Frontline health workers as brokers: provider perceptions, experiences and mitigating strategies to improve access to essential medicines in South Africa

BMC Health Services Research

David Sanders³  Roger Jeffery¹  Kim Ward⁴  Ashwin Budden²  Bvudzai Priscilla Magadzire³ 

[1] University of Edinburgh, School of Social and Political Science, Edinburgh, Scotland;University of Basel, Swiss Tropical and Public Health Institute, Basel, Switzerland;University of the Western Cape, School of Public Health, Private Bag X17, Bellville 7535, South Africa;University of the Western Cape, School of Pharmacy, Bellville, South Africa

关键词: South Africa;    TB;    Depression;    Diabetes;    HIV;    Empathy;    Broker;    Health services;    Provider perceptions;    Access to medicines;   

Others  :  1092313
DOI  :  10.1186/s12913-014-0520-6

 received in 2014-05-06, accepted in 2014-10-13,  发布年份 2014

【 摘 要 】

Background

Front-line health providers have a unique role as brokers (patient advocates) between the health system and patients in ensuring access to medicines (ATM). ATM is a fundamental component of health systems. This paper examines in a South African context supply- and demand- ATM barriers from the provider perspective using a five dimensional framework: availability (fit between existing resources and clients’ needs); accessibility (fit between physical location of healthcare and location of clients); accommodation (fit between the organisation of services and clients’ practical circumstances); acceptability (fit between clients’ and providers’ mutual expectations and appropriateness of care) and affordability (fit between cost of care and ability to pay).

Methods

This cross-sectional, qualitative study uses semi-structured interviews with nurses, pharmacy personnel and doctors. Thirty-six providers were purposively recruited from six public sector Community Health Centres in two districts in the Eastern Cape Province representing both rural and urban settings. Content analysis combined structured coding and grounded theory approaches. Finally, the five dimensional framework was applied to illustrate the interconnected facets of the issue.

Results

Factors perceived to affect ATM were identified. Availability of medicines was hampered by logistical bottlenecks in the medicines supply chain; poor public transport networks affected accessibility. Organization of disease programmes meshed poorly with the needs of patients with comorbidities and circular migrants who move between provinces searching for economic opportunities, proximity to services such as social grants and shopping centres influenced where patients obtain medicines. Acceptability was affected by, for example, HIV related stigma leading patients to seek distant services. Travel costs exacerbated by the interplay of several ATM barriers influenced affordability. Providers play a brokerage role by adopting flexible prescribing and dispensing for ‘stable’ patients and aligning clinic and social grant appointments to minimise clients’ routine costs. Occasionally they reported assisting patients with transport money.

Conclusion

All five ATM barriers are important and they interact in complex ways. Context-sensitive responses which minimise treatment interruption are needed. While broad-based changes encompassing all disease programmes to improve ATM are needed, a beginning could be to assess the appropriateness, feasibility and sustainability of existing brokerage mechanisms.

【 授权许可】

   
2014 Magadzire et al.; licensee BioMed Central Ltd.

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