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Aim of study
The aim of this study is to investigate the experiences of public sector doctors in a rural hospital in the context of a plural health care system. Using Lipsky’s concept of street-level bureaucracy,the study focuses on doctors’ daily decision making and routines and the way they manage their work in the public health care services, as well as their interactions with other arms of the plural health care system. The study is conceptualized within the framework of health systems research and policy implementation, as an empirical qualitative enquiry into healthcare delivery at the interfaces between the clinician as professional and bureaucrat and patients, the public, other health care professionals practitioners and bureaucrats.
Relevance of the study
Post 1994 the challenge of transforming and expanding the public sector to integrate and achieve an equitable system resulted in a stressed and volatile health care system. Important system level changes notwithstanding, service delivery depends on the interactions of public sector doctors with patient-citizens within the wider health care system. This fact and a weak understanding of how street-level bureaucracy works has led to the call for research into this area of enquiry in health systems policy research.(8, 9) No other studies exploring the experiences of doctors as street-level bureaucrats in developing countries were found in the literature.
Doctors as a professional group
As a professional group, doctors enjoy high social status. In South Africa, as in many regions of the world, the profession is believed to have high ethical standards, a high degree of independence and autonomy, and is assumed to draw its practices from sound scientific evidence.(13-15) Further, it is believed that philanthropy frames the profession’s work ethic (13, 16, 17).Yet, the profession finds itself under threat(18) and its standing is challenged globally by a multiplicity of complex factors, including the limits of its own influence.
Emmaus Mission and Emmaus Hospital
The early years As part of an approach to governing Natal in the mid-1800’s, Sir Theophilus Shepstone proposed the development of reserves to assign areas for settlement of specific clans.(149) The Amangwane had been highly mobile in the time prior to this(149, 150) and during the Chieftaincy of Zikhali settled in the area of the Upper Tugela Location.
Methodological considerations
The central question of the study is the experiences of public sector doctors working in a plural health care service environment. Qualitative methods were used to understand the meanings of being both civil servant and professional, as well as the relationship to the plural health care service and patients.
The professional in rural South Africa
Despite a constitutional right to health that is backed by current law and policy, severe inequities continue to exist in the rural health care systems of the new democratic order in South Africa(195, 196) . This is starkly captured in the geographical distribution of health care practitioners between urban and rural areas. Although 43% of the population lives in rural areas only 12% of doctors and 19% of nurses practice in rural areas.(33)
Doctors managing their work
Collectively, doctors at Emmaus Hospital had considerable leeway to arrange their duties in a manner that suited them. Even the decision of when the working day started, was, within limits, left up to the team of doctors themselves. Doctors met routinely every Friday morning in the library to plan the services for the following week. They also began each day with a meeting, usually in the courtyard in front of OPD, to coordinate their day’s activities. The planning and coordination meetings shape the working day for the doctors and follow wellestablished patterns that arrange the doctors in a way to ensure that all the work is covered.
The administrative process
Unlike other social support grants the disability grant requires medical certification. The applicant has to be assessed by a doctor and found to have a physical or mental disability. The verified condition has to be of sufficient severity and duration for the grant to be awarded. In urban areas the Department of Social Development or the South African Social Security Agency has contracted doctors specifically to perform the disability assessments. However, in rural areas public sector doctors, because of their limited number and historic practices, perform these assessments as part of the general outpatient function at the hospitals.
Public sector doctors relating to private health car
Up to now I have explored how public sector doctors function as street-level bureaucrats from a few perspectives within the public sector. Yet the public sector doctors do not function in isolation of the larger context of how health care is accessed and the different systems of care that exist outside of the public sector. Within this plural health care system, I will explore what the experience of public sector doctors of the private health care system is. In relation to private health care, how do public sector doctors function as street-level bureaucrats? And out of this, how do we understand private and public sectors in the provision of health care trural populations?
Chapter 1:
Aim of study
Relevance of the study
Outline of the thesis
Chapter 2: Background
Doctors as a professional group
Family Medicine and Rural Health
The public sector and the doctor employed by the state in South Africa
Background in understanding the public sector
Chapter 3: Local context
Historical and ecologic context: Okhahlamba Emmaus Mission and Emmaus Hospital
The early years
Brief history of Emmaus Hospital
Health care services in Okhahlamba at the time of the study
Private health care
Non-Governmental Organisations raditional Healers
Chapter 4: Methodology
Methodological considerations
Insider ethnography
Study Design and Research Methods Selection and overview of participants
Reflecting on gaining entry and becoming a researcher
Participant Observation
In-depth interviews
Discussions and focus groups
Chapter 5: Doctors’ experiences of being professionals in the public sector
The professional in rural South Africa
Character virtues of rural doctors
Personal commitment
Chapter 6: Doctors as bureaucrats
Doctors managing their work
Weekly Planning Meeting
Daily Morning Meeting
OPD
Chapter 7: Doctors as public officials
The administrative process
Responding to changes in regulations from SASSA
Assessing disabilities
Medicalisation of entitlements
Fraud
Gatekeeping resources
Chapter 8: Public sector doctors relating to private health care
Setting the scene
Referrals
Referring from a public sector hospital
Referrals from Private Care into the Public Sector
