Submitted in fulfillment of the requirements for the Degree in Master in Technology: Marketing, Technikon Natal, 2003. / Managed care is defined by Chetty (1999: 1) as "the practice of evidence based medicine with an approach to managing both the quality and cost of medical care". Managed care was introduced into South Africa in the last decade due to increasing cost of healthcare. All forms of managed care represent attempts to control costs by modifying the behaviour of general practitioners. / M

Due to the increasing availability of ART (antiretroviral therapy),HIV is starting to be seen as a chronic disease. This has several effects on families, one of which is the need to disclose their HIV status to children who were born with the illness. Potential barriers and available support structures with regards to paediatric HIV disclosure need to be considered before specific guidelines can be given to caretakers and health care providers. This study aimed to explore and describe the patterns of paediatric HIV disclosure or non-disclosure using a sample of caretakers or parents of children/adolescents who were born with HIV. The Disclosure Decision Making Model (DDMM) was used as a framework to understand the decision-making process that leads to either disclosure or non-disclosure. Qualitative data was gathered by means of in-depth, semi-structured interviews, conducted in English. Ten participants were recruited from a community health care centre that offers HIV counselling and testing in the Nelson Mandela Bay Health District. Data gathered was transcribed and analysed using thematic analysis. Lincoln and Guba’s model was used to determine the trustworthiness of the data. The two themes that emerged from the study were (1) caretakers wish to disclose HIV status to the child but identified barriers to doing this and, (2) caretakers identified factors that helped them to disclose the child’s status. This study provides a more in-depth understanding of the factors that influence disclosure in a resource-limited setting in the Eastern Cape.

When the current South African government came into power two decades ago they inherited a fragmented health care system whose main focus was on the tertiary care level. The strategy of the current government was to re-focus the whole health care system and prioritize primary health care system. That included setting up district health care systems and building primary health care centres in the areas within the communities in order to make health care accessible to everybody. Due to financial difficulties the majority of the people staying in these communities solely depend on these clinics as they cannot afford to buy health care services in the private sector. The study seeks to assess the current medication supply chain to these clinics with a view of coming up with recommendations that, when implemented, will ensure that the supply of medication by the clinics is able to meet the demands of their patients. Lean management is a system that was started in the manufacturing sector and because of its success there it was later adopted by the service industry. Lean is a system that seeks to eliminate all forms of waste and improve the quality of the service rendered to the satisfaction of the customer/patient. Literature review and discussion of lean implementation is discussed extensively. The findings of the study are presented, analyzed and discussed. In these findings it is noted that the system is functioning very well but there are challenges in these clinics that need to be addressed. Recommendations of how lean management can be implemented successfully to optimize the functioning of the current system are discusse The permission received from the Department of Health to conduct this study came with contractual obligations that the researcher promised to honour. One of those requirement stated clearly that the findings of the study should not be published anywhere without the permission of the Department (see addendums A & C). It is under that premise that the researcher wants to bring this to the attention of the relevant university departments, with the hope of ensuring that this contractual obligation is honoured.

