End-stage kidney disease (ESKD) is a global health and healthcare burden that is rapidly increasing [1]. It is caused by irreversible progressive chronic kidney illness and results in permanent loss of kidney function, resulting in extremely high mortality rates in this population [2]. The increasing number of patients suffering from End-stage renal disease (ESRD) requires dialysis management for enhanced results and well-being; thus, adhering to the recommended treatment is essential [3].

Adherence is a major issue in chronic kidney disease patients [2]. Patients may refuse medications, dialysis, dietary and fluid restrictions, and other facets of their treatment regimen. As a result, healthcare management intervention is required to increase patient adherence to the ESRD treatment regimen. “Healthcare management is responsible for improving patients' health by preventing illness and disease, promoting healthy lifestyles, and consistently improving the healthcare delivery system by focusing on access, equity, efficiency, quality, and sustainability” as indicated in the mission statement of the Department of Health [4].

Effective intervention might be through programmes that are aimed at increasing adherence such as support groups for ESRD patients. Introducing reward incentives to encourage conformity with the treatment schedule and also the formation of a multidisciplinary team to assist in improving the care of ESRD patients [3].

To ensure that the research is founded on the correct context, it is essential to understand the important concepts, namely adherence and compliance and what they intended. It was noticed that in practice and reality, the terms “adherence” and “compliance” are used together and synonymously as if they mean the same thing, but the definitions make it quite clear that they are distinctly separate activities.

Compliance is defined as the degree to which an individual's actual regimen corresponds to that prescribed by a medical professional [5]. The extent to which a person's conduct, such as taking medications, following a diet, and/or making lifestyle changes, equates with stipulated suggestions from a medical professional is termed “adherence” [6, 7]. As a result, the concept of adherence was used in this study because it assesses how well an individual's behavior aligns with healthcare recommendations, which includes actions as well as an indicator [8].

Background of the Study

Chronic kidney disease (CKD) is a universal medical impose including an immense economic problem in a healthcare organisation, as it is a risk contributor to cardiovascular disease (CVD) [9]. CKD is characterised as the development of a deviation in the functioning of the kidneys that persists for a period exceeding three months [10]. 1 or several of the following is involved in the following: "(1) GFR less than 60 mL/min/1.73 m2; (2) albuminuria (i.e., urine albumin 30 mg per 24 hours or urine albumin-to-creatinine ratio (ACR) 30 mg/g); (3) anomalies in urine sediment, histology, or imaging indicative of kidney damage; (4) renal tubular disorders; or (5) history of kidney transplantation.". Chronic kidney disease impacts 8% to 16% of the global population and is a leading cause of death [10].

According to the American Kidney fund (2021), diabetes and hypertension create destruction on the kidney's sorting system, ultimately resulting in CKD. CKD is a rapidly evolving worldwide health challenge, with significant physiological, psychological, and socioeconomic implications for individuals, their families, and their communities [11]. The guidelines from “Kidney Disease Improving Global Outcome (KDIGO)” described the various stages of CKD that progress to renal failure as follows: “… stage 1 there is a normal or high glomerular filtration rate(GFR) that is greater or equal to 90( (ml/min/1.73 m2), in stage 2, the GFR is mildly decreased between 60-89 (ml/min/1.73 m2), in stage 3a, the GFR is said to be mildly to moderately decrease and is equal to 45-59(ml/min/1.73 m2), the stage 3b is characterised by a moderately to severely decreased GFR 30-44(ml/min/1.73 m2), in stage 4, the GFR is severely decreased 15-29(ml/min/1.73 m2), and in stage 5 i.e. renal failure the GFR is less than 15(ml/min/1.73 m2)”. All stages of CKD are associated with an increased risk of cardiovascular complications, premature mortality, and/or decreased quality of life [9].

