This article was downloaded by: [University of Stellenbosch] On: 09 October 2014, At: 14:33 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20

A framework to expand public services to children with biomedical healthcare needs related to HIV in the Free State, South Africa a

Marianne Reid & Yvonne Botma a

b

5 Howard Street, Hillsboro , Bloemfontein , 9301 , South Africa

b

Faculty of Health Sciences, School of Nursing , University of the Free State , Idalia Loots Building, Room 36, Bloemfontein , 9301 , South Africa Published online: 22 Jun 2012.

To cite this article: Marianne Reid & Yvonne Botma (2012) A framework to expand public services to children with biomedical healthcare needs related to HIV in the Free State, South Africa, African Journal of AIDS Research, 11:2, 91-98, DOI: 10.2989/16085906.2012.698054 To link to this article: http://dx.doi.org/10.2989/16085906.2012.698054

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

African Journal of AIDS Research 2012, 11(2): 91–98 Printed in South Africa — All rights reserved

Copyright © NISC (Pty) Ltd

AJAR

ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2012.698054

A framework to expand public services to children with biomedical healthcare needs related to HIV in the Free State, South Africa Marianne Reid1* and Yvonne Botma2 5 Howard Street, Hillsboro, Bloemfontein 9301, South Africa University of the Free State, Faculty of Health Sciences, School of Nursing, Idalia Loots Building, Room 36, Bloemfontein 9301, South Africa *Corresponding author, e-mail: [email protected]

1

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

2

The study undertook the development of a framework for expanding the public services available to children with biomedical healthcare needs related to HIV in South Africa. The study consisted of various component projects which were depicted as phases. The first phase was a descriptive quantitative analysis of healthcare services for children exposed to or infected by HIV, as rendered by the public health sector in the Free State Province. The second stage was informed by health policy research: a nominal group technique with stakeholders was used to identify strategies for expanding the healthcare services available to these children. The third phase consisted of workshops with stakeholders in order to devise and validate a framework for the expansion. The theory of change logic model served as the theoretical underpinning of the draft framework. Triangulated data from the literature and the preceding two phases of the study provided the empirical foundation. The problem identified was that of fragmented care delivered to children exposed to or infected with HIV, due to the ‘over-verticalization’ of programmes. A workshop was held during which the desired results, the possible factors that could influence the results, as well as the suggested strategies to expand and integrate the public services available to HIV-affected children were confirmed. Thus the framework was finalised during the validation workshop by the researchers in collaboration with the stakeholders. Keywords: child health services, logic model, policy development, policy issues, programme assessment, public health sector

Introduction Since 1990 there has been an eight-fold annual increase globally in the number of children living with HIV. By 2007 an estimated 2 million children under age 15 years were living with HIV — 90% of them in sub-Saharan Africa (UNAIDS, 2008). HIV prevalence among children (under age 15) in the Free State Province, South Africa, is estimated at 3.1%, in comparison with 2.8% for this age group in the country overall (Jamieson, Bray, Viviers, Lake, Pendlebury & Smith, 2011). These statistics indicate that children who are maternally exposed to HIV and those who are already HIV-infected are being failed by the healthcare system. Notably, the overwhelming majority of children who acquire HIV are infected through mother-to-child transmission (World Health Organization, UNAIDS & UNICEF, 2008). Models of healthcare used within paediatric HIV/AIDS services in the public health sector in South Africa favour the biomedical model of care. The biomedical model sees health and illness in its biological context. The nature and causes of health and disease are traced to a specific aetiology. Medical treatment is organ-specific and technical in nature (Van Rensburg, 2006). In accordance with the biomedical model, seven different programmes in three health services directorates of the

