BACKGROUND: Performance Measurement and Management (PMM) systems are levers that support key management functions in health care systems. Just like many low- and middle-income countries (LMICs), Malawi strives to improve performance via evidence-based decision making and a suitable performance culture AIM: This study sought to describe PMM practices at all levels of primary health care (PHC) in Malawi SETTING: This study targeted three levels of PHC, namely the district health centres (DHCs), the zones, and the ministry headquarters METHODS: This was a qualitative exploratory research study where decision-makers at each level of PHC were engaged using key-informant interviews (KII) and focus group discussions (FGDs RESULTS: We found that there is a weak link among levels of PHC in supporting PMM practices leading to poor dissemination of priorities and goals. There is also failure to appropriately institute good PMM practices, and the use of performance information was found to be limited among decision-makers CONCLUSION: Though PMM is acknowledged to be key in supporting health service delivery systems, Malawi's PHC system has not fully embarked on making this a priority. Some challenges include unsupportive culture and inadequate capacity for PMM CONTRIBUTION: This study contributes to the understanding of the PMM processes in Malawi and further highlights the salient challenges in the use of information for performance management. While the presence of policies on PMM is acknowledged, implementation studies that deal with challenges are urgent and imperative

BACKGROUND: The near-miss approach assumes that mothers facing life-threatening conditions such as severe pre-eclampsia and postpartum haemorrhage share common risk factors. Among these women, those who survive (near-miss cases) can offer insights into the determinants, providing valuable lessons for understanding underlying factors AIM: To investigate elements of continuity and coordination leading to obstetric near misses SETTING: A major referral hospital and its referral pathway in Kenya METHODS: Explanatory sequential mixed-methods design RESULTS: Near-miss survivors had lower continuity and coordination of care indices during antenatal visits (COCI = 0.80, p = 0.0026), (modified continuity of care index [MCCI] = 0.62, p = 0.034), and those with non-life-threatening morbidity in the first trimester were more likely to experience a near miss (aOR = 4.34, p = 0.001). Facilities in the western region had a higher burden of near misses compared to the Eastern region. Qualitatively, three deductive themes were identified: sequential coordination, parallel coordination and continuity, along with factors classified as access. In mixed integration, poor continuity indices were explained by quality of interpersonal relationships and woman centredness. Poor coordination was explained by inadequate teamwork between providers in referring and referral facilities and between primary health facilities and the community. Higher near-miss rates in the western region resulted from differences in human and physical resources CONCLUSION: Promoting woman-centred care, teamwork, improving communication and introducing innovative coordination roles like case and care managers can enhance continuity and coordination of maternal healthcare CONTRIBUTIONS: This study contributes to our understanding of the challenges of continuity and coordination in maternal healthcare in resource-poor settings by applying the WHO operationalisation of continuity and coordination using mixed methodology

BACKGROUND: Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome AIM: To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum SETTING: Uasin Gishu county, Rift Valley region, Kenya METHODS: A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing RESULTS: COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001 CONCLUSION: Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy CONTRIBUTION: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss

CliMigHealth and the Education for Sustainable Healthcare (ESH) Special Interest Group of the Southern African Association of Health Educationalists (SAAHE) call for the urgent integration of planetary health (PH) and environmental sustainability into health professions curricula in Africa. Education on PH and sustainable healthcare develops much-needed health worker agency to address the connections between healthcare and PH. Faculties are urged to develop their own 'net zero' plans and to advocate for national and sub-national policies and practices that promote the Sustainable Development Goals (SDGs) and PH. National education bodies and health professional societies are urged to incentivise innovation in ESH and to provide discussion forums and resources to support the integration of PH into curricula. CONTRIBUTION: This article provides a position statement for integrating planetary health and environmental sustainability into African health professions education curricula.

BACKGROUND: Few studies in Africa have described patients' perceptions about family-centred care (FCC). AIM: The aim of this study was to explore perceptions of FCC among patients with chronic diseases. SETTING: The study was conducted at a general outpatient clinic (GOPC) in Jos, north-central Nigeria. METHODS: We used a mixed-methods phenomenological study design and conducted structured and semi-structured interviews with 21 adult patients with chronic diseases at a general outpatient clinic in north-central Nigeria. RESULTS: Patients described FCC using progressive levels of family engagement including the doctor inquiring about history of similar disease in the family, information sharing with family members and fostering of family ties. They described current family involvement in their care as either inquiring about their health, accompanying them to the clinic or offering material or social support and health advice. Also, patients considered the value of FCC based on how it meets information needs of the family, influences individual health behaviour and addresses family dynamics. Those who were literate and older than 50 years of age favoured FCC during history taking. Those who were literate, aged lesser than 50 years and had poor disease control showed preference for FCC during treatment decision-making. CONCLUSION: The acceptability of FCC is a complex synthesis of age, socio-economic status, literacy and disease outcomes. Patients older than 50 years, with good treatment outcomes, and those without formal education may need further education and counselling on this approach to care.

