PHC Re-engineering: formative research for Soul City Television Series

“If you need to go to the Clinic you have to wake up very early in the morning and arrive there around 3am to get early help because if you arrive at 7am you will wait and wait, you can even come out around 4pm having spent the whole day at the Clinic.” (Rural group 16yrs – 19yrs-KZN)

Soul City Institute for Health and Development Communication, supported by the European Union and the Department of Health, is developing a communication intervention that will support the primary health care (PHC) re-engineering process that is currently underway.  The intervention is a multi-component one, with an important part being the Soul City television drama consisting of 26 episodes. The popular television series will carry a story that engages with PHC re-engineering as well as key PHC issues (reaching about 7 million people each episode).  The TV will be backed up by radio discussions, print material, and information to children in Soul Buddyz Club (6000 childrens school based childrens clubs for 8-14 year olds which aim to increase child activism and improve their quality of life) about PHC and it's role, as well as training of clinic committees and a community-based monitoring programme.

The PHC re-engineering strategy "seeks to shift the PHC system from a passive, curative, vertically and individually oriented system to one with a more proactive, integrated and population-based approach”. PHC services will be re-engineered to focus mainly on community outreach services to ensure that service delivery extends from health facilities into communities and homes, in a manner that upholds the dignity and decision-making rights of the people. The re-engineering philosophy, in which community health workers (CHWs) form as essential part, will focus mainly on health promotion, preventative care, as well as ensuring that a quality curative and rehabilitative care is provided. All members of the population are entitled to a defined comprehensive package of health services at all levels of care – primary, secondary, tertiary and quaternary – with guaranteed continuity of health care benefits. PHC services will be delivered according to three streams: district based clinical specialist teams, school based teams and ward based PHC outreach teams.

To inform the intervention a literature review was undertaken, key stakeholders were consulted and target audience research performed. The presentation at the PHASA conference in 2013 related to the audience research and this will hence be discussed here.

A qualitative cross-sectional study was conducted in seven provinces among youth (aged 16 to 19 years); adults (16 years and older); health care workers (primarily CHWs); and traditional healers. Seventeen qualitative interviews were conducted in local languages, in urban and rural areas in Mpumalanga, North West Province, Free State Province, Limpopo, Western Cape, Gauteng, Northern Cape and KwaZulu-Natal. The focus was on Africans, but participants from other race groups were not excluded. Focus group discussions of between 8 – 12 participants were conducted, using a previously tested, open and non-directive discussion guide. A free attitude interviewing technique was followed, allowing the social construction of experiences to emerge in the words of the participants themselves, and according to their priorities. The data were analysed by inferring themes.

The themes that emerged from the data were:

  1. Barriers to the use of public health services.
    None of the barriers mentioned were new but they were consistent with previous research and anecdotes. These included long waiting times; medication not available or in insufficient amounts; poor staff attitudes (especially nurses); lack of cleanliness; shortage of staff. They also felt that the clinics were too far and that not enough services were offered (such as eye and dental care).
  2. How communities can participate in health services.
    The respondents were enthusiastic about participating in the health services and proposed a number of ways that they could participate. They proposed that the community could help in service delivery, and offer transportation where needed. They also saw a role for the church who could assist by donating items and be trained in first aid to enable them to assist in emergencies.
  3. Community experiences with CHWs.
    Community experiences with CHWs were related to home-based care; the respondents discussed how the CHW’s take care of the elderly, take care of the sick, and bring medication to those needing it.  They also saw the role of the CHWs to be a link between the community and the health services.

Themes emerging from the CHWs interviews largely related to the challenges experienced by the CHWs. These were related to the nature of the work, such as dealing with difficult issues such as violence and alcohol abuse, tracing clients in areas of high mobility, facing extremely difficult life circumstances such as poverty and terminal illness, fearing for their own personal safety at times. They do not get emotional or psychological support. Other challenges relate to the organisation of the work. They feel there is no job security, the stipend is very low and irregular, they often do not have the equipment that they need such as gloves, they have to walk long distances (often 40 minutes) and the lines of accountability are not clear to them.

Although there is nothing that is new in the research findings, they support the fact that communities are willing to participate in health services, and that CHWs are well respected.  This reinforces community acceptance of the PHC re-engineering outreach model.  The organisational and emotional support issues need to be sorted out to enable a better working environment for the CHWs.  The role of CHWs in prevention of illness needs to be emphasised in training, otherwise they will get drawn into caring for the ill and do not have time for preventive work.

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