosystem offers capabilities to create a digital environment for cooperation, data sharing and information exchange between a network of healthcare organisations. The technology offers South African healthcare facilities a new way to work seamlessly together to provide multidisciplinary and collaborative healthcare services to patients. Healthcare facilities in South Africa are urged to embrace a Digital Health Ecosystem to improve the safety and quality of healthcare and increase access to and availability of clinical, patient and administrative data.

Hyperglycemia First Detected in Pregnancy in South Africa: Facts, Gaps, and Opportunities.

This review contextualizes hyperglycemia in pregnancy from a South-African perspective. It aims to create awareness of the importance of hyperglycemia in pregnancy in low-middle-income countries. We address unanswered questions to guide future research on sub-Saharan African women with hyperglycemia first detected in pregnancy (HFDP). South African women of childbearing age have the highest prevalence of obesity in sub-Saharan Africa. They are predisposed to Type 2 diabetes (T2DM), the leading cause of death in South African women. T2DM remains undiagnosed in many African countries, with two-thirds of people living with diabetes unaware. With the South African health policy's increased focus on improving antenatal care, women often gain access to screening for non-communicable diseases for the first time in pregnancy. While screening practices and diagnostic criteria for gestational diabetes mellitus (GDM) differ amongst geographical areas in South Africa (SA), hyperglycemia of varying degrees is often first detected in pregnancy. This is often erroneously ascribed to GDM, irrespective of the degree of hyperglycemia and not overt diabetes. T2DM and GDM convey a graded increased risk for the mother and fetus during and after pregnancy, with cardiometabolic risk accumulating across the lifespan. Resource limitations and high patient burden have hampered the opportunity to implement accessible preventative care in young women at increased risk of developing T2DM in the broader public health system in SA. All women with HFDP, including those with true GDM, should be followed and undergo glucose assessment postpartum. In SA, studies conducted early postpartum have noted persistent hyperglycemia in a third of women after GDM. Interpregnancy care is advantageous and may attain a favourable metabolic legacy in these young women, but the yield of return following delivery is suboptimal. We review the current best evidence regarding HFDP and contextualize the applicability in SA and other African or low-middle-income countries. The review identifies gaps and shares pragmatic solutions regarding clinical factors that may improve awareness, identification, diagnosis, and management of women with HFDP.

Access to health care for people with stroke in South Africa: a qualitative study of community perspectives

BackgroundIncidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures.MethodsIn-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective.ResultsPWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS.ConclusionsStrategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Referral practices of medical practitioners in central South Africa to physiotherapy services for patients living with musculoskeletal conditions.

BackgroundMusculoskeletal diseases (MSDs) are a major cause of disability worldwide. It is essential to address effective MSD management, including appropriate referrals to physiotherapists and other healthcare professionals. Limited information is available regarding the referral practices of medical practitioners for patients with MSD. The doctors’ referral practices to physiotherapists can impact the patient population and the South African health system.ObjectivesTo investigate or understand the referral practices of medical practitioners in Bloemfontein, South Africa, to physiotherapy services, for individuals living with MSD.MethodA quantitative study approach, implementing a semi-structured questionnaire, was used. Forty-nine participants completed the questionnaire.ResultsThe referral of patients with MSDs by medical practitioners to physiotherapy services varied and multidimensional factors influenced their referral practices. Medical practitioners were unsure of the specific role played by physiotherapists in the management of individuals living with MSD. A need for improved relationships and communication between medical practitioners and physiotherapists was identified.ConclusionsMedical practitioners regularly referred individuals living with MSD to physiotherapists, but referral practices should be optimised in terms of evidence-based practice and the use of specialised physiotherapy services. In an attempt to decrease the burden of MSD, adequate awareness should be created for improved referral practices between medical practitioners and physiotherapists.Clinical implicationsCollaborative development of detailed guidelines for apt, evidence-based referrals should be developed, to ensure early detection and management of individuals living with MSD. Health care professionals should be educated and encouraged to refer individuals living with MSD to physiotherapists for appropriate management with clinical benefits including improvement of HRQOL and cost effectiveness of this management not only to the individual but also to the health system in South Africa. Physiotherapists should try to communicate their role in the treatment of individuals living with MSD to medical practitioners for the benefit of the patient.

