title: Limitations to practising holistically in the public sector in a rural sub-district in South Africa.
abstract: BACKGROUND
  The healthcare system in South Africa is based on the district health system through a primary healthcare approach. Although many vision and mission statements in the public healthcare sector in South Africa state that the service aspires to be holistic, it is at times unclear what exactly is meant by such an aspiration. The term 'holism' was coined in the 1920s and describes the phenomenon of the whole being greater than the sum of the parts. Over the past two decades the term has entered into many academic disciplines as well as popular culture. Also within public healthcare services, despite predominantly biomedical approaches, there is the aspiration to offer a more holistic service. As part of a larger research study, the limitations to working holistically in the public sector in a rural sub-district in South Africa were explored.
  
  
  METHODS
  The study used a participatory action research design that allowed participants a large degree of influence over the direction of the study. The research group consisted of four primary healthcare nurses and one medical doctor, all working in the public sector in a rural sub-district. The research group took part in the process of design and data gathering phases, as well as analysing and making meaning of the data generated. After a thematic analysis of the transcribed meetings, interviews and field notes, the themes were shared with the participants, who arranged them into a graphic representation showing the interrelationships of the themes.
  
  
  RESULTS
  From analysis of the data it was clear that there were significant limitations to practicing holistically in the public sector of the rural sub-district in which the study took place. The limitations were grouped into those arising from within the public healthcare system and those outside the healthcare system. Within the healthcare system, the main factors limiting holistic care were: limited resources; poor training in and knowledge of holistic care; poor supervision; distance from the community; the referral system, intersectoral work and bureaucracy. Outside the healthcare sector the following factors challenged the provision of holistic care: poverty; poor nutrition; HIV/AIDS; and the cultural context. All the limitations were found to contribute to the danger of burnout among healthcare workers who wanted to work holistically. The limitations were also found to have a negative impact on the healthcare worker-patient relationship, thereby further challenging holistic care.
  
  
  CONCLUSIONS
  A number of aspects of the healthcare provision system that contributed to limiting the provision of holistic care could be changed quite readily, if there was a will to do so. Many of the issues seemed to plague the healthcare system generally, not only in relation to the provision of holistic care (such as supervision or a response to poverty). The close relationship between difficulty in providing a holistic healthcare service and burnout was an important finding that deserves further exploration.
authors.affiliation: Emmaus Hospital, Drakensberg Mountains, KwaZulu-Natal, South Africa. besam@lantic.net
authors.forename: B
authors.initials: B
authors.lastname: Gaede
authors.forename: S
authors.initials: S
authors.lastname: Mahlobo
authors.forename: K
authors.initials: K
authors.lastname: Shabalala
authors.forename: M
authors.initials: M
authors.lastname: Moloi
authors.forename: C
authors.initials: C
authors.lastname: van Deventer
mesh_terms: D002055:Burnout, Professional; D006694:Holistic Health; D006801:Humans; D017150:Public Sector; D012423:Rural Health; D013019:South Africa