The South African Department of Health, like the health departments of many other countries, has reviewed its policies to focus on the delivery of comprehensive Primary Health Care (PHC). The South African health care sector is undergoing major restructuring in an attempt to address the inadequacies resulting from the fragmentation and duplication of health services in apartheid South Africa. Following this restructuring, the decentralisation to health services has been adopted as the model for both the governance and management of health issues (Department of Health, 2002:7). Before 1994, local government health departments were rendering certain primary health care services in terms of the Health Act 63 of 1977. Post 1994, the Constitution of the Republic of South Africa 1996 (Act 108 of 1996) classified primary health care as a provincial function. Based on this classification, primary health care services in South Africa are now being provided by two authorities, namely local government and provincial government, in the same community. Thus, in the Nelson Mandela Bay Municipality District, primary health care services are rendered by two authorities, namely the Nelson Mandela Bay Municipality and the Nelson Mandela Health District of the Eastern Cape Department of Health. These authorities are targeting the same community, with the same PHC package, with different sets of conditions of service, salary structures, infrastructure, accountability and authority. Such differences are believed to have impeded functional integration, depleted human resource capacity in rendering an effective and efficient PHC system and resulted in inefficient budget spending by both authorities. The problems of location, duplication and fragmentation of primary health care provision in the Nelson Mandela Bay Municipality District are not conducive to optimal service rendering. This will be resolved only once a unified, single integrated health service has been established. This study was undertaken to explore and describe the views of health practitioners with respect to the location of primary health care within the Nelson Mandela Bay Municipality District. The research design of this study was a quantitative, explorative, descriptive survey. Healthcare practitioners, like management, doctors and nurses, were asked to respond to a structured questionnaire. The findings of the study indicate that while health practitioners may hold diverse views on where primary health care should be located, they agree that a unified, single PHC authority would be desirable. Although primary health care is a combination of task-orientated basic health services and the process of community development, it is important that the authority of choice should ensure the highest possible quality through an integrated process, taking into account local needs. The recommendations made by the researcher on the conclusion of this study cover the principles on which a successful strategy for implementing primary health care should be based, including the need to create sustainable communities. It is hoped that the recommendations offered, will contribute to the more effective and efficient implementation of comprehensive primary health care services in Nelson Mandela Bay and also elsewhere in South African local government.

South Africa possesses a highly fragmented health system with wide disparities in health spending and inequitable distribution of both health care professionals and resources. The national health system (NHI) of South Africa consists of a large public sector and small private sectors which are overused and under resourced and a smaller private sector which is underused and over resourced. In broad terms, the NHI promises a health care system in which everyone, regardless of income level, can access decent health services at a cost that is affordable to them and to the country as a whole. The relevance of this study is to contribute to the NHI debate while simultaneously providing insights from other countries which have implemented national health care systems. As such, the South African government can then appropriately implement as well as finance the new NHI system specific to South Africa’s current socio-economic status. The objective of this study was to examine health care financing models in different countries in order to draw lessons for South Africa when implementing the NHI. A case study was conducted by examining ten countries with a national health insurance system, in order to evaluate the health financing models in each country. The following specific objectives are pursued: firstly, to review the current health management system and the policy proposed for NHI; secondly, to examine health financing models in a selected number of countries around the world and lastly to draw lessons to inform the South African NHI policy debate. The main findings were firstly, wealthier nations tend to have a much healthier population; this is the result of these developed countries investing significantly in their public health sectors. Secondly, the governments in developing nations allocate a smaller percentage of their GDP and government expenditure on health care. Lastly, South Africa is classified as an upper middle income developing country; however, the health status of South Africans mirrors that of countries which perform worse than South Africa on health matters. In other words the health care in South Africa is not operating at the standard it should be given the resources South Africa possesses. The cause of this may be attributed to South Africa being stuck in what is referred to as the “middle income trap” amongst other reasons.

The topic of the research is derived from the researcher‟s own interest as a social worker and observations of reality within youth-headed families. Over the past few years the number of published studies on child and youth-headed households has grown out of the realisation that this multi-faceted phenomenon is growing in numbers and complexity. Most of these studies and reports concentrate on the issue of scale and the severity of the crisis of child and youth-headed households (UNICEF, 2002; Maqoko & Dryer, 2007 & Kuhanen, Shemeikka, Notkola & Nghixulifwa, 2008). These studies reveal the complex nature of the phenomenon of child and youth-headed families and the challenges that face young people within these families which impact on their growth and development. In most of the studies, the phenomenon of child and youth-headed households has been reported to have an impact on societal framework as a result of its complexity (UNICEF, 2002, 2008; van Dijk, 2008; Kuhanen et al., 2008; Evans, 2010). Over the past years there has been a steady increase in studies that has focussed on coping and resilience of children and young people. Many of these studies have identified resilience-related factors through quantitative ecological approaches to research. To date, there seems to be very few qualitative studies that have been undertaken to delineate the construct of resilience in child and youth-headed families within the South African context from the perspectives of children and young people growing up in these families (Beeka, 2008; Nkomo, 2008; Leatham, 2005). McCubbin (1999, in Smith 2006:48) argues that qualitative research is well suited to understanding processes and strategies in the study of resilience. This study therefore corresponds to McCubbin‟ calling by employing a qualitative research to the study of resilience in youth-headed families. The first goal of this study was to gain a deeper understanding of the experiences and needs of youth-headed families in Port Elizabeth, South Africa, as well as to enhance understanding of the protective factors and processes within youth-headed families and their environment that enable them to cope with their circumstances. The secondary goal of this study was to formulate practice guidelines for supporting members of youth-headed families that could be used by social workers and other service providers rendering services to these families in order to enhance their coping and resilience. The following objectives were formulated to guide the research process: - To explore and describe the experiences and needs of youth-headed families; - To explore the perceptions of community members regarding the needs of youth-headed families, as well as their perceptions regarding how these needs are addressed at community level; - To identify and describe the protective factors and/or processes within individual members of youth-headed families, their families and community context that promote the coping and resilience of youth-headed families; - To explore the views of service providers rendering services to youth-headed families regarding the nature of interventions and programmes rendered to these families; - To review the literature on existing family support programmes in order to identify good practice examples to inform the formulation of practice guidelines for supporting members of youth-headed families.

