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\begin{document}

\title{Perception of healthcare workers and patients about the impact of health
facility infrastructure on healthcare services in eThekwini
Municipality, KwaZulu-Natal, South Africa}



\author[1]{Mantwa Portia Radebe}%
\author[1]{Mahlatse Lucky Moropeng}%
\author[1]{Sean Mark Patrick}%
\affil[1]{University of Pretoria School of Health Systems and Public Health}%


\vspace{-1em}



  
  \date{June 07, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background:} Although there are several health facilities with
infrastructure to cater to healthcare services, there are still
healthcare facilities with inadequate infrastructure in eThekwini
Municipality, KwaZulu-Natal Province, South Africa to provide
comprehensive healthcare services. This study investigated the
perceptions of healthcare workers and patients about the impact of
health facility infrastructure on the provision of healthcare services
in this province. \textbf{Objectives:} This study aimed to determine the
perception of healthcare workers and patients about the impact of health
facility infrastructure on healthcare services at Goodwins Clinic in
eThekwini Municipality, KwaZulu-Natal, South Africa. \textbf{Method:}
This qualitative study applied phenomenological design by conducting an
individual in-depth interview with patients (n= 20) and healthcare
workers (n= 10) purposively selected in 2022. Data were analysed using
Colaizzi's phenomenological analysis framework. \textbf{Results:}
Participants reported that health facility infrastructure affects
healthcare services. Furthermore, old facility structures, scattered
structures, and limited working spaces were found to be the leading
factors affecting healthcare services in the facility.
\textbf{Conclusion:} The facility's structural design factors need to be
considered to ensure that the health facility structure is adequate to
deliver healthcare services and motivate radical transformation to take
place in measuring and managing healthcare facilities.
\textbf{Contribution:} The results will assist in improving health
facility structure and healthcare services, help health facilities
prepare for National Health Insurance and easily reach SDG 3, motivate
future research, and provide information that will assist in
implementing programs to reduce poor healthcare services.
\textbf{Highlights:} Patients and healthcare workers perception was
investigated whereby their views stipulated that health facility
infrastructure affects healthcare services. Poor infrastructure was
noted as well and inappropriate healthcare services.%
\end{abstract}%



\sloppy


\textbf{Perception of healthcare workers and patients about the impact
of health facility infrastructure on healthcare services in eThekwini
Municipality, KwaZulu-Natal, South Africa}

Mantwa Portia Radebe\textsuperscript{1}, Mahlatse Lucky
Moropeng\textsuperscript{1}, Sean Mark Patrick\textsuperscript{1},

\textsuperscript{1.} School of Health Systems and Public Health, Faculty
of Health Sciences, University of Pretoria, Pretoria, South Africa

Corresponding author and address: Mahlatse Lucky Moropeng

Email: Mahlatse.Moropeng@up.ac.za

\textbf{AUTHORSHIP}

M.P.R planned the study, chose the target study area, conceptualised the
design, became part of data collection, analysed, and interpreted the
data. M.L.M and S.M.P critically revised the study content from protocol
development to article writing and supervised the study.

\textbf{ACKNOWLEDGMENTS}

The authors would like to thank the participants for their contribution
to the study, the eThekwini municipality district, the KZN Provincial
Department of Health for granting permission for this study to commence,
Mr. Sphamandla Hadebe (Field Worker), Miss Gopika Ramkilawon
(Statistician) for research support, and Gill Smithies (proofreading \&
language editing services) for making the project a success.

\textbf{FUNDING}

This project was supported by a bursary from the Health and Welfare
Sector Education and Training Authority (HWSETA) postgraduate research
funds.

\textbf{CONFLICT OF INTEREST STATEMENT}

The authors declare that they do not have any financial or personal
relationship that might have influenced the writing of this article.

\textbf{ABSTRACT}

\textbf{Background:} Although there are several health facilities with
infrastructure to cater to healthcare services, there are still
healthcare facilities with inadequate infrastructure in eThekwini
Municipality, KwaZulu-Natal Province, South Africa to provide
comprehensive healthcare services. This study investigated the
perceptions of healthcare workers and patients about the impact of
health facility infrastructure on the provision of healthcare services
in this province.

\textbf{Objectives:} This study aimed to determine the perception of
healthcare workers and patients about the impact of health facility
infrastructure on healthcare services at Goodwins Clinic in eThekwini
Municipality, KwaZulu-Natal, South Africa.

\textbf{Method:} This qualitative study applied phenomenological design
by conducting an individual in-depth interview with patients (n= 20) and
healthcare workers (n= 10) purposively selected in 2022. Data were
analysed using Colaizzi's phenomenological analysis framework.

\textbf{Results:} Participants reported that health facility
infrastructure affects healthcare services. Furthermore, old facility
structures, scattered structures, and limited working spaces were found
to be the leading factors affecting healthcare services in the facility.

