Table 3 Meso-contextual features of paediatric primary care in Western Cape, South Africa

Services typically provided by municipal and provincial facilities.

Municipal PHC facilities typically provide well child services (i.e. growth monitoring, development screening and immunisations on appointment basis), and services for sick children aged 0–5 years. Provincial government facilities provide services to all sick and well children, with a high proportion of children aged 0–5 years.

Delineated clinical roles and multi-disciplinary working

Professional nurses trained in IMCI routinely see sick children under the age of five. In rural facilities, CNPs are typically the first clinician to consult a child. Doctors do not routinely see children other than those who are severely ill or attending follow-up clinics for TB or HIV care. Enrolled nurses typically run immunisation services and perform growth monitoring.

I: Do any doctors see children?

M: Yes

I: And is it only when they need they need extra assistance for cases, or do they see them regularly?

M: Yeah, she prefers to see all those that are on ART and if it’s an emergency. (Manager interview, Phase 3)

Facilities frequently rotate their staff.

M: “Most are IMCI trained, on a regular basis I rotate but certain such as ARV and TB we cannot rotate as it is specialist. So that if someone is sick, others can float because of this. This ensures that the service is accessible, they all have the exposure.” (Manager interview, Phase 1)

Caregiver seeking behaviour

Children with HIV, TB and other chronic conditions referred to larger PHC facilities (“community health centres”)

M: No, we don’t see many chronic we refer them to ((name)) Community Health Centre..

I: So they don’t come here for repeat scripts or...

M: No. So when they... it’s whereby maybe there will be diagnosed for the first time here, for instance if the client is coming, let’s say for eczema, that child will be treated for eczema. If the child maybe got severe eczema, then he willget transferred to((name of tertiary level hospital)) then ((name of tertiary level hospital)) will bring it back that this child needs to be treated like a chronic child. There that time will refer back because they’ve got all the resources at ((name of hospital)) unlike us. (Manager interview, Phase 2)

Flow of children through facilities

Registration: For children requiring immunisations, care was typically accessed through an appointment system. Caregivers with a scheduled visit for an immunisation or growth monitoring arrived with their RtHB and placed it at a specific registration point with a box for appointments. Caregivers with children without appointments, coming for an acute condition or having missed scheduled visits, placed their RtHB in the non-appointment box at the registration desk. Patient records were subsequently retrieved by reception staff and placed in the weighing and triage area according to the order in which they arrived.

Weighing and triage area: The weighing and triage area was either a room or open area where children were weighed and reason for the visit established. In the majority of facilities an enrolled nurse, with more limited clinical training than professional nurses, was allocated to the weighing area. Weights were measured but typically not plotted or used to interpret growth. Heights were not routinely measured in most facilities. Temperatures were taken if the child was feverish. Both sick and well children came through the weighing/triage area. Guided by the child’s RtHB, the nurse determined if the child required vitamin A and deworming medicine. Children were separated into emergencies, well, or sick child visits and allocated to the relevant nurse, typically based on the caregiver’s report of the presenting complaint, rather than through the nurse’s clinical assessment. In two facilities, this area also functioned as the immunisation room. In one facility, children were weighed and given immunisations in the consultation room. The triage area typically had a dehydration corner and breastfeeding area.

Well child: Typically seen in the immunisation room. Caregivers and children waited in the waiting area to be called by the allocated nurse. The immunisations were mainly carried out by an enrolled nurse but in some cases, a professional nurse. Following the immunisation, the nurse plotted the child’s weight in the RtHB. Caregiver/child would then leave with their updated RtHB.

Sick child: Between one and three nurses in each facility were allocated to see sick children. These nurses were generally professional nurses, who then reported to a clinical nurse practitioner or doctor. In two facilities, sick children were prioritised and seen before adults. If the child was classified as an emergency, they went straight to the trauma room. Most of the consultation rooms for sick children had a stock of medication to dispense but, in some cases, caregivers had to go to the pharmacy to collect their prescription. In one facility, caregivers/children were required to see approximately four people if also needing treatment for Prevention of Mother to Child Transmission (PMCT) of HIV, including nurses to: triage, give immunisations, treat acute conditions and deliver PMTCT.

Local protocols/documentation for treating children

- Immunisation, developmental screening, deworming, vitamin A supplementation, health promotion and growth monitoring: RtHB and IMCI checklist or Integrated Clinical Stationery (ICS)

- Sick child (0–5 years): IMCI checklist or ICS

- Sick child (6 years and above): ICS.

- Referral forms

Provincial departments of health require facilities to complete stationery with IMCI components for consultations with children 0–5 years. ICS stationery also includes information about family, social context and chronic conditions (other than HIV and TB). ICS pages designed in columns to track previous visits.

Province applies IMCI audit tools to determine clinician alignment with IMCI guide and whether facilities are treating expected numbers of children. IMCI audit data fed back to national Department of Health and WHO figures on child mortality.

Pattern of care-seeking from PHC services

The primary health care service offering is chiefly structured as preventive care (immunization and growth monitoring) and curative (acute illness), both in children under 5, which over time has shaped care-seeking patterns at community level. Children with chronic illnesses such as asthma rarely receive routine care in primary care, and are often referred to secondary and tertiary services which are usually some distance from communities, or the Community Health Care centres where there is little continuity of care outside HIV and TB treatment programmes. This perpetuates poor care seeking outside acute episodic illnesses and does not grow an understanding of regular, planned care for children with long-term health conditions. Caregivers frequently make use of an extensive network of private general practitioners who provide acute episodic care and medication for a fixed fee, but rarely chronic care.

I: Do you think many children come with a chronic illness problem, or do they come with an acute symptom?

M: The majority is acute symptoms, but here and there we have babies that is on asthmatic treatment also, but the majority is acute, and the majority is pneumonia cases, severe pneumonia cases. (Manager interview, Phase 3)

Referrals and continuity of information

Facilities reported rarely receiving feedback from hospitals following patient referrals. Caregivers receive discharge summaries from referral centres but do not routinely bring them to PHC facilities.