Free State Department of Health render some component of paediatric HIV-related services. (Figure 1 shows the services rendered by the three relevant directorates within the Free State Department of Health.) A benefit of this approach is that the healthcare services can focus on specific health needs (Michaels, Elay, Ndhlovu & Rutenberg, 2006). However, this segmented or fragmented care implies that patients must be referred to other programmes and directorates for their needs to be fulfilled (e.g. applying for social grants, nutritional supplementation, and immunisation). Considering that 23.2% of children in the Free State need to travel at least 30 minutes to reach their nearest healthcare facility, any referral for healthcare will only add time and expense to the existing costs (Jamieson et al., 2011). This fragmented model of care is worse when dealing with HIV-infected children because their medical healthcare and psychosocial needs are more varied and complex than those of adults. In addition to developing guidelines specific to health services for children, the healthcare infrastructure must be strengthened at the level of service delivery, especially at the level of primary healthcare. Staff should be trained to ensure that the best interest of the child patient is served. Care providers must have general skills and experience in caring for children with HIV infection; otherwise they will continue to refer the majority for initiation on ART

African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

92

Reid and Botma

Department of Health

Strategic health programme and medical support branch

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

Strategic health programme chief directorate

HIV/AIDS/STI and communicable diseases control directorate Comprehensive HIV and AIDS management sub-directorate

HIV and AIDS treatment division

Other divisions or sections

Partnerships sub-directorate

Step-down care and home-based care division

Other divisions

Communicable diseases control sub-directorate

TB management directorate

Health programmes and non-communicable diseases directorate

Advocacy, social mobilisation and training sub-directorate

Other divisions or sections

Technical and clinical support sub-directorate

Other divisions or sections

Clinical advisory services sub-directorate

Nutrition and child health sub-directorate

Child health division

Expanded programmes of immunisation division

Dietetics division

Reproductive health sub-directorate

Maternal and peri-natal health division

Prevention-ofmother-to-childtransmission division

Other divisions

Environmental health sub-directorate

Figure 1: Organogram depicting the strategic health programme chief directorate of the Free State Department of Health, with shaded blocks indicating directorates and divisions rendering services to children with healthcare needs related to HIV

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

African Journal of AIDS Research 2012, 11(2): 91–98

(Jamieson et al., 2011). However only 40% of trained nurses initiate children on ART in the public health sector in the Free State (pers. comm., L. Van Turha, Director, Free State Department of Health, April 2012). Neuro-developmentally affected HIV-positive children seeking public health services are not adequately managed within the directorates that render HIV-related services to children in the province (Jamieson et al., 2011). The number of programmes and directorates within the South African public healthcare system indicates a verticalization of programmes. Heunis & Schneider (2006) believe that the political will to render comprehensive holistic care is lacking, and therefore, at the level of service delivery, health personnel are unable to conceptualise holistic and integrated care. According to Travis, Bennett, Haines, Pang, Bhutta, Hyder et al. (2004), selective care which targets specific health problems or diseases is rendered within a vertical system of programmes. This implies that there are separate programmes within the public health sector which tend to patients’ nutrition, medical treatment, and home-based care, for example. In contrast, comprehensive care involves intersectoral participation and community involvement (Dennill, King & Swanepoel, 1999). Nursing staff may choose not to follow an intersectoral approach, and they often attend inservice training within different programmes to learn how to handle specific healthcare needs that they are confronted with. Nurses frequently undergo assorted training courses (Reid, 2010) and may find this uninteresting and even confusing as there is often an overlap in the content or else gaps in the topics taught. Such a situation is an ineffective use of fiscal and human resources. During training sessions, each programme is likely to refer to its own policy and guidelines, which may overlap with those of other programmes (but hopely do not contradict one another) (see Department of Health [DoH], 2005, 2007a, 2008a and 2008b). This poses a situation where, especially in smaller clinics, there may be only one health worker who is expected to integrate all the different guidelines and protocols. In situations like these, errors may be made due to a lack of training in one or more of the healthcare programmes. In larger clinics, however, various programmes might focus on their own core functions, and, as often happens, the staff members who function within a certain programme may need to refer a child to another programme in order to provide him or her with comprehensive care. Patients might ignore these referrals, however, due to a variety of reasons — resulting in a breakdown of the referral chain and undermining any attempt to render comprehensive care (DoH, 2000; Dor, Ehlers & Van der Merwe, 2002). As a consequence of these circumstances, patients’ are deprived of adequate healthcare, and their right to effective healthcare is undermined. A vertical system of programmes also results in the duplication of services, skewed views of total healthcare needs, and the resultant disruption of comprehensive healthcare (Magnussen, Ehiri & Jolly, 2004). The comprehensiveness of care can be strengthened through collaboration between programmes and directorates (Michaels et al., 2006). Root causes of problems could be identified if monitoring and evaluation are designed to

