Many countries, including the United States, struggle with the accessibility and affordability of health care. In South Africa, health care is written as a constitutional right. However, the 45 million South Africans who live without health insurance are unable to access the private sector providers (South Africa Department of Statistics, 2017). This is a problem because the uninsured are subjected to public sector clinics, which are burdened by long queues and perceived ineffective care. The new National Health Insurance (NHI) policy was developed in 2017 to provide free health care for all. Backed by the minister of health, it promises to deliver health care as a constitutional right while improving access to high-quality care.
The author at the Cape of Good Hope, South Africa.
As a nursing student interested in global health, accessibility to care, and the variations internationally in the role of the professional nurse, I decided to pursue research on this topic in South Africa. The Unjani Clinic system was of particular interest to me. These clinics, run by professional nurses and housed in shipping containers converted into world-class health centers, sustainably increase access to primary healthcare services within underserved communities.
Historically, the role of the South African professional nurse was confined to working under a physician, unlike the Unjani model, which supports entrepreneurship and independence. I wanted to examine the policies and perspectives surrounding the current insurance and regulatory environment that might be preventing a more defined role for professional nurses in South Africa’s National Health Insurance policy.
I received a Summer Undergraduate Research Fellowship (SURF) Abroad to travel to South Africa for nine weeks to complete my research project. My objective was to gain a deeper understanding of the barriers as well as the facilitators of participation by professional nurses in the Unjani business model.
My qualitative descriptive design study used semi-structured interviews and document reviews. I created several questions to guide the semi-structured interviews. These questions focused onthe role of the professional nurse in primary health care in South Africa, the facilitators and barriers to the Unjani healthcare model, and the current insurance and regulatory environment for nurses in South Africa. I then analyzed the information gained through literature review and the interview responses to look for themes.
Unjani Clinics as a Solution to Primary Care Challenges
Nursing in South Africa faces many challenges because of the lack of quality control standards in education and practice. Although nurses are considered the “backbone of the South African healthcare system” (DOH, 2019, p. 7), there’s little support for professional nurses to work to their full scope of practice. Nurses are often not given the resources or autonomy in the public sector hospitals to meet their patients’ needs and provide care that uses their full skill sets. They are often reliant on physician orders to provide patient care, when they would be capable of more autonomous patient care.
Unjani Clinic site visit.
The government entices nurses to work in the public sector by offering higher pay than the private sector. However, this means that the nurses working in the public sector may be complacent about quality because their salary is guaranteed no matter the level of care provided. In contrast, the Unjani Clinic system offers an innovative model for empowering the professional nurse to have practice autonomy and independence and supports the nurse with the necessary resources to provide high-quality care.
Unjani’s mission statement explicitly says that their aim is to empower black women, build a sustainable network of nurse-owned and nurse-operated primary healthcare clinics nationally, and create permanent jobs. To ensure quality control, the process for applying to open a clinic within the Unjani Clinic brand consists of two sections. First, the nurse must write a business proposal with a community needs assessment. Second, she must pass a clinical competency portion in which a qualified and experienced nurse asks the applicant a series of situational questions regarding patient care. In South Africa nursing education is largely unregulated, because the country lacks an accreditation board specific to nursing schools and relies on the central regulatory board, the South African Nursing Council. As a result, the competency of nurses varies largely, depending on which school they attended and the quality of their nursing education. Unjani implements quality control measures through their interview process that sets their clinics and nurses apart.
Unjani Clinics offer the potential to drastically reduce the portion of the population that is currently being seen in the public sector for primary healthcare needs, thus reducing the patient overload in the public sector. By reducing this burden, it will allow for an increase in functionality in the public healthcare sector for those who must attend the public clinics for free healthcare services. Through researching the facilitators and barriers, I have gained knowledge about this high-quality alternative to the public health system. I plan to share my findings with the Unjani Clinics Non-Profit Company so they may share this important information with whomever will benefit from it. My aim is to publish these findings with my foreign mentor Lynda Toussaint and faculty mentor Dr. Gene Harkless.
