Background
Methods
Study design
Data collection
Sampling
Health hazards | Superordinate themes | Constituent sub-themes |
Stress | Anxiety | |
Inadequate number of midwives | ||
Infection | Blood and liquor as sources | |
Slip and fall | Splashes of liquor | |
Assault | Poor labour outcomes | |
Irritation and Burns | Use of corrosive chemicals/drugs |
Data analysis
Results
Borrowing of supplies and logistics
An analysis of why the periodic shortage of medical supplies revealed that health centres are faced with cash flow challenges. Probing further the study found that, in the era of lack of government subvention to facilities, health centres rely on their Internally Generated Funds (IGF) to restock medicines and other resources for effective service delivery.[…] Sometimes, we (health centres) run short of drugs, we cannot get common paracetamol for our clients […] (IDI_P02_Region B).
However, health centre IGF is affected by irregular payment schedules from the National Health Insurance Scheme (NHIS). Thus, this affects the availability of health resources at the health centre levels:[…] Budgetary allocations to the BMCs have dwindled or stopped completely […] Government is now funding our budgets through the services we provide […] So we just have to generate more money to survive […] (FGD_DHFP_P04_Region C).
Analysing how heath centres cope with these challenges, the study found that a borrowing initiative was introduced. In this instance, district hospitals allow health centres which run out of medical supplies to borrow from the hospital and replace at a later date:[…] For drugs, we have a problem, because of NHIS […] For instance, they owe us about eight months, there are a lot of things that are short in the health centre […] (IDI_P04_Region C).
Analysis of how the borrowing initiative works revealed both formal and informal borrowing mechanisms. Formal borrowing of medical supplies means that the borrowing arrangements are channeled through the hospital management for approval. For example:[…] With medicines and medical supplies, when they (health centres) need them, they come and we (hospital) give to them; and when they get them, they bring back to us […] (FGD_DHM_P01_Region C).
On the other hand, informal borrowing implies that district hospital transfers medical supplies to the health centres without the approval of hospital management, For instance, it was reported that healthcare providers at the district hospitals encouraged their colleagues at the health centre levels to collect items for use whenever they run out, and to replace them later:[…] If for any reason, sub-districts run short of medicines, folders or some consumables, they come and borrow (laughing) […] They call me (medical superintendent) and I give the items to them, and they replace these items later […] (IDI_P03_Region C).
It was also reported that healthcare providers of health centres talk to their colleagues at the district hospitals to collect medical supplies and replace them later:[…] Once the whole district ran out of folders, and we (hospital) had some folders in stock, so we called the sub-district to come and pick some folders, so that they can replace later […] (FGD_DHFP_P06_Region C).
Nonetheless, health centres also borrow from colleague health centres in the district. In this case, health centres contact and borrow from each other to beef-up shortage in medical supplies:[…] Some of the sub-districts just come straight to us (hospital frontline providers) to borrow, and depending on the item, we give and they return it later […] (FGD_DHFP_P02_Region A).
The analysis also revealed that medicines and medical supplies that are near expiry at the health centres could be swapped with new medicines and medical supplies at the district hospitals:[…] Yes, we borrow from other health centres, when we need something, we just call other health centres and if they have, we will borrow and give back to them when we get ours […] (IDI_P04_Region C)
Analysis of how and why this borrowing initiative is sustained revealed that health centre care providers are honest men and women. Thus, the borrowing arrangement between these PHC level institutions is sustained by trust. Participants responded to a question; ‘are there times they do not return borrowed items?’:[…] When sub-district drugs are about to expire, they bring the drugs to the hospital and they exchange for us […] (IDI_P01_Region A).
Knowledge sharing
The analysis confirmed that health centre healthcare providers constantly call the district hospital healthcare providers to discuss and seek case management guidance:[…] Whenever we (health centre staff) call, what we do not know they (district hospital staff) tell us and we continue with the treatment […] (FGD_HCFP_P02_Region C).