93

stretch across directorates and programmes (Chopra, 2005). The fact that monitoring and evaluation projects do not extend across directorates and programmes, together with other factors, results in the situation of fragmented care provided to patients. Fragmented care may be addressed through functional integration — that is, by improving communication and crossreferral systems and allowing greater flexibility in programmes (Pleaner, 2007). This article describes a framework for promoting functional integration in order to remedy fragmented public services to children with biomedical healthcare needs related to HIV in the Free State Province, South Africa. Methods A health-systems research design was employed to develop a suitable framework for expanding and integrating the health services for children affected by HIV. This approach offers policy options to assist health managers with making decisions about the health-services problems they are confronted with. Moreover, this design is tailor-made for active stakeholder participation and is theoretically and empirically founded (cf. Barron, Buthelezi, Edwards, Makhanya & Palmer, 1997; Varkevisser, Pathmanathan & Brownlee, 2003). Theoretical underpinning of the framework The theory of change logic model was used to guide the development of the framework because of its conceptualisation of programme design and planning (see Wholey, Hatry & Newcomer, 2004; W.K. Kellogg Foundation, 2004; Hernandez & Hodges, 2006). This type of logic model illustrates why a specific idea for a given programme is pursued. In an effort to explain why a programme will work, additional components are added, such as: the problem to be addressed, the reasons for selecting certain types of solutions or strategies, the connections between proven strategies, factors influencing the programme, and the assumptions held by stakeholders which could influence the programme’s effectiveness (cf. W.K. Kellogg Foundation, 2004; Taylor-Powell & Henert, 2008; Wildschut, 2009). Especially, it is the description of the relationships or causal linkages between these various components that distinguishes the theory of change logic model from other logic models (Wholey et al., 2004; Frechtling, 2007). The linkage and articulation of the components guide stakeholders in conceptualising and planning the programme. The theory of change simultaneously focuses on the problem and the reasons for suggesting specific solutions for the programme. Emphasis is placed on the ‘bigger picture’ or the whole. This allows reflection on the function of a system’s parts based on their relationships with one another and within the system’s larger context (Hernandez & Hodges, 2006; Frechtling, 2007). The larger context in this study refers to the healthcare system in which biomedical services are rendered to children exposed to or infected by HIV. Therefore, the input of stakeholders in planning and managing these services is essential. The stakeholders participated in the research from the planning phase, and during development of the framework, they had

94

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

an opportunity to examine best practice research in order to define the desired results. Empirical foundation of the framework Empirical data were collected by means of structured interviews with 117 healthcare workers who were conveniently selected from 78 randomly selected healthcare facilities in the Free State Province. The structured interviews focused on healthcare rendered to children affected by HIV and the training of relevant personnel. Eleven managerial representatives from three chief directorates within the Free State Department of Health participated in nominal group discussions. The participants in the nominal group discussions were asked to propose strategies for expanding the biomedical healthcare services available to children exposed to or infected by HIV. The responses generated during these discussions were qualitatively categorised into two themes: healthcare and training. The findings of the structured interviews and nominal group discussions are supported by the literature (as depicted in Table 1). Table 1 shows the aggregate data of both techniques, with the category ‘healthcare’ reflecting the need for monitoring and evaluation, comprehensive primary healthcare service rendering, strengthening of the prevention-of-mother-to-child (PMTCT) programme and referral system, better utilisation of guidelines and resources, as well as the effective dissemination of information. The category ‘training’ indicated the further need for training that will address the fragmentation and duplication of the services as well as monitoring and evaluation. Methodological integrity The touchstones of methodological integrity forming part of the development of the framework were the credibility of the framework, various types of validity tested by the questions posed to validate the framework, the transferability of the framework to the health setting, and a range of triangulations that strengthened the development of the framework. Internal validity refers to the extent to which there are no plausible rival hypotheses that could explain the linkages between the various variables and so distort the reflection of reality (McDavid & Hawthorn, 2006; Polit & Beck, 2006; Babbie, 2007; Burns & Grove, 2009). The variables in this framework can be seen as the components of the framework itself. During validation of the framework, stakeholders had the opportunity, through forward and backward mapping, to clarify the causal relationships between the various components and in so doing strengthen its internal validity. A method of checking questions, as suggested by Wholey et al. (2004) and Frechtling (2007), was used to enhance internal validity. Content validity is attained when an instrument covers the complete content of a particular construct. The evidence required to ensure content validity can be obtained from the literature and from those who are experts on that content (Burns & Grove, 2009). The content validity of the framework was confirmed because the findings presented in the literature and the triangulation of the data from the interviews and discussions were reflected in the framework. The stakeholders also had the opportunity during validation to verify that the intended content was captured in each