Improving South African medical curricula related to traditional health systems

Background. Increased co-ordination and co-operation between traditional and biomedical health systems in South Africa (SA) is a national priority. To improve care, practitioners in both systems must learn to recognise the value of their parallel counterparts, and such lessons should begin in medical school. However, there is little research regarding the way in which SA’s medical students are taught to interact with the traditional medicine (TM) system. Objectives. To explore how SA medical students perceive their curriculum as it relates to the traditional health system and to describe their suggestions for improvement. Methods. We conducted individual in-depth interviews and focus group discussions with 43 final-year medical students across 3 SA medical schools. We applied thematic analysis to improve our understanding of student-reported experiences with TM in their medical school curricula. Results. All 3 medical schools rely heavily on hidden curricula to educate students on the SA traditional health system. These hidden curricula are largely negative and learnt primarily from witnessing faculty-client interactions involving TM use. Students across the institutions agree that this problematic deficit in formal teaching contributes to their incompetence in treating patients who use TM. Their suggestions for improvement focused largely around 3 themes: (i) understanding the fundamentals of the traditional health system; (ii) empathising with patient use of TM; and (iii) promoting broader structural integration of the two health systems. Conclusion. Medical students in SA recognise the value of increased exposure to and education surrounding the traditional health system. Future curricular interventions should focus on increasing formal teaching of TM, directly addressing the hidden curriculum related to the topic, and instituting policies and initiatives that improve integration of the SA biomedical and traditional healing paradigms on a structural level.

A Case Study of a Point-of-Care Electronic Medical Record [SABER] in Totonicapán, Guatemala: Benefits, Challenges, and Future Directions.

Background:The adoption of electronic medical records (EMRs) in lower-income nations has progressed slowly due to the lack of adequate infrastructure, funding, and training. However, EMRs have been successfully implemented previously in resource-limited health systems in South Africa, Haiti, Cameroon, Kenya, and Peru. Detailed, organized, and easily accessible medical records are particularly important in emergency departments due to the volume and acuity of the patient population.Methods:In order to further study the plausibility of an EMR in a resource-limited emergency department, a web-based, Spanish-language EMR known as SABER was developed for use in Hospital Nacional José Felipe Flores in Totonicapán, Guatemala. The software collects patient data including demographics, triage, initial evaluation, review of systems, physical exam, and evaluation and plan. It then generates a .pdf file consistent with information requirements of the Guatemalan Ministry of Health. Local physicians, medical students, and nurses were trained in the use of the software, which debuted in July 2016. To assess the effectiveness of SABER as an EMR, focus groups and Likert scale surveys were conducted with six physicians and 31 medical students working in the Hospital Nacional emergency department.Results:Thirty of 32 medical students and six of six doctors would recommend SABER to another provider. Positive aspects identified by staff include ease of use, quick data entry, and the potential for large data set research.Discussion:Remaining challenges include incorporating electronic nursing orders and lab results, troubleshooting technology problems including printer difficulties, a lack of electronic signature capability, and lack of integration with the rest of the hospital. Our study is consistent with other studies that show use of an EMR may help to reduce health disparities through improved patient records, medical data collection, and organization.

Coronavirus Disease 2019 (COVID-19) and Psychiatric Sequelae in South Africa: Anxiety and Beyond.

The 2019 coronavirus (COVID-19) pandemic has brought unprecedented challenges to the health sector nationwide and internationally. Across all disciplines, unique and novel modes of presentation with substantial morbidity and mortality are being encountered, and growing evidence suggests that psychiatric comorbidity is likely among COVID-19 patients. This article aims to broaden the current discussion on the psychiatric sequalae of COVID-19, which has largely focused on anxiety, and examine the recently documented psychiatric sequelae of COVID-19 infection, the secondary effects of the pandemic on public mental health, and future psychiatric conditions that may arise due to COVID-19. We conducted an in-depth review of the current global psychiatric literature and describe the wide range of psychopathological presentations reported among past COVID-19 patients worldwide and those that are expected to emerge. Current discussions in the psychiatric literature on COVID-19 report anxiety and anxiety disorders as a predominant set of clinical presentations during the pandemic. The impacts of direct COVID-19 infection, associated psychopathological sequelae, and drastic lifestyle changes due to the COVID-19 pandemic in South Africa, are associated with a broad range of psychopathologies and other neuropsychiatric presentations. Pre-existing societal conditions and burdens on the health system in South Africa prompt healthcare providers and public health planners to accordingly prepare for the expected rise in new psychiatric presentations. Greater awareness of the various psychiatric conditions attributed to COVID-19 infection may allow for earlier screening, more effective treatment, and greater positive health outcomes and better prepare health systems to address the growing pandemic in South Africa.

