A Health and Well-Being Planning Model for Enhancing Primary Health Care Services in a Selected Cape Metropolitan Subdistrict

A Health and Well-Being Planning Model for Enhancing Primary Health Care Services in a Selected Cape Metropolitan Subdistrict | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Health and Well-Being Planning Model for Enhancing Primary Health Care Services in a Selected Cape Metropolitan Subdistrict Stanley Andrew Sayers, Leslie Siegelaar, S Cronje This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6635609/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Non-compliance with legislative provisions has resulted in inadequate Primary Health Care (PHC) services for the Eastern subdistrict community within the Cape Town Metropolitan area. This non-compliance includes governance failures, such as the absence of committee meetings required to oversee the responsibilities outlined in the legislation. The consequences are visible in the prevalence of infectious diseases, limited public access to clinics, and the lack of expansion of health services despite growing population trends. This challenging context forms the backdrop for the study, which aims to identify the underlying causes of legislative non-compliance, propose a planning intervention, and validate its potential to improve the situation. The research population comprises fourteen clinic managers overseeing twelve clinics in the area, alongside fifteen purposively selected ward committee members. The study employs a mixed methods design using an explanatory sequential approach, in which the results of the quantitative survey with clinic managers (conducted through a Likert-scale questionnaire) are further explained and enriched by qualitative findings from open-ended interviews with ward committee members. The analysis ultimately supports the application of a mixed planning approach to develop a model for improving PHC services in this Cape Metropolitan subdistrict. Community Involvement Eastern subdistrict Governance Primary Health Care Ward Committees Ward Councilors Health and well-being Figures Figure 1 Figure 2 Introduction Access to primary health care (PHC) clinic services remains a critical challenge in many settings, particularly for poor and disadvantaged communities. Barriers to healthcare are both significant and multifaceted [1], with one of the primary concerns being the financial burden associated with travelling outside one’s residential area to access health services, especially when certain essential health service packages are unavailable at local PHC clinics. These systemic complexities in service delivery have a harmful impact on poor, disadvantaged communities, as they isolate them from accessing basic and quality healthcare. Such barriers not only hinder equitable healthcare access but also contribute to the continued marginalization of vulnerable populations [1]. In response to these challenges, legislative frameworks mandate the establishment of health committees by civil society and community leaders. These committees are responsible for addressing a range of complex issues, including the development and oversight of quality improvement plans for underperforming PHC program indicators. According to Section 12 of the Western Cape Health Facilities Boards and Committees Act [2], these committees are also tasked with advocating for community health needs and managing complaints, thus serving as a crucial interface between communities and the health system [2]. This study aims to identify the underlying causes of legislative non-compliance, propose a planning intervention, and validate its potential to address the challenges. Literature Review The 2023/2024 Plan-Do-Review (PDR) cycle for PHC clinics [3] has come under criticism due to substandard performance. Notably, several clinics in the Cape Town Metropolitan Municipality failed to meet the target of 47 prenatal visits per month, starting in July 2023 (see Table 1). >>>add Table 1 here<< This underperformance – highlighted in red – persisted over the remaining eleven months of the financial year, ending in June 2024, resulting in a cumulative shortfall [3]. Table 1 shows that while the monthly target is clearly set at 47 visits, this benchmark is rarely met. For example, Fagan Street Clinic began the reporting period with zero bookings for pregnancies under 14 weeks, a figure that remained marked in red. Additionally, the City Health Department has reported a lack of structured engagement between civil society and government in addressing the disease burden across the twelve communities. This absence of deliberation contradicts both the principle of “full participation” as outlined in the PHC framework and the legislative requirement that community members actively participate in identifying health problems and formulating appropriate responses [2]. Data extraction plays a critical role in delivering PHC services across the 12 clinics in the Eastern subdistrict. However, this information is not being effectively utilized to monitor and manage priority disease trends in certain communities. While clinic staff routinely collect and analyze health statistics – vital for assessing PHC performance, identifying at-risk populations, informing program planning, and evaluating outcomes – these efforts often lack alignment with broader community needs. To ensure responsive and contextually relevant service delivery, community representatives should be actively involved in the planning and development of PHC programs [4]. In 2018, a National Tuberculosis survey [5] revealed that 66% of 15- to 24-year-olds did not seek care due to distance from health facilities or work commitments. Men had a 1.6 times higher prevalence of tuberculosis than women. This disparity affects clinic indicators that measure health outcomes and the effectiveness of health services. Inadequate governance has impacted clinic performance standards in child, women, and youth health across the 2020/2021, 2022/2023, and 2023/2024 financial years [3]. The aim of this paper is to identify the causes of legislative noncompliance and to propose and validate a planning intervention to address the situation. The Eastern subdistrict, which accounts for 12.75% of Cape Town’s population – an estimated 608,690 residents – relies on services from 12 municipal clinics due to widespread lack of health insurance. These clinics provide essential services, including HIV prevention, immunization, and child health care [4]. This situation continues to undermine the delivery of medical services in underdeveloped communities, with harmful effects on overall community health. While various models in the literature offer guidelines applicable to other contexts, there is limited knowledge about the specific components of these models as adapted to underdeveloped healthcare settings in South Africa. This gap informs the central research question of the study: What are the key components of a community-informed model for health and well-being? “Health for All” is a core principle underpinning PHC [6]; however, many communities in the Eastern subdistrict remain deprived of this fundamental right due to various social determinants of health [5]. These include issues such as inadequate patient safety, limited access to clinics not located near public transportation routes, and a lack of effective nonverbal communication structures between the community and healthcare providers. Likewise, the World Health Organization (WHO) advocates for a whole-of-society and whole-of-government approach, emphasizing community empowerment and the provision of integrated services as critical strategies to address these barriers and promote equitable health outcomes [6]. As the first level of contact with the national health system, PHC plays a critical role in promoting self-reliance and self-determination in health [6]. Governance in this context entails decision-making, ensuring effective implementation, and exercising authority in relation to ongoing learning and the evolution of institutions within society [7]. Complementing this, the King IV Report underscores the role of an organization’s board or committee as the cornerstone of governance, particularly in the public health sector [8]. It calls for transparency in governance practices, including appointments, terms of office, and structural design, and promotes a balanced composition in terms of skills, experience, and independence. The South African Constitution [9] guarantees that persons who suffer a sudden catastrophe can access medical care or ambulance service and must not be turned away from a clinic or hospital capable of providing the necessary treatment. It also requires municipalities to facilitate community participation in local governance processes [10]. Accessibility is a foundational principle in implementing PHC, with services meant to be available to all, especially disadvantaged populations and those living in rural areas. PHC services should be geographically accessible, cost-effective, and functionally available, and they should ideally be delivered in the language of the local community to ensure effective communication and inclusivity [11]. National legislation promotes the establishment of community-based governance structures at various levels of the health system, aiming to normalize community participation at both municipal and district levels [12]. These structures – including district health councils, hospital boards, and clinic committees – serve as