Reid and Botma

construct. Due to the contextualisation of the framework it was not possible to weigh up the content against what is reflected in other programmes. Transferability is seen as the extent to which a study’s findings have meaning in relation to findings in similar settings (Polit & Beck, 2006; Speziale & Carpenter, 2007). Transferability differs from external validity or generalisability in that demonstrating the applicability of one set of findings to another weighs more heavily with the party that makes the transfer than with the party that originated the findings (De Vos, Fouche & Delport, 2005). Thus, through the dense descriptions of the information and context the reader can determine if it is applicable to his or her situation. Methodological triangulation strengthened the development of the framework as it refers to combining qualitative and quantitative research designs, and thus to a combination of research methods (Berg, 2007; Burns & Grove, 2009), as in this study’s structured interviews, literature survey and nominal group technique. Development of the framework A draft framework based on the theory of change logic model was developed using the aggregate data depicted in Table 1. Thereafter, participating stakeholders were invited to a meeting to validate the draft framework in order to facilitate ownership. Structured questions such as ‘How did we get here?’ or ‘Why is there a connection between these components?’ provided a format for the validation (see Barron et al., 1997). Since one can use any component of the model as an entry point when asking these model-checking questions, the process is also known as forward and backward mapping (Wholey et al., 2004; Frechtling, 2007). Thus, the stakeholders added their expert advice to each component and clarified linkages between the components. With the assistance of a research colleague, the feedback of the group was immediately captured on a computer attached to a data projector with a screen, enabling the stakeholders to follow the proceedings. Next, the input from the stakeholders was combined with information already captured by the researcher in the draft framework. Consistent with the theory of change logic model, the framework now had a scientific base. It no longer consisted of only literature reviews and needs assessments which were mainly spearheaded by the researcher, but the stakeholders’ expert advice was added to the data already gathered. A diagram of the final framework is shown in Figure 2. Contributions to the framework under the heading ‘influential factors’ (Figure 2) were: • the low motivational level of health workers; • limitations due to poor data management; • traditional healers not actively part of the health team; and, • the presence or absence of a positive atmosphere for change. Discussion The framework offers a coherent way of thinking about the processes involved in programmes. Fundamental to these processes is a common understanding of the programme

African Journal of AIDS Research 2012, 11(2): 91–98

95

Table 1: Aggregate data showing needs identified from the structured interviews, nominal group discussions and the literature (ART = antiretroviral treatment; PHC = primary healthcare; PMTCT = prevention of mother-to-child transmission of HIV) Examples of responses ‘The system requires more monitoring and evaluation of paediatric ART, and training on directly observed therapy and home-based care.’ Increase regular referrals Move away from vertical ‘Get away from vertical PHC to other facilities for HIV PHC towards comprehensive towards comprehensive counselling, testing, treatment, PHC. PHC. Nurses should render and follow-up. comprehensive care.’

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

Data category Structured interviews Healthcare

PMTCT programme is used but is not fully implemented.

Guidelines are not fully implemented. The doctor-driven programme in hospitals does not fully utilise other health professionals.

Policy and guidelines are not widely available (especially in hospital settings).

Training

Staff need further training and a willingness to initiate ART.

Staff need to undergo various training courses.

Improve low training coverage in PHC and the programmes rendering services to children exposed to HIV.

Nominal group discussions Need for monitoring and evaluation across programmes.

