Endurance, resistance and resilience in the South African health care system: case studies to demonstrate mechanisms of coping within a constrained system

Abstract

BackgroundSouth 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.MethodsAs 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.ResultsThe 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.ConclusionsResistance 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.

The role of ‘social support’ in the experience of fibromyalgia - narratives from South Africa

“…, Eyles et al . ). She explained that:

I still don't think [my dad] was … really understood what [fibromyalgia] was, or that he … really believed it's what it was but … like, he knows [now].

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“…Over and above providing care and support to someone living with a chronic condition, families also absorbed the financial burden, either by supplementing medical expenditure of their dependants through insurance, or by making out‐of‐pocket payments for necessary consultations and treatments (Eyles et al . ).…”

“…Familial and partner support in accessing healthcare through medical insurance and other financial resources was a salient issue for the study population (Eyles et al . ). The participants recognised the integral effect that their supportive family members and partners had on their experience of fibromyalgia.…”

“…The inequities found in healthcare provision (Eyles et al . ) determine the ability of a person diagnosed with fibromyalgia in SA to act as a healthcare consumer. Namane (, p. 380) explains that ‘most primary healthcare (PHC) workers are not skilled in the diagnosis and management of musculoskeletal conditions, although they amount to 15% of a general practitioner's workload’ in SA.…”

An exploratory study of the experience of fibromyalgia diagnosis in South Africa

“…Therefore, SA provides a useful context in which to unpack and investigate issues that surround medically ill-defined conditions, such as fibromyalgia. The experience of fibromyalgia in SA, with the inequities found in health care provision (Eyles et al, 2015), means that behaving as a health care consumer in this context and seeking diagnosis from multiple practitioners is driven by the possession of fiscal resources and the capacity to articulate experiences in interpretable ways. Pursuit of an elusive diagnosis is consequently undertaken with access to resources that are not available to all.…”