An analysis of the meaning of integrated Primary Health Care from the KwaZulu-Natal Primary Health Care context

Tel.: (031)373-2032 Fax:(031)373-2039 E-mail: nokuthulas@dut.ac.za Abstract: Curationis 32 (2): 31-37 In South Africa, integration o f services policy was enacted in 1996 with the aim o f increasing health service utilization by increasing accessibility and availability o f all health care services at Primary Health Care (PHC) level. Integration o f PHC services continues to be seen as a pivotal strategy towards the achievement o f the national goals o f transformation o f health services, and the attainment o f a comprehensive and seamless public health system. Although the drive behind the integration of PHC services was to improve accessibility o f services to the community, the problem however, arises in the implementation o f integrated PHC (IPHC) as there is no agreed upon understanding o f what this phenomenon means in the South African context. To date no research studies have been reported on the meaning o f the integration o f PHC services. Hence, there is a need for shared views on this phenomenon in order to facilitate an effective implementation o f this approach.


Background to the study
The redirection o f the health care sys tem towards Primary Health Care (PHC) along with the concomitant establish m ent o f the D istrict H ealth System (DHS) as a framework for PHC delivery and management has been the trans formation event in the public health sphere in South Africa since 1994.One o f the forem ost changes in the early years o f the dem ocratic governm ent was the adoption o f a district-based system, which is the principal instru ment for the delivery o f comprehensive integrated PHC services, in line with the Declaration o f Alma Ata.The goal o f the DHS was to achieve equity and improve access, effectiveness and ef ficiency o f services through decentral ized management services and localized service provision (Harrison, 1997: 4).As equity and access to health care have since 1994 been considered the key principle to steer the transform a tion o f health services in South Africa, a mechanism was required to define parameters for service delivery, as well as to ensure com parability in the ren dering o f services.This m echanism was realized in the form comprehensive PHC service package that was intro duced by the National Department o f Health in 2001.According to this pack age, integration o f PHC services (IPHC) in South Africa was put in place so as to address the problem o f shortage o f staff and limited resources in PHC set ting.W hereas in the past, the model o f PHC delivery was strongly based on a vertical approach, the PHC package was aimed at defining services per level o f facility as a way to maximize the inte gration o f services (D epartm ent o f Health, 200 la: 8).

Problem statement
The year 2008 marks the 60th anniver sary o f the World Health Organisation (W HO) and the 30'h anniversary o f the Alma Ata Declaration advocating PHC as the m ain strategy for achieving Health for All by the year 2000.Over 30 years ago, integration o f health pro grammes was first raised at the Alma Ata conference and was considered a way o f achieving Health for All.With health system developm ent, the sec tor-wide approach and decentralization, integration has once again been put at the foreground o f curren t debates.Since it came to power, the aim o f the South African government has been to create a unified, single national health service for South Africa (ANC, 1994: 59).The government com m itted itself to transform the health sector in order to unify the fragmented health services at all levels into a com prehensive and in te g ra te d natio n al health system , where provincial and local authority nurses would be employed by one au thority.Despite the dedicated efforts since 1994 to integrate PHC authorities and services under one umbrella and into a seamless public service, ongo ing structural and functional fragmen tation o f PHC in South Africa still re mains a far cry from the desired inte gration that a well-functioning districtbased PHC service strives for.
In South Africa, integration o f services policy was enacted in 1996 with the aim o f increasing health service utilization by increasing accessibility and avail ability o f all health care services at PHC level (T in t, F onn, K huzw ayo and Robertson, 2000: 15).The current inte gration debate in South Africa, particu larly in KwaZulu-Natal (KZN) includes a slightly different focus from the de bate that is related to the fragmented nature o f health services, inherited by the democratically elected government in 1994.There has been a pressing need to co-ordinate local authority and pro vincial services, previously separately responsible for preventative and cura tive care respectively, and to bring to gether services offered through au thorities in the former homelands, with new provincial and national structures.This type o f integration is structural and has unique organizational require ments.The critical element that impacts on the provision o f integrated services at the primary level relates to the inter action between the provincial and lo cal spheres o f government.This inter action is further complicated by the dif ferent capacities within the different m unicipalities (Department o f Health, 2001 a:3).

