Accessibility is a key tenet of the Canadian health care system. As many older persons, age 60 years and older, are managing ongoing chronic health conditions as part of their everyday lives, issues of access to health services are particularly important. Vancouver has a substantial number of older Korean immigrants, yet little is known about their experience and perceptions about accessing Primary Health Care (PHC) services. This study explored issues related to PHC access by older (aged 60 years and older) Korean immigrants. This qualitative study employed purposive sampling and interpretive description methodology. Open-ended interview data and field notes were gathered from 10 older Korean immigrants (five male and five female) recruited in Vancouver from mid-October 2006 to April 2007. The findings revealed that older Korean immigrants have had difficulty gaining access to appropriate PHC services because of the shifts in their social positioning and other barriers which contributed to an inappropriate use of PHC services, delays in care and lack of continuity in PHC. Also, the data revealed a number of ways the PHC system is unresponsive to the health care needs of older Korean immigrants. This study offers insights that may assist health care professionals to understand the nature of the challenges older Korean immigrants face when seeking health care and how they seek to resolve them. The analysis proposes a number of interventions that respect the older Korean immigrants’ values and interventions that may improve their access to PHC. / Applied Science, Faculty of / Nursing, School of / Graduate

Introducción. En Perú, durante el servicio social en salud se han reportado problemas como condiciones laborales riesgosas, mortalidad asociada a accidentes de tránsito y déficit de cobertura de aseguramiento.Objetivo. Describir los problemas percibidos y experimentados por los profesionales de salud que realizan el Servicio Rural y Urbano Marginal de Salud (SERUMS) en Ancash, Perú, y evaluar su asociación con la práctica de los profesionales y la categoría del establecimiento donde se realiza el SERUMS.Materiales y métodos. Durante abril del 2015, se realizó un estudio transversal analítico con profesionales de salud que realizaban el SERUMS en establecimientos del Ministerio de Salud de Ancash. Se aplicaron encuestas para recolectar datos generales, características y problemas del SERUMS.Resultados. Se analizaron 364 encuestas. El 79.3% de los participantes fue de sexo femenino, la edad promedio fue de 27.4±5.0 años, 80.0% percibió carencia de insumos, 54.4% percibió carga laboral excesiva, y 14.7% sufrió algún accidente de tránsito durante el SERUMS. Ser médico y laborar en establecimientos I-1 fueron factores asociados a haber sufrido accidentes de tránsito y otros imprevistos.Conclusiones. Los encuestados reportan carga laboral excesiva, carencia de insumos y accidentes. Los accidentes son más frecuentes en médicos y en establecimientos de categoría I-1.

D.Litt. et Phil. / Health and social issues have a reciprocal relation and this is evident in the South African context. Poverty that includes poor living conditions, unemployment and the consequent low income results in disease and malnutrition. A vicious circle exists between poverty and disease. The HIV/Aids pandemic results in people being in need of care, not being able to work nor provide for their next of kin, children being orphaned and taking over the parental role, without emotional and material means. Chronic diseases, for example tuberculosis, hypertension, diabetes and chronic psychiatric disease assume enormous proportions and influence the person-and-environment interaction, which is the social work focus. Health and social issues can therefore not be seen as separate entities. Social workers should then form an integral part of health care services. The social work service rendering in the Health Sector should be effective, efficient and appropriate. Effective, efficient and appropriate health care social work services will encompass people-centred, developmental, preventative, promotative primary health care approaches with emphasis on participation, partnership and self-determination. An effective and appropriate service will rely on home-based and community-based strategies. Health care social work is however fragmented and social workers in the Health Sector practice within different governmental and non-governmental organizations. Health care social work in the Gauteng Health Department where the researcher did the research, is largely curative, rehabilitative, hospital-based, individual-based and relies on institutional care. It is therefore ineffective, inefficient and inappropriate. A shift towards an effective, efficient and appropriate health care social work service is essential especially when the reciprocal relationship between health and social issues in South Africa are taken into account. The researcher decided therefore to develop a community-based model for health care social work with emphasis on a people-centred and developmental approach emphasizing participation, partnership and self- determination of the people. This model will be utilized on a primary health care level within a community health centre and community context where the health care social worker will form part of a multi-disciplinary health care team. The main goal of this study is the development of a community-based model for health care social work. The objectives to attain the main goal of describing a community-based model for health care social workers were: ♦ To explore and describe the thoughts and experiences regarding the perceived needs with reference to the general health of the following patients: Patients who attend provincial community health centres to address their health needs; Patients who are representative of the diversity of all South African citizens and therefore include White, Black, Coloured and Indian population groups; Patients who qualify in terms of their income to utilize Governmental health services and who do not belong to medical schemes; Patients from formal, well organized and structured communities with different community resources, as well as patients from informal settlements without structured community services; Patients of different age and gender groups; and Patients with acute and chronic, including life threatening medical conditions. ♦ To describe the needs of patients after interviews were conducted and data had been analyzed; ♦ To explore and describe the needs that health care social workers can address and the intervention strategies that they can utilize in doing so; ♦ To explore and describe the priority needs that a health care social worker could address and the intervention strategies they could utilize in doing it, in the opinion of the following multi-disciplinary health care team members: Medical doctors; Nursing staff; Allied health professionals (physiotherapists or their assistants, occupational therapists or their assistants, speech therapists, dieticians, pharmacists and community based rehabilitation workers); ♦ To describe specific needs and services which health care social work exclusively or most effectively can address according to ranking on a scale; ♦ To develop a community-based model for health care social work according to the needs that a health care social worker can address and which will result in an effective and appropriate health care social work service; ♦ To evaluate the tentative model; and ♦ To revise the intervention and describe guidelines to operationalize the model. The research design utilized to attain these objectives was based on a research model that the researcher developed. The researcher developed the research model by utilizing The Intervention Design and Development model (Rothman & Thomas, 1994) qualitative research for interviews with patients, observations and field notes, data analysis and literature control. Quantitative research designs were included in the model and consisted of the Delphi technique and Lickert scale. Levels of theory generation were also included in the model and the researcher developed level of theory generation for the research based on the levels of theory generation of Dickoff et al. (1968) and Chinn and Kramer (1995). The research model that the researcher developed for developing a community-based model for health care social work encompasses certain phases and research activities, as well as theory generation and reasoning strategies. The reasoning strategies included analysis induction, synthesis, derivation and deduction. The first phase of the research was the problem analysis and project-planning phase of the research. The researcher carried into effect the following research activities. The researcher determined the feasibility of the research project; gained entry to and cooperation from setting and identified and involved role-players in the research. The identification and involvement of the role-players encompassed the sampling and the pilot study. The second phase of the research was the information gathering, analysis and synthesis phase of the research. This phase included research activities, as well as levels of theory generation. The research activities that were followed during this phase started with the conducting of semi-structured interviews with twenty-two patients and observations and the keeping of field notes. Ethical issues were addressed during this phase and formed part of the interviewing and observation process. Data analysis of interviews, with an independent coder, and literature control to affirm the findings of data analysis followed as part of the research activities. The researcher then utilized the Delphi technique with nine experts in health care social work. The aim of this was to establish the patient’s needs, established during data analysis, that a health care social worker could address and the intervention strategies that they could utilize. These needs and intervention strategies were established by questionnaires and a group session was held to reach consensus of data. The above-mentioned data established from health care social work experts were then compiled into a Lickert scale for twenty-five multi-disciplinary health care team members. The aim of the scale was to establish the needs that health care social work could address exclusively of most effectively, as well as the intervention strategies that they could utilize in the opinion of the multi-disciplinary health care team members. A final literature control completes the research activities of the information gathering, analysis and synthesis phase in order to establish if literature exist that verifying the results of the data obtained and if these could assist in the development of a communitybased model for health care social work. The levels of theory generation followed in the information gathering, analysis and synthesis phase of the research consist of the following: The first level of theory generation consisted of factor isolating theory. The researcher utilized concept analysis. Concepts were firstly identified and the researcher identified the concept health. The concept health is a central concept in all the policy documents and theory that were utilized in the problem analysis of the research. The concept health was also central in the data analysis and literature control of the interviews with patients. The concept health