\textbf{Conclusion:} The facility's structural design factors need to be
considered to ensure that the health facility structure is adequate to
deliver healthcare services and motivate radical transformation to take
place in measuring and managing healthcare facilities.

\textbf{Contribution:} The results will assist in improving health
facility structure and healthcare services, help health facilities
prepare for National Health Insurance and easily reach SDG 3, motivate
future research, and provide information that will assist in
implementing programs to reduce poor healthcare services.

\textbf{Highlights:}

Patients and healthcare workers perception was investigated whereby
their views stipulated that health facility infrastructure affects
healthcare services.

Poor infrastructure was noted as well and inappropriate healthcare
services.

\textbf{Keywords:} perception, health infrastructure, health service
delivery, patients, healthcare workers, health facility,

\section*{1. INTRODUCTION}

{\label{introduction}}

Infrastructure has been mostly used to describe transportation,
building, railways, environmental structure, material, network system,
and personal facilities that are available to be utilised by companies
or organisations to provide service to customers for profit and
non-profit reasons.\textsuperscript{(1)}However, infrastructure from a
healthcare perspective includes the built environment and supporting
elements such as equipment, access, information technology, systems and
processes, sustainability initiatives, and staff.
\textsuperscript{(2)}Health infrastructure is a key pillar supporting
the fundamental aim of promoting an improved standard of care and
well-being for patients. It also forms part of the overall health
system.\textsuperscript{(2)}As the key pillar in health systems, all
healthcare services depend on it to be provided effectively and
successfully.\textsuperscript{(2)} Therefore, a good healthcare facility
should outline the following core principles: physical availability and
physical quality of facilities; facility density and distribution;
facility design; facility amenities and safety equipment, and
precautions.\textsuperscript{(3)}The type of health facility and
healthcare services available in countries around the world depends on
factors such as the type of healthcare system in place, target
population size, disease profile, and the country's political
state.\textsuperscript{(4)}

In South Africa, health facilities and healthcare services depend on the
two-way parallel system which includes public and private
healthcare.\textsuperscript{(5)} However, this system can be affected by
factors such as socioeconomic status\textsuperscript{(5)}, lack of
infrastructure\textsuperscript{(6)}, limited healthcare
staff\textsuperscript{(5)}, and financial
mismanagement.\textsuperscript{(5)}This parallel system makes the
country have an uneven healthcare service and health facility
infrastructure across all provinces. Furthermore, facility amenities are
also considered as part of facility infrastructure, because they are
ways to enable primary healthcare (PHC) facilities to be ready to
provide quality and person-centred primary
healthcare.\textsuperscript{(7)}To ensure all populations have timely
access to healthcare requires sufficient facility infrastructure,
geographic accessibility, and determination of the most common problem
within the community.\textsuperscript{(8)}

Globally, countries have documented the association of health facility
infrastructure and quality of healthcare, and there are still gaps in
ensuring sufficient facility amenities, safety precautions, and
equipment.\textsuperscript{(9)} A study by Cronk and colleagues (2019)
on PHC facilities infrastructure in low-to-middle-income countries
(LMIC) showed that 59\% of health facilities lacked reliable energy
sources, 50\% lacked piped water on the premises, and 33\% lacked
improved sanitation facilities.\textsuperscript{(10)}These countries
have shown that only 2\% of health facilities provide services such as
water, sanitation, hygiene, and waste
management.\textsuperscript{(10)}Inequalities in healthcare service
coverage by urban versus rural settings have shown statistical
significance in managing authorities, facility type, and sub-national
administrative units.\textsuperscript{(10)}

Furthermore, a study conducted on the accessibility of electricity at
PHC facilities between 2001-2012 in 11 sub-Saharan African countries,
showed that 26\% of these PHC facilities had no access to electricity,
only 28\% had reliable electricity, and 7\% used only
generators.\textsuperscript{(11)} In addition, in the Eastern Cape (EC)
and KwaZulu-Natal (KZN) Provinces of South Africa, there were
observations of 40 HCF infrastructures, and the following were found to
exist: safe drinking water (20-25\%), electricity (45-85\%), flush
toilet (40\%-75\%), and operational telephones (5-40\%).
\textsuperscript{(12)}This study also interviewed nursing professionals,
and 80\% in both provinces indicated that other indicators interfering
with the quality of healthcare service delivery were basic resources and
cultural practices.\textsuperscript{(12)}

The study conducted by Ritshidze (2021), on the state of health in KZN,
found that 16\% of monitored facilities in different districts were in a
bad condition including eThekwini municipality facilities
(19\%).\textsuperscript{(13)}The most discovered reasons for poor
conditions included old buildings with broken or cracked roofs, walls,
and floors. \textsuperscript{(12)} In addition, the other concerns found
included no light/or no working lights in some areas of the facilities,
broken furniture, no running water, broken windows or doors, and rubbish
piles.\textsuperscript{(13)} Although these studies have reported poor
facility infrastructure, there are few or no findings on the effect of
health facility infrastructure on service delivery in SA. In addition,
Goodwins Clinic was among the 12 health facilities found to have poor
infrastructure, poor service delivery, and poor working
conditions.\textsuperscript{(13)} Thus this study investigated the
perception of healthcare workers and patients about the impact of health
facility infrastructure on the provision of healthcare services at
Goodwins Clinic in eThekwini Municipality, KwaZulu-Natal, South Africa.

