IntroductionDistrict healthcare services in South Africa face many challenges with regard to attempts to offer effective primary healthcare services. Demand for services from uninsured communities is high. There is a quadruple burden of disease characterised by human immunodeficiency virus/ acquired immune deficiency syndrome and tuberculosis; interpersonal violence and trauma, poverty-related diseases, such as diarrhoea and pneumonia; and an emerging epidemic of noncommunicable chronic diseases. The number of service providers is often inadequate to cope with the workload. Healthcare workers are inequitably distributed. For example, doctors are found in greater numbers in urban areas, the private sector and hospitals, rather than in the communities. The district health system itself is a relatively new structure and many district-, subdistrict-and facility-level managers are still being appointed. Poor leadership and governance is one of the identified challenges that faces the new health districts. 3According to the Department of Health, primary healthcare workers are expected to be caring and compassionate at the coalface, and yet becoming patient-centred and improving the quality of care in this context is a challenge: 4 "The department renders a large and complex service every day of the year, and the clinical environment is often stressful. Staff attitudes are a common source of complaints. A key issue is how greater commitment and engagement from staff can be promoted on a daily basis, moving towards a more client-centred service with a greater focus on quality improvement". Results: In total, 154 staff members completed the survey. Participants reported personal values that are congruent with a move towards more patient-centred care. The top 10 current organisational values were not sharing information, cost reduction, community involvement, confusion, control, manipulation, blame, power, results orientation, hierarchy, long hours and teamwork. Desired organisational values were open communication, shared decision-making, accountability, staff recognition, leadership development and professionalism. Organisational entropy was high at 36% of all values. Only teamwork and community involvement were found in both the current and desired culture. The organisational scorecard showed a lack of current focus on finances, evolution and patient experience. Conclusion:The organisational culture of the Metro District Health Services is currently not well aligned with the values expressed in Vision 2020, and the goal of delivering patient-centred care.Peer reviewed.

The findings indicate an association between the application of clinical audit and quality improvement in resource-limited settings. Co-interventions introduced after the baseline audit are likely to have contributed to improved outcomes. In addition, support from the relevant government health programmes and commitment of managers and frontline staff contributed to the audit's success.

Background: Non-adherence to diabetes care is a concern at Bishop Lavis Community Health Centre (BLCHC) as it results in many diabetes complications that could have been avoided. The aim was to explore the reasons for people with diabetes in the Bishop Lavis area being non-adherent to diabetes care. Methods:A qualitative study was undertaken. Focus groups and in-depth interviews were conducted with patients who had uncontrolled blood sugar and non-compliance. The framework method was used to analyse the data. Results:The main findings in this study were that the following had a negative impact on compliance with diabetes care: (1) poor knowledge of diabetes mellitus; (2) drug treatment barriers such as shift work and not knowing the importance of taking medication regularly; (3) lifestyle adjustment barriers: dietary barriers and lack of exercise; (4) staff and clinic visit problems, for example over-burdened public health-care facilities; and (5) poor support structures including support from family, the community and financially as well as poor infrastructure. Conclusion:The main findings in this study were consistent with many of the previous studies done on adherence, i.e. patient barriers, disease and drug-regime barriers and doctor-patient relationship barriers. However, in this poverty-stricken area these participants also face other constraints that influence their compliance behaviour. These include (1) over-burdened public health care facilities, (2) insufficient education, (3) poor support structures, (4) infrastructure that is not wheelchair-friendly, (5) unsafe communities, (6) low income and unemployment.

BackgroundAn integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process.AimTo determine whether clinical audits improve chronic disease care in health districts over time.SettingWestern Cape Province, South Africa.MethodsInternal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 (‘2012 old’) to districts that started auditing recently (‘2012 new’).ResultsThe number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the ‘2012 old’ districts compared to the ‘2012 new’ districts for both the facility audit and the folder review, including for eight clinical indicators, with ‘2012 new’ districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21–0.31).ConclusionThese findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes.

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