One of the greatest challenges facing sub-Saharan Africa, which incorporates South Africa, is the AIDS pandemic. The devastation wrought by this disease is unsurpassed in recent times. The health and social development structures, already overburdened, are totally overwhelmed by the needs of povertystricken households and communities affected by AIDS. Caregivers attempting to support those affected and infected are also facing unique challenges and demands, particularly relating to dealing with the large numbers of deaths due to this disease. Experiences for these caregivers are likely to be varied, ranging on a continuum from positive to negative, for instance, the recovery of patients versus the death of patients. The objectives of this study are to explore and describe the lived experiences of caregivers working with AIDS patients, particularly patients who die from this disease whilst resident in a formal institution. The research is based on a qualitative, explorative, descriptive and contextual research design. The study is grounded in a phenomenological approach to inquiry. Caregivers working fulltime in a formal institution caring for patients who are dying from AIDS were interviewed in an in-depth, unstructured manner in order to gather spontaneous, rich descriptions of their experiences. Through this study the researcher wants their voices to be heard, the potential richness of their reflections acknowledged and the generated data to be applied to the benefit of the field of HIV/AIDS – both for staff and patients. Thirteen in-depth, unstructured interviews provided saturated data, which was then transcribed and coded to yield the central and sub-themes that were identified in this study. One central theme identified the fact that in their daily duties (at their place of work), caregivers experience various challenges as a result of having to deal with the death and dying of their patients suffering from AIDS. These caregivers face the death of their patients daily, from a disease that causes untold suffering to the patient, family members and to the caregivers themselves, who wish they could prevent the anguish, the pain and the inability of the medical profession to do more than they are at present towards curing this disease. ii By describing the lived experiences of these caregivers by means of the research interviews, the researcher gained a clear picture of the AIDS environment. The information shared by the participants formed the foundation of the broad guidelines that were formulated. These are intended to provide support for the caregivers centering around the equipping of mentors of the caregivers, to enable them to support the caregivers in their daily task of caring for patients dying from AIDS. These caregivers, thus supported, will then be in a position to provide optimal care for these dying patients. These broad guidelines are intended to provide support by focusing firstly on the physical environment in which these caregivers work; secondly in providing education for the caregivers to enable them to fulfill their duties, and thirdly to provide adequate counselling to ensure that they do not succumb to caregiver fatigue/burnout, a constant threat in this type of environment. The study concludes with recommendations regarding the areas of nursing practice, education and research.

