Development of non-profit organisations providing health and social services in rural South Africa: a three-year longitudinal study

A discourse and content analysis of representation in the mainstream media of the South African National Health Insurance policy from 2011 to 2019

BACKGROUND

Media is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI).

METHODS

A descriptive, mixed methods study was conducted in five sequential phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations within media were analysed and dominant discourses that might influence the policy process were identified.

RESULTS

Discourses of 'health as a global public good' and 'neoliberalism' were identified in global and national policy documents. Similar neoliberal discourse was identified within SA media. Unique discourses were identified within SA media relating to biopolitics and corruption. Media representations revealed political and ideological contestation which was not as present in the global and national policy documents. Media representations did not mirror the lived reality of most of the South African population. The discourses identified influence the policy process and hinder public participation in these processes. They reinforce social hierarchy and power structures in South Africa, and might reinforce current inequalities in the health system, with negative repercussions for access to health care.

CONCLUSIONS

There is a need to understand mainstream media as part of a people-centred health system, particularly in the context of universal health coverage reforms such as NHI. Harmful media representations should be counter-acted. This requires the formation of collaborative and sustainable networks of policy actors to develop strategies on how to leverage media within health policy to support policy processes, build public trust and social cohesion, and ultimately decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media's role in health policy processes.

Entrepreneurial nurses in the literature: A systematic literature review

AIM

This study explores the main characteristics of entrepreneurial nursing.

BACKGROUND

Nurses have acted entrepreneurially in a multitude of ways since the very beginning of the nursing profession. Still, it is unclear what it means for a nurse to be entrepreneurial. Entrepreneurial nurses are often described inconsistently, by non-inclusive terms not founded in research. There is a need to examine the essence of entrepreneurial nursing roles.

METHOD

I conducted the research as a systematic literature review of 647 documents. Analysing empirical descriptions of entrepreneurial nurses' employment status, contexts, knowledge, activities, barriers and motivations led to the description of two entrepreneurial nursing roles.

RESULTS

The employment status of entrepreneurial nurses represents an important difference in their activities, challenges and motivations.

CONCLUSIONS

Entrepreneurial nurses may act as nurse entrepreneurs or nurse intrapreneurs. These roles are empirically rooted in the field of nursing and theoretically rooted in the field of entrepreneurship.

IMPLICATIONS FOR NURSING MANAGEMENT

Entrepreneurial nurses are influenced by the support they get and the challenges they face in the health care system. Knowing the characteristics of entrepreneurial nurses is important for nurse managers, as they lead employees who may become nurse entrepreneurs or nurse intrapreneurs.

From Community Health Workers to Community Health Systems: Time to Widen the Horizon?

-Community health workers (CHWs) have reemerged as significant cadres in low- and middle-income countries and are now seen as an integral part of achieving the goal of universal health coverage (UHC). In international guidance and support, the emphasis is increasingly shifting from a focus on the outcomes of CHW-based interventions to the systems requirements for implementing and sustaining CHW programs at scale. A major challenge is that CHW programs interface with both the formal health system (requiring integration) and community systems (requiring embedding) in context-specific and complex ways. Collectively, these elements and relationships can be seen as constituting a unique sub-system of the overall health system, referred to by some as the community health system. The community health system is key to the performance of CHW programs, and we argue for a more holistic focus on this system in policy and practice. We further propose a definition and spell out the main actors and attributes of the community health system and conclude that in international debates on UHC, much can be gained from recognizing the community health system as a definable sphere in its own right.

How Effective Is Help on the Doorstep? A Longitudinal Evaluation of Community-Based Organisation Support

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9-13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included-446 CBO attenders compared to 1402 9-13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12-15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input.

Needs assessment for home-based care and the strengthening of social support networks: the role of community care workers in rural South Africa

Background

Community care workers (CCWs) in rural South Africa provide medical, personal, household, educational, and social care services to their clients. However, little understanding exists on how provision of services is approached within a household, taking into account available social support networks.

Objective

The aim of this study was to generate an understanding of the processes that underpin the provision of care by CCWs in rural households and their engagement with clients, primary caregivers (PCGs), and other members of the social support network.