mechanisms for public involvement in health governance. However, the formation of clinic committees specifically requires enabling provincial legislation to formalize and support their establishment and functioning [12]. Planning theories are crucial for providing systemic guidance to PHC clinics, despite significant capital investment and operational costs. They help establish a structured knowledge system, define boundaries and parameters for each subject area, and mitigate financial risks, especially in developing countries with limited resources [13]. Rational planning is a key decision-making framework that involves identifying problems, setting goals, evaluating alternatives, and making choices based on merit and strategic alignment. However, in practice, decision-makers often face constraints such as limited time and resources, which hinder their ability to gather and analyze comprehensive information. While advancements in computing technologies have enhanced data processing and analysis, they still fall short of fully meeting the computational demands of rationalist models. Rational decision-making begins with the identification of a problem – a critical task in public management, where public managers are responsible for detecting anomalies and initiating appropriate corrective action [13]. A thorough problem-identification process is essential for implementing effective corrective measures. This process involves generating, analyzing, and selecting the most appropriate course of action – decisions inevitably shaped by the values and perspectives of individual decision-makers [13]. The inherent complexity and subjectivity of rational decision-making highlight the importance of public managers being critically aware of both their own value systems and those of relevant stakeholders. Operating within an open system of interrelated variables, decision-makers often find that the ideal of rational planning is difficult to achieve in practice. Constraints such as frustration, resource limitations, and the absence of a clear guiding framework render purely rational approaches unrealistic and impractical. Rational planning theory faces limitations due to its reliance on group-based decision-making, the need for highly precise assessments, and the lengthy process often required to clearly define complex problems [13]. Incremental planning theory, a widely recognized alternative to the rational planning approach, addresses several of the limitations associated with comprehensive planning, particularly in contexts characterized by time constraints and limited resources. This theory emphasizes the role of stakeholder interests and available information in policymaking, making it especially relevant in health planning settings [13]. Incrementalism focuses on small, step-by-step changes to address immediate concerns, often at the expense of long-term strategic planning. It is not a comprehensive approach and frequently relies on value judgments due to insufficient or incomplete data. In the context of the Health Planning Cycle, incremental planning theory tends to prioritize temporary objectives and short-term resource assessments. While prioritization of needs is emphasized, monitoring and evaluation processes are often neglected. Key limitations of this approach include its tendency to focus on existing practices and current problems and to address immediate needs rather than long-term systemic challenges. As a result, implementation is rarely accompanied by robust monitoring mechanisms to assess the effectiveness of the planning approach [13]. The higher-order refers to overarching frameworks such as the Health Facilities Act, while the lower-order pertains to the implementation of PHC services and alignment with community values [13]. Grounded in Etzioni’s planning philosophy, mixed planning theory integrates high-level strategic decisions with lower-level incremental actions, enabling both the preparation and refinement of broader decisions through engagement at the community level [14]. Mixed scanning is a decision-making method that allocates resources across different levels of analysis and evaluates situations by adjusting the breadth and depth of focus. Drawing on the metaphor of satellites equipped with both wide-angle and zoom lenses, it allows for a combination of broad, general scanning and detailed, focused analysis – offering a flexible alternative to rigid, simultaneous examination of all variables [13]. In the context of decision-making, mixed scanning enables the selection of a major strategy and a corresponding sub-strategy, followed by an in-depth examination of specific options within the sub-strategy. In relation to health planning, the mixed scanning theory involves several key steps [13]: Introduction of the Scanning Process: This initial step involves a continuous review aimed at identifying and anticipating major issues, thereby providing a comprehensive overview of the current state and future direction of health service development. Selection Procedure: In this stage, the fundamental issues identified during the scanning process are sorted and prioritized for further analysis and detailed planning. Detailed Planning: The final step focuses on incremental planning, targeting a relatively small subset of prioritized issues identified in the earlier stages. Information plays a pivotal role in public health assessment, influencing it in three critical ways. First, PHC clinics rely heavily on surveillance data to monitor community health status and trends, as well as to detect emerging health risks. This continuous monitoring enables timely interventions and the mitigation of potential public health crises [15]. Identifying health needs and problems requires a thorough understanding of community resources and the effectiveness of existing interventions. Such understanding allows public health agencies to allocate their efforts more efficiently and strategically. Communication is also vital in addressing health needs, as it ensures that information is tailored to meet the needs of various stakeholders, thereby enhancing the impact and effectiveness of public health initiatives [16]. Figure 1 presents a conceptual framework derived from the insights of various authors on mixed planning theory, with an emphasis on Etzioni’s perspective. >>>add Fig 1. here<< The Western Cape Health Facility Boards and Committees Act [2] outlines three interconnected phases: science, co-governance, and performance. The science phase presents disease trends from PHC clinics; the co-governance phase highlights the participatory role of health committees; and the performance phase emphasizes outcomes, timelines, and systematic review [2]. Methods Research Design This study adopted a mixed methods approach, grounded in pragmatic research philosophy, which holds that combining quantitative and qualitative data provides a more comprehensive understanding of a research problem than either approach alone [17]. The strategy selected for this research was a case study involving the 12 municipal clinics in the Eastern subdistrict of the Cape Metropole’s City Health Department. A defining feature of case study research is its researcher-centered focus, often involving direct observation of participants to generate a holistic understanding of the setting [17]. Data Collection This study employed both quantitative and qualitative methods to obtain a comprehensive understanding of community participation and governance in PHC service delivery within the Eastern subdistrict of the Cape Metropole [17]. The quantitative method involved formulating literature-based statements and administering these statements as a quantitative survey to capture general attitudes. The qualitative method involved conducting interviews to explore individual perspectives in greater depth [18]. Quantitative Data Collection The quantitative component targeted the entire population of clinic management staff across the 12 municipal clinics in the subdistrict, covering the areas from Kuils River to the Strand and Gordon’s Bay. All six clinic managers and eight senior professional nurses participated, resulting in a total sample of 14 participants. Data were collected using a Likert-scale questionnaire, which included six biographical items and 52 statements derived from the literature on public administration, public health, and community participation. The analysis identified seven key areas of concern, which were subsequently explored during the qualitative phase. Qualitative Data Collection The qualitative sample consisted of 15 ward committee members from the Cape Metropole, purposively selected based on their demonstrated leadership roles within their communities. Participants represented key sectors, including education, faith-based organizations, safety and security, women, vulnerable groups, and youth within the geographic areas served by the 12 municipal clinics. The purpose of this sampling strategy was to gain insight into levels of political commitment and active community involvement in accordance with legislative structures and governance responsibilities. Data were collected through open-ended, semi-structured interviews guided by a seven-question interview schedule. With participants’ consent, the interviews were audio-recorded and transcribed verbatim for further analysis [19]. Data Analysis Quantitative data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27, with support from a statistician at the Cape Peninsula University of Technology (CPUT). For the qualitative data, thematic analysis was used to identify recurring themes, patterns, and insights emerging from the transcribed interviews [17]. Results Both quantitative and qualitative data were analyzed. The quantitative findings are summarized first, followed by the qualitative findings derived through thematic analysis. Quantitative Findings The objective of the Likert-scale survey was to assess management’s level of legislative compliance, the quality of the relationship between clinic management and community leadership, and the degree of commitment to service delivery. The quantitative results are presented as four factors, all pointing to noncompliance in clinic governance among the clinics and communities that participated in the study. Biographic Factors All 14 participants held at least a four-year nursing diploma and had an average of 15 years of professional work experience in the healthcare sector. While this indicates they are specialists in the nursing field, they lack sufficient training in community engagement and relations. Community Factors The literature highlights that dialogue is needed between community members, local managers, clinic staff, and community health workers, particularly regarding health needs, priority setting, and the planning of interventions [20]. However, 79% of this study’s participants strongly disagreed that disease trends are discussed with community leaders as prescribed in PHC. Ideally, profiles of the poorest communities should be developed, and quarterly interventions should be held in informal settlements. Nevertheless, this is not happening, as indicated by 50% of the study’s participants. Research on PHC team training confirms that postgraduate courses and diplomas supporting PHC team development should be identified and made available [21]. Community Leadership Factors According to the WHO 1978 Alma Ata Declaration [22], it is incumbent on governments to develop strategies and action plans to establish and sustain primary health care as an integral component of a national health system, coordinated with efforts across other sectors. Furthermore, 43% of the study’s participants disagreed that health risks are discussed with community leaders. Furthermore, 93% disagreed that health committees are active in problem-solving. This situation violates global health standards, which call for community participation in planning health programs [22]. Legislative Compliance In total, 57% strongly disagreed that health committees serve as a communication tool within the communities, while 43% disagreed that ward councilors serve on their health committees. For communities to strengthen their self-determination regarding health, PHC ideology is built on a community-centered health approach [6]. The poorest communities live in informal settlements; therefore, community profiles and quarterly interventions are essential. However, the Likert-scale survey revealed disengagement between community members and clinic management teams. Clinic health program performance is not discussed in health committee meetings, which violates the Western Cape Health Facilities Boards and Committees Act [2]. Additionally, staff reported that they are unfamiliar with their ward councilors, who are supposed to serve on the committee. The dysfunctionality of certain health committees is therefore harmful to effective PHC service delivery, as prescribed in PHC policy. Presentation of Qualitative Results The quantitative results revealed four variances related to healthcare legislation and three variances related to healthcare literature, which were used to formulate seven open-ended, semi-structured interview questions for the qualitative phase. These interviews were audio-recorded to ensure accuracy and depth of analysis. Of the seven questions, the following four were identified as the most pertinent, each leading to the emergence of a corresponding theme: Question 1: A large percentage of staff do not know their ward councilors and community structures. Why do you think so? Participants 1, 2, 6, and 9 noted that clinic staff often view community leaders as merely providing guidance, rather than as partners serving the community. They also observed that staff may be unfamiliar with political structures in their own areas, and they suggested that the City of Cape Town should introduce its political structures to clinic staff through formal introductions and forums. Question 2: Many indicated that health interventions in informal settlements are seldom implemented. Can you explain? Participants 1, 2, 3, and 4 explained that there is a lack of infrastructure in informal settlements, particularly regarding lighting, roads, and safety. Planning with community leaders is essential to enhance staff safety and reduce the risk of equipment theft. Question 3: How are the health matters of the poorest of the poor addressed? What can be done to improve this area? Participants 2, 3, and 7 noted that significant housing developments have occurred in both recent and earlier years. However, they emphasized the urgent need for day hospitals and 24-hour clinic services to meet growing demand. Participants highlighted that the poorest residents remain underserved in terms of access to health and wellness services. Existing clinics are often located beyond walking distance and outside public transport routes, placing additional financial burdens on patients. Furthermore, public safety concerns were raised, with reports that patients are sometimes mugged while traveling to clinics. Question 4: As leaders, do you have significant knowledge about social conditions in your ward? Elaborate how to address this in a collective manner with clinics? Participants 4 and 7 observed that many senior citizens in their area spend up to 50% of their income on utility bills, leaving them with insufficient funds for adequate nutrition and transportation to access health services. They also emphasized the need to address the safety of community health workers (CHWs), particularly when they operate in high-risk areas. Discussion Planning Model for Health and Well-Being (MHWB) This study proposes a MHWB to fit the South African context. The MHWB is a pro-poor, evidence-based roadmap implemented on epidemiological principles by addressing health determinants rather than merely providing health care [23]. The three main objectives of the MHWB are community vitality and belonging, health equity and social justice, and the highest quality people-centered health and well-being. A notable feature of the model is its focus on the poorest communities in the South African context, particularly within informal settlements [20]. This MHWB (Figure 2) can be used by policymakers, environmental health practitioners, social workers, and clinic managers as a planning tool to enhance primary health care services in the selected Cape Metropolitan subdistrict. >>>add Fig 2. here<< Each of the eight components of the MHWB is elaborated on below. A. Community Governed: Community governance is based on epidemiology and aims to understand the health problem and who it affects [23]. The model uses a range of tools to engage communities, tools that were not reflected among this study’s participants. B. Based on Determinants of Health : The social determinants outlined in this study’s results are key to supporting community health and well-being. C. Grounded in a Community Development Approach : Community development training should be considered for healthcare staff to maximize their performance outcomes. D. Anti-Oppression and Cultural Safety : This “includes the adoption of a set of non-discriminatory behaviours” [24]. Study participants expressed concerns about the breakdown in relationships with clinics, describing it as an attitude of “them and us”. Therefore, a community-centered approach, aligned with existing Batho Pele (meaning “People First”) principles, should be reinforced. E. Equitable Access : Due to various unresolved issues, many communities continue to face unjust barriers to accessing healthcare. F. Population Needs-Based : Community leaders, taxi associations, law enforcement, and civil society organizations, among others, need to be prioritized by the health sector. G. Accountable and Efficient : Clinics must be accountable to their communities for meeting service performance standards, with clear leadership structures in place. H. Interprofessional, Integrated, and Coordinated : A whole-of-government and whole-of-society approach is needed to address health disparities; therefore, a diverse health professional team is expected when conducting community health interventions. Recommendations In addition to the proposed MHWB, four determinants of health were identified that affect the trajectory of health services. These determinants are incorporated within the model’s components. Therefore, the following recommendations are made: Access : To improve access, PHC clinics should actively engage key sectors , including taxi associations, community safety forums, ward committees, and civil society organizations , whose absence currently hinders accessibility. This can be achieved through initiatives such as clinic open days and comprehensive community profiling across the 12 communities, ensuring the equitable distribution and delivery of PHC services . Governance : Health services should be reorganized to expand PHC clinic offerings by prioritizing extended operating hours, improved chronic care services, better public