Table 2 Categories, themes, and quotes

Facilitators

Policies and guidelines for the prevention of CVD

We do have policies, although they are produced as guidelines. The guidelines are there to lead us on how to manage and prevent the diseases we are talking about. Type 1 diabetes, types 2 diabetes and hypertension have their own national guidelines separately (Participant # 15, OPM)

We do have set of operating procedures that guide us. We also have the protocol of essential drug list that guides us on how to go about doing the assessment of chronic diseases and initiating treatment for the new cases (Participant # 12, OPM)

Health education programme

Health education is the basic in every area at the primary health care level, so we give health education to community members concerning healthy lifestyle for them to be able to avoid these kinds of diseases called CVD (Participant # 1, OPM)

Every morning what we provide health education on prevention of some diseases including CVD before we start daily routine. Still, I think it is not enough, it would be good if we can start going to the communities regularly (Participant # 5, OPM)

Collaboration with other stakeholders

We have an exceptionally good relationship with the traditional leaders around here where our health facilities are. Usually, whenever we have problems, we first go to the traditional leaders; the traditional leaders have regular meetings, some on Tuesdays, and others on Thursdays. That is where we discuss health issues, and they share with us theirs concerns and together we find a way forward on how to deal with the problems related to CVD, so I think their involvement is a good strategy (Participant # 1, AM)

The traditional leaders are usually invited to address the people gathered in the funerals because many community members attend funerals in masses. We are usually given a slot with the traditional leaders to address the community about prevention of CVD (Participant # 3, AM)

There is a clinic that belongs to ZCC church. The church is the one that owns the building; they have donated it to the Department of Health. They are the ones who are responsible in assisting us with maintenance and other necessary developments. They are particularly important in the provision of healthcare to our people, and I think we need the involvement of more churches like this to work together in fight against CVD (Participant # 14, OPM)

The churches are contributing a lot, where there are no halls, we use churches for Centralised Chronic Medicines Dispensing and Distribution (CCMDD). In the past, it was a challenge when other churches did not believe in medication, but now there is a change, the pastors give us slot during their church services to address the people on prevention of CVD. Some churches also call health professionals to come and provide health education sessions during their seminars and conferences (Participant # 2, AM)

In this area we are working with the NGOs and they are contributing a lot. We utilise them for home-based care to manage CVD and other conditions. They usually go to the communities for home visits, even when nurses go out for door-to-door campaign for health awareness and sometimes we work with them (Participant # 8, OPM)

The NGOs are playing an especially important role in the prevention of CVD. For example, we do have NGOs that help with home-based care. The youth groups, the clinic committee and ‘indunas’ (community volunteer groups) are so involved in the health-related issues (Participant # 7, OPM)

The use of modern technology

We have got computers and mobile phones. The clients receive mobile phone messages and calls to collect their medication from the health care facilities. The mobile phones are also instrumental to trace clients who are defaulting treatment. Health care workers utilise mobile phone to communicate with most patients on chronic treatment even by visiting them in their farms (Participant # 2, OPM)

We have computers, although we are still learning to use them, some staff members can do so. This has made data capturing easy and help us to know the actual number of clients (head count) on treatment and those who will be starting their treatment soon (Participant # 13, OPM)

A structured healthcare system

There is a director at the provincial level who is leading the management of chronic conditions including CVD, at the district level we have a deputy director. There is an acting deputy director at a district level who is leading the management of chronic diseases around 21 clinics in Polokwane Municipality. In my office as a sub-district manager, I report to the deputy director, we have operational managers at a facility level and clinical nurses below the operational managers (Participant # 3, AM)

We have professional nurses: A male nurse, who is the coordinator of chronic diseases, and a lady professional nurse who coordinates diabetes and hypertension. Another nurse coordinates HIV/AIDS and sexually transmitted infections (HAST). Sub-districts report to the district and district to the province. The province reports to the National Department of Health (Participant # 1, AM)

We open at 07h00 and close at 18h00 for access of all people even those who go to work can be afforded primary health care services (Participant # 9, OPM)

We operate from 07h00 to 18h00, but we can see all the patients that come in according to ideal clinical practice, anybody who comes here in the facility must be seen before we close the facility (Participant # 16, OPM)

We are having a very dedicated committed team in the nursing section that manages chronic diseases in our facility. No matter how many the patients are, the team attends to them all (Participant # 2, OPM)