Life in Johannesburg, South Africa
My day-to-day life was very different in South Africa. Johannesburg is the largest city in South Africa and in the Gauteng province. Gauteng also comprises several large townships, including Soweto, home to Nelson Mandela and Trevor Noah, and Tembisa. In general, Johannesburg is a dangerous city, with high rates of crime and violence. For most of my stay, I lived in a “security estate” with my foreign mentor, Lynda Toussaint, and her partner. This was essentially a small neighborhood that had 24/7 guards, fingerprint gate openings, and electric fences. When not engaged in my research at the Unjani Clinic office or on-site visits, I spent most of my days reading books about South African health policy.
From my policy review, I learned an incredible amount about health policy and practice in South Africa. Shortly before I arrived, South Africa held its presidential elections, which put Cyril Ramaphosa into office. While I was in-country, he selected his cabinet members, including a new minister of health, and gave his presidential address in which he discussed important issues such as health care and crime rates. I felt fortunate to be able to watch the president’s address with my hosts and discuss with them the significance of this election in relation to health care.
Currently, South Africa mandates health care for all as a right of its constitution. The aim of the NHI is to create a system that offers free and equal health care to all residents of South Africa that will in turn decrease poverty, increase economic growth, and foster socioeconomic development (Still, Pearmain, Beaumont, McDonald, & Mackay, 2018). For this to occur, South Africa would require that the small number of taxpayers, approximately 3 percent of its citizens, fund “free-at-the-point-of-access” care. The government would do this through mandatory payroll and surcharge taxes (South Africa Department of Health, 2017, p. 44). However, I learned that the infrastructure necessary to make this transition is largely inadequate, with delays in project approval, lack of operating budgets, crumbling buildings, and poor maintenance (Healthcare in South Africa 2018/19, 2018). I gathered that as it stands, the country does not seem to have the resources—in terms of finances or infrastructure—to institute universal health care.
It is important to note that the goal of free and equal universal health care was driven largely by the previous health minister. Whether the universal healthcare policy will be carried out by the new minister is yet to be determined, leaving the future of South African health care unsettled. Moving forward, it will be interesting to see which direction the country chooses.
Nurses’ Insights into Unjani and Health Care
On the days I completed interviews, I traveled with the Unjani driver to various clinic locations. Eric, the Unjani Clinics NPC driver, would accompany me, because he was a familiar and respected face in the communities and at the clinics. We drove anywhere from thirty minutes to three hours to tour various Unjani Clinics and to interview the nurse who owned each clinic. I was able to interview ten Unjani nurses in this manner. After the interview we would travel back to Johannesburg and I would return to the secure estate and transcribe the interview.
Ujani Clinic exam room.
Five significant themes arose through my analysis of the interview responses and reflect the most important aspects of Unjani. The first theme, engaging the community and serving the community with primary health care, highlights the nurse’s ability to understand the community’s needs and attend to her patients on an individual level. The nurses often cited this as a reason that they joined Unjani—their passion for providing high-quality and affordable care that meets the needs of their friends and neighbors in their community. “You know time is money, so [the patients] use their time effectively because they don’t have to be here for the whole day,” responded one nurse. “And the respect [we] provide to them as individuals is unique.” Not only are the nurses able to meet their patients’ needs by providing adequate care, but they provide care in a timely and efficient manner with wait times at a maximum of two hours. This is drastically different from the public clinics, where patients often arrive at five in the morning and might not be seen by the time the clinic closes that night. This means that employed people miss an entire workday and might have to return the next day to once again wait in line for the duration of the day.
Theme two, moving from “employed nurse” to empowered entrepreneur, focuses on the nurse’s transition from working under an employer to operating her own practice independently. The desire to be an independent provider often facilitates the nurses’ transition to the Unjani model. The Unjani nurses come with clinical knowledge and learn the necessary business knowledge to run a successful clinic. All the nurses interviewed discussed their perspective on the concept of empowerment. One nurse remarked that, “We cannot believe that we are now entrepreneurs and we are standing-up entrepreneurs.” The nurses are thrilled that they are not only entrepreneurs, but successful “standing-up” and functioning business owners. They feel that since they have joined Unjani, they have been given the resources and abilities to be successful and confident in their practice.
The third theme, assuming the risk and benefits of practice autonomy, identifies a barrier to joining the Unajni model. The nurses remarked that with autonomy comes great risk. “It’s fear of the unknown,” some said, and “You have to be brave to leave the comfort of your working environment where you get pension grants, where you get everything.” Although the Unjani nurses said this risk can present a barrier to some people, they themselves saw it as a challenge they were willing to overcome to achieve their dreams.
