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 (MBA)--Stellenbosch University, 2012. / An exploratory, cross-sectional, qualitative survey was conducted to describe the market of lower income mothers who had recently given birth to a child in a state hospital in the Western Cape (WC) region of South Africa. These mothers were viewed by the researcher as potential consumers of low cost maternity plans which would provide for maternity care in Active Birthing Units (ABUs) in the private healthcare sector in South Africa. The motivation behind the research stems from various sources. The currently inequitable healthcare system in South Africa, which has been described as a two tier system in the recent Policy Paper on National Health Insurance (Republic of South Africa, 2011: 4-5), is one such source. Reports of poor maternity care in the South African public healthcare system (Vogel, 2011: E1097-E1098), is another source of motivation behind the research report. It was apparent to the researcher that given the low quality of maternity care in state hospitals, a potential market of healthcare consumers – who would be willing to pay a small premium for what they considered to be a more acceptable level of maternity care in the private healthcare sector – could exist. This view was supported by research conducted by Joan Costa and Jaume Garcia (2003: 587-599) in which the “quality gap” was confirmed as a driving force behind the demand for private health care. This focus on the lower socioeconomic groups as a market for private sector goods and services was found to be well described by Prahalad (2005). The researcher conducted interviews amongst mothers who had delivered a child in a public hospital in the previous two years. A convenience sample of 100 mothers was selected in a shopping mall in the Western Cape (WC). The researcher administered a structured questionnaire during a face-to-face interview with each of the 100 respondents. The respondents were rewarded with a shopping voucher to the value of 50 ZAR, which was both a prerequisite specified by the management of the shopping mall and consistent with rewards offered in similar studies (Francis, Battle-Fisher, Liverpool, Hipple, Mosavel, Soogun, & Nokuthula, 2011). Data collected from the questionnaire included both data on willingness to pay (WTP), as well as demographic data, which provided interesting insights into a relatively under-researched market segment. A statistical analysis of the data collected revealed that 31 respondents (31%) reported a positive WTP for private maternity care. A statistically significant relationship was revealed between respondents’ WTP and the birth experience the respondents had had during their most recent pregnancy, whereby mothers who had described their most recent birth experience as “poor” were significantly more likely to exhibit a positive WTP for private maternity care (p=0.00006). Significant relationships between respondents' WTP for private maternity care and their age and household size were also discovered, whereby younger mothers were more likely to be willing to pay than older mothers (p=0.02) and mothers from smaller households were also significantly more likely to be willing to pay than mothers from larger households (p=0.02). Amongst a sub group of 32 respondents deemed to have potential monthly savings, those with a higher monthly household income were more likely to exhibit positive WTP (p=0.02753) than were those with higher levels of monthly expenditure (p=0.04093). The researcher acknowledged that the limitations of the research included the fact that respondents were selected non-randomly, as a small isolated sample, which made the extrapolation of the results to the larger population of South African mothers impossible. The research did, however, serve to describe the demographic characteristics of a new and relatively under researched target market of mothers from the lower socioeconomic segment of the WC. Data gleaned from this survey will serve to inform further research into this target market, so as to complete a more comprehensive feasibility analysis for the establishment of low cost maternity care packages and ABUs in South Africa.

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.

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)

