This thesis explores the provision of services for people with multimorbidity in general practice. It considers 3 broad research questions: how services are organised; why they are configured in this way; and the impact this organisation has on service delivery. At present, there is no formalised system for managing multimorbidity in general practice. Current arrangements reflect the wider organisation of care for chronic conditions which typically involves managing individual chronic conditions. The needs of people with multimorbidity are often complex and require a number of services from several providers. Coordinating these services is challenging, not least because of the fragmented system within which professionals and providers are situated. Different clinical, managerial and funding arrangements complicate this situation, creating as it does a number of parallel work streams. Effective healthcare for people with multimorbidity requires different providers to work collaboratively to promote linkage across professional and service boundaries. Information flows and administration play an important role in promoting continuity and coordination within and across work streams that span primary, secondary and tertiary care. In some instances, inefficiencies in services can be linked to the lack of integrative working between the clinical and administrative aspects of care. At present, fragmented systems are perpetuated by the lack of a whole systems approach that would align clinical, managerial and financial aspects of service provision across organisations. This thesis demonstrates that, services in general practice are increasingly determined by factors external to it. Most notably the division of care across multiple providers and the financial and contractual arrangements which require an organisation of services that promotes a division of labour and a routinsation, aimed at optimising the daily through put of patients. If the present and future needs of people with multimorbidity are to be effectively met, changes to the way services are provided in general practice must be considered as part of a whole system of healthcare, whereby collaborations between different professionals and services are intentionally organised and actively managed. Although the evidence base for managing multimorbidity is limited, there is a growing recognition that in terms of improving outcomes for people with multimorbidity, improving clinical care alone is not as effective as simultaneously improving the organisation or design of services across the whole system of provision.

South Africa has the largest number of people living with HIV and the largest HIV treatment program in the world, supplying antiretroviral therapy (ART) to 66% of the 7.6 million people living with HIV in the country in 2019. To reach the remaining 34%, the already overburdened health system needs to find ways of attracting and retaining groups at higher risk of attrition and optimizing convenience for providers and patients. We identified three examples of “differentiated service delivery”, an approach that adapts HIV services to patient and health system needs: (1) male clinics, attended and staffed exclusively by men, (2) youth clinics, exclusively for youth aged 12–25, offering flexible hours and youth-targeted services and (3) a pharmacy-led fast-track ART refill program where stable ART patients can pick up medication without seeing a clinician. We explore attrition (defined as death or loss to follow-up at end of follow-up time) in these services using data from a large, established HIV cohort in Khayelitsha, a high HIV-prevalence, low-income area in South Africa. The first study examines whether males attending two male clinics (Male Clinic 1 and Male Clinic 2) show lower attrition compared to those attending general primary healthcare clinics. Using exposure propensity scores, we matched male clinic patients 1:1 to males at other clinics and used Cox proportional hazards regression to estimate the association between attrition and attending a male clinic. In the unmatched cohort, patients from male clinics (n=784) were younger than males from general clinics (n=2726), median age: 31.2 vs 35.5 years. Those initiating at male clinics had higher median CD4 counts at ART initiation (Male Clinic 1: 329 [210–431], Male Clinic 2: 364 [IQR: 260–536] vs. general clinics 258 [IQR: 145–398] cells/mm3). The matched analysis included 1563 person-years among 1568 patients. Patients initiating ART at male clinics had lower attrition (HR: 0.83; 95% CI: 0.69–1.00). When matching and modelling was conducted for Male Clinic 1 and 2 separately, only the more established Male Clinic 1 showed a protective effect (HR 0.83; 95% CI: 0.65–1.07). The second study investigates whether attrition from care among youth (aged 12–25) on ART is lower among youth attending two youth clinics (Youth Clinic A and Youth Clinic B) compared to those attending general primary healthcare clinics. We also conducted a sub-analysis of patients attending adherence clubs (a model of ART delivery led by a lay facilitator, including a peer support group). We hypothesized that the effect of peer support in adherence clubs might be enhanced by the age-specific clubs at the youth clinics. It may also be further enhanced by additional elements of the adherence club model offered only in Youth Clinic A, including integration of family planning. Youth at the youth clinics were more likely than those at general clinics to have initiated ART before August 2011, particularly those at Youth Clinic B (23% compared to 11% at general clinics). The distribution of age, sex, and CD4 count at ART initiation was similar across youth and general clinics. We observed a protective effect of youth clinics against attrition: HR 0.81 (95% CI: 0.70–0.93) for Youth Clinic A and 0.85 (0.74–0.98) for Youth Clinic B, compared to youth at general clinics. Youth Clinic A club patients had lower attrition after joining an adherence club compared to general clinic patients in adherence clubs (crude HR: 0.56, 95% CI: 0.32–0.96; adjusted HR: 0.48, 95% CI: 0.28–0.85), while Youth Clinic B showed a smaller difference (crude HR: 0.83, 95% CI: 0.48–1.45; adjusted HR: 1.07, 95% CI: 0.60–1.90). The third study assesses attrition among patients in a pharmacy-led fast-track ART refill program compared to matched stable, otherwise healthy, patients who were eligible for the fast-track program at the same point in time and at the same facility but did not join. Matched pairs were followed from the date of the fast-track patient’s first fast-track ART pick-up, and attrition was compared using Cox proportional hazards regression. Fast-track patients and matched controls had similar characteristics at ART initiation and at fast-track enrolment. Fast-track patients were less likely to have previously experienced tuberculosis (23% vs 28%), diabetes (1% vs 7%) and hypertension (12% vs 27%), compared to those not in fast-track. Fast-track enrolment was highly protective against attrition (HR: 0.40; 95% CI: 0.31–0.51). We hypothesized that some of the association could be explained by confounding, arising from clinicians differentially referring patients to fast-track, possibly based on social, health, or mental health characteristics not reflected in the data. In a bias analysis using a plausible range of effects of such unmeasured confounding, the hazard ratio accounting for random and systematic error was 0.60 (95% interval: 0.42–0.89). All three studies show some protective effects of these differentiated models of service delivery against attrition. While stand-alone youth and male clinics are not feasible in all settings, and fast-track models may not be suited to all patients, these results suggest that multiple approaches tailored to specific populations’ needs can contribute to improving retention.