South Africa faces a significant number of transmissible illnesses, and noncommunicable illnesses [12]. Previous research has estimated that the South African population has an elevated rate of CKD. [13] Found CKD in 6% of teachers in schools, and [14] discovered it in 17% of a geographical group in Cape Town. The South African government's 2030 National Development Plan emphasises disease prevention, but to some extent, CKD is the outcome of a much larger health challenge that South Africa is facing [75].

To enhance access to healthcare, the Health Department hosted a conference in 2015 to discuss the issues raised by CKD in South Africa and proposed solutions [15]. The meeting proposed increasing the kidney dialysis rate from 164 to 250 per million people (PMP) by 2025 [15]. In addition to the strategies that were suggested to reach the desired number was “the use of Private-Public Partnerships” (PPPs) [15]. This partnership was to assist in achieving healthcare quality and increasing access to healthcare. [16] refers to the quality of healthcare as care that is anticipated to maximise the well-being of patients after accounting for a proportion of anticipated benefits and costs associated with the healthcare process in all of its components. One of the Department of Health's strategic goals is to provide quality healthcare services, which will be possible with an adequate supply of financial, material, and human resources.

In a study conducted by [17], they cited that the “public-private dialysis” medical care model (PPP) could offer excellent care, which is especially important given the growing financial burden on public healthcare systems. Patients receiving hemodialysis under a PPP-care model framework got proper care that met the suggested goals for treatment and might benefit when it comes to hospitalisation and mortality results [17]. Limpopo Province takes its name from the Limpopo River. Mozambique, Zimbabwe, and Botswana are its neighbours. It also shares borders with Mpumalanga, Gauteng, and the Northwest provinces (www.sahistory.org.za, n.d.). It is home to a population of 5 951 999. Limpopo has five districts which are Capricorn, Mopani, Sekhukhune, Vhembe, and Waterberg (municipalities.co.za, n.d.).

In Limpopo Province, there was a need for a renal dialysis unit that would be able to cater for the people of Limpopo Province as a whole. Pietersburg Hospital is one of the Capricorn District's major hospitals which started with two beds and eventually had 12 beds to render renal dialysis services. Due to the increasing number of dialysis patients in the province, a structure capable of accommodating the ever-growing numbers was required. Financial limitations and a lack of infrastructure, the Provincial Department of Health collaborated with the private organisation Fresenius Medical Care to provide renal dialysis services in the province. All districts and regional hospitals transfer their patients using the Emergency Medical Services transport to Pietersburg Hospital for renal services.

The Department of Health signed a contract of 10 years with the private party to render renal services in Limpopo Province, Pietersburg Hospital. The contract which was signed for 10 years enabled the Department to render uninterrupted dialysis services to the population of Limpopo at a low cost. The handover of the project back to the public partner in October 2016 became the main issue as the Department of Health was not ready for the takeover. The contract was extended again for three years and eventually, the takeover took place in 2019.

The PPP in Limpopo Pietersburg Hospital contributed immensely to the quality of healthcare as patients received the best care possible through skilled and highly trained nurses. The Department’s takeover of the renal dialysis unit brought with it challenges such as staff shortages, pharmaceutical issues, and environmental cleanliness issues that were not present during the partnership. These are healthcare management (organisational) related problems. Healthcare management must assist and oversee all services offered within the organisation that provides healthcare [18]. Healthcare management has the responsibility to provide leadership, review staffing plans of the renal unit and ensure proper procurement processes.

The researcher has been working in a tertiary hospital and supervising the renal dialysis unit for three years which has 20 beds with four sessions in 24 hours and a total of 139 patients on hemodialysis together with 90 patients on peritoneal dialysis. Patients are expected to attend hemodialysis treatment three times a week without fail. The researcher has noted with concern that patients are missing their dialysis sessions, which was 23% in 2019 with (PPP) and now 32% in 2020 with a public programme. Sometimes, patients arrive late for their dialysis and their dialysis sessions are shortened and they don’t collect their treatments from the pharmacy as prescribed. These also include non-adherence to fluids and diet recommendations from the healthcare practitioners.