\textbf{2. METHODS}

\textbf{2.1. STUDY METHODS AND DESIGN}

A qualitative phenomenological design was used to determine the
perception of healthcare workers and patients about the impact of health
facility infrastructure on healthcare services at Goodwin's clinic in
eThekwini Municipality, KZN. Phenomenology is a research approach that
seeks to describe the essence of the phenomenon by exploring it from the
perspective of participants lived experience. \textsuperscript{(14)}

\textbf{2.2. STUDY SETTING}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1. eThekwini Metropolitan municipality map showing Kwamashu
Location~\emph{(study site circled in red).}~\textsuperscript{(15)} ~

The Primary Healthcare Centre (PHC) in eThekwini Municipality, KZN
province of South Africa was targeted as the study setting. The
municipality has a different level of health facilities which includes
99 public PHC, eight community health centres, three district hospitals,
five regional hospitals, two provincial's tertiary hospitals, and one
national central hospital. One public PHC facility, Goodwins in KwaMashu
Township (E section), in eThekwini Metropolitan Municipality shown
in\textbf{Figure1} , was randomly selected from the four facilities that
had a high percentage of reported poor infrastructure, poor service
delivery, and poor working conditions.

\par\null

\textbf{2.3. STUDY POPULATION}

The study targeted two groups of participants for a broader
understanding of the effect of health facility structure on healthcare
services. The first participants were patients (Group 1) who were
visiting the PHC for the second time, with no medical condition
severity, who were literate, and who were legally allowed to give
consent. The second participants (Group 2) were healthcare workers who
were working on a full-time basis at the target PHC over two months. The
following Inclusion and exclusion criteria were used to ensure the
proper selection of the target population:

\textbf{Inclusion criteria}

\begin{itemize}
\tightlist
\item
  Patient and health care workers who signed consent forms.
\item
  Patients attending Goodwins clinic for the second time.
\item
  Health care workers working/stationed at Goodwins clinic more than two
  months.
\item
  Patients and healthcare workers who were 18 years and older.
\item
  Illiterate patients (These participants will be assisted by
  researchers)
\end{itemize}

\textbf{Exclusion criteria}

\begin{itemize}
\tightlist
\item
  Patient and health workers who refused to sign the consent form.
\item
  \textbf{First time} patients attending Goodwins clinic on the day of
  data collection.
\item
  Visiting health care workers at Goodwins clinic.
\item
  Patient who did not understand isiZulu and English.
\item
  Minor patients
\item
  Patients who are critically ill
\item
  Health care workers who are off duty on the day of data collection
\end{itemize}

\textbf{2.4. STUDY SAMPLING STRATEGY}

Purposive sampling was used to select healthcare workers and patients.
After the study received KZN Provincial and District approval, the
researcher obtained a clinic daily roster from the PHC manager and
selected every 5th person on the roster. The total number that was
obtained counted to ten healthcare workers. The selected participants
were personally informed a week (a week after the main staff meeting)
before data collection, and they did confirm their availability and
details about the study was shared. Ten healthcare workers and 20
patients were interviewed.

\textbf{2.5. DATA COLLECTION}

Data was physically collected during clinic operating hours
(07h30-16h00) within two months. All participants preferred to use
Isizulu as the language of communication, thus data was collected using
the preferred language. After agreeing to participate in the study,
participants signed the consent forms and received the study information
sheet. There were combined types of data collection tools used, i.e.,
the interview guide and an audio recorder. Two separate adopted
interview guides named QA for group 1 and QB for group 2 were used. Both
interview guides were developed using the \emph{Primary Healthcare
Performance Initiative Guide: An Improvement Strategies model}
\textsuperscript{(9)}. The guides were also translated using a language
translator and verified by a Zulu language speaking personnel. These
guides were structured into two parts, which were demographic
information and participant interviews. Questions designed for
participant interview sections were open- and closed-ended questions.
During data collection, the researcher also took into consideration
non-verbal communication, and participants were allowed to freely
express their thoughts for obtaining sound and respectful communication.
All audio-recorded information was transcribed verbatim and each day
after data collection, the collected information was iteratively
analysed until a point of data saturation was
reached.\textsuperscript{(16, 17)}