Thesis (MTech (Business Administration))--Cape Peninsula University of Technology, 2020 / Over the past decade, under the increasingly competitive business environment, many sub-Saharan African ISO9001 certified firms are struggling continuously to improve their business processes. Adversely, the lack of continuous improvement after implementating ISO9001 in many services-oriented organizations in Gabon has contributed to the erosion of quality in service delivery. Thus, this study investigates the impact of ISO9001 on service delivery at the logistics department of a brewery in Gabon. The study also identifies the key factors affecting ISO9001 implementation in organizations and exploring standard measurements of ISO9001 on service delivery. A mixed-methods approach, which includes both qualitative and quantitative methods were used in this study. The researcher used qualitative techniques to collect data from interviews, site observations, and document analysis. A questionnaire (n=135) was distributed in the company to obtain an understanding of the views of the respondents. Data were analyzed through the Statistical Package for Social Science (SPSS) version 24. The Cronbach's Alpha value was used to measure the internal consistency of the dataset, and the Spearman‘s rank correlation tests was used to assess on the sets of questions/ statements posed to the logistics department employees. Ethical issues were well-considered during the research process. The research findings indicate that managers should ensure that employees are regularly trained, and, organizational culture is well established and understood by everyone in the organization.

Introducing technological change to an organization’s normal processes can potentially bring about positive or negative results, depending mostly on the manner in which the change was facilitated and integrated into the organization. However, very little research has been done on information technology (IT) investment among hospitals, its effect on the personnel, as well as how it influences patient care and financial performance. Consequently, little is known about users’ resistance to new technologies and the precedents of technology rejection in healthcare. Therefore, this study seeks to fill the gap of understanding South African hospital staffs’ perceptions towards change, caused by introducing an information system into one of the hospital’s daily processes. Where resistance towards change is identified, the study aims to understand the reasons behind such resistance. Finally, it aims to find appropriate intervention strategies to deal with and minimize resistance. In doing so, the study seeks to contribute to the body of research regarding change resistance to information systems in public South African hospitals. By adopting a descriptive and exploratory interpretivist paradigm, in conjunction with an inductive approach, the study aims to get a better understanding of hospital staffs’ perceptions through shared meaning. The study adopted a case study research strategy, as it affords the researcher the opportunity to participate in the study, and as such contributes to the subjective interpretation of the findings. Data was collected using a mixed method approach, and was used to describe the difference between the current and proposed process. In addition, it was used to explore the reasons for change resistance to information system-supported change, and to explore methods of successfully introducing change to tertiary public hospitals in South Africa. Fourteen participants (7 medical interns and 7 ward clerks) who were directly involved in the process being studied, were interviewed. Two other participants (the head of the pharmacy and the patient flow manager), who were indirectly involved in the process, were interviewed, to verify the observed and mapped process. Interview data was analyzed qualitatively, firstly through coding techniques before using sentiment and thematic analysis. While the mapped process followed Business Process Modelling Notation conventions. In addition to a mapped proposed process, a change resistance conceptual model was developed from a conjunction of the findings and extensive review of literature. The conceptual model asserts that five main factors contribute to change resistance: unclearly defined duties; fear of job security and technology usage; years of service; resource availability and resource mismatch; as well as insufficient training resulting from the lack of a learning culture. These factors can be moderated by: the existing state of affairs referred to as status quo; management involvement; and communication. The conceptual model can be used to better understand the causes of change resistance, as well as how to minimize change resistance and successfully introduce change into a health organization. Change agents should aim to understand the status quo that exists in the organization and find ways of incorporating that into the change process. Furthermore, management should aim to involve and communicate with all affected stakeholders during a change process. This research has provided a better understanding of hospital staffs’ reactions to change, their reasons for resistance, and ways to minimize change resistance while successfully introducing change into a health organization.