The fourth theme highlights the nurses’ ability to create a sustainable primary healthcare service that drives local economic development. Nurses are able to not only open their own clinics, but employ other members in their community. One nurse was thrilled that she has “seven people that are able to take care of themselves. Some of them have never worked in their lives.” These Unjani employees work in a variety of roles, including clinic receptionists. As the nurses’ clinics grow, they are able to employ more people, including additional clinic assistants and nurses, giving community members the opportunity to earn a consistent wage so they can provide for themselves and their families.
The final theme is pride in achieving a high-level autonomous practice as a highly skilled Unjani nursing network colleague. Nurses are able to run their practice in whatever manner they choose, within the confines of the Unjani Clinic standard operating procedures and support manual, but they also have the support of the Unjani Clinics Non-Profit Company as well as the many other Unjani nurses. A nurse mentioned that “When you’re with Unjani, [patients] go to any province they see Unjani, so [patients] know that it’s something legitimate, something concrete, and something which is empowering.”
These responses suggest that Unjani nurses are invested, motivated, and proud to serve their community as they grow a profit-generating high-quality primary healthcare business. The nurses are leaders in their communities and take the initiative to develop a business plan that addresses the needs of their community, demonstrating their motivation and their level of investment in their clinic. They are also proud of the Unjani Clinic name and their ability to provide high-quality affordable care to patients, as well as contribute to their local economy. Furthermore, the nurse-led Unjani model may be a powerful answer to global challenges in primary care access and quality.
Research Challenges
Completing this research was not without its challenges. For example, I sought to interview key informants about health policy, the historic role of the professional nurse in South Africa, and the current regulatory environment for professional nursing work in primary health care. However, upon arrival to the country, emails to the South African Nursing Council and the nursing program at the University of Pretoria were not returned. To address this, I hoped to interview public sector nurses who would offer another perspective on health care in South Africa, particularly regarding their understanding of the division in the healthcare system between the private wealthy sector and the poor public sector. As I was about to begin my interviews with public health nurses, I learned that I would need government approval to enter the public hospitals or clinics. Unfortunately, I didn’t learn this information until the eighth week of my stay, and the average processing time for this approval was four to six weeks. It was then difficult to recruit nurses to interview outside of the hospital setting. Despite this challenge, I was able to continue with my research and extract meaningful results.
In addition to my interviews with the Unjani nurses, I was able to interview two public sector nurses who gave me insight into working in the public hospitals and the care that is available for patients using the public sector system. They agreed with prior statements that the quality of care in public sector clinics is lower than that of Unjani. They also agreed that the most significant barrier to joining Unjani is fear of the unknown. I also went on multiple visits to public sector hospitals and although I could not complete interviews due to the restrictions discussed earlier, I was able to compare the conditions to the private sector facilities. On these visits I saw the discrepancy in the abundant resources available in the private sector hospitals versus the lack of resources in the public hospitals. In addition, I attended a Society for Private Nurse Practitioners meeting to learn more about the role and responsibilities of the private sector nurse. Here I learned more about the insurance necessary to access private practice providers, as well as the difficulties that nurses often face when they open their own practices independently.
Final Thoughts and Future Implications
My research experience provided incredible insight into the role of the professional nurse as a primary care provider in South Africa. Throughout my research I saw firsthand the need for the Unjani nurses related to the extreme wealth gap that separated the public from the private sectors of health care. South Africa has one of the most unequal wealth distributions, which I observed evidenced by the living conditions, healthcare resources, and employment disparities throughout different areas of the country (Beaubien, 2018). For example, it was not uncommon to drive past wealthy security estates followed by shantytowns without indoor plumbing or stable structures less than one mile down the road. The Unjani nurses mobilized to meet this need by providing holistic primary healthcare services in the areas that needed them most.
I felt fortunate to live with my hosts, Lynda and her partner, who were gracious enough to introduce me to their families and share their lives with me. I had the opportunity to go on a game drive at the Pilanesberg Reserve, and travel to Cape Town for a week during my time abroad. These trips enriched my experience, allowing me to see more of what South Africa has to offer, and were some of the highlights of my trip.