Challenges affecting the implementation of the Policy on Integration of Mental Health Care into primary healthcare in KwaZulu-Natal province.

BackgroundSince the publication of the White Paper for the Transformation of the Health System in South Africa in 1997, which included Policy on Integration of Mental Health Care into primary health care (PHC), there has been an emphasis on the promotion of health as well as the re-engineering of PHC to include the integration of mental health care into PHC. Although South Africa has made significant advances at the level of health-related policy development and legislation in trying to bring the country in line with international trends, there have been challenges with regard to implementation of policies, including that of integration of mental health care into PHC.ObjectivesThe aim of this study was to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KwaZulu-Natal (KZN) province of South Africa and to seek possible solutions.MethodA qualitative exploratory descriptive design was used to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KZN. The sample consisted of 42 participants of whom 4 were PHC managers, 6 were operational managers and 22 were professional nurses who were directly involved in implementing the policy at the operational level.ResultsThe challenges identified included lack of training in mental healthcare services for staff working in PHC, unavailability of mental health policies, inadequate resources, poor communication between management and staff, lack of skills among PHC nurses in identifying signs of mental illness and misdiagnosis of patients.ConclusionConsidering the challenges pertaining to PHC nurses’ abilities and skills to implement the Policy on Integration of Mental Health Care into PHC, PHC-trained nurses should engage in lifelong learning and be encouraged to develop their knowledge, skills and competence throughout their professional lives.

Hospital management and health policy—a South African perspective

It is 25 years since the advent of democracy in South Africa. From the start the priority was to deal with the inequity that was the hallmark of the apartheid regime. In 1994, the Government’s Reconstruction and Development Programme set out broad principles and strategies for development in all sectors to deal with the lack of services experienced by the majority of South Africans. The rights-based Constitution contains the Bill of Rights that obliges the government to ensure the rights of all citizens to have access to healthcare services. Multiple policy documents, directives and guidance have been issued by the National Department of Health but there remains a gap between policy and practice. The White Paper, Transformation of the Health System in South Africa, released in 1997 stated that the three spheres of government, NGOs and the private sector would unite in the promotion of common goals. With the preparation underway to implement a National Health Insurance Scheme the need for unity in the system has never been greater. A key challenge is the difference in the approach to management and to a large extent the difference in the calibre of management in the public and private sectors. Much has been achieved but much remains to be done to ensure a high-quality health system for all citizens.

Exploring community-based training opportunities for dental therapy students in non-governmental and private sectors in KwaZulu-Natal Province, South Africa

Background. The current health system in South Africa (SA) struggles to meet the healthcare demands of its nation adequately, especially in KwaZulu- Natal (KZN) Province, South Africa. Local communities in KZN have long since recognised the need to supplement the public health system by means of community-driven initiatives of non-governmental organisations (NGOs) and the private sector. Projects by these sectors can also provide a platform for experiential learning for dental therapy students. Objective. To explore learning opportunities for dental therapy students through the community-driven health initiatives of NGOs and the private sector in KZN. Methods. This qualitative study used face-to-face interviews with key stakeholders organising community-based initiatives in the NGO and private sectors. The interviews were audio-recorded and analysed using thematic analysis. Ethical clearance was obtained from the University of KwaZulu-Natal, Durban, SA. Results. According to the participants, there were many innovative service delivery modes, ranging from a mobile health bus, a container turned into a clinic, to well-established clinics that provided meaningful learning opportunities for dental students. By participating in these projects, respondents believed that students could gain real-world experiences and a greater sense of social accountability. Conclusion. This study showed that there are many opportunities in the private and NGO sectors that could provide support for community-driven learning initiatives for undergraduate dental therapy students.

Decentralised clinical training in optometry: a developmental strategy for eye health in KwaZulu Natal?