Some of these patients, including peritoneal dialysis patients, are admitted to the hospital with infections and stay longer, affecting hospital performance indicators such as average length of stay and average cost per day and rising hospitalisation costs [19]. Therefore, effective preventative care can result in less hospitalisation of renal patients and a reduction of costs.

 Problem Statement

In Limpopo Province’s Tertiary Hospital, not much is known about the role of healthcare management in improving patients’ adherence to ESRD treatment. The majority of the studies were on healthcare management but not specifically on ESRD patients, such as the study on "measuring patients’ satisfaction of service quality in Swedish dental clinics" conducted by [20] and a qualitative study on “Knowledge implementation in healthcare management” by [21], to name a few. In light of this, the researcher was inspired to conduct a study on the function of healthcare management in improving patient adherence to End-Stage Renal Disease.

Research Question

The present study intends to tackle the following research question: “What role can healthcare management play in improving adherence to end-stage renal disease treatment?”

Research Objectives

The following objectives serve as a starting point for this study to achieve the above study goal and to address the study's question:

• To understand and describe the literature on adherence management and explore management-related interventions that can enhance patient adherence.
• To understand the governance role of public health management in terms of the legislative framework that informs public health in South Africa.
• To contextualise, describe and explain the challenge of non-adherence to the treatment regimen of ESRD patients at Pietersburg Hospital.
• To explore the perceptions of healthcare management regarding their role in managing patient adherence and the effectiveness of the existing programmes in ensuring patient adherence.
• To recommend possible ways in which healthcare management and healthcare providers can improve adherence to treatment regimens for ESRD patients at Pietersburg Hospital.

Rationale for the Study

This study aimed to explore how healthcare management can play a role in improving adherence to ESRD treatment regimens among patients in Pietersburg Hospital, in Limpopo Province. These insights can then assist healthcare management in designing interventions to improve patient treatment programmes to improve adherence. This research aim will seek to benefit healthcare management in reducing healthcare costs and enhancing the standard of life of individuals with advanced renal failure.

Significance of the Study

This research's significance stems from the fact that fewer studies have been conducted on the role of healthcare management in improving patient treatment adherence in ESRD patients. As a result, this study attempts to fill some of that gap. The study may also aid healthcare managers in developing context-specific and relevant interventions to improve adherence among ESRD patients. The research outcomes may add to the existing body of knowledge about non-adherence as a behavioural phenomenon.

According to [22], “research study design” refers to a structure, or a collection of techniques and processes utilized to gather and evaluate information regarding factors outlined in a particular investigation's issue. According to [23], “It is a plan or blueprint of how you intend to conduct the research”. Research methodology is characterized as an approach for methodically addressing the issue being studied; thus, it can be viewed as a method of learning how research is carried out to resolve a specific problem [24]. This study used exploratory case study design.

Exploratory research is significant as it can produce new understandings of a topic for research [23] but the shortcoming of the exploratory study is that it rarely provides satisfactory answers to research questions that have to do with representativeness [23]. The researcher used an exploratory case study to discern new developments and ideas to recommend new ways that can be implemented to increase adherence.

Data Collection Methods

Primary empirical data is data that is collected for the first time by the researcher using questionnaires, observations, surveys, and interviews [23]. Non-empirical methods are classified into two types, according to [25]. On the one hand, there are methods for reviewing research progress in a specific field (e.g., systematic literature review, meta-analysis) [25]. Personal observations, reflection on current events, and/or the author's authority or experience, on the other hand, are used in non-empirical methods (e.g., critical studies, editor's introduction) [25].

This study’s primary data was collected through semi-structured interviews with selected healthcare managers and healthcare practitioners (doctors and nurses). Healthcare managers and practitioners were approached individually for the interview after hours to ensure that services were not disrupted. Secondary data is the data already collected or produced by others [23]. In any research, the review of literature is based on secondary data. Other secondary data sources include published text and statistics [26].

