Study Title: Exploring Pull and Push Influencing Human Resources at two South African Health Facilities Introduction The magnitude of the health worker shortage in developing countries such as South Africa cannot be overstated and requires an urgent, sustained and coordinated response. In South Africa, the government has introduced many initiatives, such as the rural allowance, to attract more health practitioners in rural areas. However, human resource shortages remain a challenge and therefore looking at ways to better utilize the capacity of human resources could play a significant role in addressing this problem, and could contribute to establishing a well-functioning public health system. Objectives This study was aimed at exploring and describing factors that affect human resource capacity in two district hospitals in the Eastern Cape Province: one rural, one urban, and makes appropriate recommendations to health authorities so as to better utilize and retain human resource capacity within the facilities. Methods This is a qualitative study, using explorative and descriptive research strategies. The study was conducted in two district hospitals, one urban (hospital B) and one in a rural area (hospital A), both in the Eastern Cape Province. A total of thirty six in-depth interviews were conducted with allied health professionals and administrative staff – eighteen from each site - to explore their perceptions around “pull and push factors” in their work. Additionally, four interviews were conducted with district team members and key policy documents were reviewed. Results The availability of equipment, and quality of infrastructure, as well as relationships between staff differed between the two facilities and were cited as reasons affecting staff intentions to stay or leave. Loosely labelled as “working conditions”, these were perceived to be ‘better’ in the urban-hospital B than rural-hospital A, where staff morale was lower. Geographical differences, including surrounding infrastructure and the availability of services such as schools and recreational facilities, also affected staff decisions and intentions to stay or leave (more pronounced in the rural-hospital A). Opportunities for professional development were also perceived to contribute towards the retention of professional health workers. Conclusion Interviewees emphasized wanting more opportunities for professional development and improving their working and living conditions, as well as improving relationships between the hospitals and district structures. It is important to manage any incentivisation-process (financial and non-financial), including rural allowances and professional staff development, with more caution to ensure that they address the intended goals and do not result in unwanted consequences or tensions. Recommendations Improving conditions in rural areas is indeed a necessary step. Despite the introduction of rural allowances, for health professionals working in rural areas, rural public health facilities still experience a significant shortage of healthcare professional. Further research is needed to pilot and scale-up existing models aimed at promoting staff retention in these public health facilities.

Thesis (M.A.)--University of Michigan, 1966.

Thesis (M.A.)--University of Michigan, 1966.

Thesis (M.H.A)--University of Michigan, 1961.

Thesis (M.H.A)--University of Michigan, 1961.

M.P.H., Faculty of health Sciences, University of the Witwatersrand, 2011 / Background: The hospital as an organisation employs many people who may be at risk for Injuries on Duty (IOD). Although IOD occur across the hospital and impact on staff morale and quality of care, no formal study has been conducted within the public hospitals in South Africa on the profile of employees who have sustained these injuries. This study was aimed at comprehensively describing the IOD and related factors at Klerksdorp/Tshepong/Potchefstroom (K/T/P) Hospital Complex in order to better understand and plan appropriate preventive strategies. Methodology: The study was based on a cross-sectional design involving retrospective record review obtained from the hospital information system. No primary data was collected. The study setting was K/T/P Hospital complex. All records of employees who sustained IOD during the study period were reviewed. Data was collected on relevant variables such as employee profile, type of IOD during the study period. Descriptive statistics was used to analyse the data. Results: The study found that the total number of IOD during this period was 152. The annual prevalence rate was 2.3% (Klerksdorp-Tshepong Hospital Complex) and 2.8% (Potchefstroom Hospital). . The category of employees who experienced injuries were administration (5.3%), support (18.8%), medical (34.9%), nursing (36.2%), professional (4.6%). The types of the injuries sustained were cut (8.6%), fall (19.7%), minor injuries (9.2%), needle prick (49.3%), patient related (1.3%), splash (11.8%). With regard to PEP costs, Klerksdorp Hospital incurred the highest costs of R31 231 34, followed by Potchefstroom Hospital with R23 714 83 and Tshepong Hospital with R19 305 57 during the study period

A Research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in Diagnostic Radiology. Johannesburg, 2012 / Background: There is a heavy reliance on registrars for afterhours CT reporting with a resultant unavoidable error rate. This study was done to determine this error rate. Material and Methods: A 2 month prospective study was undertaken. Provisional CT reports issued by the registrar on call were reviewed information relating to the errors made during the call were recorded and analyzed. Results: 1477 CT scans were performed with an overall error rate of 17.1%. A significant difference was found between trauma (15.8%) compared to non-trauma scans (19.2%). The difference between emergency scans (16.9%) and elective scans (22.6%) was not significant. Abdominopelvic scans elicited the highest error rate (33.9%). Increasing workload resulted in a significant increase in error rate. Missed findings were the most frequent errors (57.3%). Error rate decreased with increasing year of training.