\textbf{2.6. MEASUREMENTS}

The effect of health facility infrastructure on healthcare service
delivery is presented as the main outcome of the study. Both study
participants were asked to describe how the infrastructure of the
facility affects the quality of the services provided in the clinic and
the option responses were based on their perceptions. The description of
health facility infrastructure was treated as dependent variable and
healthcare service delivery as an independent. Both study participants'
ratings of the level of healthcare services provided in the clinic were
ordinal variables with optional responses such as excellent, very good,
fair, poor, and others. Furthermore, both participants were asked how
satisfied (satisfied, not satisfied, and other) they were with the
cleanliness of the physical environment (e.g., waiting area, toilets) of
the clinic, the availability of drinking water, and the availability of
adequate waiting area or seating arrangement. Demographic variables of
healthcare workers were age category, department placed to work,
occupation, gender, number of years working in the facility, type of
employment contract (Temporary or permanent), and level of education.
Healthcare workers also described the types of problems they have
experienced when providing healthcare services which were measured as
staff negative attitude\textbf{,} poor management,
discrimination\textbf{,}mistreatment\textbf{,} and others. The ability
to access other medical and supporting equipment was also measured as
always having access, not having access, restricted access, and Other.

The patient's demographic variables were the Participant used language
(if illiterate, please specify), name of department found, employment
status, age, gender, and highest level of education. These participants
were asked to rate the effectiveness of treatment and formation provided
at the clinic (Excellent, Good, and Fair); explanation given with
regards to the treatment plan (Excellent, Good, and Fair); the level at
which given medicine and their side effects were explained (Excellent,
Good, and Fair), their satisfaction on the healthcare worker's
explanation of the purpose and necessity of any tests to be done
(Excellent, Good, and Fair); and the level of helpfulness and
responsiveness of the staff at the clinic (Excellent, Very good, Good,
Fair, and Poor). The distance it takes patients to come to the clinic
was also determined by using estimated time of Less than 15 minutes,
15-30 minutes, 30-45 minutes, and more than 45 minutes. Patients were
also asked to describe the types of problems they encountered when
accessing healthcare services at Goodwins Clinic (Staff negative
attitude, Prolonged waiting period/hours, Discrimination, Inequality,
Provision of Incorrect type of service, and Others).

\textbf{2.7. THEMATIC ANALYSIS}

Obtained data between September 2022 and October 2022 was filed
separately for both groups in labelled files, and recorded audios were
safely saved using participants' labels (e.g., HCW as QB, Participant
1=QB1) and they were secured by a password-based file. The recorded data
underwent transcription and was combined with each participant's answer
sheet a day after data collection. The Zulu-speaking data collector
translated the data into English. Following data collection, the seven
steps of Colaizzi's thematic analysis framework \textsuperscript{(18)},
using NVIVO 14 to assist with coding.

At first, the researcher went through all the transcripts to obtain a
detailed understanding of each healthcare worker and patient's
perceptions. Following the first step, all significant statements were
extracted from the read transcripts, and this was further analysed for
code allocation using. Thirdly, the meaning of each significant
statement was determined. Fourthly, a cluster of themes was created from
these statements. Fifthly the study results were integrated into a
detailed representation of the perception of healthcare workers and
patients on the effect of health facility infrastructure on healthcare
services. Sixthly, the perception of the effect of facility
infrastructure on healthcare services was divided into themes,
subthemes, and superordinate themes. Lastly, the collected data was
verified by comparing the audio and written raw data, and a spreadsheet
with developed themes.

\textbf{3. ETHICAL APPROVAL}

The study received statistical and University of Pretoria Faculty of
Health Sciences Research ethics approval (\textbf{Ethics no.} 278/2022).
Thereafter the researcher received a letter of support from facility
managers from the target facility, and approval from eThekwini
Municipality and the KwaZulu-Natal Provincial Department of Health.

\textbf{4. TRUSTWORTHINESS}

The study established trustworthiness by following the four criteria
outlined by Lincoln and Guba.\textsuperscript{(19)} The researcher
further ensured that the study setting, and participants were clearly
described. Three types of data collection tools were used which are,
voice recorder, field notes, and answer sheets. All participant's
nonverbal cues were noted next to each answered question. Confirmability
was established by not changing participants' responses and by using
verbatim quotations. In addition, participants' nonverbal communication
was noted next to the answered question, and this was further clarified.
Consistency was obtained by using several types of data collection tools
(field notes, audio recordings, and participants' answer sheets). During
data collection, participants were informed that participation in the
study was entirely voluntary, and upon agreement, an informed consent
form was signed.

\textbf{5. STUDY FINDINGS}

The study findings are summarised into three tables which are analysis
codes and their definitions (\textbf{table 1} ), demographic
characteristics of respondents (\textbf{table 2} ), and formulated
themes (\textbf{table 3} ).