Literature references Schneider & Barron, 2008

Young, Van Niekerk & Mogotlane, 2003; McCoy, 2006; Schneider, 2006; Van Rensburg, 2006; Department of Health (DoH), 2007b; World Heath Organization, UNAIDS & UNICEF, 2008 Prioritise the PMTCT ‘PMTCT has to be prioritised.’ Rabie & Marais, 2006; programme. Schneider, 2006; Free State DoH, 2006; Michaels et al., 2006; Chintu, 2007; DoH, 2007b; Schneider & Barron, 2008 Attend to the inadequate ‘Strengthen and improve [the] Steyn, Van Rensburg & referral system. referral system.’ Engelbrecht, 2006; Van Rensburg, 2006 Improve utilisation of existing ‘Screen [patients] for TB and DoH, 2005, 2007a, 2008b guidelines. HIV at each visit.’ and 2008c Address the underutilisation ‘Make best use of all Steyn et al., 2006; or shortage of human resources available, utilising (pers. comm., Burbidge, resources. paediatricians, session administrative officer, Free doctors and ART-trained State DoH, January 2009) professional nurses and home-based carers.’ Disseminate information ‘[There must be] no DoH, 2003 effectively. misunderstanding in the coding and decoding system; various programmes do not know how to interpret the codes used.’ Need to train professional ‘All personnel [should be] DoH, 2005, 2007b and 2008c nurses to initiate ART. trained and refreshed in the HIV component of integrated management of childhood illnesses.’ Deal with the fragmentation ‘[We need] to have integrated DoH, 2001 and duplication of training. training for professional nurses included in all programmes.’ Train staff adequately. ‘HIV and AIDS management Botma, 2004; Lehmann & [must be] included in Zulu, 2005; Steyn et al., 2006 pre-service training.’

facilitated by the framework. The framework outlines cause and effect relationships, defines the problem to be addressed by the framework, and quantifies the scope of needs that explain why the problem exists. Moreover, the framework acknowledges several factors that may influence an ability to change and it applies best-practice research to the proposed strategies meant to tackle the identified problem.

The ‘community’ portrayed in the framework (see Figure 2) represents the Free State Department of Health. Their needs underline the problem of fragmented care for children with healthcare needs related to HIV. The desired results listed are: • combined monitoring and evaluation across programmes; • comprehensive and integrated care;

96

Reid and Botma

Influencial factors

4

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

x Policy constraint: no combined monitoring and evaluation projects; x Political will; x Healthcare workers’ conceptualisation of comprehensive and integrated care; x Constraints of the referral policy; x Unconsolidated guidelines and policies of the various programmes; x Underutilisation of resources; x Lack of structured community participation; x Policy constraints due to the absence of coordinated and integrated staff training; x Budgetary constraints within the Department of Health; x Competition with adult-focused programmes; x Low levels of motivation among health workers; x Limitations of data management; x Traditional healers not an active part of the health team; x Presence or absence of a positive atmosphere for change.

Strategies x Comprehensive and integrated care in relation to: ƒ Integrated management of childhood illnesses; ƒ PMTCT services; ƒ Clinical teams and task-shifting; ƒ Rollout of the Bana Pele project; ƒ Integrated home-based care. x Consolidated training.

Problem

1

Fragmented public healthcare services delivered to children exposed to or infected with HIV, due to the ‘over-verticalization’ of programmes

Community needs

5

x Monitoring and evaluation of programmes and services; x Comprehensive service rendering; x Strengthened PMTCT programme; x Improvements to the referral system; x Utilisation of current guidelines; x Better utilisation of human resources; x Dissemination of information; x Increased staff training, followed by monitoring and evaluation; x Training for staff on initiating paediatric ART; x Reduced fragmentation and duplication of staff training; x Need for policy concerning donor funding; x Less ‘brain drain’ within the Department of Health; x Attending to the confidential nature of HIV without causing fragmentation.