was then defined and refined by utilizing dictionaries and thesauruses, as well as utilizing sources of evidence namely, a model and contrary case, evidence of people and professional literature. The researcher then classified the concept health and the related concepts. The second level of theory generation, factor relating and structuring followed during the information gathering, analysis and synthesis phase of the research. The researcher related factors and associated them through statements that indicate interrelationships. The third level of theory generation consisted of the situation relating level followed by predicting relationships between concepts utilizing if-then statements. The third phase of the research was the design and early development phase. The researcher utilized the fourth level of theory generation that consisted of the situation producing level of theory generation to conduct the research activity of the creating and describing of the theoretical model for community-based health care social work. The last phase of the research consisted of the theory testing and evaluation phase of the research. The research activities that were followed encompass the planning of evaluation, selection of evaluation methods and then the evaluation process. The evaluation process was done with a panel of nine experts utilizing a specific questionnaire in the form of a Lickert scale. The panel consisted of academic staff from the Universities of the Witwatersrand, Pretoria and Randse Afrikaanse University from social work and nursing as well as multi-disciplinary health care team members from community health centres and social workers from different practice settings. The second part of the evaluation process was done during doctoral seminars where peer evaluation was done by health care social workers, medical doctors, nursing staff and allied health workers from different levels of service rendering including the Gauteng Health Department’ Head Office, community-based centres and different levels of hospitals. Participants from private hospitals also attended the doctoral seminars. The researcher then utilized the evaluation results to identify design problems and to revise the community-based model for health care social work. The final level of theory generation was then done in the theory testing and evaluation phase of the research to operationalize the model by describing guidelines for operationalization. The methods of trustworthiness that were followed during the research included the four criteria of Lincoln and Guba (1985) of credibility, transferability, dependability and conformability. The researcher finalized the research by indicating the conclusions from the research, specifying the limitations of the research and providing recommendations for social work practice, education and research. The research document might be marked by repetition of content, but this was necessary because chapter six, the model, as well as chapter eight, the guidelines for operationalizing the model, form the basis for health care social work practice at community health centres. These chapters could then be extracted from the research document as a tool for implementation. / Prof. J.B.S. Nel Prof. A. Nolte

M.Cur. / The purpose of this study is to compile a strategy for transformation management in a local authority. Traditionally local authorities rendered preventative and promotive services. The provinces were responsible for rendering of curative services. This service delivery was fragmented due to political policies and diversification. With the new political dispensation in South Africa, the White Paper for the transformation of health services in South Africa (1997), gives direction for the integration of health service delivery to achieve the following mission focussing on equity, acceptability, accessibility, affordability, availability and appropriateness. These policy/legislative changes therefore require a strategy for transformation management of primary health care services. This impacts on the current service delivery system. The type of service delivery has to be reconstructed, to accommodate free primary health care services for all South Africans, additional services like curative services, dental services and termination of pregnancy services. Human resource management will also undergo significant changes as the local authority is expected to take over the existing provincial staff allocated to clinics. This could result in labour unrest if not well managed. There are also financial constraints that will impact on this process of transformation. The scarcity or shortage of medicines, equipment and other supplies necessary for quality service delivery also impact on the transformation process. The changing environment is difficult to handle, especially as it involves human beings who react differently towards change. Some individuals adapt easily in a changing environment, others resist change. Many meetings have been held to discuss the transformation of health services. The outcomes of these meetings have clearly demonstrated that health personnel are experiencing problems which are a direct result of the transformation process. Therefore it is important for management in a local authority in the East Rand, to devise a transformation strategy in order to implement primary health care services effectively and efficiently. The transformation strategy requires careful planning and decision making, that will be beneficiary to all the role players involved. Management in a local authority will have to take a leading role in the transformation management of primary health care services. This situation can be either a "challenge" or a "dilemma".