The study found that the knowledge sharing initiative have the potential to improve health outcomes in the district. Once knowledge is shared about a particular medical case, chances are that health centre healthcare providers would be able manage the case at the health centre level. Nonetheless, if the patient is referred to the hospital, the patient information is already known at the hospital level; and this facilitates continuity of care at the hospital:[…] Whenever they have any problem, they call me (medical superintendent), we discuss the case and I assist them to manage the case; if they need to bring the patient here, I assist them to do that […] (IDI_P02_Region A).
Analysis of how knowledge sharing is sustained revealed that knowledge sharing has been institutionalized i.e. district hospital management officially informed health centres to call for professional advice whenever they face service delivery challenges:[…] At times, they also call for guidance in managing cases at the health centre level… If the directions given do not work, then they refer […] This is helping a lot to reduce our maternal deaths […] (FGD_DHFP_P03_Region B).
Further analysis of why knowledge sharing exists between district hospitals and health centres revealed that health centres recognise the expertise of the district hospitals and constantly engage them on how to manage cases at the health centre levels.[…] Doctor said whenever we have a case, we have to call first; either they give us directives or they ask us to bring the case, so we share ideas […] (FGD_HCFP_P01_Region C).
This initiative suggests that health centres seeking professional advice from the district hospitals has the potential to bridge knowledge gap in health centre service delivery.[…] so they (health centres) see us (district hospitals) as their superiors and ask for support when they need it […] (IDI_P03_Region C)
Multitasking
Secondly, the analysis revealed that health centre dispensaries also benefit from multitasking. In all the three health centres, it was observed, and participants reported that the dispensaries were manned by one person who had multiple roles in the health centre. Hence, the dispensary sections of health centres were over-burdened and required support. In such situations, colleagues from other sections of the health centre move to support in dispensing drugs to patients:[…] The laboratory receives a lot of support from colleagues in the health centre […] When the place is crowded, some colleagues come to help me with the registration of patients and entry of results, while I run the tests […] (FGD_HCFP_P04_Region C).
Thirdly, health centre records sections also benefit from multitasking. The study revealed that these sections lack qualified personnel, and this translates into a service delivery burden, especially when outpatient attendance is high. In such instances, a number of healthcare providers gather at the records section to help retrieve patient folders before they return to their official duty points:[…] At times, some people have to come in and help, because I am alone at the dispensary […] (FGD_HCFP_P05_Region C).
Finally, the analysis also revealed that health centre healthcare providers support skilled delivery services at the maternity section. A single midwife working in the health centre suggests that the maternity section requires support in order to conduct quality skilled delivery. Midwives at the health centre level workday and night to meet maternal healthcare needs of the rural communities. The health centre midwives provide antenatal and postnatal care, as well as conduct deliveries for pregnant women. During delivery, health centre midwives require support and colleague healthcare providers readily provide some form of support:[…] So people leave their places to support in retrieving folders, this morning, I came and saw you and the medical assistant retrieving folders (some laughing) […] (FGD_HCFP_P06_Region C).
Analysis of why multitasking is used during service delivery revealed that healthcare providers identify and prioritize sections of the health centre that require support in order to enhance quality of care. For instance, the records section is the starting point of the healthcare delivery process at the health centre. Therefore, any delays in this section affect the entire service delivery leading to long waiting times and patient dissatisfaction. Against this background, healthcare providers move to support the records sections of the health centres:[…] Anytime I call on anybody to support me at the maternity, they are always willing […] (FGD_HCFP_P07_Region C).
Analysis of how multitasking is sustained revealed that there is high team spirit and love for the job among healthcare providers in the health centres. It was observed and participants report that healthcare providers are very hard working and remain committed to supporting each other in order to strengthen service delivery. Above all, the healthcare providers at the health centre love and respect each other:[…] When patients delay at the records section, it affects the entire process […] (IDI_P04_Region C)
This suggests that team-spirit among health centre healthcare providers has the potential to facilitate multitask approach to health service delivery. This effort is likely to improve health outcomes in the sub-districts, districts and the national level as a whole.[…] We love each other, and we love the work […] As if they have selected us together, we are just okay with each other […] We are all hardworking and ready to support one another each other […] (FGD_HCFP_P07_Region C).