We completed qualitative interviews with 23 participants from 9 facilities in the Agincourt HDSS, 82.6% of whom were female, which is representative of the healthcare workforce in this area. The majority of providers were professional nurses (65%), with 5 enrolled nurses and 1 lay counselor. All providers approached to participate provided consent, although some did have to leave interviews early or reschedule based on clinical demands.
Providers discussed many barriers to providing quality care, which fell under the foundational categories of workforce and tools. These themes and related subthemes are discussed below.
Barriers to providing quality care
Understaffing undermines provider capacity
Providers discussed how understaffing diminished their ability to provide quality care through the creation of bottlenecks in service delivery, as well as the impacts of understaffing on their health and wellbeing. Almost all providers spoke of how they did not have enough staff working in their facility, particularly a lack of nurses but also filing clerks. Professional nurses were often required to take on duties such as checking vital signs that could be performed by enrolled nurses if they were available. Providers described how they had to hurry through patient visits and provide sub-optimal care, and some revealed they sometimes told patients to simply return the following day due to shortage of staff. As one provider said:
According to policy and guidelines it says, ‘All chronic patients should have their urine taken and tested every visit.’ But due to shortages, it becomes impossible…All chronic patients should be assessed fully from head to toe on a daily basis. How long would they wait if we practice that? (Clinic 4, professional nurse)
Providers discussed challenges with scheduling leave days and staffing throughout the week; weekends and Mondays were routinely understaffed despite high patient volume. Providers noted that there was no staffing buffer in the event of patient emergencies that occupied more experienced staff or for routine gaps such as lunch breaks, provider illness, or maternity leave. Providers were often forced to complete duties outside of their scope of work, such as collecting files and cleaning the clinics, as a result of these shortages:
On weekends there is no data capturer. The nurses have to do all the work… We don’t have cleaners. We don’t have grass cutters. As nurses we have to see that the yard is clean and we also have to clean the clinic. Again, we are the ones who have to retrieve files. This is taking our time. (Clinic 4, professional nurse)
Another scheduling issue was that of lay counsellors, whose hours are shorter than typical facility hours (weekday mornings only) as they are not part of the formal employment system of the Department of Health, and are meant to provide HIV testing services (HTS) on a part-time basis.(33) As a result, patients who come for HTS outside of the lay counsellors’ hours have to be seen by a professional nurse.
Many providers discussed their health and wellbeing suffering as a result of understaffing, with specific mentions of depression, elevated stress, physical pain, exhaustion, and interpersonal or marital problems. One noted that these detriments to providers’ wellbeing made them feel their own health was not a priority of the Department of Health. Another provider discussed how she had difficulty taking her own HIV medication due to lack of time to eat:
The shortage of staff is a serious problem at this clinic…we cannot take the lunch or breakfast breaks that we need as we are on treatment. If we carry on like this, we will collapse as this treatment requires us to eat now and again. (Clinic 9, professional nurse)
Staff development approaches can be ineffective and counterproductive
Providers discussed how the current approaches to training and supervision were ineffective and sometimes counterproductive. While providers identified a need for additional skills training, many raised issues with the in-service training model, in which senior providers were called to attend workshops and were responsible for relaying information back to staff. Providers reported concerns about the accuracy and comprehensiveness of information being conveyed back to them, if at all. The burden of trainings and under-staffing at healthcare facilities were intersecting issues. Providers discussed being chronically understaffed because nurses were at trainings or workshops, and one provider stated that they opted not to go to workshops as they knew it would leave facility staff overwhelmed. Providers also mentioned that being understaffed when they returned to the facility meant they did not have time to disseminate information learned in training. Providers cited a need for additional skills training, including care for patients with tuberculosis and HIV, as well as training on new medications:
You find that treatment is there but we don’t know how to use it. You find that the treatment comes with a pamphlet and we have to read it. But it would be better if someone was there to demonstrate it to us. Seeing it is better than reading… We all need trainings when it comes to treatment. (Clinic 5, professional nurse)
The majority of providers also discussed issues with support and supervision at their facility, primarily at the district level. Providers said that when they did receive district supervision, it was overly critical and demotivating. Some felt that district supervisors only came when there was a serious issue at the clinic and were only there to “point fingers” or “shout and make noise.” Providers expressed dissatisfaction with the way performance bonuses were given by the district. Some discussed simply not receiving the performance bonuses they were promised, or feeling that bonuses are distributed unfairly. Some providers spoke about how lay counsellors, who provide HTS, had recently gone on “go-slow” (working reduced hours and only serving a set number of patients) to demand their performance bonuses, which they felt had not been fairly distributed.
