Submitted in fulfillment of the requirements for the degree of Doctor in Public Management, School of Public Management and Economics, Durban University of Technology, Durban, South Africa, 2016. / The shortage of staff in hospitals resulted in the overcrowding of outpatients departments (OPDs) and long waiting times. The problems of the current health care system include the lack of access to transportation and high transport fees which cause delays in health seeking behaviours by patients or them resorting to traditional medicine in their neighbourhood. To alleviate the above issues, the new Primary Health Care (PHC) approach provides health care at a ward based and household level through community care giver (CCGs) and outreach teams. The study evaluated the management of rural ward-based primary health care in the UThukela District Municipality (UDM). The study intended to evaluate current performance systems in order to provide effective and efficient PHC; identify the role of the operational manager (OM) in the provision of PHC; and identify the factors affecting the performance of CCGs. A mixed methods approach was used amongst 368 CCGs and 17 OMs. Data was collected from CCGs using questionnaires while an interview schedule was used to collect data from OMs. The study showed that the performance management systems currently being used were not providing the desired performance management outputs. There were no performance bonuses to recognise best performing staff and therefore no increase in performance. The study also showed a significant relationship between the management of referrals and participation in the activities of PHC outreach teams. The clinic was not regularly giving feedback to the respondents and also not consistently conducting performance reviews. The findings indicated that OMs were playing various roles in the provision of PHC, namely policy and strategy implementation; leadership and governance; clinical care; allocation of resources; clinic budget management; supply chain management; and writing clinic reports. The extent of the allocation of resources to the wards varied from 43% for medicines and equipment to 31% for financial resources and only 18% for human resources. More than 95% of the CCGs viewed the availability of transport, resources, training and the provision of a stipend to be strong enabling factors for them to perform their work. Respondents indicated that monitoring and evaluation was done through reporting, performance reviews, feedback and supervision. The findings indicated that ward-based outreach teams are crucial in the delivery of PHC services in rural municipal wards within the Operation Sukuma Sakhe programme. Lack of management and supervisory support contribute to high rates of dissatisfaction amongst CCGs, as well as poor quality of work for community caregivers. There is a need for the Department of Health (DoH) to invest in the ward-based outreach teams (WBOTs) and allocate CCG budgets within the ward-based outreach teams. The study recommended that a review of monitoring and evaluation policy is required to clearly state the tools, activities and benefits of the implementation of the M & E performance management systems. The use of point-of-care technology by the WBOTs should be strengthened especially in deep rural wards. Therefore, biomedical technology will enhance point-of-care diagnosis, for instance, rapid home test kits for HIV diagnosis and pregnancy tests. The KwaZulu-Natal DoH should fast-track development of the sub-districts in order strengthen service delivery at a local level with top management ensuring development of OMs and PHC Supervisors in order to increase the level of competence and thereby improve service delivery at the PHC facilities. Another recommendation was to strengthen implementation of Operation Sukuma Sakhe (OSS) where the war room and the ward committee increase commitment to designing community-specific interventions with the engagement of community structures and government departments and local municipality through social planning, social action and locality development. Therefore, the results of the study should also influence the formulation of policies, programmes, methods and interventions which will enable UThukela District Municipality to improve health outcomes. / D

