The Free State’s approach to implementing the Comprehensive Plan: notes by a participant outsider

This study reviews the first two years of implementation of the Comprehensive Plan in the Free State, within the national framework and amid external influences. The features and principles of the province’s approach are analysed, in particular the phased, multimodel, PHC-centred nature and its emphasis on partnerships and inclusiveness. As implementation progresses, constraints and deficiencies are seen to emerge: a lack of leadership and support, a flawed national-provincial relationship, a lack of comprehensiveness, programme verticalisation, drug insecurity, chronic  indecision and lack of action, a fixation on operational issues with concomitant neglect of strategic matters, and breakdowns in communication and co-ordination. Despite notable progress in implementation, it  is necessary to rethink and redesign aspects of the approach. By identifying the major lessons to be learnt from the Free State’s experience, this study attempts to inform such rethinking and redesigning, as well as highlighting lessons for application elsewhere

Collaborative mental health care in the bureaucratic field of post-apartheid South Africa

South Africa's long and arduous journey from colonial and apartheid-era care for people with mental illness to more comprehensive, equitable mental health care is well-described. Deeper engagement with the structural power dynamics involved in providing collaborative mental health services are less-well described, especially in its post-apartheid era. This conceptual article positions state and non-state mental health service providers - along with their relationships and conflicts - within Bourdieu's bureaucratic field. It is suggested that key internecine struggles in South Africa's post-apartheid socio-political arena have influenced the ways in which collaborative mental health care is provided. Drawing from two recent examples of conflict within the bureaucratic field, the article illustrates the ways in which neoliberal forces play out in contemporary South Africa's mental health service delivery. Struggles between the state and private healthcare in the Life Esidimeni tragedy receive focus, as well as the shifting of responsibility onto civil society. A court case between the state and a coalition of non-profit organisations provides further evidence that neoliberal rationalities significantly influences the position and power of non-state service providers. Unless serious consideration is given to these dynamics, collaborative mental health care in South Africa will remain out of reach

Preface

The global recognition of rights to treatment reflects a significant shift in mindset. Another shift is now needed to deliver on those aspirations. Health systems cannot be built from a patchwork of non-government, vertical, ad hoc services around a crumbling public sector core. For treatment access to become a reality for more than a minority, a further step needs to be taken towards explicit global and national commitment to refinance Africa’s public health sector and district health systems (Loewenson & McCoy 2004)

Tuberculosis infection control practices in a high-burden metro in South Africa : a perpetual bane for efficient primary health care service delivery

Background: Tuberculosis (TB) prevention, including infection control, is a key element in the strategy to end the global TB epidemic. While effective infection control requires all health system components to function well, this is an area that has not received sufficient attention in South Africa despite the availability of policy and guidelines. Aim: To describe the state of implementation of TB infection control measures in a high-burden metro in South Africa. Setting: The research was undertaken in a high TB-and HIV-burdened metropolitan area of South Africa. More specifically, the study sites were primary health care facilities (PHC), that among other services also diagnosed TB. Methods: A cross-sectional survey, focusing on the World Health Organization levels of infection control, which included structured interviews with nurses providing TB diagnosis and treatment services as well as observations, at all 41 PHC facilities in a high TB-burdened and HIV-burdened metro of South Africa. Results: Tuberculosis infection control was poorly implemented, with few facilities scoring 80% and above on compliance with infection control measures. Facility controls: 26 facilities (63.4%) had an infection control committee and 12 (29.3%) had a written infection control plan. Administrative controls: 26 facilities (63.4%) reported separating coughing and non-coughing patients, while observations revealed that only 11 facilities (26.8%) had separate waiting areas for (presumptive) TB patients. Environmental controls: most facilities used open windows for ventilation (n = 30; 73.2%); however, on the day of the visit, only 12 facilities (30.3%) had open windows in consulting rooms. Personal protective equipment: 9 facilities (22%) did not have any disposable respirators in stock and only 9 respondents (22%) had undergone fit testing. The most frequently reported barrier to implementing good TB infection control practices was lack of equipment (n = 22; 40%) such as masks and disposable respirators, as well as the structure or layout of the PHC facilities. The main recommendation to improve TB infection control was education for patients and health care workers (n = 18; 33.3%). Conclusion: All levels of the health care system should be engaged to address TB prevention and infection control in PHC facilities. Improved infection control will address the nosocomial spread of TB in health facilities and keep health care workers and patients safe from infection

Human resource development and antiretroviral treatment in Free State province, South Africa

