To queue or not to queue: Facility managers and mental health care users’ experiences of integrated health care in a rural South African district

Background

As South Africa moved to a democracy in 1994, there were concomitant changes in all aspects of society, including health care. A key feature of state health care strategy since 1994 has been the development and expansion of services at primary health care level. In common with many countries with colonial histories, health expenditure in South Africa was skewed towards tertiary hospital services in major urban centres; the principle of equity in health care required an expansion of community-based health care provision across the entire country.

The concept of primary health care (PHC) has been defined as: an essential health service that is the first contact care for individuals and communities that is universally accessible and can provide comprehensive treatment (i.e. providing promotive, preventive, curative, supportive and rehabilitative care) to the health care service users as close as possible to their everyday environment. PHC is an approach to health that aims at organising and adapting services to the needs of the population served in facilitating the highest possible level of health and well-being (Muldoon et al., 2006).

With South Africa’s divided and discriminatory history, this inclusive approach rapidly became intertwined with broader political imperatives concerning integration in society as a whole. Not only were services to be fully integrated in terms of race, but a vision for services was that these would be offered in as integrated a way as possible. The term ‘one-stop shop’ (Hlongwa & Sibiya, 2019) has been used to describe the ideal PHC system, with patients being able to access all their health needs (preventive, promotive, and curative and across all health conditions) ideally in one place and at one time.

Historically, mental health (MH) services at PHC level, where available, had been offered as a specialist service within PHC, commonly staffed by specially trained MH (psychiatric) nurses, supported by psychiatrists who would visit clinics intermittently. There were specific days on which MH services were offered in what has been termed a ‘silo’ approach to service delivery. Within the new integrated system, emphasis was on integration of patients with MH care needs with other patients into what was conceived of as a streamlined service where multiple health conditions and needs would be addressed simultaneously (Dookie & Singh, 2012; Phaswana-Mafuya et al., 2008). Ideally, this desegregation of those with obvious MH care needs from other patients would lead to de-stigmatisation, with MH care patients being seen similarly to other patients with acute and chronic health conditions, such as colds, diabetes and hypertension. Indeed, a proportion of those with hypertension and diabetes would have MH needs and concerns as well, and these, it was envisaged, would be dealt with integratively.

There is no question that in certain areas of South Africa impressive gains have been made integrating MH care into PHC (Lund et al., 2010; Petersen et al., 2009). However, nearly 30 years into democracy, the question arises as to how the ideologies of integration of MH and PHC are understood and managed by frontline health care workers and patients in rural parts of South Africa, which have not been studied in relation to this issue. The Eastern Cape province has been one of the poorest parts of the country for more than a decade (Statistics South Africa, 2017). As part of a larger study into MH care in an area of the province with a predominantly rural population, we report here on experiences with the system of care of facility managers and MH service users in rural clinics. We were interested both in their views as to the advisability of the integrated model and the ways in which, at local level, they managed any challenges they may have experienced with the system.

Research methods

Participants and data collection

The participants for this sub-study were facility heads/managers at their respective establishments and adult mental health care users (MHCUs) at these facilities (see Table 1 for study population description). Participants were recruited though advertisement of the project at the health care centres. Following ethical approval, participants who volunteered participation were telephonically contacted and appointments to meet with them were scheduled. Data were collected through a once off semi-structured interview with the first author (DR) who was also the primary investigator for the project. Interviews were conducted with five facility managers and five MHCUs at the participants’ place of work (in case of facility heads/managers) or dedicated health care facility (in case of service users). Interviews were approximately 60 min in duration and audio recorded. Participants chose their own pseudonyms to anonymise their identity and ensure confidentiality.

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Table 1.

Descriptive information of the sub-study population.

Facility Managers	Occupation	Period serving in public health care	Period serving at current facility
Mrs X	Operational manager	33 years	16 years
Lollypop	Professional nurse	21 years	4 years
Nana	Professional nurse	4 years	2 years
Avy	Operational manager	34 years	5 years
Beyonce	Professional nurse	22 years	12 years
Mental health care service users	Age	First language	Employment status
Charmy	58 years	Afrikaans	Unemployed
Heksie	43 years	Afrikaans	Nail technician
Gavi	51 years	Afrikaans	Unemployed
André	41 years	Afrikaans	Unemployed
Khosinathi	33 years	isiXhosa	Unemployed

Findings

From the interviews with participants and subsequent data analysis, a number of themes emerged that addressed the aim of the project. The themes with supporting narratives are presented in Table 2:

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Table 2.

Themes that emerged during analysis of participants’ experiences.

Themes
The integration of MH care into routine primary health services poses challenges to treatment delivery.
The integration of MH care into routine primary health services poses challenges to patients who come for treatment.
Resegregating care as a solution?

Note. MH = Mental Health.

Discussion and conclusion

To our knowledge, the presented research is the first of its kind in the public primary health sector in the DBNLM district. The study provides first insights into facility managers’ and service users’ views of integrated MH care at PHC level in the rural parts of the Eastern Cape of South Africa. While MH care services have been expanded and integrated into PHC over recent years, the system may not have been as streamlined as reported in other parts of the country. Can health care facilities offer what service users may need during their visits to this ‘one-stop shop’? Can optimal levels of MH, wellness, care, and rehabilitation be reached through integration of care in this part of the country?