Human Immune Deficiency Virus (HIV), which results in Acquired Immune Deficiency Syndrome (AIDS), has many manifestations. Literature reveals that some of these manifestations may compromise the infected individual’s sense of well-being and negatively impact on health related quality of life. As the number of people living with HIV/AIDS disease grows, so does the need for their care. In the early days of the AIDS epidemic, care was primarily handled by special agencies, hospitals and clinics. These agencies have been inundated with the demands of people living with HIV/AIDS, while their resources are shrinking. As it stands now, the total assistance given to people living with HIV/AIDS is provided by relatives and this responsibility of caregiving will more increasingly rest with families. This situation is particularly salient for the rural community in South Africa, which has been disproportionately affected by the AIDS epidemic. AIDS has a tremendous impact on the entire family system, particularly on the individual who has primary responsibility for caregiving. The caregiver must cope with many circumstances that are frustrating and often beyond their control. Caring for a Person Living with HIV/AIDS (PLWHA) appears to be a major stressor in the lives of caregivers, and can be very demanding, impacting on carers financially, physically, emotionally and socially. Given the lack of research on HIV/AIDS family caregiving from a salutogenic approach, this study aimed to explore and describe the sense of coherence and coping of family caregivers of HIV/AIDS patients in the Kwazakhele area in Port Elizabeth. The sample consisted of 50 participants aged between 21 and 65 years, recruited via the Kwazakhele Masizakhe Project. An exploratory-descriptive design was employed. Data was obtained by a biographical questionnaire, the Coping Resources Inventory (CRI) and the Sense of Coherence (SOC-29) Questionnaire. A non-probability convenience sample of adult male and female family caregivers were sampled. Descriptive statistics and correlation coefficients were utilized to describe and explore the coping and sense of coherence of the family caregivers and the correlation between these constructs, respectively. The data obtained from the biographical questionnaire was analysed by using descriptive statistics and frequency counts. Key findings include the following: Results from the coping resources measure indicated that this sample perceived themselves as having an average level of coping resources. The sample tended to rely more readily on spiritual resources and less on cognitive resources. Results from the SOC-29 revealed fairly high mean scores. There is no positive relationship between the SOC-29 and the CRI for the current sample. No significant relationship existed between the SOC and the subscales of the CRI. Suggestions are made for future research, the limitations and value of research were outlined.

Purpose of this treatise- This Paper aims to investigate the Sustainability of Health Facility Committees in the Nelson Mandela Bay Health District. Design/methodology/approach – This study consists of a literature review and a pilot study. Qualitative research approach was used in order to obtain descriptive data from the targeted group. The primary sources of data collection the researcher used were from the members of the committee, health facility manager, chairperson and the health promoter who are members of the health committees. Focus group discussions with health committees were conducted to provide rich in-depth data. Literature and journal articles were also used to provide secondary data to corroborate findings. Research limitations- A major limitation to this study is that due to the nature of the nature of the research report it was not possible to assess the sustainability of health Facility Committees from other areas in the Nelson Mandela Bay Health District. Findings-The study has revealed that Community Health committees are sustained by the commitment and passion members have for the work done in the facilities and health committees. The study also revealed that social cohesion plays a major part in the sustainability of Community Health Committees (CHC). Lack of involvement by ward councilors, support from the Health Department, uncertainty of responsibilities by the health committees and limited skills were indicated as major setbacks threatening the sustainability of Community Health Committees. It can thus be concluded that these limitations must be properly addressed in order to enable and uphold the sustainability of Community Health Committees. Original/value -So far, there has been limited research which has been undertaken with regards to the subject of Sustainability of Health Facility Committees in Nelson Mandela Bay Health District. This study will aid in enabling a better understanding of what sustains Community Health Committees and the Challenges facing such communities in order to enable individuals and the parties involved to better formulate solutions to overcome these challenges in Nelson Mandela Bay.

M.Comm. / Health care in South Africa has been well described in terms of structure. However, to what extent would it be possible to describe the health care sector in South Africa in terms of that used to describe an industry? What conclusions could be drawn at the end of the study if this was or was not possible? Strong emphasis in industry analysis is placed on the nature of the competitive forces and on levels of profitability. Can the South African health care sector also be described in those terms? The following objectives can be identified in this study: To complete a literature review on the structure of health care in South Africa in terms of facilities, geographic location, services offered, manpower, financing, remuneration, population served and legislation. To complete a literature review on models and methods that can be used to analyse industries. To determine to what extent it is possible to apply Porter's model (and others) of industry analysis to the South African health care industry. To identify key success factors for the industry. To draw conclusions from the study and make some recommendations.