Significance of the Study
PHC is an approach w hich has the po tential to achieve both the Millennium Development Goals (M DGs) and the w ider goal o f universal access to health through acceptable, accessible, appro p ria te and a ffo rd a b le h e a lth care (W alley, L aw n, T inker, F rancisco, C hopra, R udan, B hutta and Black, 2008).However, there is a growing con sensus that a prim ary bottleneck to achieving the MDGs in low-income countries is health systems that are too fragile and fragmented to deliver the volume and quality o f services to those in need (Travis, Bennet, Haines, Pang, Bhutta, Hyder, Peilemeier, Mills and Evans, 2004).Thus PHC, if im ple mented, would advance health equity in all countries rich and poor and as a result, prom ote hum an and national development (Walley et al., 2008).Al though the drive behind IPHC was to improve accessibility o f services to the com m unity the problem , how ever, arises in the implementation o f inte grated PHC as there is no agreed upon understanding o f what this phenom enon means in the South African con text.Hence, there is a need for shared views on this phenomenon in order to facilitate an effective implementation of this approach.This study should bring a shared meaning o f the phenomenon integrated PHC in South Africa to guide policy formulation and implementation as the country continues in its efforts to achieve a comprehensive and seam less PHC delivery system.

Aim and objective of the study
The aim o f the study was to analyze the concept integrated PHC (IPHC) within a DHS in the province o f KZN in South Africa so as to arrive at a shared meaning o f the phenomenon.The ob jective o f the study was to analyze the phenomenon IPHC and the meaning attached to it in order to determine the participants' understanding o f IPHC.

Research design
A cross-sectional study, using a quali tative approach was employed in this study.It is crucial that the method cho sen is one that is most likely to yield a framework grounded within the South African health systems context.A l though a number o f views and/or opin ions have been advanced regarding PHC and its state o f delivery in the country, very little or none has been done to examine the meaning o f PHC integration within the South African context and as such develop a com mon frame o f reference for policy de velopment, implementation and evalua tion.Hence, the grounded theory ap proach was selected as it is a method known for its ability to make greatest contribution in areas where little re search has been done and when new viewpoints are needed to describe the familiar phenomenon that is not clearly understood (C henitz and Sw anson, 1986: 7).There are two approaches o f grounded theory; the Glaserian (after Barney Glaser) and the Straussian (af ter Anselm Strauss).The root o f the difference between Glaser and Strauss lies in the diverse philosophical stances held by the two researchers and their consequential ontological, epistemological and methodological implications (Annells, 1996:387).They differ in how they view the procedures and proc esses o f grounded theory.Strauss and Corbin (1990:23) allow for priority theory, technical and non-technical literature and personal as well as professional experience to enter the field o f research.They further state that all kinds o f literature can be used before the research study is begun and during the study itself.Strauss and Corbin warn that the previous know l edge should not be taken as a given, testable framework on how to explain a phenomena.Instead it should serve as a source o f inspiration.These au thors further argue that selective sam pling o f the second body o f literature rev iew sh o u ld be w o v en in to the emerging theory during the third stage on grounded theory induction, the stage that is termed concept develop ment.This is supported by Smith as cited by Hunter, Har, Egbu and Kelly (2005: 59) in suggesting that general reading o f literature may be carried out to obtain a feel for the issues at work in the subject area, and identify any gaps to be filled using grounded theory.
As a result o f these divergences, it is incumbent on every researcher using grounded theory to indicate which im plementation o f the methodology they are using.Strauss and C orbin's ap proach was seen as more appropriate for this study because a review o f lit erature on PHC within a district health system provided som e background knowledge.This was invaluable in fa cilitating interpretation o f participants' u n d e rs ta n d in g s an d m e a n in g s a t tached to the concept IPHC.

Sampling of participants
Q ualitative researchers collect their data in real world, naturalistic setting (Polit and Beck, 2004:248) The second stage o f the selection in volved purposive selection o f clinics located within these four districts to collect data on integrated PHC; some o f which were under the local author ity and some under the provincial serv ices.Only those clinics which had pur ported to have implemented IPHC were included in the study.The third stage involved selection o f study partici pants.These included policy makers at the district, provincial and national levels that were involved with PHC co ordination.In addition, nurses at func tional level were included in the study.Selection o f participants at the various clinics continued until data saturation had occurred.To be exact, observa tions were done in 32 clinics.Out o f 32 clinics, 53% (N=17) were located in ur ban areas and 47% (N=15) in rural ar eas.The sample size for interviews comprised o f 38 participants.O f these, six were policy makers; including one National Deputy Director, one Provin cial Deputy Director for PHC, four Pro gram m e Managers from the four se lected districts.From each sampled clinic per municipality, a professional nursc-in-charge or the deputy in case the pcrson-in-charge was not available, was interviewed.Therefore, at func tional level, 28 professional nurses-inch arg e and 4 d ep u ty p ro fessio n al nurses-in-charge were interviewed.