Philosophiae Doctor - PhD / Diabetes mellitus, an international pandemic, is one of the greatest threats to global public health. It is estimated that 70% of patients with diabetes are living in developing countries. Since the inception of the Primary Health Care approach in South Africa in 2004, the number of patients with diabetes has doubled to an estimated 1.5 million South Africans. The overall aim of the study was to develop, implement and determine the effectiveness of a health promotion intervention for adult clients with type 2 diabetes mellitus from a South African urban community. The overarching design of the study was that of mixed methods, specifically the parallel mixed design. The first phase of the study was to determine the current practices regarding the management of diabetes mellitus and the study sample comprised of three hundred and thirty five adult clients with type 2 diabetes mellitus and eighteen health care professionals of randomly-selected community health centres (CHCs) in the four sub-structures of the Cape Metropolitan District. Data was collected from the adult clients with type 2 diabetes mellitus with structured, self-administered questionnaires and focus group discussions while semi-structured interviews were done with the health care professionals. The second phase of the study aimed to design a health promotion programme and both a review of the literature and a Delphi study were done to develop the proposed programme.

In today’s society 67% of women in the age of 16-29 doesn’t experience happiness in life. Even though people talk more freely of mental illness today there are still a shame and taboo about feeling unhappy and reach out for help to get better. The purpose of this study is to examine what motivates women with mental illness to search for help within the primary health care. To get an additional view of the work three sociologic theories and conceptions have been used to showcase the phenomenon. Ervin Goffmans theory about stigma, Thomas J Scheffs conception shame and Axel Honneths theory about confession. This study issued from a qualitative method in the shape of interviews with eight different women, where their vision of what motivates them, their experience and in what way it has been meaningful for them to seek help for their mental illness was showcased. The result established that family and friends is a motivator to seek help but also that the experience of seeking help was defective. The conclusion explained that it has been meaningful for them to get help and that the majority feels better today, but that they still have rough periods that in some cases won’t meet the requirements from the primary health care.

MPH / Department of Public Health / Prostate cancer (PC) screening is a strategy to identify cancer before it causes symptoms. However, men’s participation in prostate cancer screening seems inadequate and remains a public health concern worldwide. This leads most men to be diagnosed with an advanced prostate cancer where cancer cells spread to other parts of the body. The aim of this study was to assess the knowledge and attitudes of males towards prostate cancer screening at a selected village in Thulamela Municipality, Limpopo province. The study adopted a quantitative approach using a descriptive cross-sectional survey. A well-structured questionnaire was used to collect data from 245 men who are 40 years and above. The sample was selected using the simple random sampling technique. The Statistical Package for Social Scientists (SPSS) version 25.0 was used to analyse the collected data; and the results were presented in percentages, frequencies and tables. Cross tabulation, Chi square and Phi and Cramer’s V test were also utilised to test for association and effects size respectively at .05 level of significance. Respondent’s knowledge as an explanatory variable, screening practices as response variable was assessed. The findings of this study showed that 64.1% of respondents had inadequate knowledge about prostate cancer. About 62.4% respondents had no prior knowledge regarding prostate cancer and 69% of respondents didn’t know the age at risk for the development of PC, while 81.9% of respondents had never heard about PC, and 35.9% didn’t know that PC can be treated. 84.9% of respondents had positive attitudes towards PC screening, however, 96.7% had never undergone screening for prostate cancer and 46.9% indicated that they will never undergo PSA test. Furthermore, the study found a significant association between men’s knowledge of PC and their willingness to undergo PC screening, X2 (3, N=245) = 48.44, p = .001; men’s knowledge of PC was significantly related to their attitudes towards PC, X2 (1, N = 245) = 17.63, p = .001. The effect size was moderate, ɸ = .27. Knowledge was significantly associated with all the demographic variables. Therefore, this study recommends widespread public health campaigns focusing on educating men about prostate cancer risk factors, symptoms, treatment and ways to prevent and manage it through healthy lifestyles. / NRF

Master of Public Health - MPH / Twenty percent of the global population receiving antiretroviral therapy (ART) reside in South Africa (UNAIDS, 2017). Demand within the public health system, already constrained by human resource scarcities and budgetary and infrastructural challenges, is expected to increase given the estimate that only 56% of an estimated 7.1 million HIV positive people in South Africa are currently on ART (UNAIDS, 2017). Technical assistance (TA) interventions are deployed to support in-house government services to optimise services, however, rigorous studies to evaluate the impact of TA strategies are scarce.