BACKGROUND: Primary care (PC) is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by the general practitioners, also known as family doctors (FDs). The majority have no postgraduate training. Little is known about how patients perceive their capability. AIM: To assess patients' perceptions of the scope of practice of FDs working in private sector PC clinics in Nairobi and their awareness of the new category of family physicians (FPs) and the discipline of family medicine. SETTING: Private sector PC clinics in Nairobi. METHODS: A descriptive survey using a structured, self-administered questionnaire. Simple random sampling was used to recruit 162 patient participants. RESULTS: Of the participants, 30% knew the difference between FPs and FDs. There was a high to moderate confidence that FDs could treat common illnesses; provide lifestyle advice; family planning (66%) and childhood immunisations (64%). In adolescents and adults, low confidence was expressed in their ability to manage tuberculosis (58%), human immunodeficiency virus (55%) and cancer (33%). In the elderly, there was low confidence in their ability to manage depression (55%), anxiety (57%), urinary incontinence (57%) and diabetes (59%). There was low confidence in their ability to provide antenatal care (55%) and Pap smears (42%). CONCLUSION: Patients did not perceive that FDs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing FPs.

BACKGROUND: In public healthcare facilities, where the patient numbers and the available resources are often disproportionate, triage is used to prioritise when patients are seen. Patients may not understand the triage process and have strong views on how to improve their experience. AIM: This study explored the views of patients who had undergone triage in the emergency centre of a primary care facility. SETTING: Gugulethu Community Health Centre, Cape Town. METHODS: A purposive sample consisted of five women (one coded green, three orange, one yellow) and four men (one coded green and three yellow). A semi-structured qualitative interview was conducted in either Xhosa or English and the transcripts analysed using the framework method. RESULTS: All of the respondents complained of a lack of information and poor understanding of the triage process. Those coded green experienced the process as biased and unfair and reported that the triage nurse was rude and unprofessional. By contrast, those coded yellow or orange found the triage nurse to be helpful and professional. Most patients turned to support staff (e.g. security staff or cleaners) for assistance in dealing with the triage system. Most patients waited longer than the guidelines recommend and the green-coded patients complained about this issue. CONCLUSION: Patients did not have a good experience of the triage system. Managers of the triage system need to design better strategies to improve patient acceptance and share information. The important role of support staff needs to be recognised and strengthened.

CONTEXTE: Nous sommes confrontés à une épidémie globale de maladies non transmissibles (MNT), liées à quatre comportements à risque. Nous recommandons que les prestataires de soins primaires (PSP) offrent des consultations individuelles visant à modifier les comportements (CIMC) dans le cadre des soins de santé primaire; cependant, il faudra organiser des formations pour renforcer les capacités. Les programmes de formation locaux ne suffisent pas pour développer les compétences. OBJECTIF: Cette étude avait pour but de remanier la formation actuelle des PSP en Afrique du Sud, autour d'un nouveau modèle pour la CIMC qui offrirait une approche normalisée pour s'occuper des comportements à risque des patients. LIEU: La population de l'étude comprenait des infirmières cliniques et des médecins de soins primaires dans la province du Western Cape. MÉTHODES: Le modèle ADDIE a offert une approche systématique à l'analyse des besoins d'apprentissage, à la conception et au développement du programme de formation, à sa mise en œuvre et à son évaluation initiale. RÉSULTATS: Cette étude a conçu un nouveau programme de formation pour les PSP en CIMC, basé sur un modèle conceptuel combinant 5 processus (demander, alerter, évaluer, assister et organiser) avec un style directeur fondé sur l'entrevue motivationnelle. Le programme a été conçu comme un programme de formation de huit heures combinant la théorie, la modélisation et la simulation avec des feedback, pour les infirmières cliniciennes ou les médecins de soins primaires CONCLUSION: C'était la première fois qu'on élaborait et mettait en œuvre un programme de formation de meilleure pratique en CIMC dans notre contexte, qui ciblait une variété de PSP, et abordait les différents facteurs de risques.

