Measuring the move towards equity - from the site of service delivery

Purpose of the survey

The overall aim of the research was to evaluate the quality of service provision rendered at the primary level in South Africa, and to describe any major differences between provinces and between rural and urban / peri-urban parts of the country.

A total of 160 clinics, 3 from every region of each province in South Africa were visited. 71 were rural, 39 peri-urban and 50 urban. A questionnaire was used to collect information which was then collated.

Indicators
The following primary level care indicators related to inputs, processes and outputs were used to measure service provision at the selected clinics:

• Infrastructure: availability and reliability of electricity, water and telephone
• Workload: number of patients per nurse per month
• Support: visit by doctor and / nurse in the last month
• Equipment: availability of working scales for weighing babies, availability and reliability of refrigerator
• Drugs availability: a selection of drugs from the essential drugs list and oxygen
• Emergency referral: response time for emergency transport
• Management of STDs: use of syndromic management approach to STD management
• TB services: time to get sputum results
• Integration of services: days on which family planning and immunisation services were available
• Antenatal care services: availability of syphilis testing facilities

Findings
Findings were collated under the following categories:

• Infrastructure: Unreliable electricity, water and telephone services and functional refrigerators are all issues of concern.
• Human Resources: It was encouraging to note that nurse supervision appeared relatively high in all provinces, however this was not complemented by adequate doctor visits, especially to rural clinics.
• Quality of Care: In the area of child health services and family planning services there were some encouraging findings, for example a relatively acceptable level of child health services and about 72% clinics offering family planning services on a daily basis. Areas of concern included two priority health problems, namely sexually transmitted diseases and tuberculosis, being far from attaining standards set for their management.

Recommendations
Particular attention needs to be placed on rural areas and on the poorest provinces of the country, thereby reducing those aspects of inequity illustrated by this study.
An ongoing process of monitoring the quality of service provision, particularly at the primary health care level is essential to ensure that it is the worst areas that are benefitting the most by the restructuring of South Africa's health system.