Thesis (MPhil)--Stellenbosch University, 2012. / ENGLISH ABSTRACT: An exploration of the integrated nature of sustainable development planning and health care was done in the context of people living and working in the town of Grabouw in the Western Cape. The problem that was investigated was that people working within local government and community health networks treated sustainable development planning and health care as separate issues. The notion of wellness, as different from health, was used as a central theme in the study. It allowed for an acknowledgement of the multidimensionality and contextual nature of human well-being. The notion of sustainable community wellness was used to guide the research, and was viewed as a complex phenomenon. The meanings of sustainable community wellness to people who work and live within local government and community health networks in Grabouw were observed and documented. Complexity theory was then used to discuss the observed perspectives on sustainable community wellness. Two factors informed the selection of Grabouw as a research site: Firstly, a comprehensive sustainable development programme was being carried out in the town of Grabouw during the research. Secondly, a few community health care initiatives were also being implemented at the time. Community care workers who worked in one of the community health organisations participated as primary research participants. The research combined conceptual and empirical research. The conceptual research consisted of a literature review of perspectives on wellness in Grabouw. The empirical research methods that were used combined ethnography in the form of participant observation, and participatory action research in the form of participatory photography. The researcher accompanied community care workers on their daily visits to patients. The care workers took photographs of aspects of their surroundings that represented sustainable community wellness, or the lack thereof, to them. Photographs were analysed through focus group discussions and pertinent themes were subsequently identified. Three meanings of sustainable community wellness were discovered. The first was the structural, governmental meaning that gave importance to health and socio-economic statistics, based on the mortality profile of the area. Wellness was seen from this perspective as a challenge that could be met with strategic planning. The second meaning was the community-based experience of environmental factors in Grabouw that had an impact on wellness, such as water, community forums and living spaces. In this case, wellness was experienced as a rich and diverse set of factors, both social and environmental. The third meaning was observed as instances where the apparent separate entities of local government, the community, and the physical environment were seen as one socio-ecological system, of which sustainable community wellness was an emergent property. These instances demonstrated the importance of managing the quality of relationships within the system, the need to enhance the autonomy of people working in the system and the potential of community care workers to be agents of sustainable community wellness. / AFRIKAANSE OPSOMMING: Ondersoek is gedoen na die geïntegreerde aard van volhoubare ontwikkelingsbeplanning en gesondheidsorg in die konteks van mense wat in die dorp Grabouw in die Wes-Kaap woon en werk. Die probleem wat ondersoek is, is dat mense wat in plaaslike regerings- en gemeenskapsgesondsheidnetwerke werk, volhoubare ontwikkelingsbeplanning en gesondheidsorg as afsonderlike sake beskou. Die begrip ‘welstand’, wat in betekenis van ‘gesondheid’ verskil, is as 'n sentrale tema in die studie gebruik, en is soortgelyk aan die begrip ‘welwees’. Dit het erkenning verleen aan die meerdimensionele en kontekstuele aard van menslike welwees. Die begrip volhoubare gemeenskapswelstand wat as 'n komplekse verskynsel beskou is, het die ondersoek gerig. Die betekenis van volhoubare gemeenskaps-welstand vir mense wat in plaaslike regerings- en gemeenskapsgesondheidnetwerke in Grabouw woon en werk, is waargeneem en gedokumenteer. Kompleksiteitsteorie is voorts gebruik om die waargenome perspektiewe op die volhoubare gemeenskaps-welstand te bespreek. Twee faktore het die besluit om Grabouw as 'n navorsingsgebied te gebruik, beïnvloed: Eerstens was daar tydens die navorsingstydperk reeds 'n omvattende volhoubare ontwikkeling program in Grabouw aan die gang. Tweedens was 'n paar gemeenskapsgesondheidsorg-inisiatiewe ook in dié tydperk aktief. Gemeenskapgesondheidswerkers wat in een van die gemeenskapsgesondheidsorganisasies gewerk het, was primêre deelnemers aan die navorsing. In hierdie ondersoek is konseptuele en empiriese navorsing gekombineer. Die konseptuele navorsing het uit 'n literatuuroorsig van perspektiewe op welwees in Grabouw bestaan. Die empiriese navorsingsmetodes wat gebruik is, het etnografie in die vorm van deelnemende waarneming, asook deelnemende-aksie-navorsing in die vorm van deelnemende fotografie, behels. Die navorser het gemeenskapsgesondheidswerkers op hul daaglikse besoeke aan pasiënte vergesel. Hierdie werkers het foto's geneem van die aspekte van hul omgewing wat na hulle mening die volhoubare gemeenskaps-welstand, of die gebrek daaraan, verteenwoordig. Foto's is tydens fokusgroepbesprekings ontleed en relevante temas is daardeur geïdentifiseer. Drie betekenisse van die volhoubare gemeenskaps-welstand het tydens die ondersoek na vore gekom. Die eerste is die strukturele, regeringsverwante betekenis wat bestaan het uit gesondheidsen sosio-ekonomiese statistiek, gebaseer op die sterftesyferprofiel van die gebied. Welstand is vanuit hierdie perspektief gesien as 'n uitdaging wat deur middel van strategiese beplanning aangepak kon word. Die tweede betekenis is die gemeenskapsgebaseerde ervaring van omgewingsfaktore wat 'n uitwerking op welstand het, soos water, gemeenskapsforums en leefareas in Grabouw. Welstand is in hierdie geval ervaar as bestaande uit 'n reeks ryke en diverse faktore wat beide sosiaal en omgewingsverwant is. Die derde betekenis is waargeneem deur die identifisering van die gevalle wat die kompleksiteit van die stelsel wat bestudeer is, verteenwoordig het. In hierdie gevalle is die oënskynlike aparte entiteite van plaaslike regering, die gemeenskap, en die fisiese omgewing gesien as 'n sosio-ekologiese sisteem waarvan volhoubare gemeenskaps-welstand 'n ontluikende element is. Deur hierdie gevalle is daar aangetoon dat dit belangrik is om die gehalte van die verhoudings binne die stelsel te bestuur en om die outonomie van die mense wat binne die stelsel werk te ondersteun. Ten slotte is die potensiaal van gemeenskapsgesondheidswerkers om as agente van die volhoubare gemeenskaps-welstand op te tree, uitgelig.