2

Desired results

3

x Combined monitoring and evaluation across programmes; x Comprehensive and integrated care: ƒ A paradigm-shift regarding integrated care; ƒ The decentralisation of care delivery; ƒ Screening, treatment and follow-up of HIV-positive children at the most immediate level of primary healthcare; ƒ The merging of projects across relevant programmes; ƒ Use of the PMTCT programme as a means to achieve integrated and comprehensive service delivery; ƒ A family-centered approach; ƒ The functional integration of programmes. x A better-functioning referral system. x Increased impact of policies and guidelines: ƒ Disseminate and implement the current policies and guidelines; ƒ Consolidate the policies and guidelines between relevant programmes. x Optimal utilisation of human resources: ƒ Correct the underutilisation or shortage of human resources; ƒ Community participation in rendering healthcare services in a structured and organised manner; ƒ Evaluate current indicators used to describe the services rendered to children with HIV infection or those who are exposed to HIV x Consolidated paediatric HIV-related training across all programmes.

Figure 2: A framework for expanding and integrating the public services for children with biomedical healthcare needs related to HIV in the Free State Province, South Africa. The ‘community’ represents the Provincial Department of Health; ‘influential factors’ are factors that could block or support the desired results

• •

a better-functioning referral system; increased impact of policies and guidelines, including consolidation and dissemination; • optimal utilisation of human resources; and • consolidated paediatric HIV/AIDS training. For each desired result, influential factors that could act as potential barriers or support mechanisms were identified. Stakeholders should not feel discouraged when the identified influencing factors fall outside their domain, but should rather develop performance partnerships with others whose mission it is to solve the same problem and

who are subjected to the same influencing factors (Wholey et al., 2004). Most of the influencing factors identified in the framework originated from areas of the healthcare system which render services to children, thus necessitating partnerships between directorates, divisions and sections, etc. The main factors identified were policy-related constraints, a lack of political will, and the underutilisation of resources. The findings of this study substantiate the recommendation of the Children’s Institute (see Jamieson et al., 2011) to implement a comprehensive package of care for children in South Africa.

African Journal of AIDS Research 2012, 11(2): 91–98

The two proposed strategies, namely comprehensive and integrated healthcare and consolidated training (see Figure 2), imply that in the presence of such an approach to healthcare the other identified problems would become redundant. For instance, the integration of monitoring and evaluation, as well as the fuller utilisation of policies and guidelines, would be dealt with by an integrated approach. And a poor referral system would no longer constitute an issue because a human-resources plan would ensure effective utilisation of personnel within a system of comprehensive healthcare delivery.

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

Conclusions The article proposes a framework for expanding the public healthcare services to children exposed to or infected by HIV in the Free State Province. However, a one-size-fits-all model of paediatric care and treatment is not possible due to geographic and structural differences. The capacity and management of human resources can further worsen the difficulty. The development of the framework was necessitated by the fragmentary nature of the biomedical services currently being delivered to children with healthcare needs related to HIV. Using the theory of change logic model as a theoretical basis created a platform from which to develop the framework. Most of the issues reflected in the framework are not new, but have been thoroughly described in the literature. The value of the framework lies in the careful integration of its various components, thus presenting a plausible approach with which to extend the services available to children. The framework reflects the sentiment that the Alma-Ata principles of primary healthcare should be revitalised (cf. Magnussen et al., 2004; Schneider & Barron, 2008). The Alma-Ata principles emphasise the rendering of integrated care, which safeguards against fragmented care. Even though this study highlights healthcare for children affected by HIV, in many ways the response to HIV and AIDS in relation to young children offers a microcosm of the inherent difficulties in achieving an effective response overall (Panos London, 2008). Upon examination of what the framework might or might not accomplish, we note that health-policy research (as used here) aims to inform higher-level management in terms of health-policy choices. The stakeholders’ participation was promoted as a spirit of collaboration prevailed between the parties, as a willingness to learn from and incorporate the experience and knowledge of the different parties laid a foundation for this participation. However, even though the Free State Department of Health participated in the development of the framework, the extent to which the framework will actually inform policy will be up to them. We hope that sensitivity and a sense of urgency for delivering comprehensive and integrated care to children with health needs related to HIV will be kindled among the many role players who render this care in a somewhat complex network. Acknowledgements — The researchers acknowledge the National Research Foundation of South Africa for their financial support.

