Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system.
Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system.
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DOI：
10.1186/s12913-015-1112-9
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发表时间：
2015-09-29
影响因子：
2.8
通讯作者：
Munyewende P
中科院分区：
文献类型：
--
作者：
Eyles J;Harris B;Fried J;Govender V;Munyewende P
南非目前正在进行一系列改革，以转变公共卫生服务，使其更有效、更能满足患者和提供者的需求。这些改革的一个重点是初级保健及其负担过重、功能失调和等级森严的性质。这项比较案例研究以应对和代理文献为理论视角，探讨了患者和提供者如何在该系统中做出反应，并通过耐力、抵抗和复原力机制应对其系统需求。作为 2009 年至 2010 年间开展的一项大型研究项目的一部分，本研究对南非三个省份的卫生机构进行了半结构化访谈和观察。这项研究探讨了患者获得医疗保健的经历，特别是应对方式以及医疗保健提供者如何应对医疗保健系统的现实。从这个解释基础中，选择了四个案例（两名患者，两名提供者），因为他们最了解耐力、抵抗力和复原力。添加了其他受访者的一些评论，以强调这些应对机制更为普遍的性质。四个人的案例凸显了在一个负担过重、资源不足、有时管理不善的系统中，不同形式的忍耐力和被动性、基于情绪和问题的应对医疗保健互动的复杂性。患者的叙述展示了他们用来应对治疗的微观做法，他们不承认受害者身份，有时还会采取不健康的行为。提供者表明他们如何通过利用同伴支持并在提供良好服务方面变得知识渊博来应对工作情况。抵抗力和复原力叙述显示了个人在应对疑难疾病、环境或治疗环境时的适应能力。它们允许个人做的不仅仅是忍受（本身就是一种应对机制）他们的处境，尽管抵抗力和恢复力可能是有限的。这些是个体对系统力量的反应。为了改变医疗保健，患者和提供者之间需要相互支持的互动，但它们作为微观实践的性质可能会为系统变革指明前进的方向。
South Africa is at present undertaking a series of reforms to transform public health services to make them more effective and responsive to patient and provider needs. A key focus of these reforms is primary care and its overburdened, somewhat dysfunctional and hierarchical nature. This comparative case study examines how patients and providers respond in this system and cope with its systemic demands through mechanisms of endurance, resistance and resilience, using coping and agency literatures as the theoretical lenses. As part of a larger research project carried out between 2009 and 2010, this study conducted semi-structured interviews and observations at health facilities in three South African provinces. This study explored patient experiences of access to health care, in particular, ways of coping and how health care providers cope with the health care system’s realities. From this interpretive base, four cases (two patients, two providers) were selected as they best informed on endurance, resistance and resilience. Some commentary from other respondents is added to underline the more ubiquitous nature of these coping mechanisms. The cases of four individuals highlight the complexity of different forms of endurance and passivity, emotion- and problem-based coping with health care interactions in an overburdened, under-resourced and, in some instances, poorly managed system. Patients’ narratives show the micro-practices they use to cope with their treatment, by not recognizing victimhood and sometimes practising unhealthy behaviours. Providers indicate how they cope in their work situations by using peer support and becoming knowledgeable in providing good service. Resistance and resilience narratives show the adaptive power of individuals in dealing with difficult illness, circumstances or treatment settings. They permit individuals to do more than endure (itself a coping mechanism) their circumstances, though resistance and resilience may be limited. These are individual responses to systemic forces. To transform health care, mutually supportive interactions are required among and between both patients and providers but their nature, as micro-practices, may show a way forward for system change.