Thesis (MPA (Public Management and Planning))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: The accessibility of anti-retroviral drugs to patients and families affected by HIV and AIDS, and the affordability of these drugs, have been challenges to the Du Noon community in the Cape Peninsula. The aim of the study was to assess the effectiveness of primary health care services in addressing HIV/AIDS in the light of these challenges. The focus was on patients registered on the ARV programme and who were receiving treatment at Du Noon Clinic. Interviews were conducted with 15 groups of 10 patients each using a patient questionnaire. During these interviews qualitative and quantitative data were gathered and secondary data was used for quantitative analysis. The results that the data analysis yielded are in keeping with the hypothesis that the HIV/AIDS programme is effective in meeting the needs of the HIV/AIDS patients of Du Noon. After content analysis of qualitative data, two themes related to patient satisfaction emerged: positive and negative feelings that were categorised as satisfied and not satisfied with the service. Most often noted was the feeling of satisfaction with the services rendered at the clinic and that the staff were helpful. The staff rendering the service were also satisfied with the kind of service offered to the patients, but were dissatisfied with the allocation of resources. An increase in enrolment figures of patients was noted in the statistical analysis for the period 2004-2008 with 1,018 patients registered. The statistics illustrate the linear tendency in the enrolment of patients, which indicated the accessibility and affordability of the service. / AFRIKAANSE OPSOMMING: Geredelike toegang tot en die bekostigbaarheid van anti-retrivorale middels (ARM’s) vir pasiënte en families wat deur MIV en VIGS aangetas is, is ‘n uitdaging vir die Du Noon-gemeenskap in die Kaapse Skiereiland. Die doel van die studie was om die doeltreffendheid van primêre gesondheidsorgdienste te bepaal wanneer MIV/VIGS aangespreek word. Die fokus is op geregistreerde pasiënte wat die ARM-program volg en behandeling by die Du Noon Kliniek ontvang. Met behulp van ‘n pasiëntevraelys was onderhoude met 15 groepe van 10 pasiënte elk gevoer. Tydens hierdie onderhoude is kwalitatiewe data versamel en vir kwantitatiewe analise was sekondêre data aangewend. Die resultate wat uit die data analise verkry was, strook met die hipotese dat die MIV/VIGS-program doeltreffend is om die behoeftes van die pasiënte en die gemeenskap van Du Noon aan te spreek. Nadat ‘n inhoudsanalise van die kwalitatiewe data onderneem was, het twee temas rakende positiewe en negatiewe gevoelens – gekategoriseer as tevrede en nie tevrede nie – ten opsigte van die gelewerde diens na vore getree. Veral die gevoel van tevredenheid teenoor die diens gelewer by die kliniek en die personeel as behulpsaam, is opgemerk. Die personeel wat die diens lewer, was ook tevrede met die diens wat aan die pasiënte gelewer word, maar was ontevrede oor die toekenning van hulpbronne. By die statistiese analise is ‘n toename in die inskrywingsgetalle deur pasiënte waargeneem. Toename in inskrywingsgetalle deur pasiënte is gemerk in statistiese analise van 2004 - 2008, met 1,018 pasiënte geregistreer. Die statistiek het die lineêre tendens toegelig ten aansien van die inskrywing van pasiënte wat die toeganklikheid en bekostigbaarheid van die diens uitbeeld.

This research investigated the availability and nature of the rehabilitation service at primary health care level rendered by rehabilitation staff in the Metropole district health services. The aim of the study was to determine the extent to which selected elements of the rehabilitation components of the primary health care service package are currently being implemented. In doing so, the study aimed to identify obstacles within the district management as perceived by rehabilitation therapists that hinder the implementation of the rehabilitation programme, so as to make recommendations for future planning.