To determine the level of self-assessed competence various registrars possessed in emergency skills as well as to identify any factors that may have contributed to their level of competence. Materials and Methods: Questionnaires were completed by registrars working in General Surgery, Internal Medicine, Psychiatry and Radiology in three academic hospitals in Johannesburg. Information regarding demographic data, educational background, work experience in emergency-related environments and resuscitation courses attended were collected. Registrars rated their level of perceived competence in a list of 25 emergency skills according to a ranking scale of 1 to 5. Results: A total number of 94 registrars participated in the study which amounted to an estimated response rate of 35%. General Surgery registrars had the highest mean competence scores of 3.7 and 3.9 for the respective basic and advanced skills groups. General Surgery and Internal Medicine registrars had the highest mean competence scores of 3.7 for the intermediate skills group. Psychiatry registrars had the lowest mean competence scores of 2.7, 2.4 and 1.5 in each of the skill groups. Registrars who had current certification in a PALS course had competence scores 0.6 units higher than others in both basic (p=0.027) and advanced (p=0.035) emergency skills. Conclusions: General Surgery and Internal Medicine registrars have a higher level of perceived competence in various emergency skills. The General Surgery group rated themselves the highest in levels of competence in the basic and advanced emergency skills groups. Current certification in BLS, ACLS, PALS and AMLS has a positive impact on registrars‟ self-perceived levels of competence in emergency skills. Registrars who had spent less time between community service and starting their specialist training had higher levels of self-perceived competence in intermediate and advanced emergency skills.

This work explored perceptions regarding the roles, norms and incentives influencing the performance of Clinical Officers (COs) in rural district hospitals in Kenya. In order to improve access to health care mainly in rural areas, COs are increasingly being used to perform tasks that were previously the preserve of physicians. The assumption underlying their use is that they are a viable option to doctors. Studies have shown with reference to HIV care and obstetric and gynaecological surgical tasks that COs’ performance is comparable to that of physicians. Other studies also show that the care offered by COs is cost effective when compared with the costs associated with physicians and obstetricians care. However, there is emerging work which shows that COs are not happy in their assigned role in the health system. These studies report CO’s dissatisfaction with the low remuneration, poor career progress and limited career options inherent their jobs as compared with those accorded to physicians. As revealed by a systematic review of mid-level worker literature, addressing these issues is at present difficult due to gaps in our understanding of CO functioning. The existence of these gaps is explained by the limited empirical work on COs in general. The aim of this thesis was to address this issue by exploring issues that affect their routine functioning in a typical rural hospital setting going beyond the fact that they are technically competent. To investigate these issues, a conceptual framework was adopted that explores the tension between what institutions demand and what individuals within them feel able to do. Qualitative methods comprising of interviews, participant observation, review of official policy and hospital level documents on COs, and review of hospital statistics were used. A comparative approach was adopted that sought to; (1) examine perceptions regarding influences on the performance of COs from a variety of sources (COs, doctors, nurses, supervisors, hospital managers, policy makers and policy documents); (2) compare perceptions of respondents based in three faith-based hospitals with those in three government facilities; and, (3), explore features of different work settings (outpatient department, specialist clinics and vertically supported clinics) within these hospitals that encouraged good CO performance. Preliminary findings were reported back to respondents in the six study hospitals. Analysis of the data showed three major issues. First, perceptions of CO roles are problematic despite an acknowledgement of the important function performed by COs in the health system. This is revealed by the variety of images regarding their roles that highlights the need for a redefinition of CO roles. An example of this is shown by the inconsistency between their importance as the ‘backbone of the health system’ versus the poor remuneration and career prospects that their position attracts. Second, there were differences in the norms of CO performance that have resulted in variations regarding what is expected of them. While there was much attention paid to norms of performance about technical aspects of work, less attention focussed on non-technical aspects of work. The adoption of a holistic approach to the notion of CO performance is needed that will enable facilities and the system to meet the needs of the CO which should prompt COs to reciprocate by working better. Third was the issue that there were minimal incentives were attached to COs work. In the public sector, there were some incentives but their availability depended on the work settings. For example, while COs in vertical clinics got training their colleagues in the outpatient department had few chances to get training opportunities. Faith-based hospitals did provide performance related bonuses that encouraged health workers to perform better although notably basic salaries in faith-based hospitals were no better than those given in the government sector. However, major incentives such as salary and promotions in the public sector are handled by the central government giving public sector hospital managers little opportunity to utilise such incentive mechanisms. Where hospital managers may have some leeway in implementing actions at the local level to improve performance, for example through improving CO recognition and working conditions, it was observed that public sector managers were generally less engaged in utilising such incentives. Therefore while it is important to consider and address system level factors that influence CO performance such as salaries and promotions, among others, facility managers would also appear to have some scope to improve performance. In discussing these issues, it is becoming clear that the assumption that COs are altruistic and will continue to work flawlessly in their assigned niche presents a naïve view of COs. This thesis shows that COs are also influenced by self–interest and find ways to overcome or work around any perceived barriers to their growth, some of which may work against the institution. This calls for a re-examination of who COs are, what they do and how they should be managed. Ways of resolving the tension that exists between COs and the health institution exist and can be derived from examining the coping mechanisms that COs have adopted to make their lives better. These coping mechanisms show areas that need attention. Further, there should be greater consideration of the important role that facility managers play in mediating and/or modifying system level influences by creating local environments suitable for better staff performance. Underlying all this is the fact that a long term view of COs is needed. The long term view must go beyond the notion of ‘substitute physician’ as Kenya has made huge investments in this cadre over the last 40 years or more and, with other countries, is likely to continue to rely on such a cadre for much clinical care. This thesis therefore concludes with recommendations that seek to address issues identified with the performance of COs in the Kenyan health system focusing on potential hospital level and system level solutions. Also included is a reflection of the relevance of findings for countries similar to Kenya that are currently using or seek to use COs as a physician substitute.