Design

We analysed in-depth interviews conducted in a triad of participants involved in a home-based care (HBC) encounter – 32 clients, 32 PCGs, and 17 CCWs. For each triad, a purposefully selected CCW was linked with a purposefully selected client and the corresponding PCG using maximum variation sampling. Three coders used an inductive content analysis method to describe participants’ references to the nuances of processes followed by CCWs in servicing HBC clients. Written informed consent was obtained from all participants.

Findings

The results suggest that, by intuition and prior knowledge, CCWs treated each household uniquely, depending on the clients’ care needs, cooperation, availability of a social network, and the reliability and resilience of the social support system for the client. Four distinct processes took place in rural households: needs assessment for care, rationing of care, appraisal of care, and reinforcement of a social support system. However, there was no particular order or sequence established for these processes, and caregivers followed no prescribed or shared standards.

Conclusions

CCWs bring a basket of services to a household, but engage in a constant, dynamic, and cyclical process of weighing needs against services provided. The service package is uniquely crafted and tailored for each household, depending on the absorptive capacity of the social support network available to the client, and preferences of the clients remain central to the process of negotiating care.

Exploring the perceptions and experiences of community health workers using role identity theory

Background

Community health workers (CHWs) are an integral resource in many health systems, particularly in resource-poor settings. Their identities – ‘who’ they are – play an important role in their hiring, training, and retention. We explore the perceptions, experiences, and identities of CHWs as they adopt a CHW role in rural South Africa, using ‘role identity theory’.

Design

From April to December 2010, we conducted 18 semi-structured interviews with CHWs volunteering in non-governmental home-based care (HBC) organisations in one rural sub-district in South Africa. The role identity theory framework was used to understand the work of CHWs within their communities, addressing themes, such as entry into, and nature of, caring roles, organisational support, state resourcing, and community acceptability. A thematic content analysis was used to analyse the collected data.

Results

The study found that CHWs usually begin their ‘caring work’ before they formally join HBC organisations, by caring for children, neighbours, mothers, fathers, friends, and the community in some way. CHWs felt that becoming a health worker provided an elevated status within the community, but that it often led community members to believe they were able to control resources. The key role identities assumed by CHWs, as they sought to meet patients’ and their own needs, were a complex mix of community ‘insider’, ‘outsider’, and ‘broker’. Each of these role identities served as a unique way to position, from the CHW's perspective, themselves and the community, given the diversity of needs and expectations.

Conclusions

These role identities reveal the tensions CHWs face as ‘insider’ members of the community and yet at times being treated as ‘outsiders’, who might be regarded with suspicion, and at the same time, appreciated for the resources that they might possess. Understanding role identities, and how best to support them, may contribute to strategies of retention and sustainability of CHW programmes, as their formalisation in different contexts continues to grow.

Community care workers, poor referral networks and consumption of personal resources in rural South Africa

Although home-based care (HBC) programs are widely implemented throughout Africa, their success depends on the existence of an enabling environment, including a referral system and supply of essential commodities. The objective of this study was to explore the current state of client referral patterns and practices by community care workers (CCWs), in an evolving environment of one rural South African sub-district. Using a participant triangulation approach, in-depth qualitative interviews were conducted with 17 CCWs, 32 HBC clients and 32 primary caregivers (PCGs). An open-ended interview guide was used for data collection. Participants were selected from comprehensive lists of CCWs and their clients, using a diversified criterion-based sampling method. Three independent researchers coded three sets of data - CCWs, Clients and PCGs, for referral patterns and practices of CCWs. Referrals from clinics and hospitals to HBC occurred infrequently, as only eight (25%) of the 32 clients interviewed were formally referred. Community care workers showed high levels of commitment and personal investment in supporting their clients to use the formal health care system. They went to the extent of using their own personal resources. Seven CCWs used their own money to ensure client access to clinics, and eight gave their own food to ensure treatment adherence. Community care workers are essential in linking clients to clinics and hospitals and to promote the appropriate use of medical services, although this effort frequently necessitated consumption of their own personal resources. Therefore, risk protection strategies are urgently needed so as to ensure sustainability of the current work performed by HBC organizations and the CCW volunteers.