Date Published: May 17, 2018
Author(s): Robert I. Caldwell, Merridy Grant, Bernhard Gaede, Colleen Aldous.
There exists a major disparity in access to specialist care between patients in urban and rural areas. Specialists are a scarce resource and are concentrated in urban areas. Specialist outreach attempts to fill the gap in service provision for patients situated remotely. While there is international evidence that multifaceted specialist outreach has achieved varying levels of success, factors that influence the effectiveness of outreach have not yet been fully elucidated in South Africa.
This study attempts to uncover some of the factors that enable good multifaceted specialist outreach.
The study was conducted in hospitals in western KwaZulu-Natal province. This health area is served by a tertiary hospital and 20 peripheral hospitals; three of these are regional level and the majority are district level hospitals. Specialist outreach emanates from the tertiary hospital.
Specialists providing outreach services from the tertiary hospital and medical officers at seven receiving hospitals were interviewed to explore perceptions regarding factors that might enable successful specialist outreach. Framework analysis on the transcribed interviews was carried out using NVivo version 11.
A major positive finding concerns the relationships formed between outreach specialists and doctors at the recipient hospitals. The management of the programme with respect to structure, dependability, data management, transport provision, communication technology and public health systems was also seen as beneficial in specialist outreach.
Specialist outreach plays an essential role in providing equality in health care. To enable effectiveness, it is important to make full use of the multifaceted nature of this intervention.
South Africa (SA) and KwaZulu-Natal (KZN) are not unique regarding the inequality of specialist services available to different sections of the population: this is a worldwide phenomenon. Nevertheless, this distinction could not be emphasised more starkly than by that between urban and rural citizens of western KZN.
In-depth interviews were conducted with 23 doctors: 9 specialists in PMB and 14 MOs or medical managers at peripheral hospitals who had participated in the outreach programme.
Concerning the importance of liaison or relationships in outreach programmes, participants, whether they were specialists providing MSO or MOs at peripheral hospitals receiving MSO, had the same opinion. Therefore, SO, even if multifaceted, need not be viewed as simply bringing services and teaching to the periphery: liaison may be more important than the actual clinical performance of MSO. ‘Outreach’ may even be a patronising and dated term and should perhaps be replaced by another: ‘liaison’ or ‘relationships’ or ‘collaboration’. Indeed, collaboration may capture the essence of MSO as it was regarded as its crux by so many participants in this study. Teamwork and shared responsibility were also identified as important elements of outreach. Therefore, the collaboration component extends to a joint responsibility for the recipient hospital as a whole.22,23
Seven dominant themes describe enabling factors for an MSO programme. Long-term relationships are crucial to MSO. The structure of MSO implies both uniformity and flexibility. Effective MSO requires regularity. Available data are often not properly documented or utilised. Transport is critical to the existence of MSO. Telehealth is desirable, but technology failure and potential obsolescence jeopardise it. Multifaceted specialist outreach should be part of NHI policy.