97

The authors — Marianne Reid is a lecturer in the School of Nursing at the University of the Free State. She presents and coordinates training for professional nurses specialising in HIV/AIDS care and provides clinical guidance to master’s degree students on the topic of community/public-health nursing with a focus on HIV-related care. Yvonne Botma is a lecturer in the School of Nursing at the University of the Free State, where she primarily coordinates and initiates research projects and lectures on research methodology. Her particular research interests are HIV/AIDS and innovative educational approaches.

References Babbie, E. (2007) The Practice of Social Research (11th edition). Belmont, California, Thomson Wadsworth. Barron, P., Buthelezi, G., Edwards, J., Makhanya, N. & Palmer, N. (1997) Health Systems Research: A Manual. Durban, South Africa, Kwik Kopy Printing. Berg, B. (2007) Qualitative Research Methods for the Social Sciences. Boston, Massachusettes, Pearson. Botma, Y. (2004) Evaluation of Implementation Training for Comprehensive HIV and AIDS Care. Management and Treatment in the Free State Department of Health. Bloemfontein, South Africa, University of the Free State. Burns, N. & Grove, S. (2009) The Practice of Nursing Research: Appraisal, Synthesis and Generation of Evidence. St Louis, Missouri, Elsevier. Chintu, C. (2007) Tuberculosis and human immunodeficiency virus co-infection in children: management challenges. Paediatric Respiratory Reviews 8(2), pp. 142–147. Chopra, M. (2005) ARV treatment and health systems: avoiding the pitfalls. AIDS Bulletin 14(1), pp. 3–6. Dennill, K., King, L. & Swanepoel, T. (1999) Aspects of Primary Health Care: Community Health Care in Southen Africa. New York, Oxford. Department of Health [South Africa] (2000) The Primary Health Care Package for South Africa: A Set of Norms and Standards. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2001) The Primary Health Care Package for South Africa: A Set of Norms and Standards. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2003) Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2005) Guidelines for the Management of HIV-Infected Children. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2007a) South African National Tuberculosis Guidelines Draft 1. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2007b) Department of Health [South Africa] (2007a) HIV and AIDS and STI Strategic Plan for South Africa 2007–2011. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2008a) Integrated Management of Childhood Illnesses, Including Aspects of the Management of HIV-Infected Children: A Handbook for Health Professionals. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2008b) Policy and Guidelines for the Implementation of the PMTCT Programme. Pretoria, South Africa, Government Printer. Department of Health [South Africa] (2008c) Integrated Management of Childhood Illnesses, Including Aspects of the Management of HIV-Infected Children: A Handbook for Health

Downloaded by [University of Stellenbosch] at 14:33 09 October 2014

98

Professionals. Pretoria, South Africa, Government Printer. De Vos, A.S.H., Fouche, C.B. & Delport, C.S.L. (2005) Research at Grassroots for the Social Sciences and Human Services Professions. Pretoria, South Africa, Van Schaik. Dor, M., Ehlers, V. & Van der Merwe, M. (2002) Analysis of referrals received by the psychiatric unit in a general hospital. Health South Africa 7(1), pp. 103–112. Frechtling, J.A. (2007) Logic Modeling Methods in Programme Evaluation. San Fransisco, California, Jossey-Bass. Free State Department of Health (FSDoH) [South Africa] (2006) Free State Department of Health Strategic Plan 2006/2007– 2010/2011 Part B. Bloemfontein, South Africa, FSDoH. Hernandez, M. & Hodges, S. (2006) Applying a theory of change approach to interagency planning in child mental health. American Journal of Community Psychology 38(3/4), pp. 165–173. Heunis, J.C. & Schneider, H. (2006) Integration of ART: concepts, policy and practice. Acta Academica 2006 (supplement 1), pp. 256–285. Jamieson, L., Bray, R., Viviers, A., Lake, L., Pendlebury, S. & Smith, C. (eds.) (2011) South African Child Gauge 2010/2011. Cape Town, South Africa, University of Cape Town, The Children’s Institute. Lehmann, U. & Zulu, J. (2005) How nurses in Cape Town clinics experience the HIV epidemic. AIDS Bulletin 14(1), pp. 42–47. Magnussen, L., Ehiri, J. & Jolly, P. (2004) Comprehensive versus selective primary health care: lessons for global health policy. Health Affairs 23(3), pp. 167–176. McCoy, D. (2006) Expanding access to ART in sub-Saharan Africa: an advocacy agenda for health systems development and resource generation. Acta Academia 2006 (supplement 1), pp. 1–16. McDavid, J.C. & Hawthorn, L. (2006) Programme Evaluation and Performance Measurement: An Introduction to Practice. Thousand Oaks, California, Sage Publications. Michaels, D., Elay, B., Ndhlovu, L. & Rutenberg, N. (2006) Exploring Current Practices in Pediatric ARV Rollout and Integration with Early Childhood Programs in South Africa: A Rapid Situational Analysis. Johannesburg, South Africa, The Population Council. Panos London (2008) From Word to Action: Support for Young Children Challenged by Poverty and AIDS. London, Panos London. Pleaner, M. (2007) HIV standards: a toolkit to strengthen integrated comprehensive HIV service at PHC facilities. Paper presented at the 3rd Priorities in AIDS Care and Treatment Conference, Johannesburg, South Africa, 2 October 2007. Polit, D. & Beck, C.T. (2006) Essentials of Nursing Research: Methods, Appraisal and Utlisation. Philadelphia, Pennsylvania, Lippincott, Willilams and Wilkens. Rabie, H. & Marais, B.C.F. (2006) Preventing and diagnosing HIV infection in infants and children. Professional Nursing Today 10(4), pp. 33–36.