Decentralised clinical training (DCT) in optometry is an emerging concept in South Africa. In 2016, the University of KwaZulu Natal (UKZN) implemented this adaptive model of clinical training for undergraduate health professions. The initiative, which emanated through an agreement between UKZN's College of Health Sciences and the KwaZulu Natal Department of Health, centres on the placement of undergraduate optometry students within public health facilities for clinical training purposes. Optometry services in South Africa have, however, had a historical bias towards a private sector model of training and a curative practice approach resulting in access barriers for the rural poor and high levels of unmet need. It has further contributed to a general state of underdevelopment of eye health services within the public sector. DCT challenges historical undergraduate programme structures and modes of teaching and learning in optometry. It is largely underpinned by a need to strengthen health service delivery through a primary health care-centred, community-based training approach and produce 'fit-for-purpose' graduates who have contextually appropriate competencies for effective, local health service delivery. The historical absence of optometry services within the public sector has, however, contributed to limited planning for, and development of eye health services in this sector. This has inadvertently contributed to the burden of avoidable vision impairment in the country. The public health system in South Africa, therefore, faces various developmental challenges which impact eye health services and student clinical training. While the model is still in a developmental state and resourcing challenges potentially affecting DCT are noted, early experiences of the Discipline of Optometry at the UKZN are that DCT shows promise in terms of its potential contribution towards the development of eye health services within the public health sector from graduate readiness, resource strengthening, access improvement and health service development perspectives.

THE COST OF INDIFFERENCE IN A MEDICAL NEGLIGENCE CASE: Lushaba v MEC for Health, Gauteng (17077/2012 [2014] ZAGPJHC 407 (16 October 2014))

The much-debated diagnostic report, the National Development Plan 2030 (NDP), paints a worrying picture about the state of the health system in South Africa. The NDP simply states that, “At institutional level, healthcare management is in crisis” (Republic of South Africa 2012, National Development Plan of 2030: 52). One of the remedial measures proposed by the NDP is the introduction of the National Health Insurance in South Africa (Republic of South Africa 2012, National Development Plan of 2030: 52). It is hoped that the National Health Insurance “will ensure that everyone has access to appropriate, efficient and quality health services” (Republic of South Africa 2012, National Development Plan of 2030: 4).The Constitution of the Republic of South Africa, 1996 sets the benchmark and the ideals towards which public servants must strive as they deliver the much-needed services to the general populace (s 195(1)(a)−(i)). Among others, public servants must promote and maintain a high standard of professional ethics (s 195(1)(a)). Further, the Batho Pele Principles require it of government institutions to, inter alia communicate the level and quality of service, which the public must expect from them (Batho Pele Principles Principle 2). It is therefore not misguided to say that generally, people are aware of the standard of service they should expect from state institutions. As a matter of fact, people have gone to the courts of law to hold state institutions accountable. In this regard the medical fraternity has in the recent past witnessed an upsurge of court cases of negligence against the health department. This rise in litigation has led to a crisis of another kind. According to the Minister of Health, healthcare in South Africa is facing a crisis because some medical practitioners, particularly gynaecologists and obstetricians, have opted not to perform operations for fear of lawsuits.The concerns of the Minister notwithstanding, the daily experiences of people point to the fact that despite the lofty ideals in the Constitution and the Batho Pele Principles, the general public continues to receive sub-standard service from public institutions, especially from public hospitals. The case of Lushaba v MEC for Health, Gauteng (The original case) provides a good illustration of a nation, which is in a state of paralysis ethically. The case paints a picture of “state employees who could not be bothered to do their work” (The rule nisi case par 87). What is even more ominous is the observation by Robinson JA that shaming such public officials no longer has any effect (The rule nisi case par 90).The Lushaba case has all the hallmarks of the cost of indifference on the ethical values of a nation. Axiomatically, such a cost cannot only be measured in Rands and cents. Later in the discussion, we hope to make it clear that indifference impacts on the valuable time of the court and the plaintiff, the reputation of the various institutions involved, quality of life of the child born with cerebral palsy as a result of indifference, the dignity of both the mother and her son and, of course, the taxpayers’ money. These factors combined provide a good basis for reflection on the cost of indifference in this case. To provide some background, the facts of the Lushaba case are discussed briefly, after which the indifference of every role player in the events leading up to the two court cases are highlighted. In the process, our discussion also makes mention of the trajectory that the case followed from the court a quo all the way to the Constitutional Court (MEC for Health, Gauteng v Lushaba [2015] ZACC 16). In the Constitutional Court’s judgment, even the High Court judge came under scrutiny.

The bird’s-eye perspective: how do district health managers experience the impact of family physicians within the South African district health system? A qualitative study

Background: Health policy-makers in Africa are looking for local solutions to strengthen primary care teams. A South African national position paper (2015) described six aspirational roles of family physicians (FPs) working within the district health system. However, the actual contributions of FPs are unclear at present, and evidence is required as to how this cadre may be able to strengthen health systems.
 