<p>Abstract</p> <p>Background</p> <p>In common with other developing countries, South Africa's public health system is characterised by human resource shortfalls. These are likely to be exacerbated by the escalating demand for HIV care and a large-scale antiretroviral therapy (ART) programme. Focusing on professional nurses, the main front-line providers of primary health care in South Africa, we studied patterns of planning, recruitment, training and task allocation associated with an expanding ART programme in the districts of one province, the Free State.</p> <p>Methods</p> <p>Data collection included an audit of professional nurse posts created and filled following the introduction of the ART programme, repeated surveys of facilities providing ART over two years to assess the deployment of staff, and secondary data analysis of government personnel databases to track broader patterns of recruitment and training.</p> <p>Results</p> <p>Although a substantial number of new professional nurse posts were established for the ART programme in the Free State, nearly 80% of these posts were filled by nurses transferring from other programmes within the same facility or from facilities within the same district, rather than by new recruits. From the beginning, ART nurse posts tended to be graded at a senior level, and later, in an effort to recruit professional nurses for the ART programme, the majority (54.6%) of nurses entering the programme were promoted to a senior level. The vacancy rate of nurse ART posts was significantly lower than that of other posts in the primary health care (PHC) system (15.7% vs 37.1%). Nursing posts in urban ART facilities were more easily filled than those in rural areas, exacerbating existing imbalances. The shift of nurses into the ART programme was partially compensated for by the appointment of additional support staff, task shifting to community health workers, and a large investment in training of PHC workers. However, the use of less-trained, mid-level enrolled nurses and nursing assistants in the ART programme remained low.</p> <p>Conclusion</p> <p>The introduction of the ART programme has revealed both strengths and weaknesses of human resource development in one province of South Africa. Without concerted efforts to increase the supply of key health professionals, accompanied by changes in the deployment of health workers, the core goals of the ART programme – i.e. providing universal access to ART and strengthening the health system – will not be achieved.</p

Mentoring children guilty of minor first-time crimes: methods, strengths and limitations

In the absence of evidence regarding the impact of mentoring on child offenders in South Africa, this article explores the strengths and limitations of this approach in a local context. It investigates the theory and methods of mentoring, and presents a case study of the strategy as practised by the National Youth Development Outreach in Pretoria. Mentoring appears ineffective for children with hardened negative attitudes and chronic offending as their value preferences may contradict those of mentors. Three months are insufficient to establish meaningful relationships and achieve mentoring goals. Reconciliation – a central objective of the Child Justice Act (75 of 2008) – is difficult to achieve given the absence of victims in the mentoring process

Tuberculosis: the complexity of the phenomenon and the magnitude of the problem

From text: The rationale for studying tuberculosis (TB) in a multidisciplinary manner is to be found in both the complex nature of the TB phenomenon and the magnitude of the TB problem. TB is caused, spread and sustained by various factors. To control the epidemic this multiplicity of factors has to be unravelled and coherently addressed

Human resources for ART in the Free State public health sector: recording achievements, identifying challenges

The shortage of human resources for health poses a serious threat to public sector ART in South Africa. In the Free State, recruitment of staff for ART emphasises the challenges of securing the necessary number and categories of health professionals. Amongst others, not all posts were filled, and some appointments left vacancies in other programmes and facilities. Practice indicates that sites should be staffed according to the demand for the service, instead of general staffing norms. It is argued that health workers who currently do not work in the programme should receive training in ART in order to spread workloads more evenly in facilities. The realities of staff frustrations and discontent also call for improved supervision and support. The study suggests that the strengthening of the health system via human resources for ART is still to transpire. To achieve this, improved strategic planning is required

Tuberculosis control in South Africa: reasons for persistent failure

This study reviews the origins and spread of tuberculosis in South Africa in the international context. It shows that TB is far from being under control, despite the availability of effective technology. Five arguments offer   explanations for this failure. First, control strategies fail to eradicate the macro-conditions that create a breeding ground for TB. Secondly, new disease conditions — especially HIV/AIDS and MDRTB — confound efforts at control. Thirdly, the health system and its priorities are insufficiently focused and resourced to cope with TB. Fourthly, healthcare staff responsible for TB care are often weak links in the chain of control. Fifthly, TB patients fail due to ignorance, delay in seeking care, and non-adherence to treatment regimens. TB consequently remains a major public health challenge, today more than ever in its protracted history

State and non-state mental health service collaboration in a South African district : a mixed methods study

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