**2. Methods**

The Health District Sisonke (DC43) in KwaZulu-Natal was the site for this study. Located in the foothills of the southern Drakensberg mountains, about 90 kms from Pietermaritzburg, this area has a demographic profile with a variety of rural communities broadly representative of the country as a whole. It also has a history of public health involvement and innovation dating back to the 1940s [Jeeves, 1998]. The legacy of apartheid has created a highly uneven landscape, with marked inequalities in access to land, resources, employment, income and services. Migration remains a commonly practiced response to extreme poverty and unemployment in large parts of the district under study, continuing a long-established tradition of migrant labour.

The study setting is a traditional tribal area with poor secondary roads and almost complete lack of public/private transport. There are health clinics at Pholela, Bulwer, Underberg and Ixopo, a district mission hospital at Centacow, as well as a larger referral hospital in the

An Institutional Analysis of Access to

creates problems in quality of care:

leaves gaps in service:

service lacunae:

*within my scope.* 

*the floor?* 

privacy:

*patients.* 

*their medication properly.* 

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 95

lacking. Doctors are not only in short supply, but many are temporary. South African medical practitioner licensing requires a one year community residency [Republic of South Africa 1997] which has increased the number of young doctors in rural areas, but often

*Doctors here are very nice but very junior. I think for them it's "let's stick some chest drains in, put a CVP line in and do a 'caesar'. It's because we are only here for a year …let's turn it into an* 

Distinctions between various medical professions and their scope of practice also creates

*These patients need to have their bloods taken for CD4 counts, as a nurse I have to do that but it's not* 

Additionally, strict clinical guidelines for administering ART and considerable job stress

*When I'm giving everybody else their medication usually at 1800h, the HIV patient won't take it because they have to take it at 2000h. Who is going to sit down and wait for 2000h to give them their treatment? So they must remember for themselves because if they don't then they won't be taking* 

*Our ward accommodates 26, especially female medical, so we have floor beds and there we nurse some conditions, and now you as a nurse will have to be on your knees, and how can you put up a drip on* 

However, respondents hold differing views regarding the treatment of patients within the physical space of clinics. Some value the use of physical space for purposes of 'integration' of HIV/AIDS patients, while others value it for the purpose of 'separation'. Both views are linked to issues of ethics. Integration of HIV/AIDS patients with the general outpatient population is recommended by some respondents for the purpose of maintaining privacy of HIV status. Integration is also preferred to maintain equity of service for non-AIDS patients. For others, separation of HIV/AIDS outpatients is desirable for confidentiality of information. Most respondents recommend the separation of inpatients to ensure such

*The sad thing with HIV positive patients is that they are not protected. We don't have an isolation ward for them, the medical patients are mixed with them … There is no confidentiality for the HIV* 

Numerous respondents identify problems related to the lack of essential medical equipment and supplies for HIV/AIDS care. First, there is a basic lack of equipment (e.g., suction machines, blood pressure instruments) for various clinic locations and needs. Further, existing equipment is not well maintained, or may be lost or stolen. Second, protective supplies (e.g., masks, gloves) that are necessary for working in a HIV/AIDS environment are lacking, especially in the communities. Basic supplies such as HIV test kits, oxygen and medications are not always available. Third, preventive immunizations (e.g., for hepatitis) are not routinely provided to health workers without cost. Although PEP is provided adequately to health workers, it is not necessarily provided to members of the public who might be exposed to the virus through caring for an HIV positive person. Finally, there is lack of coordination in using the available resources. A significant example is the lack of

*educational experience. I'm going to do all these courses and come up with these skills."* 

**3.1.3 Lack of physical space, resources and confidentiality** 

transport for delivery of blood samples to regional laboratories.

Having sufficient working space is a concern for all hospital and clinic staff:

town of Edendale. From these locations, a sample of 46 key informants was drawn that included doctors, nurses, and VCT counselors. Semi-structured interviews were taped and administered by trained medical students, in Zulu, English or Xhosa, as appropriate. Interviews were done with fully informed consent and the right to refuse consistent with Research Ethics Board approval of universities in Canada (Queen's University) and South Africa (University of KwaZulu-Natal). The overall purpose of the interviews was to understand health workers' attitudes towards HIV/AIDS and GBV and how it affected their own work. However, a subset of questions focused on their experiences and roles, responsibilities and capacities in HIV/AIDS-GBV service delivery, which are reported here. In addition, relevant material was utilized from other interviews done for a larger study with local women, men, faith leaders and traditional healers.

Transcripts were analyzed and categorized according to concepts and issues derived from the literature review.

