title: Quality of integrated chronic disease care in rural South Africa: user and provider perspectives.
abstract: The integrated chronic disease management (ICDM) model was introduced as a response to the dual burden of HIV/AIDS and non-communicable diseases (NCDs) in South Africa, one of the first of such efforts by an African Ministry of Health. The aim of the ICDM model is to leverage HIV programme innovations to improve the quality of chronic disease care. There is a dearth of literature on the perspectives of healthcare providers and users on the quality of care in the novel ICDM model. This paper describes the viewpoints of operational managers and patients regarding quality of care in the ICDM model.
  
  In 2013, we conducted a case study of the seven PHC facilities in the rural Agincourt sub-district in northeast South Africa. Focus group discussions (n = 8) were used to obtain data from 56 purposively selected patients ≥18 years. In-depth interviews were conducted with operational managers of each facility and the sub-district health manager. Donabedian’s structure, process and outcome theory for service quality evaluation underpinned the conceptual framework in this study. Qualitative data were analysed, with MAXQDA 2 software, to identify 17 a priori dimensions of care and unanticipated themes that emerged during the analysis.
  
  The manager and patient narratives showed the inadequacies in structure (malfunctioning blood pressure machines and staff shortage); process (irregular prepacking of drugs); and outcome (long waiting times). There was discordance between managers and patients regarding reasons for long patient waiting time which managers attributed to staff shortage and missed appointments, while patients ascribed it to late arrival of managers to the clinics. Patients reported anti-hypertension drug stock-outs (structure); sub-optimal defaulter-tracing (process); rigid clinic appointment system (process). Emerging themes showed that patients reported HIV stigmatisation in the community due to defaulter-tracing activities of home-based carers, while managers reported treatment of chronic diseases by traditional healers and reduced facility-related HIV stigma because HIV and NCD patients attended the same clinic.
  
  Leveraging elements of HIV programmes for NCDs, specifically hypertension management, is yet to be achieved in the study setting in part because of malfunctioning blood pressure machines and anti-hypertension drug stock-outs. This has implications for the nationwide scale up of the ICDM model in South Africa and planning of an integrated chronic disease care in other low- and middle-income countries.
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa|Department of Community Medicine, College of Medical Sciences, University of Calabar, Calabar, Cross River State, Nigeria
authors.forename: Soter
authors.initials: S
authors.lastname: Ameh
authors.affiliation: Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Kerstin
authors.initials: K
authors.lastname: Klipstein-Grobusch
authors.affiliation: Institute of Applied Health Sciences and Centre for Sustainable International Development University of Aberdeen, UK.
authors.forename: Lucia
authors.initials: L
authors.lastname: D'ambruoso
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa|The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana|Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
authors.forename: Kathleen
authors.initials: K
authors.lastname: Kahn
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa|The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana|Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Tollman
authors.affiliation: Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa|The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Ghana
authors.forename: Francesc Xavier
authors.initials: FX
authors.lastname: Gómez-Olivé
mesh_terms: D000328:Adult; D000959:Antihypertensive Agents / Q000600:supply & distribution; D001071:Appointments and Schedules; D001795:Blood Pressure Determination / Q000295:instrumentation; D002908:Chronic Disease / Q000628:therapy*; D019033:Delivery of Health Care, Integrated / Q000592:standards*; D015658:HIV Infections / Q000188:drug therapy*; D006282:Health Personnel / Q000592:standards; D006280:Health Workforce / Q000592:standards; D006801:Humans; D006973:Hypertension / Q000188:drug therapy; D017060:Patient Satisfaction; D011787:Quality of Health Care / Q000592:standards; D012423:Rural Health; D057545:Social Stigma; D013019:South Africa; D013997:Time Factors
chemical_list: D000959:Antihypertensive Agents