We also have enrolled nurses (staff nurses) that are assisting clinical nurse practitioners. Despite their workload, they see to it that our clients are properly cared for. Without them, the fight against CVD would have been lost long ago (Participant # 4, OPM)

Barriers

Poor infrastructural development

The structure is too small we do not even have privacy for patients when we take vital signs and interviews because we do not have a room for these kinds of procedures. Where we put our files is also where we take vital signs (Participant # 5, OPM)

Yes, infrastructure is a barrier as you can see that our infrastructure is too small during days for consultations for chronic conditions, you find that the place is just packed all over, overcrowded with few chairs for patients to sit outside” (Participant # 2, OPM)

No, the infrastructure does not facilitate the prevention of CVD, it is an exceedingly small clinic and the clients sometimes undermine our capacity due to its size (Participant # 11, OPM)

Shortage of medical supplies and equipment

We do sometimes experience shortage of treatment [medication]. Sometimes when patients come, we give them incomplete prescriptions because of shortage. We usually do this when we are running short of medication (Participant # 6, OPM)

In this facility, we do not have enough BP machines and glucometers. Yes, we may have some glucometers, but you will find out that there are only 2 glucometers for the entire facility to share in 4 consulting rooms, so sometimes we rely on history taking (Participant # 1, AM)

The electronic BP machines we have are designed by the manufacture to check few numbers of patients at a time, but now imagine a nurse must take BP for 20 patients, which end up giving the wrong readings. So, some patients end up being diagnosed falsely (Participant # 16, OPM)

Lack of health promotion activities

We are having a health promotion manager who coordinates health promotion programmes. She is located at the district office. The challenge is that she only visits the communities on invitation during special calendar events. No health promotion practitioner is available at the sub-district and local levels. We encourage our clinics to liaise with her to organise imbizo (community meetings) and awareness campaigns where the manager for health promotion comes in. She usually assists in terms of preparation for those awareness campaigns by supplying posters, reading material and handouts. But the health behavioural change activities that are essential are not dealt with daily (Participant # 4, AM)

Unfortunately, the health care system now is not the same as it was in the 1980s and early 1990s. This is because in the previous decades mentioned, you would see community health nurses, specifically going out to do community outreach services. This is political, hee hee (laughing). Let us say, in the mobile teams we used to have a team specifically for schools, the mobile would have a specific team for TB. They were having their own vehicles and they specialised in those services. Those teams were disbanded due to poor management. I think they have seen that the old system was functional. That is why they are now trying to bring those teams back (Participant # 3, AM)

Health promotion activities are usually limited with no capacity to deal with the predisposing factors of CVD such as obesity and lack of physical activity (Participant # 2, AM)

Shortage of nurses and other personnel

Serious challenges are at the clinic facility level. Nurses are understaffed. People retire, people die, and they are not replaced. We identify vacant post for advertisements, we write to the Human Resource section to motivate for additional posts, but there was a red tape since 2012 up to now. No retired nurse has been replaced. This is a political decision that hinders prevention, care, and management at the clinics. In my area of work, I have 3 acting operational managers. At least 4 OPMs have been appointed long ago and they are due to retire soon. Two of them will be retiring this year (Participant # 4, AM)

Unfortunately, there is no visiting medical doctor in our clinic. We refer our patients who need to see the doctor to Mankweng Hospital. The pharmacy assistant visits every Wednesday, and the physiotherapist, speech, and hearing therapist maybe once a month. We do not have an environmental officer and a health promotion practitioner. We liaise with the district if we seriously need them. The dietician that we had unfortunately resigned. So, for now we do not have, but other facilities do have dieticians and visiting medical doctors (Participant # 15, OPM)

We do not have an administrative officer to capture those files there. We do not have enough staff that is why you see today’s situation. I am the only nurse who was on duty (Participant # 15, OPM)

The first one is shortage of staff, I am working here at this clinic, at the same time I should manage 5 catchment areas, how is that possible? (Participant # 2, OPM)

Poor accessibility to PHC services

The opening hours are not conducive and primary health care is not accessible because we are only opening for 10 h in a day from 7 am to 6 pm. During the night, the facility is closed, so if a patient has a problem at night, the family will have to carry him/her to the hospital (Participant # 11, OPM)

The family calls the ambulance to where they stay, or they hire a neighbour’s car to carry their member the hospital during the night. Our facility is not opened to operate at night, so I trying to say that accessibility to healthcare services is a problem in this area (Participant # 8, OPM)