Essential health services delivery in South Africa during COVID-19: Community and healthcare worker perspectives

Background: Between May 2020 and February 2022, South Africa’s health system bore strain as it battled mitigating the coronavirus pandemic. The country’s pandemic response was scrutinized. This period also brought into focus pre-existing shortcomings in the healthcare system and its governing bodies. Contextually, there is a paucity in literature on the experiences of healthcare providers and users. This study aimed to contribute information on COVID-19, with the intention of providing guidance on preparing for future infectious disease outbreaks. Methods: Cross sectional exploratory qualitative methodology was employed using semi-structured interviews and focus group discussions with community members (CM) and healthcare workers (HCW) from two South African study sites: (a) rural Bushbuckridge (run by Agincourt Health and Socio-Demographic Surveillance Site) and (b), Regions D and F in Johannesburg Metropole. Results: After interviewing 42 CMs and 43 HCWs, it emerged that mandated process changes while minimizing COVID-19 exposure, necessitated healthcare personnel focusing on critical care treatment at the expense of less acute ones. COVID-19 isolation protocols, extensive absenteeism and HCWs with advanced skills being perceived as more adept to treat COVID-19 patients contributed to HCWs experiencing higher workloads. Fears regarding contracting and transmitting COVID-19, suffering financial losses, and not being able to provide adequate advice to patients were recurrent themes. Dissemination of relevant information among healthcare facility personnel and communities suffered due to breakdowns in communication. Conclusion: Concessions and novel strategies to avail medication to patients had to be created. Since providence was lacking, government needs to formulate health intervention strategies that embrace health literacy, alternate methods of chronic medication dispensation, improved communication across health care platforms and the use of telehealth, to circumvent the threats of possible further infectious disease outbreaks.

The achievement of UHC is dependent on a strong and resilient health care system with high-caliber essential health services. The WHO established a framework for action on strengthening health systems based on six health system building blocks (Figure 1) (18). Using thematic analysis (19), this qualitative study was conducted to report how each block was affected by the COVID-19 measures from the perspective of healthcare workers (HCW) and community members (CM). We used the Lincoln and Guba criteria (credibility, confirmability, dependability, and transferability) to guide the rigor of our data processes (20). To ensure transferability and dependability a detailed study protocol with comprehensive process documents, minutes of stakeholder engagements, and field and reflexive notes from multiple research team members have been maintained for auditing and/or data accessibility to other researchers. The six building blocks of a health system (18). The study was undertaken at two sites: Healthcare service are primarily nurse led and include acute and chronic care, services for HIV, tuberculosis, sexual and reproductive health, maternal and child health and mobile services for some facilities. Using a combination of our experience and guidance from Hennink et al. (21) we expected to collect data from up to 25 community members and 25 healthcare workers from each of the settings (rural and urban), i.e., ~100 participants in total until data saturation would be reached. Purposive sampling was used to identify CMs 18 years or older accessing services for HIV, non-communicable diseases, or maternal and child health, and HCWs across both sites. In Agincourt, CMs were identified through a clinic-link system which provides details on participants’ diagnosis, chronic medication, utilization of services and missed visits during the COVID-19 pandemic. In Johannesburg, HCWs and health promoters worked with the study team to recruit CMs attending health facilities based on the same criteria. CMs were consented to access their healthcare records to confirm eligibility. HCWs were purposively selected based on their role, facility level and department. This was a qualitative study based on in-depth interviews (IDIs) and focus group discussions (FGD). Due to COVID-19 restrictions a hybrid (telephonic and in-person) model of data collection was used. For in-person interviews COVID-19 protocols were maintained. This included mask wearing by both interviewer and participants, maintaining a social distance, interviews being conducted outdoors and sanitizing of any shared items or surfaces (e.g., pens, chairs, and tables). IDIs and FGDs were conducted in the local languages (IsiZulu, IsiXhosa, SeSotho, SePedi, SeTswana in Johannesburg; Xitsonga in Mpumalanga) and English. Using semi-structured data collection guides, IDIs and FGDs were performed by four research experienced, protocol trained local field workers (2 males and 2 females) who are familiar with the study contexts. Data collection guides were piloted in Region F and adapted for data collection in the other research sites. Researchers performed quality checks in real time by listening to interview recordings and reading transcripts to ensure that questions were asked and interpreted as intended and that the transcripts produced were an accurate reflection of the interviews. These activities contributed to the study credibility and dependability. All data were collected between March and September 2021. Interviews lasted 35–60 min. As we were interested in community members and healthcare workers’ experiences and perceptions of healthcare service delivery and utilization during COVID-19, the data collection guides focused on the following three issues: (1); perceptions and individual experience of COVID-19 and lockdown, (2) access to health services before and during COVID-19, and (3) delivery of healthcare services before and during COVID-19. All interviews were audio-recorded, transcribed, and translated verbatim into English. Transcripts were de-identified and quality checks for accuracy and completeness were conducted by the research team. The thematic analysis approach was used (19), based on Strauss and Corbin’s method of open, axial and selective coding (22). To develop an initial list of codes (open coding), seven researchers independently coded three transcripts line by line, with one transcript from each of the following groups: CM individual IDIs, HCW individual IDIs and CM FGDs. A process of continuous comparison was employed whereby subsequent transcripts were coded using this is and new themes which emerged from the new transcripts were added to the list after consultation and agreement across the analysis team. Data analysis was facilitated using MAXQDA 2020 software to manage transcripts, themes and quotes. Codes were organized and re-organized into broader categories based on thematic similarities between codes (axial coding). Thereafter selective coding was conducted to place codes into categories. This was guided by a deductive approach where categories were aligned to the research question of how the WHO building blocks (18) were affected by COVID-19 measures. Eight deductive themes included: service delivery, service utilization, information and communication, health workforce, medication and resources, financial impact, quality of care, and recommendations. To ensure credibility and consistency of coding and consensus on axial and selective codes each transcript was double coded and checked by a third coder. Any discrepancies were resolved through discussions during the coding team bi-weekly meetings. To further strengthen all four aspects of trustworthiness, there were ongoing stakeholder (other researchers (monthly), field staff (bi-weekly), advisory committee (quarterly) engagements to discuss the data and findings. During these engagements the qualitative findings were presented and reviewed alongside the quantitative service delivery results (published elsewhere) to assess confirmability. Ethical clearance for the overall study was received from the University of the Witwatersrand Human Research Ethics Committee (M201084) in January 2021. Departmental approval was granted in February 2021 by the Johannesburg Health District (DRC Ref: 2020-11-015), Mpumalanga Province Ethics Committee (MP_202102_03) and National Health Research Database (GP_202011_066). All participants provided informed consent for study participation and recording prior to data collection commencement; community members received ZAR 300 (approximately USD 17.60) reimbursement for their time and travel in Johannesburg, whereas interviews were conducted at respondent’s home in the Agincourt HDSS.

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• Dima Health