\textbf{5.1 Analysed codes and definitions.}

\textbf{Table 1: Analysis codes and their definitions}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Codes} & \textbf{Code definitions}\tabularnewline
\midrule
\endhead
\textbf{Health facility infrastructure description} & Any description of
health facility structure including each department in the facility, the
whole facility structure, building structure, roof, ceiling, materials,
doors, windows, and support equipment' used on daily basis to provide
healthcare services.\tabularnewline
\textbf{Impact of facility infrastructure on healthcare services} & Any
or every facility infrastructure that will impact the provision of
healthcare services.\tabularnewline
\bottomrule
\end{longtable}

\textbf{5.2 Participants Characteristics}

Table two illustrate HCWs and patient's demographic characteristics
participated in the study.

\textbf{Table 2: Demographic characteristics of respondent}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\textbf{Participant Code} & \textbf{Gender} & \textbf{Age} &
\textbf{Education} & \textbf{Position} & \textbf{Number of years
working} & \textbf{Employment status}\tabularnewline
\midrule
\endhead
\textbf{Healthcare workers} & \textbf{Healthcare workers} &
\textbf{Healthcare workers} & \textbf{Healthcare workers} &
\textbf{Healthcare workers} & \textbf{Healthcare workers} &
\textbf{Healthcare workers}\tabularnewline
Participant-QB1 & Female & 50 & ND & ENA & 16y & Employed\tabularnewline
Participant-QB2 & Male & 38 & Diploma & EN & 11m &
Employed\tabularnewline
Participant-QB3 & Female & 41 & AC & LC & 18y & Employed\tabularnewline
Participant-QB4 & Female & 34 & Diploma & EN & 2y &
Employed\tabularnewline
Participant-QB5 & Female & 59 & Bachelors & RPN & 19y &
Employed\tabularnewline
Participant-QB6 & Female & 47 & Diploma & EN & 16y &
Employed\tabularnewline
Participant-QB7 & Female & 42 & Bachelors & FIO & 16y &
Employed\tabularnewline
Participant-QB8 & Male & 34 & NSC & LC & 11y & Employed\tabularnewline
Participant-QB9 & Male & 42 & NSC & Security & 16y &
Employed\tabularnewline
Participant-QB10 & Female & 47 & Diploma & EN & 2y &
Employed\tabularnewline
\textbf{Participant Code} & \textbf{Gender} & \textbf{Age} &
\textbf{Education} & \textbf{Position} & \textbf{Number of years
working} & \textbf{Employment status}\tabularnewline
\textbf{Patients} & \textbf{Patients} & \textbf{Patients} &
\textbf{Patients} & \textbf{Patients} & \textbf{Patients} &
\textbf{Patients}\tabularnewline
Participant-QA1 & Female & 26 & NSC & & & Employed\tabularnewline
Participant-QA2 & Male & 27 & NSC & & & Employed\tabularnewline
Participant-QA3 & Female & 31 & Grade 11 & & & Unemployed\tabularnewline
Participant-QA4 & Male & 26 & NSC & & & Student\tabularnewline
Participant-QA5 & Female & 40 & NSC & & & Unemployed\tabularnewline
Participant-QA6 & Female & 55 & Grade 10 & & & Unemployed\tabularnewline
Participant-QA7 & Female & 26 & NSC & & & Student\tabularnewline
Participant-QA8 & Female & 47 & Grade 11 & & & Employed\tabularnewline
Participant-QA9 & Female & 67 & NE & & & Pensioner\tabularnewline
Participant-QA10 & Male & 52 & NSC & & & Employed\tabularnewline
Participant-QA11 & Male & 48 & Grade 6 & & & Employed\tabularnewline
Participant-QA12 & Male & 34 & NSC & & & Employed\tabularnewline
Participant-QA13 & Male & 31 & NSC & & & Employed\tabularnewline
Participant-QA14 & Male & 32 & NSC & & & Employed\tabularnewline
Participant-QA15 & Female & 55 & Grade 5 & & & Unemployed\tabularnewline
Participant-QA16 & Male & 28 & NSC & & & Employed\tabularnewline
Participant-QA17 & Female & 36 & Grade 11 & & & Employed\tabularnewline
Participant-QA18 & Female & 35 & Grade 10 & & &
Self-employed\tabularnewline
Participant-QA19 & Male & 32 & NSC & & & Employed\tabularnewline
Participant-QA20 & Female & 47 & NSC & & & Unemployed\tabularnewline
\bottomrule
\end{longtable}

\emph{AC: Advanced Certificate, EN: Enrolled Nurse, ENA: Enrolled
Nursing Assistance, FIO: Facility Information Officer, ND: National
Diploma, NSC: No Secondary School,} \emph{RPN: Registered Professional
Nurse,}

\textbf{5.3 Themes}

Table 3 illustrates the overarching themes emanating from the thematic
analyses from the participants depicted experience on the impact of
health facility infrastructure on service delivery. The responds were
firstly grouped into themes, then emergent themes, and clusters of
themes.

