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Health sectors reform, coping strategies and professional identity of phc clinicians in Mozambique and South Africa

Objective

The present research proposal aims at a deeper understanding of the coping strategies of health professionals, their consequences and determinants, including structural determinants. Based on this understanding it further aims to influence the strategies of development and implementation of health personnel norms and policies. The fields for this research are Mozambique and South Africa. The purpose is however to develop a framework of analysis allowing to address these questions to be addressed in other societies.

The underlying hypotheses are:

* That the coping strategies of health professionals are among the key elements for attempts at health sector reform.

* That the structural conditions that affect these coping strategies include the characteristics of the organisation of the health care system as well as the social, cultural and economic environment of the society, and the way history and politics have shaped the development process and its impact in the process of socialisation of students and young professionals.

* That in order to make coping strategies of individual health personnel compatible with the objectives of the health care system it is essential to promote the existence, acceptance and interiorisation of a role model of a generalist practitioner (patient-centred, community-oriented and guided by the universal principles of family medicine) as a cornerstone of health sector reform.

* That even in an adverse social environment it is possible and feasible to create favourable conditions that allow health personnel to adopt coping strategies compatible with equity and quality health care delivery, while responding to their aspirations for survival, social status and professional satisfaction.

Measurable objectives

* To identify historical factors of relevance to the transformation of the health sector over the past 20 years in Mozambique and South Africa;

* To identify present coping strategies, role-images and profession-identity patterns of medical practitioners medical assistance and nurse practitioners in Mozambique and South Africa;

* To identify the extent to which Primary Health Care clinicians are aware of, interpret and adhere to the principles of family medicine in their day to day practice;

* To identify the positive and negative associations of these coping strategies with indicators of quality of care;

* To identify positive and negative consequences of these coping strategies as perceived by the users and as contrasted between the different sectors of health care (public, private);

* To identify alternative coping strategies that limit the negative consequences and favour the positive consequences of health care delivery, and the structural conditions under which these alternative strategies can thrive;

* To test and demonstrate the feasibility of these alternative coping strategies in select settings;

* To develop a conceptual framework for analysing and influencing such coping strategies that takes into account the structural conditions related to health care organisation issues, and to the social context and the process of development;

* To formulate recommendations for health authorities and development agencies, that allow them to deal with health personnel issues in ways compatible with the development and reform of the health sector, resulting in greater efficiency, rather than in ways that favour the dysfunctioning of the health personnel.
Expected Outcome

* development of the framework referred to in objective 8;
* local action for change through the participatory action-research approach;
* policy recommendations for local, national and international health
* authorities;
* publications;
* capacity building and training in research methods, management and in the
* principles of family medicine.
* To identify historical factors of relevance to the transformation of the health sector over the past 20 years, in Mozambique and South Africa

* Analysis of available documents and literature related to:

- the overall process of development
- the history of the modern health sector
- health policy issues
- health personnel demographic data
- health services organisation
- health services utilisation
- social position of different health professionals in society
- training curricula of medical and nursing practitioners and medical assistants
- role of professional associations
- past and present characteristics of traditional healers

This will be complemented by structured interviews of key informers (e.g.
ex-ministers of health).

* To identify present coping strategies, role-images and professional identity-patterns of medical practitioners, medical assistants and nurse practitioners and students in Mozambique and South Africa.

A sample of medical practitioners, medical assistants and nurse practitioners and students in Mozambique and South Africa is to be selected from existing registers. Selection criteria will be considered according to sex, urban/rural residence, ambulatory/hospital care, private/public sector, years in practice, social visibility. Data to be collected according to standard interview schedules adapted to each country and professional category. Questions will include open and closed answer options.

The above information will be complemented by an analysis of the schedules of complaints of the Medical and Nursing Councils in South Africa and the Ministry of Health in Mozambique. In Mozambique there has been an intense debate in the written press, on the issue of professional coping strategies. This will be reviewed. Some health facilities have a box for complaints and suggestions, and these will be analysed.

This information will be used at the selected sites to develop an in-depth understanding by a participatory action-research approach.

* To identify the extent to which PHC clinicians are aware of, interpret and adhere to the principles of family medicine in their day to day practice.

Participant observation will take place at a number of selected PHC settings to identify structural, organisational and relational factors in the care process.

Clinical records will be reviewed according to a standard check list to evaluate completeness and comprehensibility of clinical record, comprehensiveness of care provided (curative, preventive, promotive, rehabilitative) adherence to protocol, use of essential drug list/drug formulary, continuity of care. Taped consultations will be analysed to measure patient-centredness.

* To identify positive and negative associations of these coping strategies with indicators of quality of care:

Monitoring of tracer diseases and sentinel events (identified in a participatory way), measurement of Patient-centredeness through scoring of tapes and patient satisfaction interviews, measurement of waiting times, measurement of ratios of new to repeat patients, case studies of wards and clinics or health centres. This information will be compared for private and public sector activities and for practitioners grouped according to the most important coping strategies identified.

* To identify the positive and negative consequences of these coping strategies as perceived by the users and funders (M0H health insurers) and as contrasted between the different sectors of health care (public, private and traditional).

Focus group discussions will make use of projective techniques, stakeholders and key informer structured interviews. If necessary use will be made of consensus promoting techniques that guarantee anonymity (Delphi technique), on the basis of the above.

* To identify alternative coping strategies that limit the negative consequences and favour the positive consequences of health care delivery, and the structural conditions under which these alternative strategies can thrive; to generate hypotheses of change; the negotiation of change with field actors and authorities.

This will be done at a series of workshops for the researchers, and for the researchers together with key people in policy-making institutions and on sites selected as potential field stations for the action-research phase. If necessary, use will be made of consensus-promoting techniques that guarantee anonymity.

Funding Scheme

CSC - Cost-sharing contracts

Coordinator

Medical Uinversity of Southern Africa
Address

0204 Po Medunsa
South Africa

Participants (3)

INSTITUTE OF TROPICAL MEDICINE PRINCE LEOPOLD
Belgium
Address
Nationalestraat 155
2000 Anvers /Antwerpen
UNIVERSIDADE NOVA DE LISBOA
Portugal
Address
Rua De Junqueira 96
1349 Lisboa
Universidade Eduardo Mondlane
Mozambique
Address
Avenida Salvador Allende
00200 Maputo