Re-imagining community participation at the district level: Lessons from the DIALHS collaboration.

In South Africa, the value of community participation as one of the central components of a primary health care approach is highlighted in legislation, policy documents and strategic plans. There is widespread acceptance that community participation strengthens community empowerment, disease prevention and access to services. Since 2010, the District Innovation and Action Learning for Health System Development collaboration has co-produced knowledge about how to strengthen district health systems. Nested within this collaboration is a series of engagements seeking to understand and strengthen community participation including a multi-stakeholder health risks and assets mapping activity; ‘Local Action Group’ initiatives; reflective meetings with service colleagues about community participation experiences; and a capacity-development initiative (community participation-related short courses and mentoring). These engagements hold a number of lessons for those interested in enhancing the population orientation of primary health care and the district health system, the first of which is the clear benefit to those interested in community roles and engagement of convening spaces for dialogue. However, it is not easy to generate and sustain these spaces. Through the application of a framework of collective capacity, this chapter aims to shed light on why this is the case, and in so doing, to highlight a second lesson, which is the perhaps unrecognised capacities of certain cadres, particularly environmental health practitioners, in the implementation of community participation. Ultimately, the chapter seeks to stimulate thinking and engagement about the ways in which dialogue and participation can enrich the South African health system

Managerial competencies of hospital managers in South Africa: a survey of managers in the public and private sectors

<p>Abstract</p> <p>Background</p> <p>South Africa has large public and private sectors and there is a common perception that public sector hospitals are inefficient and ineffective while the privately owned and managed hospitals provide superior care and are more sustainable. The underlying assumption is that there is a potential gap in management capacity between the two sectors. This study aims to ascertain the skills and competency levels of hospital managers in South Africa and to determine whether there are any significant differences in competency levels between managers in the different sectors.</p> <p>Methods</p> <p>A survey using a self administered questionnaire was conducted among hospital managers in South Africa. Respondents were asked to rate their proficiency with seven key functions that they perform. These included delivery of health care, planning, organizing, leading, controlling, legal and ethical, and self-management. Ratings were based on a five point Likert scale ranging from very low skill level to very high skill level.</p> <p>Results</p> <p>The results show that managers in the private sector perceived themselves to be significantly more competent than their public sector colleagues in most of the management facets. Public sector managers were also more likely than their private sector colleagues to report that they required further development and training.</p> <p>Conclusion</p> <p>The findings confirm our supposition that there is a lack of management capacity within the public sector in South Africa and that there is a significant gap between private and public sectors. It provides evidence that there is a great need for further development of managers, especially those in the public sector. The onus is therefore on administrators and those responsible for management education and training to identify managers in need of development and to make available training that is contextually relevant in terms of design and delivery.</p

Is the Alma Ata vision of comprehensive primary health care viable? Findings from an international project

BACKGROUND: The 4-year (2007 2011) Revitalizing Health for All international research program (http://www. globalhealthequity.ca/projects/proj_revitalizing/index.shtml) supported 20 research teams located in 15 lowand middle-income countries to explore the strengths and weaknesses of comprehensive primary health care (CPHC) initiatives at their local or national levels. Teams were organized in a triad comprised of a senior researcher, a new researcher, and a 'research user' from government, health services, or other organizations with the authority or capacity to apply the research findings. Multiple regional and global team capacityenhancement meetings were organized to refine methods and to discuss and assess cross-case findings. OBJECTIVE: Most research projects used mixed methods, incorporating analyses of qualitative data (interviews and focus groups), secondary data, and key policy and program documents. Some incorporated historical case study analyses, and a few undertook new surveys. The synthesis of findings in this report was derived through qualitative analysis of final project reports undertaken by three different reviewers. RESULTS: Evidence of comprehensiveness (defined in this research program as efforts to improve equity in access, community empowerment and participation, social and environmental health determinants, and intersectoral action) was found in many of the cases. CONCLUSION: Despite the important contextual differences amongst the different country studies, the similarity of many of their findings, often generated using mixed methods, attests to certain transferable health systems characteristics to create and sustain CPHC practices. These include: 1. Well-trained and supported community health workers (CHWs) able to work effectively with marginalized communities 2. Effective mechanisms for community participation, both informal (through participation in projects and programs, and meaningful consultation) and formal (though program management structures) 3. Co-partnership models in program and policy development (in which financial and knowledge supports from governments or institutions are provided to communities, which retain decision-making powers in program design and implementation) 4. Support for community advocacy and engagement in health and social systems decision making These characteristics, in turn, require a political context that supports state responsibilities for redistributive health and social protection measures.IS

Emerging roles and competencies of district and sub-district pharmacists: a case study from Cape Town