 Methods: Using semi-structured interviews, this study sought to obtain the views of South African district health managers regarding the impact made by FPs within their districts on health system performance, clinical processes and health outcomes. 
 
 Results: A number of benefits of FPs to the health system in South Africa were confirmed, including: their ability to enhance the functionality of the local health system by increasing access to a more comprehensive and coordinated health service, and by improving clinical services delivered through clinical care, capacitating the local health team and facilitating clinical governance activities.
 
 Conclusions: District managers confirmed the importance of all six roles of the FP and expressed both direct and indirect ways in which FPs contribute to strengthening health systems’ performance and clinical outcomes. FPs were seen as important clinical leaders within the district healthcare team. Managers recognised the need to support newly appointed FPs to clarify their roles within the healthcare team and to mature across all their roles. This study supports the employment of FPs at scale within the South African district health system according to the national position paper on family medicine.
 
 (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp)
 
 S Afr Fam Pract 2018; DOI: 10.1080/20786190.2017.1348047

The perceived impact of family physicians on the district health system in South Africa: a cross-sectional survey

BackgroundEvidence from first world contexts support the notion that strong primary health care teams contain family physicians (FPs). African leaders are looking for evidence from their own context. The roles and scope of practice of FPs are also contextually defined. The South African family medicine discipline has agreed on six roles. These roles were incorporated into a family physician impact assessment tool, previously validated in the Western Cape Province.MethodsA cross-sectional study design was used to assess the perceived impact of family physicians across seven South African provinces. All FPs working in the district health system (DHS) of these seven provinces were invited to participate. Sixteen respondents (including the FP) per enrolled FP were asked to complete the validated 360-degree assessment tool.ResultsA total number of 52 FPs enrolled for the survey (a response rate of 56.5%) with a total number of 542 respondents. The mean number of respondents per FP was 10.4 (SD = 3.9). The perceived impact made by FPs was high for five of the six roles. Co-workers rated their FP’s impact across all six roles as higher, compared to the other doctors at the same facility. The perceived beneficial impact was experienced equally across the whole study setting, with no significant differences when comparing location (rural vs. metropolitan), facility type or training model (graduation before and ≥ 2011).ConclusionsThe findings support the need to increase the deployment of family physicians in the DHS and to increase the number being trained as per the national position paper.

Fit for purpose? A review of a medical curriculum and its contribution to strengthening health systems in South Africa

Background: Medical education in the 21st century needs to produce health professionals who can respond to health systems challenges and population health needs. Although research on medical education is increasing, insufficient attention is paid to the outcomes of medical training, in particular graduates’ competencies and the effects of their training on healthcare and population health in Africa. Method: This baseline study assessed whether the current Stellenbosch University medical curriculum enabled graduates to acquire health systems strengthening competencies. The teaching of competencies in public health, evidence-based healthcare, health systems and services research, and infection prevention and control was assessed through a document review of study guides and a survey of recent medical graduates. Results: We found that teaching of most competencies was included in the curriculum, but appeared fragmented with a lack of continuity across phases of the curriculum. Health systems and health leadership and management teaching was weak, and important public health competencies in human rights and health advocacy received little attention. Recent graduates said their training was ‘adequate’, but were unable to apply knowledge and skills to address health systems challenges within working environments. They wanted more integrated, practical, problem-based teaching in environments in which they would one day work, and their teachers to be role models for the competencies students were expected to acquire. This study is contributing to improvements to the medical curriculum at Stellenbosch University.

Developing an outcomes-based charter to direct teaching and assessment of medical professionalism

Background. Components of professionalism in undergraduate medical studies at the University of  Pretoria (UP) were previously defined as nine ‘Golden Threads’. Although specific outcomes were  formulated for the threads, the need for more explicit professional standards became increasingly evident. The restructuring of the health system in South Africa contributed to the need for more explicit standards. The Charter for Medical Professionalism was developed during 2006 - 2008 as a reference document within the local context to serve as a standard for professionalism in the medical curriculum. Another aim was to guide academics in medical studies to act as good role models of professional behaviour. Objective. To document the development of the Charter for Medical Professionalism and to evaluate  lecturer and student perceptions on the formulation of the Charter to make appropriate changes and increase acceptance. Methods . The project took the form of action research, and a working group comprising academics from UP’s Faculty of Health Sciences developed the Charter from relevant source documents, employing thematic and content analysis and recursive abstraction. An online survey was conducted to assess lecturer and student acceptance of the Charter. Results . The outcomes-based approach was perceived as acceptable and appears to broaden the scope of assessment of professionalism. Conclusion . Inclusion of outcomes proposed by other work groups relating to research, practice   management, teaching, mentoring and leadership roles of the medical doctor may be considered in future.