In addition to my personal growth, this research has contributed to my career aspirations as well as my field of study on a global level. This project furthered my research abilities and provided me with the necessary experience for a career in health policy, global health implementation, and sustainable community development. I plan to attend graduate school to study public health and sustainable community development, an area in which the professional nurse plays a crucial role. The completion of this project has provided me with valuable perspectives on global health policies and practices. Furthermore, it has shed light on the importance of primary health care, an area to which I had little prior exposure. After graduation I hope to take time to solidify my nursing knowledge while working as a nurse in some capacity. I would then like to return to graduate school and continue to travel to gain a deeper understanding of the international healthcare scene. The nurse-led Unjani Clinics are a powerful model that provide high-quality primary health care at low costs, and this model can be transferable to healthcare systems in other countries. This research may have significant implications for a wider international audience interested in improving healthcare delivery in a high-quality yet affordable manner.
I would like to extend a thank-you to all the amazing people who have supported me throughout this process. I could not have completed this work without the Hamel Center for Undergraduate Research staff, including Peter Akerman and Dr. Georgeann Murphy. I would also like to thank Mr. Dana Hamel, Mr. Ellis Woodward, and Ms. Margaret Norman for their support through the Summer Undergraduate Research Fellowship. Finally, thank you to my mentors, Dr. Gene Harkless and Ms. Lynda Toussaint, and everyone at Unjani Clinics NPC for making this research possible. I am hugely thankful for the opportunity I had to complete this project, and everyone who helped me along the way to achieve this goal.
References
Beaubien, J. (2018, April 2). The country with the world’s worst inequality is ... Goats and Soda: Stories of Life in a Changing World. Retrieved from https://www.npr.org/sections/goatsandsoda/2018/04/02/598864666/the-count...
Department of Health. (2019). National Policy on Nursing Education and Training. Retrieved from https://www.gov.za/sites/default/files/gcis_document/201904/42380gon544.pdf
Department of Health. (2017). National Health Insurance for South Africa: Toward universal health coverage. Retrieved from https://www.gov.za/documents/national-health-act-national-health-insuran...
Still, L., Pearmain, D., Beaumont, V., McDonald, K., Mackay, A. (2018). Healthcare in South Africa (2018). Profile Media.
South Africa Department of Statistics. (2017). Public healthcare: How much per person? Retrieved from http://www.statssa.gov.za/?p=10548
Author and Mentor Bios
Bri McGrath, from Wakefield, Rhode Island, decided to enter the field of nursing because of its “tremendous ability to break the barriers we use to separate ourselves.” She points out that most people need health care in their lifetimes, and she is inspired to be “a care provider when patients are in their most vulnerable states.” Bri came to the University of New Hampshire with the goal of participating in its undergraduate research opportunities. Dr. Harkless supported her interest in global health and healthcare accessibility by connecting her with Lynda Toussaint, CEO of Unjani Clinics NPC in South Africa. Bri learned an incredible amount not only about healthcare policy but also about individualized and culturally competent patient care from each nurse she interviewed. She decided to publish in Inquiry to share her belief in the importance of her research. After graduating in May 2020 with Honors in Major and a bachelor of science degree in nursing, Bri plans to practice nursing before attending graduate school to study public health and health policy. She says that her research experience “deepened my respect for nursing as a profession” and “has given me the experience and resources to move forward in pursuing a career in global health.”
Gene Harkless, DNSC, ARNP, is an associate professor and chair of the Department of Nursing at the University of New Hampshire. A family nurse practitioner who has taught at UNH since 1985, Dr. Harkless is a frequent mentor and enjoys working with students such as Bri as they take on international endeavors. “For past recipients of a grant for international research, it has been life changing. They create a whole new lens through which to see the world,” she said. “Students grow to understand their own academic abilities, to ask a question and search for answers and perspectives outside of expert text materials.”
Lynda Toussaint is chief executive officer of Unjani Clinics, NPC, based in Pretoria, South Africa. She is a chartered accountant and runs this nonprofit company that empowers black women professional nurses to operate and ultimately own primary healthcare clinics as businesses in low-income communities of South Africa. Ms. Toussaint visited the University of New Hampshire for a round table in 2017, where she met nursing professor Gene Harkless. Dr. Harkless connected Bri with Ms. Toussaint for Bri’s research project about Unjani Clinics. Ms. Toussaint’s support of Bri’s research in South Africa encompassed hosting Bri in her home, providing industry insights, and managing Bri’s visits to Unjani nurses and access to the Unjani Clinics.
Copyright 2020, Bri McGrath