Pilot Study

In social science research, the term “pilot study” is used in two different contexts [27]. According to [28], “pilot study” may refer to feasibility studies, which are “small-scale version(s) or trial run(s) done to prepare for the major study” [27]. [29], expands on this definition by stating that a pilot study can also be defined as the pre-testing or “trying out” of a specific research instrument.

Existing literature suggests that a pilot study sample should be 10% of the sample projected for the larger parent study, according to [30]. [31], on the other hand, cautions that this is not a simple or forthright issue to address since these kinds of studies are influenced by a variety of factors. Nonetheless, [32] recommended 10 to 30 partakers for survey research pilots; [33] recommended 10 to 30 partakers for survey research pilots; [34, 35] recommended 12; and [36] recommended 10% of the project sample size.

The “parent” study had a sample size of 35, and the researcher used 10% of the sample size, which is four. The researcher opted for a sample size of five in case one withdraws from participating in the pilot study. The pilot phase of this study was conducted at Pietersburg Hospital. A total of three professional nurses, one healthcare manager and one doctor were interviewed to test the interview tools. The researcher approached potential pilot study subjects separately and in person. Before obtaining permission from the study respondents, the researcher explained the study objectives and clarified any issues that arose during the study. Following the pilot study of the interview tools, the identified problems were discussed with the supervisor, and appropriate corrections were made.

Study Population

According to [28], a “population” is defined as the shared or whole of all the objects, subjects, or participants who adhere to an array of conditions. It is also defined as the set of components that are used when the sample is drawn [23]. The following population was chosen based on the researcher's knowledge that they have relevant knowledge, skills, and experience in one form or another on the topic:

• In this current research, population A was the Healthcare Managers of Limpopo Province's tertiary hospitals for the 2019-2020 year of study, who were selected as the study's population. The researcher compiled a list of (15) healthcare managers who are responsible for planning and managing adherence programmers, have information on the budget of the hospital and are knowledgeable about the information system in the hospital.
• Study population B was (15) professional nurses who were experienced in rendering renal care services and interacted with renal patients daily; and
• Study population C was (5) doctors who were responsible for the care of renal patients and interacted with them daily.

Sampling Frame and Technique

A sampling frame is a collection of real cases wherein a sample is going to be drawn which must be population representative [24]. A list of all Healthcare Managers and Healthcare Professionals (Doctors and Nurses) employed at Pietersburg Hospital during the fiscal year 2019 to 2020 was sought for this study. The Non-probability - Purposive sampling technique was employed to select the sample of study participants. To be precise, the research samples were selected using this technique:

• Sample selection for study populations A, B and C: Non-probability – Purposive sampling was used in selecting participants for interviews where the researcher purposely chose the participants based on their capability to provide the required data. Purposive or judgmental sampling, according to Maxwell [37], is a method through which specific events are chosen on purpose to offer important data that cannot be gathered from other options. The advantage of this method is that it is affordable, suitable, not time-consuming, and perfect for exploratory research design [37]. The disadvantage of the method is that it does not allow generalisation [37]. There is also the possibility of subjectivity and bias, which is a disadvantage of the technique.

Data Analysis

Thematic analysis and Atlas.ti were employed to analyse the primary data from the semi-structured interviews. This approach was employed to methodically discover, organise, and provide an understanding of significant trends in sets of data [38]. This section is discussed in detail in Chapter 4.

End-Stage Renal Disease (ESRD) is a major public health issue that has been linked to an increasing burden on healthcare systems and the global economy [39, 40] defined “adherence” as “the extent to which a person’s attitude matches with the agreed recommendations of a healthcare giver in terms of taking medications, following a recommended diet regimen and/or carrying out lifestyle changes.” Hence, healthcare professionals and management need to implement interventions that increase adherence of patients to ESRD treatment.

In this study health education, support groups and home visits emerged as the important programmes that are available to increase adherence to treatment regimens by renal patients. The low percentages indicated poor knowledge of healthcare practitioners on programmes that are implemented to increase adherence. Training and skills development of healthcare practitioners through continuous and professional tools such as workshops and information sessions can improve the knowledge, quality, efficiency, and effectiveness of the implementation of the available renal disease programmes.