Introduction Bihar ranks among the most socio-economically disadvantaged states in India, and its public health system had long suffered from structural deficiencies which contributed to poor health outcomes. In November 2013, the Bihar government, with funding from Gates Foundation and technical support from CARE India, launched the state-wide Bihar Technical Support Program (BTSP) – seeking to address gaps in infrastructure, supply chain, and human resources, as well as the quality of service delivery, so as to improve reproductive, maternal, newborn and child health (RMNCH) and nutrition service provision. BTSP adopted a two-pronged strategy – conducting (i) periodic comprehensive facility assessments (CFAs) to identify and address the structural gaps; and (ii) nurse-mentoring programs to develop competency among nursing cadres in providing basic and comprehensive emergency obstetric and newborn care (BEmONC/ CEmONC) services. Through three inter-linked papers, the dissertation aimed to conduct an evidence-based assessment of this health system strengthening program. “Facility readiness” (structural readiness of public health facilities) was operationalized in terms of infrastructure, essential supplies, and human resources, while “facility performance” was operationalized based on the direct observation of normal vaginal deliveries and newborn care (including management of immediate complications if needed) and infection prevention practices in the labor rooms. The first paper describes the evolution of BTSP, and examines the initial progress made in facility readiness between 2015 and 2016. The second paper: (i) conducts a comparative assessment of facility readiness between 2017 (at end of the first four years of BTSP) and 2019, and describes the continuation of progress or lack thereof; (ii) quantifies facility readiness through a scoring system that reflects the readiness to provide maternal and newborn care (MNC) services; and (3) compares the change in this score over time (2015, 2017 and 2019) across different districts and levels of health facilities in Bihar. Thus, the first and second papers together examine the extent to which Bihar’s public health facilities were structurally strengthened in terms of physical infrastructure, supplies and workforce by utilizing data from all four rounds of CFAs conducted till date. The third paper asks the next logical question in a health system strengthening process – was facility readiness positively and significantly associated with facility performance? This is an important query, as it aims to provide evidence of synergistic progress, as envisioned under BTSP. First, the paper examines whether the facility-level performance changed, by comparing baseline (May-December, 2018) and endline (October-December, 2019) assessment data from the nurse-mentoring program (locally called AMANAT Jyoti). Second, it assesses the association of facility readiness (based on CFA 2019 data) with endline facility performance in providing MNC services. Methods The first paper utilizes a structured, narrative review of scientific and grey literature to describe evolution of the BTSP since 2014, based on programmatic learnings through prior years (2011-2013) of collaborative vertical interventions. Subsequently, the paper measures the tangible change in select facility-level characteristics, utilizing quantitative data generated through two rounds of CFAs conducted by CARE India in 2015 (n=534 facilities) and 2016 (n=550 facilities). The second paper utilizes quantitative data generated through two rounds of CFAs conducted by CARE India in 2017 (n=550 facilities) and 2019 (n=552 facilities). Each CFAs covered all Level 2 (primary health centers) and Level 3 (higher-level facilities) public health facilities in Bihar that conducted at least 100 deliveries in the preceding year. Subsequently, the paper constructs a “facility-level MNC structural readiness score” – henceforth referred to as facility readiness score, based on a common set of indicators from CFA 2015, 2017 and 2019, to reflect human resources, infrastructure and essential supplies related to delivering MNC services. The paper uses this score to map the change at 2-year intervals, from 2015 to 2019, at both facility and district levels. The third paper utilizes quantitative data generated through two separate assessments conducted by CARE India – the 2019 CFA, and the 2018-2019 assessment of AMANAT Jyoti (nurse-mentoring program), which involved direct observation of normal vaginal deliveries, newborn care, and infection prevention practices in the labor rooms. The paper constructs baseline and endline facility-level MNC performance scores – henceforth referred to as facility performance scores based on data