\par\null\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Overarching Theme}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Main Themes}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Sub-Themes}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Health facility infrastructure description}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Departmental structure\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1. Poor structure 2. Small space 3. Old clinic structure 4. Unhygienic
5. Good clinic infrastructure\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Working and physical environment\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1. Not safe 2. Limited space\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\textbf{Impact of facility infrastructure on healthcare services}\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Poor service\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1. Insufficient equipment 2. Shortage of medicine 3. Old facility
structure\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Insufficient service\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1. Limited facility structure. 2. Unsafe structure\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Disrupted service\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
3. Scattered facility structure\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3: Summary of formulated themes}

\emph{Overarching:Health facility infrastructure description}

The study findings revealed that departmental structure and working and
physical structure were potential descriptors of the whole health
facility infrastructure.

\par\null

Departmental structure

The study results showed that patients and HCWs indicated that poor
structure, small space, old clinic structure, and unhygienic described
the facility department's structure. In addition, a few patients
positively revealed that some of the departmental structures they were
visiting had good infrastructure.

Poor structure

The study indicated that the departmental structure was not good which
means that the facility structure might not be well structured:

\emph{``The waiting area is not good as it is outside, I am afraid that
if it rains people will be wet.'' \textbf{{[}Participant-QA2{]}}}

\emph{``The toilets are clean, but the doors are not lockable which
makes it not good and not private.'' \textbf{{[}Participant-QA7{]}}}

Other participants did mention that due to the open top of the
consultation rooms, they feel like their information can be heard by
everyone, which might not be safe and confidential:

\emph{``The consultation rooms are not closed on top, so everyone can
hear when the nurse is talking to you.''\textbf{{[}Participant-QA20{]}}}

Small space

Participants indicated that the facility departments had small or
limited space:

\emph{``Feels like the toilets are two small and consultations rooms,
they need the extension''}

\emph{\textbf{{[}Participant-QA4{]}}}

The study further revealed that the facility had too many compartments
or sections:

``\emph{The structure is not good, there are too many
sections.''\textbf{{[}Participant-QA13{]}}}

Old clinic structure

Based on the study findings one of the main problems with the facility
structure was that it was old:

``\emph{Other parts of the clinic structure are ok, but most parts are
old and not good,'' \textbf{{[}Participant-QA17{]}}}

\emph{``The clinic structure is old'' \textbf{{[}Participant-QA9{]}}}

Unhygienic

The study findings showed that the facility departments were unhygienic:

\emph{``As a person working with contiguous diseases, such as COVID-19,
I have to go to the other section to wash my hands after seeing a
patient, which is a bit of a distance.''\textbf{{[}Participant-QB10{]}}}

\emph{``We do not have water near our working station, which makes it
unhygienic, and sometimes we use toilet
water.''\textbf{{[}Participant-QB9{]}}}

Good clinic infrastructure

The study also found that some of the facility departments had good
structure:

\emph{``One part of the clinic infrastructure is good, especially the
newly built structure.'' \textbf{{[}Participant-QA6{]}}}

\textbf{Working and physical environment}

The study revealed that the working and physical environment had the
same descriptions as the departmental structure. These descriptions were
only provided by HCW wherein they mentioned that the working and
physical environment was not safe and had limited space,

Not safe

The study results indicated that the working and physical environment
was not safe:

\emph{``The working environment is not
safe\ldots{}''\textbf{{[}Participant-QB7{]}}}

\emph{``There is a big hole in my office, which can cause you to fall,
it once trip one nurse and she got
injured.''\textbf{{[}Participant-QB5{]}}}

Limited space

The study revealed that the working environment and physical environment
had limited space:

\emph{``There is limited space and only two toilets used by
patients.''\textbf{{[}Participant-QB9{]}}}

\emph{Overarching: Impact of facility infrastructure on healthcare
services.}

The study findings indicated how patients and HCWs described the
facility infrastructure impact on healthcare services. The impact of
health infrastructure caused poor service delivery, insufficient
service, and disrupted service delivery.

\textbf{Poor services}

The study findings revealed how facility infrastructure affects
healthcare services. These indicated that Insufficient equipment,
shortage of medicine, and old facility caused poor services.

