‘Building on shaky ground’—challenges to and solutions for primary care guideline implementation in four provinces in South Africa: a qualitative study

Abstract

ObjectivesClinical guidelines support evidence-informed quality patient care. Our study explored perspectives of South African subnational health managers regarding barriers to and enablers for implementation for all available primary care guidelines.DesignWe used qualitative research methods, including semistructured, individual interviews and an interpretative perspective. Thematic content analysis was used to develop data categories and themes.SettingWe conducted research in four of nine South African provinces with diverse geographic, economic and health system arrangements (Eastern Cape, Western Cape, KwaZulu-Natal, Limpopo). South Africa is a middle-income country with high levels of inequality. The settings represented public sector rural and peri-urban health facilities.ParticipantsTwenty-two participants with provincial and district health management roles, that comprised implementation and/or training on primary care guidelines, were included.ResultsParticipants recommended urgent consideration of health system challenges, particularly financial constraints, impacting on access to the guidelines themselves and to medical equipment and supplies necessary to adhere to guidelines. They suggested that overcoming service delivery gaps requires strengthening of leadership, clarification of roles and enhanced accountability. Participants suggested that inadequate numbers of skilled clinical staff hampered guideline use and, ultimately, patient care. Quality assurance of training programmes for clinicians—particularly nurses—interdisciplinary training, and strengthening post-training mentorship were recommended. Furthermore, fit-for-purpose guideline implementation necessitates considering the unique settings of facilities, including local culture and geography. This requires guideline development to include guideline end users.ConclusionsGuidelines are one of the policy tools to achieve evidence-informed, cost-effective and universal healthcare. But, if not effectively implemented, they have no impact. Subnational health managers in poorly resourced settings suggested that shortcomings in the health system, along with poor consultation with end users, affect implementation. Short-term improvements are possible through increasing access to and training on guidelines. However, health system strengthening and recognition of socio-cultural–geographic diversity are prerequisites for context-appropriate evidence-informed practice.

Implementing the Ideal Clinic Program at Selected Primary Healthcare Facilities in South Africa

“…Professional nurses expressed concerns regarding delays in reporting broken equipment and machines, as well as the long period taken to have them fixed. This finding concurs with the study by Kredo, Cooper, Abrams, et al, conducted in four provinces in South Africa, which suggested an urgent need for the National Department of Health (NDoH) to prioritize the existing challenges in the healthcare system in accessing and using medical supplies, which impacted adherence to guidelines [27]. Steinhobel, Mossyn, and Peer outlined that the implementation of the IC program includes maintenance of the infrastructure and the availability of resources [28].…”

Indicator-focussed technical assistance in South Africa’s HIV programme: A stepped-wedge evaluation

“…Technical assistance in health systems with varying levels of competence and diverse, localised challenges needs to be flexible and adaptable to effectively respond to the specific contexts in which health services operate. As Kredo et al 7 noted with regard to the implementation of the Clinical Practice Guidelines (CPG) in the South African context, '… for effective CPG implementation in health services to occur, considerations of the unique settings in each province, including culture, geography and social needs, must be undertaken'.…”

“…6 Its process is more dynamic and adaptable and is jointly developed and implemented by TA implementers and recipients. 6 Kredo et al 7 noted that in addressing gaps in translating evidence into practice in healthcare settings, tailored, multifaceted approaches that address specific issues seem to be most effective in facilitating change. The healthcare system in SA varies widely in terms of staff capacity, availability of resources and local social, cultural and geographical contexts.…”

“…8 In SA, challenges include financial, budgetary, resource constraints, unreliable drug supplies, poor quality of the physical infrastructure, challenges in governance and leadership, human resource constraints and a lack of capacity amongst front-line staff members. 7,8 The variation in the severity of specific local challenges suggest that effective TA must be tailored to local health-related constraints and contexts. Access to and the quality of healthcare in LMICs must be addressed if improvements in patient outcomes are to be realised.…”

Diabetic Foot Amputations at Central and Provincial Hospital in Gauteng. A Signpost for Inadequate Foot Health Services at Primary Healthcare Level in South Africa

“…However, despite the RSA government allocating 8.5% of gross domestic product (GDP) to healthcare, the health outcomes remain relatively poor compared to other middle-income countries with similar GDP percentage expenditure on health. [35,39] When considering clinical outcomes in diabetic patients, we should include our ability to deal with DFCs across the continuum of care and preventing amputations. The ndings of this study suggest we may still be a long way off from achieving improved health outcomes for diabetic patients.…”