Data collection
The collection o f data was done by means o f observation and in depth in dividual interviews.The process en tailed non-participant observation o f the clinic processes in the provision o f IPHC.Essentially, the aim was to ob serve how the services were offered from the time a patient arrives at the clinic until discharge.Observations in cluded looking, listening and asking questions as they arose out o f obser vations in order to offer insight into what was observed.
Individual interviews were then con ducted with one PHC nurse, preferably the person in charge at the clinic level after doing the observation.The two broad questions that were asked to fa cilitate the discussion were, in your view: • W hat is the meaning o f inte grated PHC?
• W hat is the nature o f events regarding the integration o f PHC services?
In addition, questions o f clarification based on the data that emerged during observations were included during the interview.Glaser maintains that in grounded theory "there is no such thing as observation w ithout in ter views to give them m eaning; the re v e rse is a lso tr u e " (1 9 9 8 : 109).
Purposive sam pling o f clinic nurses continued until participants had no new information to share.A tape re corder was used to backup the notes com piled during the interview ses sions.Hand written notes were utilized to provide backup information through out the process o f data collection.The interviews were transcribed within 24 hours o f being conducted, together with the field notes, formed the data base for the research.

Ethical considerations
Permission to conduct the study was obtained from the KZN Department o f Health.Authorities from the different in s titu tio n s c o n c e rn e d w e re a p pro ach ed for consent to conduct a study.The rights o f participants were safeguarded through written informed consent and confidentiality.Partici pants were assured that participation in the study would not in any manner affect their lives in the settings either as em ployees or consumers.Partici pants were informed that they were free to withdraw at any time from the study.

Results and discussion
In the context o f this study, it emerged that there were three core categories that were used by the participants as discrim inatory dimensions o f IPHC in South Africa.These core categories were: • Comprehensive health services

IPHC as a supermarket approach
The concept "superm arket" is not a health care service intervention.It origi nates from the retail sector.According to the findings o f this study, IPHC was conceptualized as a superm arket ap proach w here patients that required more than one service were seen by different nurses allocated in different consulting rooms.These patients had to join different queues in order to ac cess different services.This was ob served m ostly in larger clinics.The following excerpts from the interviews with the participants demonstrate this: "IP H C is an app ro a ch w here the nurses offer all the services that the patient wants under one roof.It does not necessarily mean that a p a tien t will access all services in one consult ing room but it means that the patient will get all other services in the clinic.
A ll the services that are needed by the patient are available in the clinic.This includes ante natal care service, Fam ily Planning (FP), m ental health and other services.It is a supermarket serv ice.It is like going to O K Bazaars.I f you go to OK, whether you want nee dles or you want m eat or you want mealie meal or hardware, it is there under one roof." "It is a superm arket type o f an ap proach.The patient m ust be able to access all the services that she needs, and not to leave the clinic and go else where.When you go to Shoprite, you get everything.There are items that are kept in the fridge; there are things that are kept in shelves.Everything is well organized.We think o f the ve>y same shop when we integrate services in PHC." "It is a supermarket approach where we do everything fo r the patient be fo r e she leaves the clinic.The patient will not be asked to come to the clinic on different days fo r different services Today's world health care is plagued with increasing cost, long lines for ob taining quality care, inconvenience and inaccessibility, and duplication o f ef forts.Shah, Bruni and Darling (2002: 106) argue that a sim ilar situation ex isted in the food and food products industry where one had to go from shop to shop to buy different items.These authors state that consumers did not have knowledge o f the quality o f each and every product and prices could be unreasonable and bargained.The revo lution in the food and food products w as th e " s u p e r m a r k e t m o d e l" whereby consumers were guaranteed quality products at a reasonable price and the availability was great.
According to Halper (2006) superm ar ket is a difficult term to define.To un derstand such a complex and important institution, H alper argues that "one needs to know the origin, the compo nents that make it what it is and how its business model was molded " (2006: 253).The supermarket got its start in the very early phases o f the Great De pression and w as m olded by World War II.Michael Cullen, a Kroger as sistant store manager launched Ameri ca's first supermarket on 4 August 1930 in an effort to cut costs while im prov ing custom er services.The 1930s saw the rise o f the self-service supermarket as we know it today.Self-service re duced the cost o f store operations, and the savings were passed on to the cus tom ers in the form o f low er prices.Low er prices, in turn boosted sales volume and profits.Large stores made it possible to carry many more product categories without sacrificing the depth o f inventory that makes it possible to avoid turning away customers looking for the numerous well-advertised prod ucts available (Halper, 2006).
In the health care sector, the supermar ket approach was initiated in Tanzania and has been successfully adopted in several East African countries.Accord ing to the Report o f the Study Group on integration o f health care delivery, the emphasis o f this approach is cli ent-oriented and provision o f all serv ices at the time o f visit to the clinic (W HO, 1996).However, the process that is followed in Tanzania for the im plem entation o f this approach is not described.The South African hand book for Clinic/Community Health Cen tre (CHC) M anagers also describes the supermarket approach as the daily pro vision o f all services to the community but does not specify how these serv ices will be offered (Pillay and Asia, 1999).More recently, in the UK the su permarket approach to health service d e liv e ry is re -su rfa c in g .K en d all-Raynor(2009: 10) reports that commu nity nurses are beginning to explore ideas from superm arkets in order to improve their own productivity, includ ing "ways o f organizing their work ing environment as p a rt o f the produc tive community services program m e IPHC as a one stop shop IPHC was also conceptualized as the provision o f services to the patient by one nurse.Functional integration as explained before, meets both patient and organizational needs since the pa tient receives the comprehensive pack age o f primary health services in one location, in one visit.Toomey (2000:14) refers to this approach as a one stop shop.T he com prehensive prim ary health care service package for South Africa states that through a one-stop approach, the facility provides compre hensive integrated PHC service for a minimum o f eight hours per day, five days a w eek (D epartm ent o f Health 2001 b: 12).In support o f this, Harrison (1997: 29) argues that one stop shop will ensure that people are treated as a whole not in "bits and p ie c e s " like body parts.Tint, e tal. (2000: 15) state that IPHC implies that services will be rendered by the same provider(s) in the same consultation in one visit.The following extracts are a representation o f some o f the responses from the par ticipants with regard to the understand ing o f IPHC: "We are using a one stop shop, so the nurse does everything fo r the patient because we have our room s packed w ith a ll the e q u ip m e n t a n d dru g s needed to provide all the services so as to avoid delaying the patient.I f I run out o f drugs, I personally go out o f my room to get the necessary treatment fo r the patient." "The nurse will do everything f o r the p a tie n t to a v o id a n y delays.O ur room s are w ell eq uipped a nd have drugs in our rooms.We serve a very p o o r com m unity who is in a hurry to go back to the fields, so we do not want to delay them.Our s ta ff members have developed bonding with their patients so we try to do everything f o r the p a tient so that the patient is comfortable to list all his/her ailments." "I will render all the services that the patient wants except immunization that will be prescribed and the child will be taken to another room for immunization because vaccines are kept in one place for the reasons o f the cold chain and econom ic reasons like saving those vaccines that can never be opened for less than children" .
In the USA, Sage (2007: 503-519) re ports on the emergence o f retail m edi cal clinics.According to him these re tail clinics share a num ber o f distinc tive features; they are open till late, some are completely run by nurses and/ or physician assistants.Admittedly, the PHC clinics are in no way comparable to this phenomenon, except perhaps for the principle o f increased access at af fordable cost.The results o f the study that was con ducted by M essinger and Narasim han (1997) revealed that greater prevalence o f one-stop shopping was in response to growing consumer demand for timesaving convenience.However, one cannot be sure if one stop shop saves time as it may take longer for one nurse to provide all the services required by the patient.