Integrated healthcare may be helpful – especially during initial stages of assessment and treatment of patients or for screening for comorbidities. The findings from our study however suggest that in the absence of adequate resources; integration of MH into PHC can pose various challenges to facilities, health care providers, and MHCUs. Integration of care, it appears, may have contributed to the phasing-out of the, already scarce (De Kock & Pillay, 2016), dedicated MH nurses who previously cared for MH patients. MH service users now have to wait in the same queue as others with acute or chronic health conditions before they can be attended to by the next available health care worker. As a result, facilities are burdened with high service user load, creating long queues and waiting times before treatment. Health care workers frequently have to rush to get through their patient load, which makes them question the quality of care provided. Some health care providers go so far as stating that their rushed work leads to neglect and ineffective treatment.

One of the key arguments in favour of integrating MH into PHC in South Africa, as we have shown, is that having patients with MH problems as part of the general pool of patients may reduce stigma. This is essentially an argument about the potential benefits of intergroup contact. Literature on intergroup contact, however, shows that for social integration and acceptance to succeed, as when people are grouped together across various domains of society, certain core conditions must be met, for example, status equality across groups and support for contact from those in authority are key (Dixon et al., 2010; Pettigrew, 1998). In the case of this health authority, and, likely, many others, these facilitating interventions are not in place. It seems evident that the integration of care at rural level may have overstretched the capacity of care that facilities and health workers can offer. Service users experience feeling othered and labelled as a result of their mental illness. Furthermore, MH service users experience the queues as distressing; they feel non-prioritised and annoyed at having to wait long periods before being attended to. Some service users experience these long waiting times as increasing their levels of distressing symptoms. Our study supports the work of other local literature by Swartz and MacGregor (2002) in showing that certain populations, such as MH patients, may not necessarily benefit from integrated health care modalities as others with other chronic conditions may, given current resource constraints. The experiences reported in our study show that providing open, unstructured, first-come-first-serve health care at PHC level may in fact hinder and diminish MH care access to the vulnerable populations in low-resourced contexts.

We are aware that our findings contrast with much of current wisdom on service planning. Literature suggests that silo or independent treatment modalities can be problematic to overall service delivery and management of patients (Mokitimi et al., 2019). Yet facility managers in these constrained circumstances have observed that segregating MH care from physical treatment, as in the past, may deem more effective for health care provision and reception. This does not imply removing multi-disciplinary referral pathways or intervention, but rather shows a practice to some degree of separating MH care from physical health care. As a result, some facilities strategically structured their service provision in a manner which looked like resegregation. Resegregating mental and physical health into two different lines of care may portray that one is more important than the other. It may also mimic silo treatment modalities that may seem to neglect holistic health care. However, the change towards resegregated treatment delivery contributed to service users receiving their MH treatment during fixed appointments when the clinics are more quiet, which allowed health workers to longer attend to patients’ presenting needs. For patients, shorter queues and waiting times facilitated their experiences of care reception and wellness. Perhaps a possible way forward is that MH service users can have different appointment slots for their physical and mental treatment when needed/desired. In such case patients may experience that their health needs are attended to at set times and limit the distress caused by having to wait in uncertainty for prolonged periods of time before receiving care.

Our study suggests that the integration of MH care with physical care at PHC level in this part of the country may not be as effective as may be assumed. It is well established in the field of disability inclusion more broadly, that simply having people in the same place is not the same as inclusion. For example, placing children with disabilities in a classroom with others, but without appropriate support where necessary, may lead to increased exclusion and marginalisation than providing specialised services (Bantjes et al., 2015). Disability inclusion in health, as the recent World Health Organization (WHO) Global Report on Health Equity for Persons with Disabilities (World Health Organization [WHO], 2022) emphasises (and this includes inclusion of people with what the WHO would term ‘psychosocial disabilities’ or mental disorders), requires broader institutional and attitudinal change. It is not just a question of having people in the same place or the same queue. The question arises if segregated care may be more effective; or if better integrated care should be facilitated. Inclusion requires resourcing, support and attitudinal change, as well as sensitivity and responsiveness to specific care needs. In a resource constrained environment like the one we have studied, thoughtful integration may well be an ideal, de facto segregation of a sort may be more practical as an approach. Facilities and health care providers must be supported to be cognisant of their specific structures, resources, and service provider/user needs. Generalised integration of MH treatment with physical care should be approached with caution unless there is wider scale provisioning and greater organisational change. Adjusting to changes may be difficult to accommodate for facilities, health care providers, and service users. Facilities, health care workers, and patients in our study showed a preference, in their context, for a degree of segregation and specialisation of services. Some of the preference to status quo at some time may have been related to adverseness to change; but the current operational method has been in place for many years. Marais and Petersen (2015) have similarly highlighted the importance of health system governance changes as fundamental to integration efforts; where such changes are not in place, integration may, paradoxically perhaps, do some harm. It is important to stress that we are not suggesting that integrated care is not desirable or helpful; what we have found however is that with limited infrastructure and resources to support integrated care, many practical challenges may arise. Full and successful integration of MH care integration into PHC requires more than a simple integration of queues, but requires the comprehensive assessment of the circumstance in which health care is delivered as a whole.