Facility infrastructure and limited space impact ability to provide care
Providers revealed how problems with facility infrastructure and limited space impacted their ability to provide quality care. Some providers interpreted poor facility infrastructure as an indication of the government’s lack of concern for its constituents. Descriptions of inadequate space included insufficient meeting rooms, cramped service rooms, overcrowded reception areas with limited space for patients to wait comfortably, and lack of shelter for patients who had to wait outside. Structural issues in and around the clinic also impacted providers’ ability to provide quality care; providers cited worries about their safety and patient safety due to issues such as lack of secure fencing, leaking roofs, and, in one clinic, a bat infestation in a collapsed roof. Periodic electricity outages were also noted in several clinics. Providers at one clinic described how the lack of filing cabinets jeopardized patient confidentiality, and providers avoided opening new files to save space.
Poor infrastructure also had a significant impact on confidentiality of patient care. Providers were concerned that patients could see or hear what was going on in consultation rooms because of the facility layout and size; in three facilities consultation rooms were separated only by a curtain. Providers mentioned having to take patients’ vital signs in the waiting area, where they could not guarantee privacy. Another said there may often be two providers in one room seeing patients at the same time. Others were concerned that the facility layout made it difficult for patients to maintain confidentiality after testing for HIV:
If you cry, that side, they will hear you. If you come out, there is no other door for you to use when coming out. The doors are looking at each other and people will see that you have a problem. The infrastructure is the problem. (Clinic 5, professional nurse)
Providers also cited issues with water and sanitation, including lack of clean water, broken toilets, and deficient cleaning materials, as impacting quality of care. Providers reporting issues with their water supply also claimed that the municipal water tanker responsible for delivering their water did not come regularly. Without water and proper cleaning materials, custodial staff (or providers, in clinics without custodial staff) could not clean the facility:
[The clinic] is dirty and smells bad. You cannot say it is clean by looking at it. You cannot wash the floor just with water. You need to get soap that can kill bacteria. It is easy for people to get infected with tuberculosis here as the place is not clean. (Clinic 5, professional nurse)
Lack of equipment and medication reduces ability to provide quality care
Providers discussed how insufficient equipment impacted their ability to provide competent care. Specific items mentioned include hemoglobin meters, beds with stirrups, wheelchairs, incubators, a child’s scale, diapers, an autoclave to sterilize equipment, pregnancy tests, otoscopes, batteries, linen savers, HIV rapid test kits, and air conditioning units (important for optimal storage of medication).
The lack of equipment and/or faulty equipment caused delays in patient care, wasting patients’ time and making visits longer as providers had to share equipment.
Providers discussed lacking medication, including cough medicine, diphtheria and tetanus vaccines, injectable contraceptives, blood pressure medication, and antiretroviral therapy (ART). Providers linked these issues to problems with deliveries of medication from the Mpumalanga Department of Health. They reported that orders placed with the medication depot were not fulfilled, fulfilled late, or fulfilled in different quantities than ordered. One provider linked this routine shortage of chronic medications (i.e. blood pressure medication, ART) contributing to patients’ poor adherence:
Sometimes they come and you see that this person is really sick, but there is no treatment... Sometimes we are going to the nearest clinic to ask but also those clinics have limited treatment for their patients. We are worried about this issue. We keep on reporting and tell [the Department of Health] what we have done, but still they will tell you that the depot doesn’t have treatment at the moment. (Clinic 2, enrolled nurse)
Indicators of quality care
Providers provided their own definitions of quality care. The resulting themes and subthemes are discussed in detail below.
Providers from facilities with a newer clinic infrastructure identified this as an indicator of quality care. Providers from other facilities mentioned infrastructure at their clinics as an indicator of poor quality.