Insufficient equipment

The study revealed that participants had perceptions of the effect of
facility infrastructure on provided healthcare services. Their
perception showed that lack of equipment did cause poor service
provision in the clinic, which indicated facility infrastructure's
relation to healthcare services:

``\ldots{}\emph{There is no equipment that I need to work, I bought my
laptop and data to use them for work purposes, the chairs are not
comfortable and there is no ventilation, this makes me not to provide
the right health services.'' \textbf{{[}Participant-QB7{]}}}

Shortage of medication

The study participants had perceptions of the effect of facility
infrastructure on provided healthcare services. They indicated that lack
of shortage of medication did cause them not to provide full services,
which indicated facility infrastructure's relation to healthcare
services:

\emph{``There is always a shortage of medication, which makes us not
provide full service.'' \textbf{{[}Participant-QB1{]}}}

Old facility structure

According to the study findings, an old facility structure poorly
affected the provided healthcare services:

\emph{``The facility's main building is too old, there are too many
capons, which makes the service not well
provided.''\textbf{{[}Participant-QB9{]}}}

\textbf{Insufficient service}

According to the study findings, participants showed that limited
facility space and unsafe structure resulted in insufficient healthcare
service in the facility:

Limited space

The limited space was described as one of the causes of insufficient
healthcare services.

\emph{``Limited space and structure not good to provide other
services.'' \textbf{{[}Participant-QB2{]}}}

Unsafe structure and level of service

Study participants revealed that the unsafe structure compromises
healthcare services to be provided:

\emph{``One day the ceiling board fell a minute after I walked out of
the department, which was so scary, there are also too many holes around
the clinic which can injure patients and HCW will lead to staff shortage
while affecting the level of service.'' \textbf{{[}Participant-QB5{]}}}

\textbf{Disrupted service delivery}

Participants also indicated that having scattered facility structure
affects the provided healthcare service:

Scattered facility structure

Scattered facility structure has shown to disrupt the healthcare
service.

\emph{``The infrastructure of the facility is scattered wherein you must
go far to collect things to work, which makes patients wait for a longer
time.'' \textbf{{[}Participant-B8{]}}}

\emph{``Too many sections can make you end up not getting the service
that you want.'' \textbf{{[}Participant-QA13{]}}}

\emph{``The structure is not good and well arranged, and some people are
thinking of going to the other clinic.'' \textbf{{[}Partcipant-QA14{]}}}

\textbf{6. DISCUSSION}

The study findings showed that health facility infrastructure affects
the provided healthcare services in the target study settings. How the
facility was structured, and the support equipment was among the factors
which affected healthcare services. These findings agreed with the
report by the South African Human Rights Commission(2009), which
revealed that the physical structure of health facilities is
overcrowded, leading to compromised quality of healthcare service due to
lack of privacy, poor cleanliness, and outdated
technology\textsuperscript{(20)},and the workload has increased shift
work, which causes long working hours.\textsuperscript{(20)} The high
probability of dying in public health facilities was also found to be
affected by hospital infrastructure and quality of
service.\textsuperscript{(21)}Furthermore, the relation between the
health facility infrastructure and healthcare service in the current
study showed that insufficient equipment, limited facility space, unsafe
structure, and old facilities affected the level of healthcare service
provided.

In addition, an Annual Inspection Report was issued by the Office of
Health Standards Compliance (OHSC) to determine whether health
establishments complied with prescribed norms and standards.
\textsuperscript{(28)} This report covered four functional areas around
the maintenance of health infrastructure. Among the litany of adverse
findings, the outstanding outcomes included the non-existence of
maintenance plans for most facilities across the eight SA provinces
audited. \textsuperscript{(28)}In addition, adverse outcomes related to
the maintenance of buildings, equipment, and vehicles, were found by
this study.\textsuperscript{(28)} Ultimately, Manyisa and others (2017)
further showed that poor health facility infrastructure, inadequate
resources, and shortage of staff were the major factors contributing to
poor working conditions. \textsuperscript{(22)}

Service delivery is linked with all other elements in the health
system.\textsuperscript{(23)}The availability of resources, such as
qualified staff, and the organisation of their use determine the studies
in possibilities for service provision. \textsuperscript{(23)} In all
countries, it is the government's task to determine the optimal delivery
models for different health services to the public and to steer and
motivate providers to behave accordingly. A cross-sectional study
assessing patients' perception of quality nursing care and services in
an emergency department in Jordan, found that there was a high level of
patients' perception of quality nursing care and related emergency
department services. \textsuperscript{(24)} This study was looking at
both private and public health facilities, and it reported low quality
of health service in the public sectors which the correlate with the
current study findings, whereby the healthcare service was rated as poor
by 15\% and 20\% of patients and HCWs, respectively. Despite these
ratings, there was positive feedback recorded by both patients and HCWs
in the current study. In addition, another study that evaluated the
level of satisfaction of patients hospitalized at Ibn Al Jazzar
University Hospital in Kairouan in 2018 \textsuperscript{(25)} supported
our findings of poor healthcare services. The study results reported
that patient satisfaction was low concerning the quality of the services
provided, mostly in the areas related to the conditions of stay and the
globality of care. \textsuperscript{(25)}