from AMANAT Jyoti assessments, and examines the association between endline facility performance and facility readiness scores. While descriptive statistics was used to present findings from the CFAs and AMANAT Jyoti assessments, paired t tests were used to test the mean change in scores over time and between the different levels of facilities. The association between endline facility performance and facility readiness scores was tested using simple as well as multiple linear and multinomial logistic regression modelling. Results With a demonstrated intent to improve the ailing public health sector, the Bihar government in 2010 forged a collaboration with Gates Foundation to accelerate progress across RMNCH and nutrition programs. Through the Integrated Family Health Initiative program (IFHI, 2011-2013), outreach-based and facility-based solutions were implemented in eight programmatically-prioritized districts to address the stated goals. However, over this period, it became apparent that long-term success of such initiatives remained critically dependent on strengthening the foundational components of Bihar’s public health system –physical infrastructure, supply chain for drugs, consumables and equipment, and the skilled health workforce. These programmatic learnings motivated a re-think and consequent state-wide launch of the BTSP – characterized by a novel structure of health governance that was deeply embedded within the public health system, and a robust information management system that could generate, analyze and disseminate data on community- and facility-level services to support decision making. The quantitative analyses of CFA data (in first and second papers) provided an assessment of the changes that happened at the level of health facilities, likely supported by the policy-level modifications. There was a clear sense of prioritization of the limited resources – with constant focus on structurally preparing health facilities to deliver basic MNC services, more so at Level 2 (primary health centers). By 2019, at least 99% facilities at either level provided 24x7 delivery services and had designated labor rooms, 97% had designated newborn care corners which were mostly located inside the labor rooms, 70% or more had at least one functional fetal doppler, baby weighing machine, radiant warmer, and AMBU bag with neonatal oxygen masks. The improvement in availability of essential supplies like oxytocin, misoprostol, magnesium sulphate, antibiotics, and reproductive health commodities (condoms, intrauterine contraceptive devices, sanitary napkins, iron-folic acid tablets, contraceptive pills) were particularly notable during the 2017 and 2019 CFAs. However, the supply chain variably faltered for a number of other essential supplies like oral rehydration solutions, functional oxygen cylinders, normal saline and ringer lactate solutions. The data revealed that facility-level inefficiencies in utilizing the electronic inventory management system to accurately reflect actual status of supplies within the facility, likely compromised procurement and distribution. With regards to human resources, while a large number of auxiliary and general nurse midwives were available for service during CFA 2019, the BTSP faced continuing challenges (2015-2019) in recruiting and/or retaining physicians, especially the specialist physician cadres. By CFA 2019, these structural changes were also supported by remarkable improvements in two related services areas –availability of emergency transport, and laboratory services. The comparison of facility readiness scores (second paper) based on CFA 2015, 2017 and 2019 showed that while the mean scores increased sharply for both Level 2 (increase=1.51 (95% confidence interval: 1.39, 1.63)) and Level 3 (1.39 (1.1, 1.69)) facilities between 2015 and 2017, the progress was less pronounced at both levels between 2017 and 2019. 25 of the 38 districts in Bihar demonstrated a continuous increase in mean scores over the 3 CFAs. As for the remaining 13 districts, their 2019 mean scores remained higher than that during 2015. The analysis of AMANAT Jyoti assessment data (third paper) revealed improvements across 36 (80%) of the 45 performance parameters assessed through direct observation of deliveries between the baseline and endline. However, at least 80% compliance was observed for only 11 of 45 (24%) assessed parameters at baseline, and 16 of 45 (36%) at endline. The mean facility performance score increased significantly among both types and levels of facilities – but the increase was higher among Level 3 (mean increase = 1.56, p=0.0005, n=13) and CEmONC (1.82, p=0.0029, n=9) facilities, than among Level 2 (0.32, p =0.0288, n=121) and BEmONC (0.33, p=0.0168, n=125) facilities. The