The purpose of this study was to explore and describe staff experiences in managing data and/or information when utilising the District Health Information System (DHIS) as a support mechanism for data quality improvement, including the strengths and weaknesses of current data management processes. It was also aimed to identify key barriers and to make recommendations on how data management can be strengthened. Key informants included in this study were those based at the district office (health programme managers and information officers) and at the primary health care (PHC) facilities (facility managers, clinical nurse practitioners and data capturers). An exploratory, descriptive and generic qualitative study was conducted. Consent was requested from each participant. Data were collected through semi-structured interviews. The study findings highlighted strengths, weaknesses and key barriers as experienced by the staff. Strengths, such as having data capturers and DHIS software at most if not all facilities, were highlighted. The weaknesses and key barriers highlighted were staff shortages of both clinical and health management information staff (HMIS), shortage of resources such as computers and Internet access, poor feedback, training needs and data quality issues. Most of the weaknesses and key barriers called for further and proper implementation of the District Health Management Information Systems (DHMIS) policy, the standard operating procedures (SOP), the eHealth strategy and training of the staff, due to the reported gaps between the policy and the reality and/or practice at the facility / Health Studies / M. A. (Public Health with specialisation in Medical Informatics)

Introduction: The aim of this research was to establish the attitudes, knowledge, job satisfaction and professional development of community service dietitians because negative attitudes, poor knowledge, low levels of job satisfaction and poor professional development would be detrimental to the process of community service and ultimately to the provision of health services. Methodology: Three distinct annual intakes of qualified dietitians completing compulsory community service were the subjects of an analytical cross sectional survey conducted biannually for the period 2003-2005. Data collection methods included telephone interviews, mail, emailed questionnaires and focus group discussions. Individual factors: sex, population group, language, university attended; institutional factors: organisation of community service, mentorship rating, hospital manager support type of facility, rural allowance, hospital location, access to resources, working and living conditions and personal safety and other factors: attitude, community nutrition knowledge, job satisfaction and professional development were included in the data set. Management of data: Data were divided into 2003 cohort (n=20) and 2004-2005 cohorts (n=26). Analysis of the demographic details for 2003 and 2004-2005 cohorts were, respectively: mean ages 23.6 (±0.99) and 24.05(±4.96) years, 60 percent and 73 percent white, 90 percent and 96 percent female, 35 percent and 73 percent University of KwaZulu-Natal graduates and 65 percent of both cohorts were placed in rural facilities. Results: Community nutrition knowledge of the 2003 cohort was unacceptable but improved in the 2004-2005 cohort. Subjects had a generally positive attitude towards community service. Community nutrition levels of knowledge of the 2003 ranged between 60 percent at entry and 67 percent at exit and for the 2004-2005 between 72.8 percent and 78.42 percent. The job satisfaction level of the 2003 cohort at exit was 13.65 (±3.573). In the 2004-2005 cohort job satisfaction was 15.75(±3.360) at entry and 15.75 (±3.360) at exit. 85 percent of the 2003 cohort rated their professional development positively whereas 65 percent of the 2004-2005 cohort rated theirs' positively. This decline and associated problems were to some extent shown in the interview responses. The 2004-2005 cohort did however show a tendency for improvement in the professional practitioner ranking (p=0.088). The majority (95%) of the 2004-2005 cohort rated the dietetic services positively. Focus group discussions highlighted problems that the community service dietitian (CSD) encountered such as lack of supervision and support, lack of basic facilities, poor hospital administration, problems with transport, work overload and problem with their professional role in the community and health facility. A model showing the results of the research indicated that the objectives of the Department of Health for improved service in rural areas were obtained but the retention of health professionals and capacity was lost due to annual rotation of subjects. Community service as a strategy to overcome service delivery has merit provided identified problems are addressed. / Thesis (Ph.D.)-University of KwaZulu-Natal, Pietermaritzburg, 2006.

This research investigated the availability and nature of the rehabilitation service at primary health care level rendered by rehabilitation staff in the Metropole district health services. The aim of the study was to determine the extent to which selected elements of the rehabilitation components of the primary health care service package are currently being implemented. In doing so, the study aimed to identify obstacles within the district management as perceived by rehabilitation therapists that hinder the implementation of the rehabilitation programme, so as to make recommendations for future planning.