Educational programmes intended for individual patients to increase adherence are important because they promote positive habits. A recent study by [41] discovered substantial improvements in dialysis, medication, diet, and fluid adherence following educational intervention. The previous meta-analyses' findings indicated that educational programmes improved treatment adherence [42, 43].

Support groups play a very important role in ESRD patients' lives according to the respondents because they can discuss their problems and share with other patients their experiences on how they can handle their condition. According to research, group participation and the support that these patients can offer to one another minimises stress and enhances life expectancy, which in turn enhances the quality of life [44-47]. This result is also coherent with the findings of [48], where educational and group support interventions improved the quality of life.

Renal professional nurses and social workers conducting continuous home visits are enabled to assess if home conditions and the environment are conducive for the renal patient and also allow them to observe if the family can support the end-stage renal disease patients. Constant home nursing visits are a type of nursing service with the goal to sustain and enhance the patient's health [49].

The effectiveness of the programmes that are implemented to increase adherence emerged in this study as participants agreed that the programmes are effective. This study has shown that healthcare management does support the implementation of the available programmes. A relatively small number (16 %) of participants stated that they were ineffective, and some (21%) did not respond to the question. This research highlighted the need for management to be visible, strengthen management by walking around and visiting the renal dialysis unit more often and support the implemented programmes. The support of implemented programmes will also assist healthcare management in building a good rapport with healthcare professionals and renal patients.

Reliable transport to the dialysis centre is important as it determines the time of arrival and attendance of the sessions by renal patients. Late coming results in shortened dialysis sessions for renal patients and impacts the effectiveness of the dialysis treatment. This study has shown that transport is one of the key challenges of patients in attending dialysis sessions. According to [50], transportation is one of the challenges that may cause dialysis patients to fail to attend or shorten their dialysis sessions, impacting their health, and resulting in a rise in hospitalisation and mortality rates. Research teaches us that providing in-centre hemodialysis is dependent on adequate, dependable transportation (Iacono, n.d).

Distance to the dialysis centre emerged as one of the key challenges experienced by renal patients in this study because renal services are centralised, and patients travel from different districts to access them. According to [11], the availability and accessibility of dialysis centres affect chronic kidney disease (CKD) patients' adherence to prescribed treatment regimens. In another study, patients' quality of life (QOL) was compromised physically, psychologically, socially, and most importantly economically due to the time it took to access health services [51]. This study also discovered that, due to transportation issues, some patients sleep overnight on benches at their nearest hospitals to be transported the next day, causing fatigue and sleep problems for renal patients.

According to research on fatigue in ESRD patients, fatigue is a serious issue that must be addressed to enhance life quality and poor health outcomes [52]. Sleep deprivation has a negative impact on psychological as well as physical health [53, 54].

According to the study's findings, 100% of healthcare practitioners have shortened dialysis because of a lack of water, which is a critical resource that an organisation must have to continue to exist and function. These findings are also in accordance with the resource dependency theory, which states that an organization will respond to and grow reliant on those organizations in its surroundings that have authority over resources that are both essential to its activities and over which it has little authority, according to [55], which in this case it is the Polokwane Municipality which is responsible for supplying water to the hospital.

The other reason for shortening dialysis sessions was due to technical problems that required the attention of the technician. This is also coherent with the results of [3] who observed a shortening of dialysis sessions, which could be related to technical issues with dialysis machines because they require ongoing servicing.

According to the National Kidney Foundation, missing dialysis treatments puts a patient at risk of accumulating high levels of the two following minerals: (1) Hyperkalaemia, which can cause heart problems such as arrhythmia, heart attack, and death, and (2) High phosphorus levels, which can weaken the bones and raise the likelihood of cardiovascular disease over time. This study also discovered that young patients miss their dialysis sessions. These findings resonate with the previous study which suggested which found that younger individuals believe they are healthier physically than older people, allowing them to “get away with” missing treatments [56].