Magister Administrationis - MAdmin / The research investigates the reason why service delivery is slow and not enough or just not available in many areas. It highlights the problems that hamper progress toward achieving service delivery. Some of the problems discussed are: (a) The non-availability of enabling legislation to enable the state department to carry out their projects and plans, including the difficulty of implementing policy. While the government is quick to announce that it is going to achieve certain goals, it does not follow through to achieve these goals. (b) Some of the government ministers are unwilling to bring about a speedy recovery because- (1) they are busy building their own images and wealth; and (2) most of all are party loyalists whose hands are tied by the socialist ideology. While the ministers preach about how successful they are in providing basic services to the people, the very same people we are told are served, are complaining that the government is not doing enough to address the problems that affect the poor. In more cases than one, the situation of the people has remained the same as if they were living during the old apartheid days.

B.URP / Department of Urban and Regional Planning

Presents real-life and day-to-day examples of service delivery problems which will be familiar to all readers. Then provides practical re-engineering solutions to remedy the problems. The vignettes illustrating the problems are all real-life cases based on the experiences of the authors, and the solutions they propose are also based on their encounters with service providers as educators and consultants, and talks to business audiences by both parties.

The objective of this study is to examine the applicability of process reengineering in a healthcare operational environment. The intake process of a mental healthcare service delivery system is analyzed systematically to identify process-related problems. A methodology which utilizes an open system orientation coupled with process reengineering is utilized to overcome operational and patient related problems associated with the pre-reengineered intake process. The systematic redesign of the intake process resulted in performance improvements in terms of cost, quality, service and timing.

The integration of mental health services in primary care settings has expanded rapidly in recent years with psychologists being at the forefront of efforts to promote healthy behaviors, reduce disease, and care for behavioral, emotional, and developmental needs to promote overall health and well-being for children and families (Asarnow, Kolko, Miranda,&Kazak, 2017; Stancin& Perrin, 2014). While there are many psychologists working in pediatric primary care (PPC), little is known about the specific activities that these psychologists engage in, the training they receive, or funding mechanisms that support their work. This study sought to address this gap in the literature through a survey of psychologists working in PPC. An anonymous online survey was disseminated to members of professional organizations and listservs who were identified as having interest in PPC. Psychologists (N-65) currently practicing in PPC completed the survey by reporting on clinical roles and practices, professional training, practice settings, and funding supports in PPC settings. Results indicate that psychologists assume a number of roles in PPC including providing individual and family therapy, conducting screenings for child mental health concerns, and providing consultation to medical colleagues. Many psychologists also provide supervision and offer educational opportunities for those in related fields, such as medicine and social work. Engagement in research activities was identified as a secondary activity. It was reported that a number of clinical activities were not billed for on a regular basis. Additional areas of research will be discussed along with implications for clinical services in PPC..

A thesis submitted in fulfillment of the requirements for the degree of Master of Arts in Communication Science at the University of Zululand, South Africa, 2012. / Relationship in banking has become very competitive in the recent past, more especially in the aftermath of the recent global economic meltdown. Most of the major banks in South Africa are not only striving to improve the quality and quantity of their clientele but also to maintain their survival in the corporate market. Most relationship in banks focus on customer satisfaction and customer loyalty, however, the issue of language barrier is being neglected in many banking halls. South Africa hosts eleven official languages and it is obviously not feasible for one particular bank to embrace all these languages for customer service, however, there can be varied strategies for individual banks to cater for clients in specific locations. This thesis examines how particular banks cater for the language needs of its immediate community. The primary goal of this study is to examine the current quality of service offered by the banking sector in South Africa especially in terms of service delivery proposed by the banking code of practice (ABSA COBP).The clients and staff of a bank in Zululand (KwaZulu-Natal) provided valuable information for this study. The data was collected through the use of structured interviews of clients and staff members. The study is informative and insightful in that it infiltrates the responsibilities policy makers in communicating with clients. Furthermore, the study exposes provocative and controversial issues in communication policy and hopes to stir awareness within the banking sector to improve relationship banking. This ground-breaking study also demonstrates how challenges faced by the clients cause banks to fail to meet its intended purpose. This study also exposes provocative and controversial challenges which place our banking sector at risk of total annihilation if left unattended. The study speaks to issues of accountability such as: planning and decision making and the plight of the people of our nation.