ABSTRACT:
The prevalence of multiple long-term conditions is rising globally , yet healthcare systems in sub-Saharan Africa remain reactive and vertically organised. The co-designed ENHANCE intervention , incorporating clinical decision support, patient health diaries, and treatment literacy tool (detailing medications, indications and side effects), was developed to bridge these gaps in South African primary health care (PHC). While a randomised controlled trial (RCT) showed that ENHANCE significantly improved a composite primary outcome of treatment intensification, diagnosis and condition control, this did not consistently translate into improved control. This process evaluations aimed to explain these RCT outcomes comparing the effectiveness of the ENHANCE intervention with usual care. This qualitative case study process evaluation was conducted in parallel to the RCT across four Western Cape PHC facilities. Data included facility profiles, semi-structured interviews, focus groups, and ethnographic observations with clinicians, patients and community health workers (CHWs). Using Bronfenbrenner’s ecological systems model, we mapped macro-, meso- and micro-contextual determinants of care, triangulating clinical consultations coding, with stakeholder perspectives. Three levels of contextual determinants shaped implementation: (i) Macro (Structural): Severe time constraints resulting from national staff shortages and high patient-to-staff ratios; (ii) Meso (Systemic): Disrupted continuity between facility-based clinical services and stigmatised community level CHW support; and (iii) Micro (Informational): Poor clinical insight into patients’ personal stressors and challenge of communicating complex, evolving information amidst frequent medication supplier changes due to government split tender processes. These supply shifts result in different packaging and pill appearances 3-4 times annually, creating significant patient confusion. These interacting factors limited the ability of providers to support self-management and adherence. While ENHANCE successfully catalysed treatment intensification, systemic pressures limited its impact on control of index conditions. Health system interventions must move beyond clinical decision support to actively address the macro and meso-level barriers that obstruct continuity and patient self-management .