transport access, and enhanced public safety measures, as highlighted by community leadership. Additionally, service planning must proactively address the rising demand driven by rapid housing developments in the area . Planning : Clinic managers should develop and implement systematic PHC program plans in direct collaboration with community representatives, ensuring that planning addresses both legislative standards and local needs. This includes jointly developing safety protocols with community leaders to protect staff and clinical equipment when working in informal settlements . Reorganization of Health Services : Health services should be reorganized to expand PHC clinic offerings, prioritizing extended operating hours, enhanced chronic care services, improved public transport access, and strengthened public safety measures, as identified by community leadership. Additionally, planning must account for the increased demand created by rapid housing developments in the area . Conclusion This study reveals significant gaps between PHC clinic operations and community needs in South Africa’s Eastern subdistrict. Through a mixed methods analysis, key issues were identified in legislative compliance, accessibility, and participatory governance. The Planning MHWB offers a structured, evidence-based framework for reorienting PHC toward a more inclusive, community-centered approach. While the findings are context-specific, they have broader implications for strengthening PHC in similar urban-poor settings. Further research is needed to evaluate the implementation and sustainability of the adapted model across diverse communities. References Abrahams GL, Thani XC, Kahn SB. South African public primary healthcare services and challenge. AP. 2022;30(2):73–74. Western Cape Provincial Parliament Western Cape Health Facility Boards and Committees Act, 2016 (Act No. 4 of 2016). Provincial Gazette No. 7648. July 5, 2016. City of Cape Town. City Health Department, Eastern Sub District. Plan Do Review 2023/2024. Parliamentary Monitoring Group. City of Cape Town & Department of Health collaboration; District Health Plan. 2018. https://pmg.org.za/committee-meeting/26452/. Accessed July 2024. Theron M. TB prevalence survey report – first in South Africa [email]. 2021 June 09. [cited 2025 May 8]. Alperstein M. Primary health care: health for all. In: Coetzee D, editor. Primary health care: fresh perspective. 2nd ed. Cape Town: Juta; 2018. pp. 14–32. World Health Organization, United Nations Children’s Fund. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. 2022. https://www.who.int/publications/i/item/9789240044210. Accessed 7 Apr 2025. Institute of Directors in Southern Africa. King IV Report. 2016. https://www.proethics.co.za/wp-content/uploads/2016/11/Ethics-first-in-King-IVFINAL.pdf. Accessed 2 May 2024. Republic of South Africa. 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Los Angeles: Sage Publications; 2018. Nieuwenhuis J. Qualitative research design and data gathering techniques. In: Maree K, Creswell JW, Ebersohn I, Eloff R, Ferreira R, Ivankova NV, Jansen JD, Pietersen J, Plano Clark VL, editors. First steps in research . 3rd ed. Pretoria, South Africa: Van Schaik Publishers; 2019. Ivankova NV, Creswell JW, Plano Clark VL. Foundations and approaches to mixed methods research. In: Maree K, Ebersohn I, Eloff R, Ferreira NV, Jansen JD, Pietersen J, editors. First steps in research . 3rd ed. Hatfield, Pretoria, South Africa: Van Schaik Publishers; 2019. Maree K, Pietersen J. Qualitative research designs and data gathering techniques. In: Ebersohn I, Eloff R, Ferreira NV, Jansen JD, editors. First steps in research . 3rd ed. Hatfield, Pretoria, South Africa: Van Schaik Publishers; 2019. Mash R, Goliath C, Mahomed H, Reid S, Hellenberg D, Perez G. A framework for implementation of community-oriented primary care in the Metro Health Services, Cape Town, South Africa. Afr J Prim Health Care Fam Med . 2020;12(1):1-5. World Health Organization (WHO). Declaration of Alma-Ata. 1978. https://www.who.int/publications/i/item/WHO-EURO-1978-3938-43697-61471 Accessed 6 Apr 2025. Rayner J, Muldoon L, Bayoumi I, McMurchy D, Mulligan K, Tharao W. Delivering primary health care as envisioned: a model of health and wellbeing guiding community-governed primary care organizations. J Integr Care . 2018;26(3). Human I, Wray R. Toronto Public Health. Health inequalities and racialized groups: a review of the evidence . Toronto: Toronto Public Health; 2013. Table Table 1 is available in the Supplementary Files section. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6635609","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":464631183,"identity":"7edfa301-24ad-4d87-89f7-3f5a9a8e3416","order_by":0,"name":"Stanley Andrew Sayers","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDElEQVRIie3RsWrDMBCAYQkRexE443lpt84ygZIhkFepMXhy2i04U9VFXZLdj+G8gYyGLiJzTTukBDq1U5cYTIhCvLUWZOugHzR+nE5CyOX6hwWEVFvID9Tzl7fQtOqRE7Ile9ZPwmeRsLGWVwHdzMOVUBT5giHI+wnT+gYWQo7C4uFnNDgRqocItOVmrxmCWrzHZf293uETgQyhSPQLXMxkVGw+4/JtVircdiS2EAL3dwnMSUd4RyoL8SBjqvUMqTU7k+svhJ8O/YRSHXEQyqxPmRqcpwwJtkwBXyTmfVLzyBmrVjylHqRmnIVMFXnZQz4xX6mZbPiEBpB87BoL+WM7c+QlwOVyuVy/OwKFGF6yj7sw1AAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0006-4523-4953","institution":"Cape Peninsula University of Technology Faculty of Business and Management Sciences","correspondingAuthor":true,"prefix":"","firstName":"Stanley","middleName":"Andrew","lastName":"Sayers","suffix":""},{"id":464631184,"identity":"ee0ceaf9-9026-4a53-ad81-38440a7f226c","order_by":1,"name":"Leslie Siegelaar","email":"","orcid":"","institution":"Cape Peninsula University of Technology Faculty of Business and Management Sciences","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"","lastName":"Siegelaar","suffix":""},{"id":464631185,"identity":"c7345583-0003-4429-a35b-be428d30814b","order_by":2,"name":"S Cronje","email":"","orcid":"","institution":"Cape Peninsula University of Technology Faculty of Business and Management Sciences","correspondingAuthor":false,"prefix":"","firstName":"S","middleName":"","lastName":"Cronje","suffix":""}],"badges":[],"createdAt":"2025-05-10 15:16:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6635609/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6635609/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84270045,"identity":"c22a87b9-5e5c-424f-a060-baa2e299bdf6","added_by":"auto","created_at":"2025-06-10 03:51:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":61186,"visible":true,"origin":"","legend":"\u003cp\u003eMixed Planning Theory Conceptual Framework\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6635609/v1/3f9c947e0ca8e0551c82ac93.png"},{"id":84270047,"identity":"1b37ce72-cc27-4be5-b0b2-8e54c2584802","added_by":"auto","created_at":"2025-06-10 03:51:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":609186,"visible":true,"origin":"","legend":"\u003cp\u003ePlanning Model for Health and Well-Being (MHWB) (adapted from Rayner et al.) [23]\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6635609/v1/cb997317eba9a0c6036000fd.png"},{"id":84270736,"identity":"1f15492b-2d31-4aba-8b9e-e192a58f6281","added_by":"auto","created_at":"2025-06-10 04:07:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1602067,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6635609/v1/cc9d007b-7703-4bfa-8663-fcee6e6840ea.pdf"},{"id":84270044,"identity":"46540e33-88fa-4dc0-8e48-d7ab960d1bfd","added_by":"auto","created_at":"2025-06-10 03:51:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28044,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6635609/v1/9586135b9fbc84e5215099a6.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eA Health and Well-Being Planning Model for Enhancing Primary Health Care Services in a Selected Cape Metropolitan Subdistrict\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAccess to primary health care (PHC) clinic services remains a critical challenge in many settings, particularly for poor and disadvantaged communities. Barriers to healthcare are both significant and multifaceted [1], with one of the primary concerns being the financial burden associated with travelling outside one\u0026rsquo;s residential area to access health services, especially when certain essential health service packages are unavailable at local PHC clinics. These systemic complexities in service delivery have a harmful impact on poor, disadvantaged communities, as they isolate them from accessing basic and quality healthcare. Such barriers not only hinder equitable healthcare access but also contribute to the continued marginalization of vulnerable populations [1].\u003c/p\u003e\n\u003cp\u003eIn response to these challenges, legislative frameworks mandate the establishment of health committees by civil society and community leaders. These committees are responsible for addressing a range of complex issues, including the development and oversight of quality improvement plans for underperforming PHC program indicators. According to Section 12 of the Western Cape Health Facilities Boards and Committees Act [2], these committees are also tasked with advocating for community health needs and managing complaints, thus serving as a crucial interface between communities and the health system [2]. This study aims to identify the underlying causes of legislative non-compliance, propose a planning intervention, and validate its potential to address the challenges.