Health facility infrastructure constitutes a major component of the
structural quality of a health system\textsuperscript{(27)}, and is one
of the reasons that enables the rendering of health services. Health
infrastructure in many countries differs depending on the government's
support. This current study described health facility infrastructure by
looking at how each department was structured and the working and
physical environment. This study results described the departmental
structure as being insecure, having limited space, being old,
unhygienic, and good structure. Some of the descriptions were the same
as the ones for the working and physical environment (insecure and
limited space). These were similar to the one of a rapid assessment
conducted in Tanzanian OHCs, which covered seven PHCs ranging between
dispensary and district hospital. \textsuperscript{(27)} This rapid
assessment encompassed the facilities as entities, as well as 42
facility buildings and 80 pieces of technical medical
equipment.\textsuperscript{(27)} A full and rapid assessment of facility
infrastructure was undertaken by healthcare professionals and facility
staff wherein the results revealed serious infrastructural
deficiencies.\textsuperscript{(27)} However, there were no interviews
conducted in these rapid assessments to explain the study's aim.

In addition, another study, which looked at the perceptions of HCW on
facility infrastructure in an East Ethiopian hospital, reported that
59.3\% of the respondents perceived that their hospital did not place
enough emphasis on the quality of service it provided and 69.6\%
reported that there were inadequate facilities. \textsuperscript{(28)}In
addition, a study conducted to investigate the impact of technological
infrastructure on the quality of service in Nigerian health sectors
reported inadequacy of manpower and utilities and extremely inadequate
laboratory equipment. \textsuperscript{(29)}Moreover, a study exploring
quality standards implementation at South African municipality's health
facilities reported that the interviewed participants observed
dilapidated infrastructures in the target health facilities and
contributed to the noncompliance with quality
standards.\textsuperscript{(36)}

Furthermore, patients' perceptions also showed a gross inadequacy of
manpower, with a mean of 1.94, 1.88, 1.65, and 1.50 for doctors, nurses,
ward aids, and laboratory staff respectively, with laboratory staff
being the most inadequate, similar to the perception of the hospital
workers. \textsuperscript{(29)} These results concur with a monitoring
report conducted by Ritshidze (2021) on the state of health in KZN. This
report found that 16\% of monitored facilities in different districts
were in a poor condition, which agrees with the current study
findings.\textsuperscript{(13)} Most common provided reasons for poor
conditions were old buildings (64\%), and broken or cracked roofs,
walls, and floors (36\%). \textsuperscript{(13)} Other concerns found
included no lights/no working lights in some areas of the facility,
broken furniture, no running water, broken windows or doors, and rubbish
piles.\textsuperscript{(13)}

\textbf{7. STUDY LIMITATIONS}

The current study was limited to one KwaZulu-Natal municipality, which
is eThekwini Municipality. The study findings were based on healthcare
workers and patients, however, the perception of facility managers and
other non-governmental organisations which were supporting the facility
was missing in the study. These limitations should be borne in mind when
interpreting the explored perceptions in this study.

\textbf{8. CONCLUSION}

The current study showed how the health facility infrastructure impacted
healthcare services. Health facility infrastructure remains one of the
core skeleton pieces of the health systems; thus, if health facilities
are not well structured and customized to provide public health service,
this can lead to an increase of double burden disease, an increase in
mortality, and a shortage of HCWs. There is a major need to close the
identified gaps to ensure public health is protected and that healthcare
service in SA is improved. The type of SA health system needs to be
relooked at as well as the current interventions in place to improve
healthcare, to ensure healthcare equity and quality.

\textbf{9. RECCOMENDATIONS}

It is recommended that there be continued discussions on improving
infrastructure while we are navigating NHI and understanding the
resources we will need. The current study results indicate that South
African healthcare facilities require urgent collaborative intervention
to restructure and improve infrastructure for better healthcare service
provision. Although this might be a long-term intervention, there is a
serious need for change. Apart from the current target of PHCs, there
have been reports or analyses about the poor state of South African
health facilities. This study posits that poor infrastructure may led to
highly trained medical professionals leaving the country due to
unbearably poor working conditions. There may be a gap in the
availability of high-quality medical services for patients due to
several resignations caused by poor infrastructure; this will increase
morbidity and mortality among the SA population if less or no action is
taken. Future research is required to learn the broader views of
patients and HCWs in all SA provinces about the impact of health
infrastructure on service delivery and causes of poor healthcare
services.

\textbf{10. ACKNOWLEDGMENTS}

The authors would like to thank the participants for their contribution
to the study, the eThekwini municipality district, the KZN Provincial
Department of Health for granting permission for this study to commence,
Mr. Sphamandla Hadebe (Field Worker), and Gill Smithies (proofreading \&
language editing services) for making the project a success.

\textbf{11. DISCLAIMER}

The expressed views and opinions in this article are those of the
authors and do not outline any official policies, guidelines, or
positions of the affiliated agency of the authors.

\par\null

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