BACKGROUND: We are facing a global epidemic of non-communicable disease (NCDs), which has been linked with four risky lifestyle behaviours. It is recommended that primary care providers (PCPs) provide individual brief behaviour change counselling (BBCC) as part of everyday primary care, however currently training is required to build capacity. Local training programmes are not sufficient to achieve competence. AIM: This study aimed to redesign the current training for PCPs in South Africa, around a new model for BBCC that would offer a standardised approach to addressing patients' risky lifestyle behaviours. SETTING: The study population included clinical nurse practitioners and primary care doctors in the Western Cape Province. METHODS: The analyse, design, develop, implement and evaluate (ADDIE) model provided a systematic approach to the analysis of learning needs, the design and development of the training programme, its implementation and initial evaluation. RESULTS: This study designed a new training programme for PCPs in BBCC, which was based on a conceptual model that combined the 5As (ask, alert, assess, assist and arrange) with a guiding style derived from motivational interviewing. The programme was developed as an eight-hour training programme that combined theory, modelling and simulated practice with feedback, for either clinical nurse practitioners or primary care doctors. CONCLUSION: This was the first attempt at developing and implementing a best practice BBCC training programme in our context, targeting a variety of PCPs, and addressing different risk factors.

CONTEXTE: Les maladies non contagieuses et les facteurs de risques associes (la cigarette, l'abus d'alcool, l'inactivite physique et un regime malsain) contribuent fortement à la morbidité des soins primaires et au fardeau de la maladie. Le Département de la Santé national reconnait le besoin de former des prestataires de soins pour modifier les modes de vie. Cependant, les études locales suggèrent que les conseils donnés par les prestataires pour changer les modes de vie sont insuffisants ce qui peut être attribué en partie à un manque de formation OBJECTIF: Cette étude avait pour but d'évaluer les formations actuelles pour les prestataires de soins primaires dans la province du Western Cape CADRE: Université de Stellenbosch et Université de Cape Town MÉTHODES: Des entrevues qualitatives ont eu lieu avec six informateurs importants (formateurs d'infirmières en soins primaires et secretaires généraux de médecine familiale) et deux groupes de consultation (neuf infirmières et huit médecins) des Universités de Stellenbosch et de Cape Town RÉSULTATS: Les formateurs manquaient de confiance dans l'efficacité des conseils à donner pour effectuer un changement de comportement et dans l'approche actuelle à la formation. La formation actuelle est limitée par des contraintes de temps et n'est pas intégrée dans tout le programme - l'accent est plutôt mis sur la théorie que sur le modèle et la pratique, et il y a un manque d'évaluation formatrice et globale. La mise en pratique de la formation est limitée par le manque de matériel éducatif pour les patients, la continuité des soins et la mauvaise tenue des dossiers, des conseils de mode de vie contradictoires et une absence de culture d'organisation CONCLUSION: Il faut réviser la démarche actuelle de formation pour améliorer les compétences des prestataires de soins primaires qui aideront à faire changer les comportements. Les établissements de soins primaires doivent créer un environnement plus adapté qui soutient les services de conseils pour changer les comportements

BACKGROUND: Non-communicable diseases and associated risk factors (smoking, alcohol abuse, physical inactivity and unhealthy diet) are a major contributor to primary care morbidity and the burden of disease. The need for healthcare-provider training in evidence-based lifestyle interventions has been acknowledged by the National Department of Health. However, local studies suggest that counselling on lifestyle modification from healthcare providers is inadequate and this may, in part, be attributable to a lack of training AIM: This study aimed to assess the current training courses for primary healthcare providers in the Western Cape SETTING: Stellenbosch University and University of Cape Town METHODS: Qualitative interviews were conducted with six key informants (trainers of primary care nurses and registrars in family medicine) and two focus groups (nine nurses and eight doctors) from both Stellenbosch University and the University of Cape Town RESULTS: Trainers lack confidence in the effectiveness of behaviour change counselling and in current approaches to training. Current training is limited by time constraints and is not integrated throughout the curriculum - there is a focus on theory rather than modelling and practice, as well as a lack of both formative and summative assessment. Implementation of training is limited by a lack of patient education materials, poor continuity of care and record keeping, conflicting lifestyle messages and an unsupportive organisational culture CONCLUSION: Revising the approach to current training is necessary in order to improve primary care providers' behaviour change counselling skills. Primary care facilities need to create a more conducive environment that is supportive of behaviour change counselling