\u003c/p\u003e"},{"header":"Literature Review","content":"\u003cp\u003eThe 2023/2024 Plan-Do-Review (PDR) cycle for PHC clinics [3] has come under criticism due to substandard performance. Notably, several clinics in the Cape Town Metropolitan Municipality failed to meet the target of 47 prenatal visits per month, starting in July 2023 (see Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u0026gt;add Table 1 here\u0026lt;\u0026lt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis underperformance \u0026ndash; highlighted in red \u0026ndash; persisted over the remaining eleven months of the financial year, ending in June 2024, resulting in a cumulative shortfall [3]. Table 1 shows that while the monthly target is clearly set at 47 visits, this benchmark is rarely met. For example, Fagan Street Clinic began the reporting period with zero bookings for pregnancies under 14 weeks, a figure that remained marked in red.\u003c/p\u003e\n\u003cp\u003eAdditionally, the City Health Department has reported a lack of structured engagement between civil society and government in addressing the disease burden across the twelve communities. This absence of deliberation contradicts both the principle of \u0026ldquo;full participation\u0026rdquo; as outlined in the PHC framework and the legislative requirement that community members actively participate in identifying health problems and formulating appropriate responses [2]. Data extraction plays a critical role in delivering PHC services across the 12 clinics in the Eastern subdistrict. However, this information is not being effectively utilized to monitor and manage priority disease trends in certain communities. While clinic staff routinely collect and analyze health statistics \u0026ndash; vital for assessing PHC performance, identifying at-risk populations, informing program planning, and evaluating outcomes \u0026ndash; these efforts often lack alignment with broader community needs. To ensure responsive and contextually relevant service delivery, community representatives should be actively involved in the planning and development of PHC programs [4].\u003c/p\u003e\n\u003cp\u003eIn 2018, a National Tuberculosis survey [5] revealed that 66% of 15- to 24-year-olds did not seek care due to distance from health facilities or work commitments. Men had a 1.6 times higher prevalence of tuberculosis than women. This disparity affects clinic indicators that measure health outcomes and the effectiveness of health services. Inadequate governance has impacted clinic performance standards in child, women, and youth health across the 2020/2021, 2022/2023, and 2023/2024 financial years [3]. The aim of this paper is to identify the causes of legislative noncompliance and to propose and validate a planning intervention to address the situation.\u003c/p\u003e\n\u003cp\u003eThe Eastern subdistrict, which accounts for 12.75% of Cape Town\u0026rsquo;s population \u0026ndash; an estimated 608,690 residents \u0026ndash; relies on services from 12 municipal clinics due to widespread lack of health insurance. These clinics provide essential services, including HIV prevention, immunization, and child health care [4]. This situation continues to undermine the delivery of medical services in underdeveloped communities, with harmful effects on overall community health. While various models in the literature offer guidelines applicable to other contexts, there is limited knowledge about the specific components of these models as adapted to underdeveloped healthcare settings in South Africa. This gap informs the central research question of the study: What are the key components of a community-informed model for health and well-being?\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Health for All\u0026rdquo; is a core principle underpinning PHC [6]; however, many communities in the Eastern subdistrict remain deprived of this fundamental right due to various social determinants of health [5]. These include issues such as inadequate patient safety, limited access to clinics not located near public transportation routes, and a lack of effective nonverbal communication structures between the community and healthcare providers. Likewise, the World Health Organization (WHO) advocates for a whole-of-society and whole-of-government approach, emphasizing community empowerment and the provision of integrated services as critical strategies to address these barriers and promote equitable health outcomes [6]. As the first level of contact with the national health system, PHC plays a critical role in promoting self-reliance and self-determination in health [6]. Governance in this context entails decision-making, ensuring effective implementation, and exercising authority in relation to ongoing learning and the evolution of institutions within society [7]. Complementing this, the King IV Report underscores the role of an organization\u0026rsquo;s board or committee as the cornerstone of governance, particularly in the public health sector [8]. It calls for transparency in governance practices, including appointments, terms of office, and structural design, and promotes a balanced composition in terms of skills, experience, and independence.\u003c/p\u003e\n\u003cp\u003eThe South African Constitution [9] guarantees that persons who suffer a sudden catastrophe can access medical care or ambulance service and must not be turned away from a clinic or hospital capable of providing the necessary treatment. It also requires municipalities to facilitate community participation in local governance processes [10]. Accessibility is a foundational principle in implementing PHC, with services meant to be available to all, especially disadvantaged populations and those living in rural areas. PHC services should be geographically accessible, cost-effective, and functionally available, and they should ideally be delivered in the language of the local community to ensure effective communication and inclusivity [11].\u003c/p\u003e\n\u003cp\u003eNational legislation promotes the establishment of community-based governance structures at various levels of the health system, aiming to normalize community participation at both municipal and district levels [12]. These structures \u0026ndash; including district health councils, hospital boards, and clinic committees \u0026ndash; serve as mechanisms for public involvement in health governance. However, the formation of clinic committees specifically requires enabling provincial legislation to formalize and support their establishment and functioning [12].\u003c/p\u003e\n\u003cp\u003ePlanning theories are crucial for providing systemic guidance to PHC clinics, despite significant capital investment and operational costs. They help establish a structured knowledge system, define boundaries and parameters for each subject area, and mitigate financial risks, especially in developing countries with limited resources [13].\u003c/p\u003e\n\u003cp\u003eRational planning is a key decision-making framework that involves identifying problems, setting goals, evaluating alternatives, and making choices based on merit and strategic alignment. However, in practice, decision-makers often face constraints such as limited time and resources, which hinder their ability to gather and analyze comprehensive information. While advancements in computing technologies have enhanced data processing and analysis, they still fall short of fully meeting the computational demands of rationalist models. Rational decision-making begins with the identification of a problem \u0026ndash; a critical task in public management, where public managers are responsible for detecting anomalies and initiating appropriate corrective action [13].\u003c/p\u003e\n\u003cp\u003eA thorough problem-identification process is essential for implementing effective corrective measures. This process involves generating, analyzing, and selecting the most appropriate course of action \u0026ndash; decisions inevitably shaped by the values and perspectives of individual decision-makers [13]. The inherent complexity and subjectivity of rational decision-making highlight the importance of public managers being critically aware of both their own value systems and those of relevant stakeholders. Operating within an open system of interrelated variables, decision-makers often find that the ideal of rational planning is difficult to achieve in practice. Constraints such as frustration, resource limitations, and the absence of a clear guiding framework render purely rational approaches unrealistic and impractical. Rational planning theory faces limitations due to its reliance on group-based decision-making, the need for highly precise assessments, and the lengthy process often required to clearly define complex problems [13].\u003c/p\u003e\n\u003cp\u003eIncremental planning theory, a widely recognized alternative to the rational planning approach, addresses several of the limitations associated with comprehensive planning, particularly in contexts characterized by time constraints and limited resources. This theory emphasizes the role of stakeholder interests and available information in policymaking, making it especially relevant in health planning settings [13]. Incrementalism focuses on small, step-by-step changes to address immediate concerns, often at the expense of long-term strategic planning. It is not a comprehensive approach and frequently relies on value judgments due to insufficient or incomplete data.