Die Queen Victoria Gedenkhospitaal van Stellenbosch, wat sedert 1904 die Stellenbosse gemeenskap bedien het, het as gevolg van 'n groeien~e inwonergetal geleidelik 'n gebrek aan ruimte ondervind. Daarom is daar gedurende die 1930's pogings aangewend vir die oprigting van 'n groter hospitaal. Hierdie pogings is uiteindelik met sukses bekroon en in 1944 het die Stellenbosch Hospitaal sy deure geopen. Spoedig na die opening van die hospitaal is verskeie probleme, soos byvoorbeeld 'n tekort aan beddens en 'n behoefte aan meer moderne mediese toerusting, ondervind. Die Hospitaalraad het deur voortdurende verto~ tot die Kaapse Provinsiale Administrasie en met die finansi~le steun van die Stellenbosse gemeenskap daarin geslaag om belangrike moderne algemene en mediese toerusting aan te koop. Die Stellenbosch Hospitaal, in samewerking met die Cloetesville Gemeenskaps Gesondheidsentrum, wat onder die beheer van die hospitaal staan, se belangrikste doelwit was, en is, om die beste moontlike diens aan die gemeenskap te lewer. Daarom het die Hospitaalraad met verloop van tyd 'n omvattende gemeenskaps gesondheidsprogram ontwikkel. Sedert die dae van die Queen Victoria Gedenkhospitaal het die Stellenbosse gemeenskap 'n aktiewe rol in die lewering van noodsaaklike hospitaaldienste gespee!. As gevolg van die betrokkenheid en die finansi~le bydraes van die gemeenskap kon die Hospitaalraad noodsaaklike uitbreidings, soos 'n kraamsaal en 'n verpleegsterstehuis finansier. Omdat die gemeenskap besef het dat dit nie net die staat se verantwoordelikheid was om gesondheidsdienste te lewer nie, is die Aksie Stellenbosch Hospitaal, die gemeenskapsarm van die hospitaal, in 1988 gestig. Hierdie Aksie Stellenbosch Hospitaal speel dus in 'n tydperk waar staatsfondse beperk is, 'n belangrike rol om die Stellenbosch Hospitaal doeltreffend te laat funksioneer en om steeds hoe standaarde met betrekking tot gesondheidsorg te handhaaf.

The research focused on employee wellness and explored and described the role of spirituality in the wellbeing of CHCWs of HIV/AIDS patients. It was important to determine how CHCWs dealt with the stress of caregiving, due to the increasing number of HIV infections and burden on government resources. The approach was a phenomenological qualitative study using faceto- face interviews to collect data from a purposive sample of eight CHCWs from a population of 250 at Temba. The audio-recorded interviews were transcribed verbatim and analysed for emerging themes using thematic analyses. The research findings provided evidence that spirituality impacted positively on the wellbeing of the CHCWs by providing the coping mechanism to deal with stress. The conclusions drawn were that personal and organisational wellbeing operated at an optimal level due to the influence of spirituality. Recommendations were that formalised spiritual programmes were offered as a tool to equip CHCWs in their duties. / Industrial and Organisational Psychology / M. Com.

Since 1994 a number of health reforms took place in furthering democracy. These changes included the decentralisation of Primary Health Care Services. This study is a phenomenological research that chronicles the Primary Health Care decentralisation experiences in the Bophirima District of the North-West Province. Using a descriptive phenomenological orientation, the purpose of this study was to describe the experiences of participants associated with decentralisation in the Bophirima District. Also, to illustrate how the participants perceive these experiences in relation to Primary Health Care services. Furthermore, to provide scientific evidence regarding factors related to the decentralisation of PHC services in the Bophirima District. These and other issues remain of paramount importance given the current state of health care in the South Africa. This study took place in the outskirts of the semi-rural area of Bophirima and Central District in the North-West Province. The investigation followed qualitative research design that was descriptive, exploratory, contextual and phenomenological in nature. The sampling procedure involved non-probability purposive, sampling technique with a sample size of five participants. Data was collected by using an unstructured interview technique. The modified Giorgi method of analysis was used for qualitative data analysis. These are contained in Burns and Grove (2001:596) and Polit and Beck (2004:394) are fully explicated in Chapter Four. Guba model (in Babbie & Mouton, 2001:180) was utilised to ensure the trustworthiness of the study. Ethical requirements were considered throughout and these are reflected in chapter four of the thesis.Three forms of decentralisation: deconcentration, delegation and devolution were identified in the findings. The investigation further indicated that the integration of primary health care services was also underway at the time of decentralisation. This integration triggered different psychological and emotional states amongst research participants. Most importantly, the research revealed that the interest of leadership across three spheres of government played a key role in the decentralisation of PHCs and integration of PHCs, while highlighting the importance of community participation in health service delivery (CP). In conclusion, the decentralisation process was generally perceived as empowering although, nationally, leadership needs to be strengthened to support provinces and districts regarding major policy issues such decentralisation. Key recommendations were made and further research was suggested. / Health Studies / D. Litt. et Phil. (Health Studies)