Patients require dialysis four hours a day, three times a week to survive. Scheduling sessions has emerged as one of the most significant obstacles encountered by renal patients, contributing to unemployment. According to research, one of the challenges to staying or joining the workforce is a scheduling conflict with dialysis and some employers' presumption that dialysis patients are too sick or unreliable to work [57]. The results are in line with the results of [51] on dialysis schedules which hinder patients on dialysis from working, leading to financial dependence on their families and a harmful effect on patients' quality of life (QOL).

This study revealed that (0%) of respondents failed to engage patients daily in discussing the importance of adhering to diet and fluids which might be due to the attitudes of the nurses and doctors, as indicated by one (6%) respondent and poor interaction between patients and healthcare practitioners. Diet and fluids are essential in the management of ESRD patients. As a result, doctors and nurses must educate patients on the importance of following the recommended diet and fluids daily. Daily discussions with patients on the importance of adhering to diet and fluids are critical for quality of life and better outcomes for end-stage renal disease patients. According to Sabate [58], bridging gaps in delivery of care and improving interaction among healthcare professionals and patients are key components of health-system-related initiatives that can improve patient adherence.

Adherence to the treatment regimen is the primary determinant of treatment success, and failure to follow the suggested therapy schedule is harmful, affecting both the patient's quality of life and the system of healthcare [59]. Daily discussions on diet and fluids will enable doctors and nurses to uncover problems with adherence and refer to the dietitians on time to enhance the quality of life of renal patients. Dietary education and patient counselling provided by a registered dietitian (RD) is essential for preventing and managing CKD, according to [60]. Furthermore, cautious, and comprehensive dietary scheduling, regular evaluation of health status, and nutritional monitoring adherence are essential to achieve effective management of dietary requirements [60].

The Congressional Budget Office Report [61] revealed that medications are a cost- effective treatment modality but with projections of 50% non-adherence to long-term therapy for chronic illnesses [7], intentional and unintentional medication non-adherence is a prevalent and tenacious healthcare problem [62].

 This study revealed that there are ongoing discussions with patients concerning their medications. These continuous discussions will assist doctors and nurses in identifying problems with medication adherence and prompt intervention where necessary to prevent costs of hospitalisation due to non-adherence to medications. Enhancing adherence to medications offers the potential for significant cost savings to healthcare organizations [62].

Renal patients must follow a number of intricate treatment regimens and way of life limitations [63. Lack of knowledge of the condition or level of education, lack of family support and poor acceptance of the condition emerged in this study as contributory factors of non-adherence. According to [64] knowledge is the primary enabler of positive treatment adherence. They further said that low adherence has been linked to a lack of patient education due to a poor correlation between disease and treatment knowledge [64].

According to [65], having a family can provide valuable assistance to patients and reduce depressive disorders in CKD patients. Therefore, patients must be educated about their condition to increase their knowledge and compliance to treatment regimens. Renal patients who are empowered with information are able to embrace and cope constructively with their end-stage renal disease condition.

Respondents (75%) indicated that non-adherence to treatment regimens will result in fluid overload and pulmonary oedema and 50% of the respondents indicated that death could occur if patients are not adhering to their dialysis treatment. This result is coherent with the findings of [66], who found that non-adherence to dialysis treatment causes bone demineralisation, pulmonary oedema, metabolic disorders, the development of cardiovascular disorders, and, eventually, death. This result is also coherent with the studies of [67], who indicated that in CKD, adherence to medication is an essential aspect of disease management success. Therefore, ESRD patients must adhere to their prescribed treatment.

In this study, respondents identified psychological problems as one of the factors contributing to ESRD patients' non-adherence to treatment regimens. This is also consistent with previous findings by [67] that showed that distress and emotional difficulties are commonly experienced by patients with ESKD, especially concerning the rigours of dialysis treatment and the limitations that this imposes on their everyday activities. Doctors and nurses must assess and refer patients who are having psychological problems to a psychologist to enhance their quality of life and increase compliance to treatment regimens.