\u003c/p\u003e\n\u003cp\u003eIn the context of the Health Planning Cycle, incremental planning theory tends to prioritize temporary objectives and short-term resource assessments. While prioritization of needs is emphasized, monitoring and evaluation processes are often neglected. Key limitations of this approach include its tendency to focus on existing practices and current problems and to address immediate needs rather than long-term systemic challenges. As a result, implementation is rarely accompanied by robust monitoring mechanisms to assess the effectiveness of the planning approach [13].\u003c/p\u003e\n\u003cp\u003eThe \u003cem\u003ehigher-order\u003c/em\u003e refers to overarching frameworks such as the Health Facilities Act, while the \u003cem\u003elower-order\u003c/em\u003e pertains to the implementation of PHC services and alignment with community values [13]. Grounded in Etzioni\u0026rsquo;s planning philosophy, \u003cem\u003emixed planning theory\u003c/em\u003e integrates high-level strategic decisions with lower-level incremental actions, enabling both the preparation and refinement of broader decisions through engagement at the community level [14]. \u003cem\u003eMixed scanning\u003c/em\u003e is a decision-making method that allocates resources across different levels of analysis and evaluates situations by adjusting the breadth and depth of focus. Drawing on the metaphor of satellites equipped with both wide-angle and zoom lenses, it allows for a combination of broad, general scanning and detailed, focused analysis \u0026ndash; offering a flexible alternative to rigid, simultaneous examination of all variables [13]. In the context of decision-making, \u003cem\u003emixed scanning\u003c/em\u003e enables the selection of a major strategy and a corresponding sub-strategy, followed by an in-depth examination of specific options within the sub-strategy. In relation to health planning, the mixed scanning theory involves several key steps [13]:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eIntroduction of the Scanning Process:\u003c/strong\u003e This initial step involves a continuous review aimed at identifying and anticipating major issues, thereby providing a comprehensive overview of the current state and future direction of health service development.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSelection Procedure:\u003c/strong\u003e In this stage, the fundamental issues identified during the scanning process are sorted and prioritized for further analysis and detailed planning.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDetailed Planning:\u003c/strong\u003e The final step focuses on incremental planning, targeting a relatively small subset of prioritized issues identified in the earlier stages.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eInformation plays a pivotal role in public health assessment, influencing it in three critical ways. First, PHC clinics rely heavily on surveillance data to monitor community health status and trends, as well as to detect emerging health risks. This continuous monitoring enables timely interventions and the mitigation of potential public health crises [15].\u003c/p\u003e\n\u003cp\u003eIdentifying health needs and problems requires a thorough understanding of community resources and the effectiveness of existing interventions. Such understanding allows public health agencies to allocate their efforts more efficiently and strategically. Communication is also vital in addressing health needs, as it ensures that information is tailored to meet the needs of various stakeholders, thereby enhancing the impact and effectiveness of public health initiatives [16].\u003c/p\u003e\n\u003cp\u003eFigure 1 presents a conceptual framework derived from the insights of various authors on mixed planning theory, with an emphasis on Etzioni\u0026rsquo;s perspective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u0026gt;add Fig 1. here\u0026lt;\u0026lt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Western Cape Health Facility Boards and Committees Act [2] outlines three interconnected phases: science, co-governance, and performance. The science phase presents disease trends from PHC clinics; the co-governance phase highlights the participatory role of health committees; and the performance phase emphasizes outcomes, timelines, and systematic review [2].\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003eResearch Design\u003c/h2\u003e\n\u003cp\u003eThis study adopted a mixed methods approach, grounded in pragmatic research philosophy, which holds that combining quantitative and qualitative data provides a more comprehensive understanding of a research problem than either approach alone [17]. The strategy selected for this research was a case study involving the 12 municipal clinics in the Eastern subdistrict of the Cape Metropole\u0026rsquo;s City Health Department. A defining feature of case study research is its researcher-centered focus, often involving direct observation of participants to generate a holistic understanding of the setting [17].\u003c/p\u003e\n\u003ch2\u003eData Collection\u003c/h2\u003e\n\u003cp\u003eThis study employed both quantitative and qualitative methods to obtain a comprehensive understanding of community participation and governance in PHC service delivery within the Eastern subdistrict of the Cape Metropole [17]. The quantitative method involved formulating literature-based statements and administering these statements as a quantitative survey to capture general attitudes. The qualitative method involved conducting interviews to explore individual perspectives in greater depth [18].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQuantitative Data Collection\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe quantitative component targeted the entire population of clinic management staff across the 12 municipal clinics in the subdistrict, covering the areas from Kuils River to the Strand and Gordon\u0026rsquo;s Bay. All six clinic managers and eight senior professional nurses participated, resulting in a total sample of 14 participants. Data were collected using a Likert-scale questionnaire, which included six biographical items and 52 statements derived from the literature on public administration, public health, and community participation. The analysis identified seven key areas of concern, which were subsequently explored during the qualitative phase.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQualitative Data Collection\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThe qualitative sample consisted of 15 ward committee members from the Cape Metropole, purposively selected based on their demonstrated leadership roles within their communities. Participants represented key sectors, including education, faith-based organizations, safety and security, women, vulnerable groups, and youth within the geographic areas served by the 12 municipal clinics.\u003c/p\u003e\n\u003cp\u003eThe purpose of this sampling strategy was to gain insight into levels of political commitment and active community involvement in accordance with legislative structures and governance responsibilities. Data were collected through open-ended, semi-structured interviews guided by a seven-question interview schedule. With participants\u0026rsquo; consent, the interviews were audio-recorded and transcribed verbatim for further analysis [19].\u003c/p\u003e\n\u003ch2\u003eData Analysis\u003c/h2\u003e\n\u003cp\u003eQuantitative data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27, with support from a statistician at the Cape Peninsula University of Technology (CPUT). For the qualitative data, thematic analysis was used to identify recurring themes, patterns, and insights emerging from the transcribed interviews [17].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBoth quantitative and qualitative data were analyzed. The quantitative findings are summarized first, followed by the qualitative findings derived through thematic analysis.\u003c/p\u003e\n\u003ch2\u003eQuantitative Findings\u003c/h2\u003e\n\u003cp\u003eThe objective of the Likert-scale survey was to assess management\u0026rsquo;s level of legislative compliance, the quality of the relationship between clinic management and community leadership, and the degree of commitment to service delivery. The quantitative results are presented as four factors, all pointing to noncompliance in clinic governance among the clinics and communities that participated in the study.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eBiographic Factors\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAll 14 participants held at least a four-year nursing diploma and had an average of 15 years of professional work experience in the healthcare sector. While this indicates they are specialists in the nursing field, they lack sufficient training in community engagement and relations.\u003c/p\u003e\n\u003ch2\u003eCommunity Factors\u003c/h2\u003e\n\u003cp\u003eThe literature highlights that dialogue is needed between community members, local managers, clinic staff, and community health workers, particularly regarding health needs, priority setting, and the planning of interventions [20]. However, 79% of this study\u0026rsquo;s participants strongly disagreed that disease trends are discussed with community leaders as prescribed in PHC. Ideally, profiles of the poorest communities should be developed, and quarterly interventions should be held in informal settlements. Nevertheless, this is not happening, as indicated by 50% of the study\u0026rsquo;s participants. Research on PHC team training confirms that postgraduate courses and diplomas supporting PHC team development should be identified and made available [21].