Dissertation presented to the Faculty of Health Sciences at the Durban University of Technology in partial compliance with the requirements for a Master’s Degree in Technology: Chiropractic, 2009 / Background: In order to develop a balanced healthcare system, healthcare integration and inter-professional communication is important and allows for optimum healthcare benefits for a patient and improves cost-effectiveness. The chiropractic profession has been trying to improve inter-professional communication with the medical profession. Kimberly Hospital Complex (KHC) is a tertiary provincial hospital situated in the Northern Cape and since 1998, a permanent chiropractic post exists at this hospital, making it the only state hospital in South Africa with a full-time chiropractic clinic and post. Purpose: To determine the knowledge and perceptions of the medical staff about chiropractic at KHC. Method: This study was achieved by means of a questionnaire, which was modified to suit a South African context by means of a focus group. The questionnaire was personally delivered to 975 medical staff members at KHC. A response rate of 30% (n = 292) was achieved and the data was analysed using SPSS version 15 (SPSS Inc., Chicago, III, USA). Results: The mean age of the respondents was 37.3 years and most were female (78.9%, n = 289). Doctors (62.5%, n = 54) and therapists (61.6%, n = 10) had a higher knowledge percentage score than nurses (48%, n = 213) or other healthcare professions (56.8%, n = 15). Doctors (77.8%, n = 42), therapists (100%, n = 10) and other healthcare professions (69.2%, n = 9) were more inclined to think that chiropractic is an alternative healthcare service, while nurses perceived chiropractic as a primary healthcare service (43.3%, n = 91). Many respondents were unaware of the fact that Diagnostics, Emergency Medical Care, Pharmacology and Radiology are included in the chiropractic curriculum and that chiropractic leads to a Master’s degree. Seventy five percent (n = 203) believed that chiropractors are competent in the general medical iv management of patients, but they would still rather refer patients to physiotherapists and orthopaedic surgeons. Despite the poor level of knowledge of chiropractic, 79.2% (n = 224) believed that it is sufficiently different from physiotherapy to warrant two separate professions and few (24%, n = 69) perceived it as unscientific. A large proportion of the respondents (80.3%, n = 228) believe that chiropractic is not well promoted in South Africa and only 20.8% (n = 59) felt that they know enough about the profession to advise a patient. The majority wanted to learn more about the chiropractic profession (95.8%, n = 277), especially pertaining to the scope and the treatment employed by chiropractors. Seventy-nine percent (n = 212) believed that patients benefit from chiropractic at KHC and 95.4% (n = 268) felt that South African hospitals would benefit from chiropractic care. Conclusion: Due to the poor level of knowledge at KHC, an educational drive should be employed to educate the medical staff in order to increase their understanding of chiropractic and to aid chiropractic integration into the state hospital system of South Africa.