MCur / Department of Advanced Nursing Science

See the attached abstract below

PhDH / Department of Advanced Nursing Science / Background: The National Committee for the Confidential Enquiries into Maternal Deaths recommend the implementation of “Saving Mothers’ recommendations” as a measure to reduce maternal deaths. However, this objective has not been achieved because the Maternal Mortality Rate in South Africa was standing at 134.33/100 000 live births and Limpopo Province at 165.16/100 000 live births. The national target for reduction of maternal mortality was 20% for all provinces for 2016. Limpopo Province’s reduction was below 12.5% for 2016. Purpose: The purpose of the study was to develop a strategy to enhance the implementation of the Saving Mothers’ recommendations in the maternity units of Limpopo Province. Methods: The convergent parallel design was used in this study. The study was conducted in phases, namely: Phase 1(a) was a qualitative research approach and a non-experimental, descriptive and exploratory design. The population consisted of district managers who were managing the Maternal Health Services and registered midwives who were working in the maternity units of Limpopo Province. Non-probability purposive sampling was used for both the district managers and the registered midwives. Data were collected using a central question for the managers managing Maternal Health services which was “What support are you giving to facilitate the implementation of the recommendations by the Saving Mothers Report?” and the question for the registered midwives was “What challenges are you experiencing when implementing the Saving Mothers’ recommendations.” Tesch’s open-coding technique was used to analyse qualitative data. Trustworthiness was ensured through credibility, confirmability, dependability, transferability and authenticity. Phase 1(b) was a quantitative and a non-experimental descriptive design. The population comprised of 200 patients who were included in the study. Questionnaires were developed and used to collect ABSTRACT vi data. Data was analysed using the Statistical Package for Social Sciences (SPSS, version 24.0) with the assistance of the statistician. Discussion of data were done in an explanatory sequential way where data from Phase 1a was discussed and supported by data from Phase 1b. Findings: The themes that emerged were: Challenges related to implementation of the recommendations of the Saving Mothers Report in maternity units, Description of existing training programmes and in-service education for health care professionals, Knowledge on implementing recommendations for the Saving Mothers Report when providing care in maternity units and Suggestions related to improvement of adherence to recommendations for the Saving Mothers Report in maternity units. Some of the themes were supported by the quantitative results whilst some not supported. Validity and reliability were ensured by giving the questionnaires to experts on the subject, colleagues and promoters to analyse and determine if items adequately represent content in the correct proportion. Ethical considerations were ensured by obtaining ethical approval from the University of Venda Ethics Committee and permission to access the facilities from the Limpopo Province Department of Health. The participants signed informed written consent. Phase 2 entailed strategy development and validation of the developed strategy. Recommendations: The recommendations included that the Department of Health should employ more staff and put operational managers in permanent positions. Sufficient equipment and supplies essential for maternal health care and maternal health infrastructure should be procured and a good plan for the managing thereof implemented. It is also recommended that health care workers should work hand in hand with the community structures and the ‘mosate’. / NRF

MPM / Department of Public Health / The dawn of democracy in 1994 saw huge strides in the adjustment of various statutory instruments that aimed at opening the systems to all South Africans particularly the previously excluded groups. Health care system was one of the ear marked areas by the South African government for post-apartheid transformation. Resultantly, access to health care was declared a right and incorporated into the Constitution of the Republic of South Africa 1996. Numerous legislative and practical steps towards achieving access to health care for all have been made with notable results. However, due the apartheid spatial planning which persuaded separate development left some sections of the community remote and with no infrastructure to support health care delivery. As a result, this has made the realization of the health care for all dreams elusive. Reportedly, the most affected communities were mainly homelands which were largely rural and townships. Despite notable improvements in the delivery of health care services across the Republic, there are still major challenges faced in this sector mainly in the rural areas and townships. Therefore, the study was set to investigate and evaluate the state of health care service delivery in rural Ndengeza Township. The study employed both qualitative and quantitative method following a descriptive design (cross-sectional) and data was collected using a self-administered questionnaire and interview questions. The results revealed that transport, staff-patient relationship, unavailability of medication and medical staff were the major challenges of health care service delivery in rural areas. The respondents alluded that to improve health service delivery in the area, there is need to make available basic medication and trained medical personnel. It is believed, by the participants, that adding the number of staff will go a long way in changing the negative perceptions such as long queues, unavailability of critical services and unprincipled professionals that the public have of the local health care centers / NRF

In the following chapters, I will discuss the effectiveness of radio and audiotapes as appropriate tools for health communication particularly suited to reaching deprived and isolated communities. I will refer to the striking achievements in radio and audiotape projects by drawing on the experiences of more than sixty radio and cassette projects concerned with primary health care in developing countries. I will present a detailed description of my Argentinean and South African radio experiences, focussing on how the two programmes came into existence, the different stages they have gone through, the problems and constraints encountered as well as their strengths and successes. I will describe the audiotape project I am involved in, and demonstrate how audiotapes can be used alone or in conjunction with radio for primary health education.

PURPOSE Explore the competencies required by the child nurse practitioners in the child nursing practice in order to refine the current competencies in a programme for Child Nursing Science presented at a Nursing Education Institution in Gauteng. DESIGN AND METHOD A quantitative, non-experimental, descriptive, exploratory and applied research design was used. A structured self reported questionnaire was constructed based on the competencies derived from the current programme for Child Nursing Science used at the Nursing Education Institution, the Specialist Paediatric and Child Health Nurse by the Australian Confederation of Paediatric and Child Health Nurses and the World Health Organization Children’s Nursing Curriculum. The structured self reported questionnaire was distributed to 110 child nurse practitioners working in child nursing practices in Gauteng and a total of 82 responded. FINDINGS All competencies were regarded as important, except for competencies related to research, family-centred child care, complementary and traditional child care practices, evidence-based practice, mentoring and play activities. CONCLUSION Findings were used to refine the current competencies in a programme for Child Nursing Science / Health Studies / M.A. (Health Studies)