Training of professional nurses working with renal patients on adherence to treatment is important as it might have a beneficial effect on the adherence of renal patients to their prescribed treatment. The majority of the participants (60%) stated that they had no treatment adherence training. This finding suggests a lack of systematic adherence training and skills associated with supporting renal treatment adherence. It also suggests that renal patients are not given complete information while undergoing dialysis, implying a lack of renal patients’ health education.

These results further indicate an absence of mentorship of healthcare professionals in the renal unit. Having a mentor in the renal unit will benefit both the patients and the staff. According to research, mentors offer assistance, direction, and motivation to student nurses, recent graduates, and nurses transitioning into a speciality or practice [68]. Therefore, having a mentor in the renal unit will assist with the continuous professional development of the staff and increase their knowledge and skills in increasing adherence of ESRD patients to treatment.

Guidelines serves a crucial part in enhancing medical treatment as well as patient results in assisting doctors in making the most appropriate decisions based on research for those they treat in the shortest amount of time [69]. Governance and leadership in kidney care are critical for driving strategies and providing guidelines to improve quality care [76]. According to the findings of this study, 66% of the respondents were not knowledgeable about the guidelines implemented to increase treatment adherence. Knowledge facilitates the use and adherence to clinical practice guidelines [70]. According to the National Kidney Foundation, renal guidelines are an important step in the process of improving dialysis practice quality and ESRD patient outcomes. Therefore, nurses and doctors must be knowledgeable and function according to the set renal guidelines to enhance the medical condition of renal patients.

 The role of healthcare providers and management is to enforce the notion of a multidisciplinary approach to provide a holistic intervention. A multidisciplinary approach to health interventions involves bringing together experts from various disciplines to collaborate and address a health issue. The findings of this study show that doctors and nurses do refer to the multidisciplinary team, despite the fact that the low percentages indicate that they need to improve and strengthen their referral of renal patients to the multidisciplinary team. Some of the respondents (16%), indicated that they have never been referred to the multidisciplinary team which suggests a lack of assessment and communication with renal patients. The multidisciplinary team is important in a renal unit to enhance the standard of treatment and also allows patients with renal disease to be treated holistically.

According to [71], the Chronic Kidney Disease (CKD) care system is complex because it is made up of many different components, including patients, care providers, organisational structure, and policy. Hence, members of the interdisciplinary team must first come together as a group and identify a general medical objective for the individual they are treating [72]. He further submitted that compartments among different healthcare providers can be handled using systems theory, and this might help in determining a common objective to enhance the treatment of patients [72]. This emphasises the importance of the multidisciplinary approach in increasing adherence to treatment by ESRD patients [73].

Suggest that the strategy is based on an in-depth review of the present circumstances as well as an informed assessment of the company’s potential efficiency. Gaps identified by this study necessitate healthcare managers adapting to the situation that arises, as mentioned by [74], and applying the contingency theory of management, also known as the “Leaders- Managerial-Adaptation theory”, to create the desired future state, which is increasing patients’ adherence to the treatment regimen of end-stage renal disease treatment. The respondents identified the following effective strategies that can be implemented;

• Good attitudes are to be displayed by nurses, doctors, and ambulance drivers, which will motivate patients to attend dialysis. Respondents also stated that healthcare management of the organisation should engage with Emergency Medical Services (EMS) management about the importance of patients arriving on time for their dialysis treatment, as late arrival was identified as a key factor in healthcare professionals shortening patients' dialysis sessions. Participation in the multidisciplinary team was also recommended by the respondents as a strategy to increase adherence. Decentralisation of dialysis services to different districts was also suggested by the respondents as one of the strategies that can be implemented to increase adherence because services will be delivered to people rather than centrally where transportation is a major issue [75]. The respondents also recommended awareness campaigns to be conducted in different district hospitals and to activate support groups for the patients and their families. Continuous health education of the patients. Avoiding nursing staff rotation to other units especially those that are experienced in renal services. Having a compliance team that will be able to monitor treatment adherence.