Reid and Botma

Reid, M. (2010) A framework to expand public healths services to HIV-exposed and HIV-positive children. PhD thesis, University of the Free State, School of Nursing, Bloemfontein, South Africa. Schneider, H. (2006) Reflections of ART policy and its implementation: Rebuilding the ship as we sail? Acta Academica 2006 (supplement 1), pp. 17–43. Schneider, H. & Barron, P. (2008) Achieving the Millenium Development Goals in South Africa through the Revitalisation of Primary Health Care and a Strengthened District Heatlh System. Durban, South Africa, Health System Trust. Speziale, H.S. & Carpenter, D.R. (2007) Qualitative Research in Nursing. Philadelphia, Pennsylvania, Lippincott, Williams and Wilkens. Steyn, F., Van Rensburg, D. & Engelbrecht, M. (2006) Human resources for ART in the Free State public health sector: recording achievements, identifying challenges. Acta Academica supplement 2006(1), pp. 94–139. Taylor-Powell, E. & Henert, E. (2008) Devloping a Logic Model: Teaching and Training Guide. Maddison, Wisconsin, University of Wisconsin. Travis, P., Bennett, S., Haines, A., Pang, T., Bhutta, Z., Hyder, A.A., Pielemeier, N.R., Mills, A. & Evens, T. (2004) Overcoming healthsystems constraints to achieve the Millennium Development Goals. The Lancet 364(9437), pp. 900–906. UNAIDS (2008) Report on the Global AIDS Epidemic. Geneva, UNAIDS. Van Rensburg, D. (2006) The Free State’s approach to implementing the comprehensive plan: notes by a participant outsider. Acta Academica 2006 (supplement 1), pp. 44–93. Varkevisser, C.M., Pathmanathan, I. & Brownlee, A. (2003) Designing and Conducting Health Systems Research Projects. Volume 1: Proposal Development and Fieldwork. Amsterdam, The Netherlands, KIT Publishers. Wholey, J.S., Hatry, H.P. & Newcomer, K.E. (2004) Handbook of Practical Programme Evaluation. San Fransisco, California, Jossey-Bass. Wildschut, L. (2009) Introduction to logic modeling clarification evaluation. UNEDSA Grantee Logic Modeling Workshop, Pretoria, South Africa, 31 May–3 June 2009. W.K. Kellogg Foundation (2004) W.K. Kellogg Foundation Logic Model Development Guide. Battle Creek, Michigan, W.K. Kellogg Foundation. World Heath Organisation (WHO), UNAIDS & UNICEF (2008) Towards Universal Access — Scaling-Up Priority HIV/AIDS Interventions in the Health Sector. Geneva, WHO. Young, A.,Van Niekerk, C. & Mogotlane, M.S. (eds.) (2003) Juta’s Manual of Nursing. Volume 1. Lansdowne, South Africa, Juta Academic.