Core functions of primary care in Amathole District, South Africa: a descriptive study

Summary

Patients rated primary care performance as acceptable. Person-centredness, coordination, and utilisation were rated as good. Continuity and comprehensiveness were seen as acceptable. Relational continuity was weak, while informational continuity was stronger. Service delivery for dental care, social problems, minor injuries, minor surgery, people with disabilities, hearing and eye care, palliative care, and care for older people undermined the score for comprehensiveness. Access was scored poorly as people could not access any primary care on evenings or weekends, neither at their facility nor in their home or via mobile phone. Nevertheless, affiliation to the facilities was high.

Patients who had worse health or a chronic condition scored primary care performance lower. There was also unequal performance between subdistricts, with more rural subdistricts performing better. There was some evidence that both the poorest and the most affluent sections of the community rated performance lower.

Strengths and limitations

To the authors’ knowledge, this is the first study to use the PCAT-SSA, with a focus on the core functions of primary care. The study obtained the required sample size and followed the intended sampling template. The results, therefore, should be generalisable to the district. The results were more positive than expected but there did not appear to be any social desirability bias with the research assistants who were not identified as doctors. They were perceived as young Xhosa speaking women and external to the clinics. The findings came from three different assistants and 40 different facilities across the whole district, which should have minimised any such bias. It might have been helpful to triangulate the patients’ scores with those of the managers or healthcare workers to get a more complete picture of the core functions. The predominance of women attending primary care is consistent with patterns elsewhere,¹² and may also reflect migrant labour issues, with many working-age men in the Eastern Cape looking for work in other provinces.

Comparison with existing literature

Table 6 compares Amathole with other studies that used PCAT in South Africa, Kenya, and Uganda.^9,12,13 The study from South Africa combined data from four other provinces, but not the Eastern Cape. By comparison, Amathole scored slightly higher for all the core functions, apart from access. The study from Kenya was in metropolitan private sector primary care facilities, while the Ugandan study was from rural public sector primary care facilities. These previous studies used country level adaptations of the PCAT that differed slightly in the number of items and constructs. Again, Amathole performed better on all core functions, apart from access. It is difficult to attribute reasons for this, but two possible factors are active participation in the Ideal clinic programme and a well-functioning district clinical specialist team, led by a family physician, that consistently focused on supportive supervision and quality improvement.

Access to care can be related to geography, finances, and organisational issues.¹⁴ Many of the facilities in Amathole are in remote rural areas where roads are poor and people may need to walk to the facility. In South Africa there are no direct fees to use primary care, although costs may be incurred in travel or time off work. Many employers have a ‘no work, no pay’ approach, so working people prefer to access care outside of working hours. This could also be true of students who are committed during the day. Unfortunately, in Amathole there are no primary care services available outside of working hours and people with emergencies try to access care at the district hospital. The lack of access to primary care has been noted as a key factor in people with non-emergencies attending emergency departments.¹⁵ It should also be noted that only 3% of hospitals in the Eastern Cape were rated as ’ideal’ in 2023.⁴ Many of the communities had community health workers; however, it did not appear that people saw them as a resource outside of working hours. The public sector in South Africa has not developed any telehealth services that could support people afterhours.

Continuity is related to lower mortality and reduced hospitalisation and use of out-of-hours services.¹⁶ Such continuity is still an aspirational goal for South African primary care. Although coordination scored well, referral to specialist care required a doctor, and doctors were mostly available at the district hospitals. Therefore, primary care was unable to directly refer patients to specialists.

Implications for practice

The most important issue to address is access to primary care outside of normal working hours. Although the health centres are open 24 hours a day they do not provide access to a doctor and there were only five health centres across the whole district. Extended hours on evenings and weekends might assist students and employed patients in some areas. Consideration should be given to help from community health workers out-of-hours and to the use of telehealth.

The comprehensiveness of primary care needs to be addressed and linkage to care for services related to dentistry, hearing loss, visual loss, and disability. Primary care nurses might need training in some issues such as social problems and linking people to social services. Palliative care may be an additional area for training as well as assisting older adults. Minor injuries and minor surgery might require better access to doctors at the primary care level. Even at the district hospital level some of these services may be problematic.

Improving the coordination of care for patients needing referral to specialist services should be streamlined. Ideally, clinics should be supported by visiting primary care doctors, or nurses should have access to specialist referral via digital solutions such as the Vula application.¹⁷ The Vula application allows a nurse to present the patient and receive feedback from the specialist via their mobile phone. An appointment can then be made without necessarily requiring an additional visit to the district hospital.

The model of care should be re-visited to enable more relational continuity with the primary care provider. This may be a particular issue in larger facilities with multiple providers.

The user version of the regional PCAT worked well in this setting and could be completed within 10 to 15 minutes. Creating health workers and manager versions might be useful to allow triangulation of results in the analysis.

Primary care performance in the Amathole District was acceptable and person-centredness, coordination, and utilisation were strengths. Comprehensiveness and continuity of care were acceptable but could be strengthened further. Access was poor and needs attention within the performance management process. The new regional version of the PCAT was easy to use and provided novel information on performance.