regression analysis failed to identify any linear relationship between facility readiness and performance scores. However, a significant positive association was observed between facility readiness score and the middle tertile of endline facility performance score (vs. lowest tertile as reference) in multiple multinomial logistic regression modeling (n=132 facilities). With increasing facility readiness score, the odds of a facility being in the middle tertile of the endline facility performance score relative to the lowest tertile was 1.68 (95% CI = 1.02, 2.76), after controlling for baseline facility performance score, mean delivery volume, and the facility level. Conclusion The BTSP can be best described as a diagonal health system strengthening initiative –one that starts with a focus on specific programmatic (RMNCH) outcomes, but strives to achieve these through identifying and addressing bottlenecks across the health system. The efforts made to revamp health governance through creating structures for technical support from the state- to block-levels is particularly laudable, as is the remarkable capacity building in collecting and using facility-level data to inform programs and policies. The dissertation identified that BTSP has made appreciable progress in structurally preparing Bihar’s public health facilities to deliver basic MNC services – with improvements in related infrastructure, essential supplies, and supportive services like referral transport and laboratory facilities, as well as through recruitment of large number of ANM and GNM nurses. However, the process encountered a number of challenges, and it may be worthwhile to adopt a targeted approach to address some of these concerns. For example, it is important that the BTSP works to equip all facilities with electronic inventory management systems, while simultaneously training the personnel using such systems. To circumvent the chronic shortage of specialist physicians, a “task shifting” approach may help maximize utilization of existing health workforce to strengthen service delivery capacity. Further, the overall level of facility performance of MNC service delivery remained low at endline despite improvement from the baseline scores, and there was limited evidence of a significant positive association between facility readiness and performance scores. As these scores reflect the minimum essential requirements for a MNC service delivery setting, the BTSP clearly has challenges ahead. They must continue to address the persistent challenges in facility readiness and facility performance so that these two facility-level interventions will complement each other and influence outcomes. As the onus of this diagonal health system strengthening program incrementally shifts from development partners to the government, it will be important to recognize the significance and complexity of this effort.

Background The University of Cape Town Faculty of Health Sciences (UCT FHS) adopted the Primary Health Care (PHC) approach as its lead theme for teaching, research, and clinical service in1994 Aim To develop indicators to monitor and evaluate the implementation of the PHC approach in Health Sciences Education . Method A Delphi study, conducted over two rounds, presented indicators of Social Accountability from the Training for Health Equity Network (THEnet), as well as indicators derived from the principles of the PHC approach in the UCT FHS, to a national multidisciplinary panel. An electronic questionnaire was used to score each indicator according to relevance, feasibility/measurability, and its application to undergraduate and postgraduate curricula. Qualitative feedback on the proposed indicators was also elicited. Results Round 1: Of the 59 Social Accountability indicators presented to the panel, the 20 highest ranked indicators were selected for Round 2. Qualitative feedback challenged the link between social accountability and PHC, resulting in an additional 19 PHC-specific indicators being presented in Round 2. Round 2: The indicators which scored >85% and made the final list were: PHC: Continuity of care (94%); Holistic understanding of health care (88%); Respecting human rights (88%); Providing accessible care to all (88%); and Promoting health through health education (88%). THEnet: Safety of learners (88%); Education reflects communities' needs (86%); Teaching embodies social accountability (86%); Teaching is appropriate to learners' needs (86%) Conclusion These PHC and THEnet indicators can be used to assess the implementation of PHC in Health Sciences Education. The specific indicators identified reflect priorities relevant to the local context. One limitation is that some key priority indicators did not make the final list.