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eCommunity Leadership Factors\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAccording to the WHO 1978 Alma Ata Declaration [22], it is incumbent on governments to develop strategies and action plans to establish and sustain primary health care as an integral component of a national health system, coordinated with efforts across other sectors. Furthermore, 43% of the study\u0026rsquo;s participants disagreed that health risks are discussed with community leaders. Furthermore, 93% disagreed that health committees are active in problem-solving. This situation violates global health standards, which call for community participation in planning health programs [22].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eLegislative Compliance\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eIn total, 57% strongly disagreed that health committees serve as a communication tool within the communities, while 43% disagreed that ward councilors serve on their health committees. For communities to strengthen their self-determination regarding health, PHC ideology is built on a community-centered health approach [6]. The poorest communities live in informal settlements; therefore, community profiles and quarterly interventions are essential. However, the Likert-scale survey revealed disengagement between community members and clinic management teams. Clinic health program performance is not discussed in health committee meetings, which violates the Western Cape Health Facilities Boards and Committees Act [2]. Additionally, staff reported that they are unfamiliar with their ward councilors, who are supposed to serve on the committee. The dysfunctionality of certain health committees is therefore harmful to effective PHC service delivery, as prescribed in PHC policy.\u003c/p\u003e\n\u003ch2\u003ePresentation of Qualitative Results\u003c/h2\u003e\n\u003cp\u003eThe quantitative results revealed four variances related to healthcare legislation and three variances related to healthcare literature, which were used to formulate seven open-ended, semi-structured interview questions for the qualitative phase. These interviews were audio-recorded to ensure accuracy and depth of analysis. Of the seven questions, the following four were identified as the most pertinent, each leading to the emergence of a corresponding theme:\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQuestion 1: A large percentage of staff do not know their\u0026nbsp;\u003c/em\u003e\u003cem\u003eward councilors and community structures. Why do you think so?\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants 1, 2, 6, and 9 noted that clinic staff often view community leaders as merely providing guidance, rather than as partners serving the community. They also observed that staff may be unfamiliar with political structures in their own areas, and they suggested that the City of Cape Town should introduce its political structures to clinic staff through formal introductions and forums.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQuestion 2: Many indicated that health interventions in informal settlements are seldom implemented. Can you explain?\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants 1, 2, 3, and 4 explained that there is a lack of infrastructure in informal settlements, particularly regarding lighting, roads, and safety. Planning with community leaders is essential to enhance staff safety and reduce the risk of equipment theft.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQuestion 3: How are the health matters of the poorest of the poor addressed? What can be done to improve this area?\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants 2, 3, and 7 noted that significant housing developments have occurred in both recent and earlier years. However, they emphasized the urgent need for day hospitals and 24-hour clinic services to meet growing demand. Participants highlighted that the poorest residents remain underserved in terms of access to health and wellness services. Existing clinics are often located beyond walking distance and outside public transport routes, placing additional financial burdens on patients. Furthermore, public safety concerns were raised, with reports that patients are sometimes mugged while traveling to clinics.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eQuestion 4: As leaders, do you have significant knowledge about social conditions in your ward? Elaborate how to address this in a collective manner with clinics?\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants 4 and 7 observed that many senior citizens in their area spend up to 50% of their income on utility bills, leaving them with insufficient funds for adequate nutrition and transportation to access health services. They also emphasized the need to address the safety of community health workers (CHWs), particularly when they operate in high-risk areas.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003ePlanning Model for Health and Well-Being (MHWB)\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis study proposes a MHWB to fit the South African context. The MHWB is a pro-poor, evidence-based roadmap implemented on epidemiological principles by addressing health determinants rather than merely providing health care [23]. The three main objectives of the MHWB are community vitality and belonging, health equity and social justice, and the highest quality people-centered health and well-being. A notable feature of the model is its focus on the poorest communities in the South African context, particularly within informal settlements [20]. This MHWB (Figure 2) can be used by policymakers, environmental health practitioners, social workers, and clinic managers as a planning tool to enhance primary health care services in the selected Cape Metropolitan subdistrict.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026gt;\u0026gt;\u0026gt;add Fig 2. here\u0026lt;\u0026lt;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach of the eight components of the MHWB is elaborated on below.\u003c/p\u003e\n\u003cp\u003eA. \u003cstrong\u003eCommunity Governed:\u003c/strong\u003e Community governance is based on epidemiology and aims to understand the health problem and who it affects [23]. The model uses a range of tools to engage communities, tools that were not reflected among this study\u0026rsquo;s participants.\u003c/p\u003e\n\u003cp\u003eB. \u003cstrong\u003eBased on Determinants of Health\u003c/strong\u003e: The social determinants outlined in this study\u0026rsquo;s results are key to supporting community health and well-being.\u003c/p\u003e\n\u003cp\u003eC. \u003cstrong\u003eGrounded in a Community Development Approach\u003c/strong\u003e: Community development training should be considered for healthcare staff to maximize their performance outcomes.\u003c/p\u003e\n\u003cp\u003eD. \u003cstrong\u003eAnti-Oppression and Cultural Safety\u003c/strong\u003e: This \u0026ldquo;includes the adoption of a set of non-discriminatory behaviours\u0026rdquo; [24]. Study participants expressed concerns about the breakdown in relationships with clinics, describing it as an attitude of \u0026ldquo;them and us\u0026rdquo;. Therefore, a community-centered approach, aligned with existing Batho Pele (meaning \u0026ldquo;People First\u0026rdquo;) principles, should be reinforced.\u003c/p\u003e\n\u003cp\u003eE. \u003cstrong\u003eEquitable Access\u003c/strong\u003e: Due to various unresolved issues, many communities continue to face unjust barriers to accessing healthcare.\u003c/p\u003e\n\u003cp\u003eF. \u003cstrong\u003ePopulation Needs-Based\u003c/strong\u003e: Community leaders, taxi associations, law enforcement, and civil society organizations, among others, need to be prioritized by the health sector.\u003c/p\u003e\n\u003cp\u003eG. \u003cstrong\u003eAccountable and Efficient\u003c/strong\u003e: Clinics must be accountable to their communities for meeting service performance standards, with clear leadership structures in place.