Providers' Definitions of Quality and Barriers to Providing Care: a Qualitative Study in Rural Mpumalanga Province, South Africa

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Abstract Background: Facing a quadruple burden of disease (infectious disease, non-communicable disease, maternal and child mortality, high levels of violence and injury), South Africa requires high-quality primary health care to retain patients and optimize outcomes. National health policy is focused on strengthening primary care. While prior research has identified implementation challenges within the primary health care system, there is less understanding of how providers define quality, their perceptions of barriers to providing quality care, and how they overcome these barriers. This study assesses provider views on quality at primary care clinics in a rural region of Mpumalanga Province. Methods: We conducted in-depth interviews with providers in Bushbuckridge sub-district in early 2019 on the value of quality metrics for providers and patients, what indicators they would use to assess clinic performance, and barriers and facilitators of delivering care. Interviews were conducted in Shangaan, audio-recorded, translated, and transcribed into English. A deductive approach was used to develop a provisional coding schema based on study questions, which was refined using an inductive approach in response to patterns and themes emerging from the data.Results: 23 providers were interviewed (83% female, 65% professional nurses). Definitions of quality were focused on clinic structure and resources. Few providers identified patient outcomes as indicators of quality. Providers linked deficiencies in infrastructure and support to deficits in care delivery, such as long wait times due to limited staffing, privacy breaches due to insufficient space, and a chronic lack of medication and equipment. Providers identified mitigating strategies including informal coordination across clinics to address medication shortages in individual facilities. Interwoven throughout the providers’ discussion was the poor communication between the district, PHC supervisors, and implementers at the facility level. Conclusion: Providers connected deficits in quality of care to inadequate infrastructure and insufficient support from district and provincial authorities; mitigating strategies across clinics could only partially address these deficits. The existence of a national quality measurement program was not broadly reflected in providers’ views on quality care. These findings underscore the need for effective district and national approaches to support individual facilities, accompanied by feedback methods designed with input from frontline service providers.

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