District and sub-district pharmacist positions were created during health sector reform in South Africa. High prevalence of HIV/AIDS, tuberculosis and increasing chronic non-communicable diseases have drawn attention to their pivotal roles in improving accessibility and appropriate use of medicines at the primary level. This research describes new roles and related competencies of district and sub-district pharmacists in Cape Town. Between 2008 and 2011, the author (HB) conducted participatory action research in Cape Town Metro District, an urban district in the Western Cape Province of South Africa, partnering with pharmacists and managers of the two government primary health care (PHC) providers. The two providers function independently delivering complementary PHC services across the entire geographic area, with one provider employing district pharmacists and the other sub-district pharmacists. After an initiation phase, the research evolved into a series of iterative cycles of action and reflection, each providing increasing understanding of district and sub-district pharmacists’ roles and competencies. Data was generated through workshops, semi-structured interviews and focus groups with pharmacists and managers which were recorded and transcribed. Thematic analysis was carried out iteratively during the 4-year engagement and triangulated with document reviews and published literature. Five main roles for district and sub-district pharmacists were identified: district/sub-district management; planning, co-ordination and monitoring of pharmaceuticals; information and advice; quality assurance and clinical governance; and research (district pharmacists)/dispensing at clinics (sub-district pharmacists). Although the roles looked similar, there were important differences, reflecting the differing governance and leadership models and services of each provider. Five competency clusters were identified: professional pharmacy practice; health system and public health; management; leadership; and personal, interpersonal and cognitive competencies. Whilst professional pharmacy competencies were important, generic management and leadership competencies were considered critical for pharmacists working in these positions. Similar roles and competencies for district and sub-district pharmacists were identified in the two PHC providers in Cape Town, although contextual factors influenced precise specifications. These insights are important for pharmacists and managers from other districts and sub-districts in South Africa and inform health workforce planning and capacity development initiatives in countries with similar health systems.Web of Scienc

Options for health: Western Cape: preliminary findings on the feasibility of incorporating options in to routine adherence counselling practice

Report prepared for feedback meeting between the Options Research Team and Stakeholders, HSRC, 1 JulyIn response to a recent finding that 44.7% of people initiating ARV treatment in public health clinics in Cape Town had had unprotected sex at last sex (Eisele et al., 2009), we conducted a process evaluation of Options for Health: Western Cape, an intervention delivered by ARV adherence counsellors and aimed at reducing sexual risk behaviour and optimising ARV adherence among people on ARV treatment in Cape Town. Based on Motivational Interviewing and the Information, Motivation and Behavioural (IMB) skills model of behaviour change, Options is a model for counselling that is different to the model in which lay counsellors are currently trained by the AIDS Training, Information and Counselling Center (ATICC). The purpose of the report is to present findings relating to the implementation of Options for Health: Western Cape that will inform the decision on how to proceed with the rollout of the intervention

Role of health extension workers in improving utilization of maternal health services in rural areas in Ethopia: a cross sectional study

Currently under review for publicatio

Translating research into practice: the implementation of options for health: Western Cape

Poster presented at the 6th PHASA 2010 Conference, 29 November - 1 Decembe

Improving the counselling skills of lay counsellors in antiretroviral adherence settings: a cluster randomised controlled trial in the Western Cape, South Africa

Little research has investigated interventions to improve the delivery of counselling in health care settings. We determined the impact of training and supervision delivered as part of the Options: Western Cape project on lay antiretroviral adherence counsellors' practice. Four NGOs employing 39 adherence counsellors in the Western Cape were randomly allocated to receive 53 h of training and supervision in Options for Health, an intervention based on the approach of Motivational Interviewing. Five NGOs employing 52 adherence counsellors were randomly allocated to the standard care control condition. Counselling observations were analysed for 23 intervention and 32 control counsellors. Intervention counsellors' practice was more consistent with a client-centred approach than control counsellors', and significantly more intervention counsellors engaged in problem-solving barriers to adherence (91 vs. 41 %). The Options: Western Cape training and supervision package enabled lay counsellors to deliver counselling for behaviour change in a manner consistent with evidence-based approaches.

Behaviour change counselling for ARV adherence support within primary health care facilities in the Western Cape, South Africa

Health care systems have been described as ideal settings for behaviour change counselling interventions. There is little research evaluating the feasibility of implementing such interventions in routine practice in primary care facilities. We implemented an intervention called Options for Health within routine adherence counselling practice in 20 antiretroviral facilities in Cape Town, South Africa. Lay counsellors were trained to use Options to help clients to optimise ARV adherence and reduce sexual risk behaviour. Counsellors delivered the intervention to 9% of eligible patients over 12 months. Interviews with counsellors revealed barriers to implementation including a lack of counselling space, time pressure and patient resistance to counselling. Counsellors felt that Options was not appropriate for use with all patients and adherence problems, and used parts of the intervention as it suited their needs. Findings revealed weaknesses in the current adherence counselling system that have implications for the feasibility of behaviour change counselling within this context.

"It's important to take your medication everyday okay?": an evaluation of counselling by lay counsellors for ARV adherence support in the Western Cape, South Africa

There is growing interest in standard care programmes for antiretroviral (ARV) adherence support. In South Africa, individual counselling following ARV initiation is a main strategy for supporting adherence in the public sector. Egan's client-centred "Skilled Helper" counselling model is the predominant model used in HIV counselling in this context. This study evaluated counselling delivered by lay ARV adherence counsellors in Cape Town in terms of adherence to Egan's model. Thirty-eight transcripts of counselling sessions with non-adherent patients were analysed based on the methods of content analysis. These sessions were conducted by 30 counsellors. Generally counsellors' practice adhered neither to Egan's model nor a client-centred approach. Inconsistent with evidence-based approaches to counselling for ARV adherence support, counsellors mainly used information giving and advice as strategies for addressing clients' non-adherence. Recommendations for improving practice are made. The question as to how appropriate strategies from developed countries are for this setting is also raised.