The views of key leaders in South Africa on implementation of family medicine: critical role in the district health system.

BackgroundIntegrated team-based primary care is an international imperative. This is required more so in Africa, where fragmented verticalised care dominates. South Africa is trying to address this with health reforms, including Primary Health Care Re-engineering. Family physicians are already contributing to primary care despite family medicine being only fully registered as a full specialty in South Africa in 2008. However the views of leaders on family medicine and the role of family physicians is not clear, especially with recent health reforms. The aim of this study was to understand the views of key government and academic leaders in South Africa on family medicine, roles of family physicians and human resource issues.MethodsThis was a qualitative study with academic and government leaders across South Africa. In-depth interviews were conducted with sixteen purposively selected leaders using an interview guide. Thematic content analysis was based on the framework method.ResultsWhilst family physicians were seen as critical to the district health system there was ambivalence on their leadership role and ‘specialist’ status. National health reforms were creating both threats and opportunities for family medicine. Three key roles for family physicians emerged: supporting referrals; clinical governance/quality improvement; and providing support to community-oriented care. Respondents’ urged family physicians to consolidate the development and training of family physicians, and shape human resource policy to include family physicians.ConclusionsFamily physicians were seen as critical to the district health system in South Africa despite difficulties around their precise role. Whilst their role was dominated by filling gaps at district hospitals to reduce referrals it extended to clinical governance and developing community-oriented primary care - a tall order, requiring strong teamwork. Innovative team-based service delivery is possible despite human resource challenges, but requires family physicians to proactively develop team-based models of care, reform education and advocate for clearer policy, based on the views of these respondents.

Profile of patients and referrals at a midwife obstetric unit in Tshwane North subdistrict, Gauteng province

Midwife obstetric units (MOUs) are primary health level facilities at which antenatal care and delivery for low-risk patients are performed. They are important facilities because they are at the interface of the health system in South Africa and the population. One of their main functions is the identification and referral of high-risk patients. However, few recent published studies describe the profile of patients utilising the services of MOUs and their referral data in detail in South Africa. The study design was a cohort study. Three hundred and nineteen patients reporting their pregnancies at the MOU were enrolled in the study, and were monitored for the duration of their pregnancies. 20.1% of the women were classified as high risk at booking. Additionally, 18.2% were referred in labour. Of the high-risk patients, 21.2% of them delivered at the MOU. These women should have delivered at hospital and therefore presented a considerable risk for the MOU. 3.4% of women in the study delivered at home. This constitutes a significant risk for these women. Finally, the data showed the detailed distribution of risk factors, taken from history and examination, as well as important delivery information on the study patients. For example, 6.2% of the women had had a Caesarean section for a previous pregnancy, 2.8% had had pregnancy-induced hypertension, 1.5% tested positive for syphilis during their current pregnancy, and 1.8% developed severe anaemia.

Migration of South African health workers: the extent to which financial considerations influence internal flows and external movements.

BackgroundThe loss of human resource capacity has had a severe impact on the health system in South Africa. This study investigates the causes of migration focussing on the role of salaries and benefits. Health professionals from public, private and non-governmental (NGO) health facilities located in selected peri–urban and urban areas in KwaZulu-Natal, South Africa were surveyed about their current positions and attitudes toward migration.MethodsThe study uses cross-sectional data collected in 2009. A total of 694 health professionals (430 in the public sector, 133 in the NGO sector and 131 in the private sector) were surveyed. An additional 11 health professionals were purposively selected for in-depth interviews. Odds ratios with 95% confidence intervals were calculated to determine whether salaries influenced HWs decisions to migrate.ResultsHWs decision to move was not positively associated with lower salaries. It was found, instead, that the consideration to move was determined by other factors including age, levels of stress experienced and the extent to which they were satisfied at their current place of work.ConclusionsThe OSD appears to have lowered the risk of HWs migrating due to low salaries. However, the results also indicate that the South African Department of Health needs to improve working conditions for HWs within the public health sector to assist in retention.