\u003c/p\u003e\n\u003cp\u003eH. \u003cstrong\u003eInterprofessional, Integrated, and Coordinated\u003c/strong\u003e: A whole-of-government and whole-of-society approach is needed to address health disparities; therefore, a diverse health professional team is expected when conducting community health interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn addition to the proposed MHWB, four determinants of health were identified that affect the trajectory of health services. These determinants are incorporated within the model\u0026rsquo;s components. Therefore, the following recommendations are made:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAccess\u003c/strong\u003e: To improve access, PHC clinics should actively engage key sectors\u003cem\u003e,\u003c/em\u003e including taxi associations, community safety forums, ward committees, and civil society organizations\u003cem\u003e,\u003c/em\u003e whose absence currently hinders accessibility. This can be achieved through initiatives such as clinic open days and comprehensive community profiling across the 12 communities, ensuring the equitable distribution and delivery of PHC services\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGovernance\u003c/strong\u003e: Health services should be reorganized to expand PHC clinic offerings by prioritizing extended operating hours, improved chronic care services, better public transport access, and enhanced public safety measures, as highlighted by community leadership. Additionally, service planning must proactively address the rising demand driven by rapid housing developments in the area\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePlanning\u003c/strong\u003e: Clinic managers should develop and implement systematic PHC program plans in direct collaboration with community representatives, ensuring that planning addresses both legislative standards and local needs. This includes jointly developing safety protocols with community leaders to protect staff and clinical equipment when working in informal settlements\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReorganization of Health Services\u003c/strong\u003e: Health services should be reorganized to expand PHC clinic offerings, prioritizing extended operating hours, enhanced chronic care services, improved public transport access, and strengthened public safety measures, as identified by community leadership. Additionally, planning must account for the increased demand created by rapid housing developments in the area\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study reveals significant gaps between PHC clinic operations and community needs in South Africa\u0026rsquo;s Eastern subdistrict. Through a mixed methods analysis, key issues were identified in legislative compliance, accessibility, and participatory governance. The Planning MHWB offers a structured, evidence-based framework for reorienting PHC toward a more inclusive, community-centered approach. While the findings are context-specific, they have broader implications for strengthening PHC in similar urban-poor settings. Further research is needed to evaluate the implementation and sustainability of the adapted model across diverse communities.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbrahams GL, Thani XC, Kahn SB. South African public primary healthcare services and challenge. \u003cem\u003eAP.\u003c/em\u003e 2022;30(2):73\u0026ndash;74.\u003c/li\u003e\n \u003cli\u003eWestern Cape Provincial Parliament Western Cape Health Facility Boards and Committees Act, 2016 (Act No. 4 of 2016). Provincial Gazette No. 7648. July 5, 2016. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCity of Cape Town. City Health Department, Eastern Sub District. Plan Do Review 2023/2024.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eParliamentary Monitoring Group. City of Cape Town \u0026amp; Department of Health collaboration; District Health Plan. 2018. https://pmg.org.za/committee-meeting/26452/. Accessed July 2024.\u003c/li\u003e\n \u003cli\u003eTheron M. TB prevalence survey report \u0026ndash; first in South Africa [email]. 2021 June 09. [cited 2025 May 8].\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAlperstein M. Primary health care: health for all. In: Coetzee D, editor. \u003cem\u003ePrimary health care: fresh perspective.\u003c/em\u003e 2nd ed. Cape Town: Juta; 2018. pp. 14\u0026ndash;32.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization, United Nations Children\u0026rsquo;s Fund. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. 2022. https://www.who.int/publications/i/item/9789240044210. Accessed 7 Apr 2025.\u003c/li\u003e\n \u003cli\u003eInstitute of Directors in Southern Africa. King IV Report. 2016. https://www.proethics.co.za/wp-content/uploads/2016/11/Ethics-first-in-King-IVFINAL.pdf. Accessed 2 May 2024.\u003c/li\u003e\n \u003cli\u003eRepublic of South Africa. Constitution of South Africa Act (No. 108 of 1996). Pretoria: Government Printers; 1996.\u003c/li\u003e\n \u003cli\u003eCity of Cape Town. Local Government: Municipal Systems Act (No. 32 of 2000). Pretoria: Government Printers; 2000.\u003c/li\u003e\n \u003cli\u003eLondon L. \u003cem\u003eUnderstanding health and illness\u003c/em\u003e. Pinelands, Cape Town: Pearson Education and Prentice Hall, South Africa; 2019.\u003c/li\u003e\n \u003cli\u003eRepublic of South Africa. National Health Act (No. 61 of 2003). Pretoria: Government Printers; 2003.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eManaf RA, Juni MH, Mohammad Z, P. Planning theories in primary health care planning. \u003cem\u003eInt J Public Health Clin Sci\u003c/em\u003e. 2018;5(4):12\u0026ndash;28.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEtzioni A. Mixed-scanning: a \u0026ldquo;third\u0026rdquo; approach to decision-making. \u003cem\u003ePublic Adm Rev.\u003c/em\u003e 1967;27(5):385.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTurnock BJ. \u003cem\u003ePublic health: what it is and how it works\u003c/em\u003e. 6th ed. Jones and Bartlett Learning; 2016.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDennill K, Rendall-Mkosi K. \u003cem\u003ePrimary health care in Southern Africa\u003c/em\u003e. 3rd ed. South Africa: Oxford University Press; 2015.\u003c/li\u003e\n \u003cli\u003eCreswell W, Creswell J. \u003cem\u003eResearch design: qualitative, quantitative and mixed methods approaches.\u0026nbsp;\u003c/em\u003e5th ed. Los Angeles: Sage Publications; 2018.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eNieuwenhuis J. Qualitative research design and data gathering techniques. In: Maree K, Creswell JW, Ebersohn I, Eloff R, Ferreira R, Ivankova NV, Jansen JD, Pietersen J, Plano Clark VL, editors. \u003cem\u003eFirst steps in research\u003c/em\u003e. 3rd ed. Pretoria, South Africa: Van Schaik Publishers; 2019.\u003c/li\u003e\n \u003cli\u003eIvankova NV, Creswell JW, Plano Clark VL. Foundations and approaches to mixed methods research. In: Maree K, Ebersohn I, Eloff R, Ferreira NV, Jansen JD, Pietersen J, editors. \u003cem\u003eFirst steps in research\u003c/em\u003e. 3rd ed. Hatfield, Pretoria, South Africa: Van Schaik Publishers; 2019. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMaree K, Pietersen J. Qualitative research designs and data gathering techniques. In: Ebersohn I, Eloff R, Ferreira NV, Jansen JD, editors. \u003cem\u003eFirst steps in research\u003c/em\u003e. 3rd ed. Hatfield, Pretoria, South Africa: Van Schaik Publishers; 2019. \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eMash R, Goliath C, Mahomed H, Reid S, Hellenberg D, Perez G. A framework for implementation of community-oriented primary care in the Metro Health Services, Cape Town, South Africa. \u003cem\u003eAfr J Prim Health Care Fam Med\u003c/em\u003e. 2020;12(1):1-5.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWorld Health Organization (WHO). Declaration of Alma-Ata. 1978. https://www.who.int/publications/i/item/WHO-EURO-1978-3938-43697-61471 Accessed 6 Apr 2025.\u003c/li\u003e\n \u003cli\u003eRayner J, Muldoon L, Bayoumi I, McMurchy D, Mulligan K, Tharao W. Delivering primary health care as envisioned: a model of health and wellbeing guiding community-governed primary care organizations. \u003cem\u003eJ Integr Care\u003c/em\u003e. 2018;26(3).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHuman I, Wray R. \u003cem\u003eToronto Public Health. Health inequalities and racialized groups: a review of the evidence\u003c/em\u003e. Toronto: Toronto Public Health; 2013.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Community Involvement, Eastern subdistrict, Governance, Primary Health Care, Ward Committees, Ward Councilors, Health and well-being","lastPublishedDoi":"10.21203/rs.3.rs-6635609/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6635609/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNon-compliance with legislative provisions has resulted in inadequate Primary Health Care (PHC) services for the Eastern subdistrict community within the Cape Town Metropolitan area. This non-compliance includes governance failures, such as the absence of committee meetings required to oversee the responsibilities outlined in the legislation. The consequences are visible in the prevalence of infectious diseases, limited public access to clinics, and the lack of expansion of health services despite growing population trends. This challenging context forms the backdrop for the study, which aims to identify the underlying causes of legislative non-compliance, propose a planning intervention, and validate its potential to improve the situation. The research population comprises fourteen clinic managers overseeing twelve clinics in the area, alongside fifteen purposively selected ward committee members. The study employs a mixed methods design using an explanatory sequential approach, in which the results of the quantitative survey with clinic managers (conducted through a Likert-scale questionnaire) are further explained and enriched by qualitative findings from open-ended interviews with ward committee members. The analysis ultimately supports the application of a mixed planning approach to develop a model for improving PHC services in this Cape Metropolitan subdistrict.\u003c/p\u003e","manuscriptTitle":"A Health and Well-Being Planning Model for Enhancing Primary Health Care Services in a Selected Cape Metropolitan Subdistrict","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 03:51:14","doi":"10.21203/rs.3.rs-6635609/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d9397bad-7fa5-4551-941a-29fdc3da2dc0","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-06-10T03:51:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 03:51:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6635609","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6635609","identity":"rs-6635609","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}