Facultad presidencial para determinar los asuntos de guerra y paz

The macro-system setting embraces the institutional systems of a culture in which an individual exists including the economic, social, education, and political systems

(Bronfenbrenner, 1979). Bronfenbrenner states that the effect of the macro-system on the lower systems can be seen by observing how the lower systems function (Rosa, & Tudge,

2013). It appears that the causes of the structural barriers experienced within the lower levels of analysis are contextualised in two themes, namely communication and funding.

4.4.1 Communication

Communication between healthcare providers and their representatives in government, i.e. those that make financial decisions regarding substance abuse and

healthcare, is reported as ineffective. Seven participants reported feeling that the government does not understand the full extent of the crisis of substance abuse, not only amongst

pregnant women but across the general population.

“Look, I feel that they don’t know the extent of what we go through on a daily basis here at the facility. If they did know, yes I feel that would maybe allocate more resources and funding” (F17)

You know if I can meet with Helen Zille or if I can meet with the president. I can meet with all of them that are sitting there at parliament and the two of us could tell them really, what substance abuse really is and how it's affecting our communities and our young children. I mean they don't see it really. (F11)

I think people working on the ground or working with the clients are seeing certain trends. So you know, proposals are put out there for certain things that government feels that, drawing from their research or from wherever they compile that

information, they’re putting it into where they think best. Yet people working on the ground may feel otherwise. Let’s say, into office there is an influx of youth but funding is given for something else. Why not then put in where the need is greater so that the funding can meet that? I also think that it creates a problem when the program that is being sponsored is not being met, you know in terms of funders wanting certain outcomes. (F12)

I think they know it they just don’t realise it. They can see the figures and the stats and studies but they don’t realise that we are sitting with a big problem. Just referring to substance abuse; we are sitting with a major crisis. (M5)

Furthermore, the mere fact that there is only one female only facility in the Western Cape is representative of the government’s lack of understanding regarding firstly, the rate of

substance abuse amongst women and, secondly, the low rate of women accessing treatment. A social worker at an outpatient facility mentioned this point at a conference in Durban; she found that there are many more government-funded female treatment facilities in other provinces

I attended two workshops in Durban that was more gender based with specific focus on… I think it was the GROW program. I’m not sure if you know the GROW program, but it focused on the recovery of women, specifically women in treatment and women who are pregnant. Then when I was asked questions in my presentation on pregnancy, they were shocked because there was just no facilities. That time it was only [facility name] which has recently closed. So there are just no resources. If you look in other provinces, there’s much more focus and funding on or for pregnant women and for normal women. So that is something in the Western Cape that is less focused on. (F6)

4.4.2 Funding. Discussing funding on the macro-system level concerns the effect of the decisions made by the Minister of Health and the Department of Social Development who do not have any direct contact with the healthcare providers in the field. The poor allocation of funding to treatment facilities, prominent in the reports of all 20 of the healthcare

providers, is seen as a problem, together with the lack of staff and resources and infrastructural challenges within facilities.

4.4.2.1 Staff and resources. All 20 participants mentioned the continuing lack of staff as a barrier that they experienced to effective treatment.

“We are always short on staff. You end up getting frustrated because you must be here you must be there you must be all over. You must cut yourself in four to cover all the areas” (F9)

What happens is the ladies come into the clinic and then we have to tell them that it is not the right day or they must wait and then they do not come back. We do that because we don’t have enough staff to run every department every day. (F8)

So, I don’t know if there is something to do because it actually has more to do with… how can I say, inter-management. There are outside factors that come from outside the facility that can change out circumstances for the better. Unless you can give us a bigger hospital with 40% more staff. Bigger wards, sufficient staff, all equipment that

we need and everything in working condition and if it breaks then we’d have replacements for it. (F10)

I think, for me there are so many things I’m doing now. For example, having that support group for pregnant women, I wouldn’t be able to do that even though I see the need, because there is just not enough staff. So I think structurally, I think we’d need more staff big time. That’s what we would make things easier. (F13)

4.4.2.2 Infrastructure and space. Furthermore, 11 of the 20 healthcare providers reported that even if there were enough staff and specialised services available for patients, there is insufficient space within current facilities to allow for these services to be rendered.

We already have a problem with infrastructure and that’s why I cannot say this is the department for basic antenatal care. It’s the same person that’s doing the sick children who is assigned to doing basic antenatal care, you understand because we don’t even have enough rooms to equip that room with a specific service. (F18)

“We do have a sick room, but it’s a kitchen too. It’s everything in one. We do have a bed there but it is so high and very uncomfortable” (F19)

Furthermore, one of the primary healthcare clinics servicing six suburbs in the surrounding area is only offering antenatal care once a week due to short staffing and infrastructural challenges.

“We can only give antenatal care one day a week because the space is too small and we do not have room” (F8)

Similarly, an administration and screening assistant reported that she conducts all screening and history documentation of walk-in patients in any office that is not being used at that particular time. If there are no offices available, she has to ask patients to return at a later stage, effectively losing potential patients.

“In terms of if offices are not available to use, then where do I see that person that is a walk- in client? We either have to ask them to come back on another day or they don’t return” (F15)

4.4.2.3 Procurement. Thirdly, where funding is made available, there is a difficulty and lack of communication surrounding the procurement of those funds. Although only mentioned by 2 healthcare providers, it is an important issue for these facilities. A social worker reported not knowing where to apply for funding for factors such as contingency management as government does not have a specific vendor for this.

The problem with funding, we’ve got the money, but the problem is kind of procurement. There are all these processes of getting stuff and that takes a while. Sometimes stuff that you need, they don’t have specific vendors on the system, so we can’t get the stuff because there are no vendors and we have to try look. (F13)

While the problem of procurement of funding was noted by 2 healthcare providers, six of the 20 participants mentioned that they would like to implement contingency

management for their patients. This included a small incentive for milestones reached during treatment, fun educational outings, perhaps a small cup of soup before treatment for poverty- stricken patients or even bus passes to get to treatment. However, difficulties with

procurement do not allow for this.

So in that regard I feel that the funding is quite limited. In the past we sometimes took the patients to the ice rink and it was about socialising and having interpersonal skills where there isn’t a budget for that now. That’s too expensive to accommodate patients so where that is concerned I think there is a lack of funds. Yeah, there’s not much you can do with R10 per patient. (F20)

Well things like providing child care. What also works well, and that we can’t

currently do, is to provide food. For a lot of the people, they only have one meal a day or it is cold in winter, so having a hot cup of soup might be a good motivation and would help. (M1)