Lack of resources
Lack of resources in the clinic, including medication, equipment, cleaning supplies, and staff were all associated with less ability to provide quality care. Shortage of medication was cited as an indicator of care quality, with providers from three different facilities discussing how their lack of medication was indicative of low-quality care. Providers also discussed how the lack of medical equipment meant that they could not provide quality care to their patients:
“I think what can help me to provide good quality care or to do my work well is when I have equipment. We don’t have enough but with the little that we have, we are trying.” (Clinic 5, professional nurse)
Some providers also spoke about staff shortages and how it impacted their ability to provide quality care. Other providers spoke of resource availability more generally as an indication of good quality care and a source of pride.
Providers cited positive staff behavior as an indicator of quality, including communicating in a positive and open manner, explaining treatments, and conducting adequate counselling. Conversely, providers who reported colleagues having “attitudes” or showing lack of empathy for patients indicated that their care was of poor quality. Respectful care also included maintaining patient confidentiality. Some providers discussed confidentiality as a factor enabling patients to come to clinic and adhere to medication.
“When it comes to HIV patients and confidentiality, we are providing high quality compared to other clinics of Bushbuckridge. We are the best and I know that.” (Clinic 9, professional nurse)
Time spent in the clinic
Time spent in the clinic, including short waiting times for services and longer face-to-face visits with providers, were seen as indicators of quality care. Some clinics with short wait times credited the central chronic medication dispensing and distribution (CCMDD) program (part of the national differentiated care facility decongestion initiative) for their ability to provide quicker service to HIV-positive patients:
“I would say our clinic is the best when comes to treating patients who are HIV positive. Particularly the chronic [care]…the treatment is packed with the [recipient’s] name on the outside of the package…They don’t stay for more than an hour.” (Clinic 1 (CHC), lay counsellor)
Providers also cited their lack of ability to spend time with patients as an indicator of poor quality. Some discussed how they did not have enough staff to attend to the high patient volume, leading to long wait times and rushed care. Several providers discussed how time constraints led to diminished or complete lack of counseling, including on how to take their antibiotics properly, or HIV counseling and testing; or skipping procedures like Pap smears or getting sputum samples.
Adherence to clinical guidelines
Providers discussed the importance of knowing and adhering to clinical guidelines, and of attending district-supported trainings and workshops in informing quality patient care.
Some providers reported using patient and service (i.e. number of HIV tests or Pap smears) data to determine quality. One provider interpreted clinic data showing low utilization rates as a sign of poor quality:
“Our utilization statistics are also low; this is proof that we don’t provide good quality care. If we were, we would have higher numbers.” (Clinic 5, professional nurse)
Patient data are not utilized as indicators of quality
Patient data were not broadly discussed as indicators of quality care. A few providers identified patient utilization of the facility, particularly by patients from other villages who may be bypassing their nearest healthcare facility, as an indicator of quality care. Providers also discussed seeing patients’ health improve after receiving treatment from their facility as an indicator of quality care.
While challenges in providing quality care have been documented, less on how providers overcome these barriers has been documented. An emergent theme in our analysis of the data were mitigating strategies that providers used to combat challenges to address barriers to providing quality care.
Reallocation of resources within the clinic
To address understaffing, providers took shorter lunch breaks and split staff into teams to balance leave days. To maximize clinic space and maintain confidentiality, several facilities moved their lay counsellors to a space that could be devoted to HIV counselling and testing, such as a mobile unit, the meeting room, or the nurses’ accommodation on site. Facilities with more space also recommended designating one building for CCMDD both to keep the queue moving quickly and to streamline treatment pickup for all chronic patients.
Sharing resources across clinics
To make up for resource shortages, providers shared equipment across facilities, bought their own supplies (i.e. batteries, soap, toilet paper), and sometimes went as far as driving a patient to the hospital in their own car if an ambulance was not available. Many providers expressed a sense of duty to help their patients, despite the shortage of resources and personal costs. Providers also tried to circumvent the system by ordering quantities of medication greater than the expected patient population, sharing medication between facilities, or prescribing medications in smaller quantities at a time than recommended by guidelines (i.e. one month of ART instead of three, in order to supply more patients). Providers in the Agincourt HDSS area discussed using a WhatsApp group across facilities to discuss supply of ART in particular:
With HIV treatment [stock-outs] were not happening as we are trying by all means to ask for it from nearby clinics. They are assisting us. We have a WhatsApp group that we use to talk to each other. If we have a shortage of this treatment, we will WhatsApp it so everyone in our group will know. (Clinic 5, professional nurse)