Summary of the Findings

The analysis and interpretation of the results revealed that there is a potential for improvement based on the exploration of the perceptions of healthcare management and healthcare providers through questionnaires and interviews. A few of the outcomes are as follows;

• Programmes for increasing adherence are available but not known to all staff members as some did not respond to the question.
• A lack of discussion exists with patients on the importance of not missing their dialysis sessions as indicated by low percentages of the respondents.
• Dialysis sessions with healthcare providers are 100% shorter due to a shortage of water from the municipality, late coming of patients due to transport issues, sudden changes in patients’ conditions e.g., hypotension, muscle cramps, etc. and technical problems of the machines.
• There was no discussion with patients on the importance of following the recommended diet and fluids as indicated by 0% of the participants.
• According to 60% of the respondents, there was also an absence of treatment adherence training.
• There was a lack of knowledge of guidelines used to manage patients’ adherence to treatment as indicated by low percentages of the respondents.

There was a lack of referral to the multidisciplinary team as indicated by 26% of the participants who indicated that they have never referred ESRD patients to the MDT.

It is critical for ESRD patients to adhere to treatment regimens to improve their QOL.Healthcare management and practitioners play an important role by ensuring that the available programmes for increasing adherence such as health education, group support and home visits are implemented regularly, and families of the patients are also involved in support [76]. Patients can benefit from these programmes and support groups particularly can assist them in coping with the struggles of their condition. Transport of patients to the treatment centre has been emphasised by the participants as being problematic in adherence to treatment regimens by end-stage renal patients. Arriving on time for dialysis sessions by patients will assist them in completing the four- hour sessions of treatment as prescribed. Healthcare management is to have quarterly meetings with Emergency Medical Services (EMS) management where they will be able to identify gaps, plan, implement and evaluate the implemented strategies to improve transport problems for renal patients. It is further recommended that daily interaction among doctors and patients on the importance of following the recommended diet, fluids and medications be strengthened to improve adherence to treatment regimens for ESRD patients. A compliance team is necessary to monitor treatment adherence. It is also recommended that procedures and guidelines for the management of ESRD patients should be communicated and then implemented by healthcare practitioners. Health education of patients and mentorship of healthcare professionals need to be strengthened.

Monitoring and evaluation of the healthcare system need to be active and involved in the delivery of renal services. Nurses, doctors, and ambulance drivers need to be debriefed regularly to improve communication and attitudes towards renal patients.

Recommendations for Further Research

This investigation added to the wealth of information on increasing adherence to treatment regimens by ESSRD patients. More research is needed to investigate the unit costs of hospitalization for renal patients caused by failure to adhere to treatment, as well as the benefits of decentralizing nephrology therapy into district hospitals throughout the Limpopo province.

Limitations of the Study

Delay in obtaining permission from the two ethical committees, Polokwane/Mankweng and the Department of Health, caused the researcher to work in a rush to collect data to meet the deadline of the given period of data collection. A person-to-person gathering of information may have introduced bias for the researcher as the respondents were familiar to the investigator. The study's use of the purposive sampling method was also a limitation as it has been linked with a high risk of bias during selection. It is suggested that subsequent investigations use different methods of sampling.

Considering all the information above, the objectives of the thesis have been met. An exploration of how healthcare management can improve adherence to ESRD treatment regimens among renal patients at Pietersburg Hospital has been done. Perceptions of healthcare management and healthcare providers were explored, and key challenges experienced by ESRD patients and the contributory factors concerning non-adherence to treatment regimens were identified. Strategies to improve adherence to ESRD treatment regimens among patients were recommended for implementation. It is assumed that if healthcare management can adopt the recommendations, adherence of ESRD patients to treatment regimens can be improved.

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