The quality of care for sexually transmitted infections in primary health care clinics in South Africa: an evaluation of the implementation of the syndromic management approach

Abstract

Sexually transmitted infections (STIs) are a problem for both developed and developing countries. Sub-Saharan Africa has the highest rates in the 15-49 years old group. The discovery that these infections playa vital role in the transmission of HIV raised their profile and made their control one of the central strategies of stopping the HIV/AIDS epidemic. In response to the challenge of improving the quality of care for people infected with STIs in the public health sector, the South African Ministry of Health adopted the syndromic management approach, recommended by the World Health Organisation as suitable for resource-poor settings, for use in primary health care clinics. In addition to providing guidelines on clinical management of STIs, the syndromic approach requires health providers to counsel and educate patients about STIs, encourage patients to complete treatment even if symptoms abate, promote condom use and the treatment of all sexual partners. While the management guidelines are clear and detailed around the diagnostic and medication issues, the processes of education and counseling are not as clearly outlined. Furthermore, although the syndromic approach is a viable way of providing good quality care to larger sections of the population than could be serviced through dedicated STI clinics, it requires health providers working in primary health care clinics, most of whom are professional nurses, to perform some tasks for which they may not be adequately trained. This study evaluated the quality of care for persons infected with ST!s by examining the extent to which the syndromic approach was being implemented in primary health care clinics. Interviews, using semi-structured interview schedules, were conducted with ST! patients and health providers in twenty-four clinics located in four provinces. In depth qualitative interviews were also conducted with a sub-sample of the patients. For further triangulation the methods of participant observation, through the use of simulated patients, and focus group discussions with various community groups were used. The findings of the study indicate that although primary health care clinics in South Africa are well-resourced, the management of patients with ST!s is inadequate. Adherence to the various aspects of syndromic management was poor. Similar to other studies in South Africa, the attitudes of health providers towards patients with ST!s were found to be problematic, a finding that has implications for health-seeking behaviours. The thesis argues that a large part of the problem is related to the multiple roles that nurses have to play in primary health care settings, as well as the content and methodology of the training of nurses who manage ST! patients. It further argues for the constitution of the basic health team at primary health clinics to be multi-disciplinary, and for a multi-disciplinary input in the training of health providers.