Conclusion and recommendations
IPHC is context-driven.The phenom enon, IPHC means different things to different contexts.According to Owen (1998: 67), a contingency approach to an organization takes a different view.There is no one best way to describe IPHC.In a country with such huge in equities in the distribution o f health services and related enabling factors such as staff adequacy, infrastructure etc., whether a supermarket or one stop shop view o f IPHC underpins practice, is always going to be a function o f the context in which the PHC practitioners have to function.O f essence, is that the patient, the practitioner and the service should find meaning in what works for all concerned.IPHC was put in place to improve accessibility o f serv ices to the community.However, the important patients' voice is silent in this study.Therefore, further research is needed to assess the impact o f such approach to the community or client satisfaction.

References
. In grounded theory the selection o f settings is di rected by relevant concepts.An es sential feature o f grounded theory re search is the continuous cycle o f col lecting and analyzing data.Purposive sampling is generally accepted as a criti cal feature o f grounded theory.A three stage selection plan was applied to se lect a sample from the accessible popu lation.The first stage o f the selection involved the purposive sam pling o f those health districts that purported to have implemented integrated PHC in KZN.The researcher then purposively selected regions according to their g e o g ra p h ic a l lo c a tio n sin c e the boundaries o f the health district coin cide with the district and metropolitan municipal boundaries.These districts are central (Health district A), midlands (Health district B), south (Health dis trict C) and north (Health district D).Health districts A and B are situated in urban areas and Health districts C and D are situated in rural areas.There are 61 municipalities in KZN: 1 metropoli tan area (Category A); 50 local munici palities (Category B) and 10 district municipalities (Category C) (KZN De partm ent o f Health, 2007).Health dis trict A falls under category A and health districts B, C and D fall under category C.
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