Lesson learnt in the implementation of PHC - Health Systems Trust

LESSONS LEARNT IN THE IMPLEMENTATION OF 

PRIMARY HEALTH CARE 

Experiences from health districts in South Africa 

Edited by: 

Assistant Editor: 

Peter Barron, Fiorenza Monticelli 

Natalie Leon 

Based on contributions by: 

Carmen Baez, Faith Kumalo, Natalie Leon, Marian Loveday, Muzi Matse, Puleng Molefakgotla, 

Thando Ford-Ngomane, Evangeline Shivambu, Sabine Verkuijl, Ronel Visser, Thuli Zondi 

December 2003 

ISBN: 1-919743-76-6 

This publication is also available 

on the internet 

www.hst.org.za 

Published by Health Systems Trust 

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Salmon Grove, Durban, 4000 

Victoria Embankment, Tel: +27-31-307 2954 

Durban 4001 Fax: +27-31-304 0775 

Email: hst@hst.org.za 

Funders of the HST include the Department of Health, the Henry J. Kaiser Family Foundation (USA), the Commission of 

the European Union, the Department for International Development (UK), the Rockefeller Foundation, the W K Kellogg 

Foundation, Ireland Aid, UNICEF, Swedish International Development Agency and the Ford Foundation. 

The information contained in the publication may be freely distributed and reproduced, 

as long as the source is acknowledged, and it is used for non-commercial purposes. 

Designed by The Press Gang, Durban - Tel: 031 - 566 1024

Acknowledgements 

This publication would not have been possible without two broad groups of people. Firstly the ISDS 

Facilitators working for long periods of time in often quite lonely circumstances are to be thanked, not 

only those whose case studies are included here, but all these committed professionals. 

The second group are the district health workers, from managerial level to unskilled labourer, all of 

whom are striving to make a better life possible for all the people in their districts. 

Note to the reader 

How this publication can be used 

Scan through the lessons learnt and the 

recommendations in this booklet and if you 

find something that is pertinent to your particular 

situation or district, go on to read the case study, it 

may save you a lot of time and provide you with 

solutions you had not thought of before. 

LESSONS LEARNT 

Recommendation 

Acronyms 

CDC 

DHS 

DMT 

DoH 

DSM 

HST 

IDMT 

ISDS 

MCWH 

Communicable Diseases Coordinator 

District Health System 

District Management Team 

Department of Health 

Drug Supply and Management 

Health Systems Trust 

Interim District Management Team 

Initiative for Sub-district Support 

Maternal Child Women’s Health 

PHCPrimary Health Care 

PPIP 

PRM 

Sub-DMT 

STIs 

TB 

Peri-natal Problem Identification Programme 

Peri-natal Review Meeting 

Sub-District Management Team 

Sexually Transmitted Infections 

Tuberculosis

Acknowledgements 

Acronyms 

Introduction 

1 Strengthening the District Health System 

Capacity Building of Health Councillors 1 

Functional Integration 4 

Management and Support Services 8 

Decentralising TB Management 11 

2 Support Services 

Clinic Supervision 15 

The District Health Expenditure Review 18 

Quality of Routine Primary Health Care Data at Facility Level 20 

Drug Supply and Management 24 

3 Quality of Care Issues 

Improving the Quality of STI Management 27 

The Use of the District STI Quality Of Care (DISCA) Tool 31 

Monitoring Quality of Care in Maternal Health 34 

Addressing Maternal Mortality Rate 38 

The TB Control Programme 41 

Conclusion 45

“ 

Between the idea 

And the reality 

Between the motion 

And the act 

Falls the shadow 

Between the conception 

And the creation 

Between the emotion 

And the response 

Falls the shadow 

” 

TS Elliot – The Hollow Men 

There are gaps between policy and practice in primary health care and improving primary level 

health services is notoriously slow. The Initiative for Sub-district Support (ISDS) has grappled with the 

dilemma of improving the technical aspects of primary health care delivery, whilst at the same time 

balancing this with a developmental approach that capacitates local staff. This document is evidence 

of the success achieved by ISDS in this balancing act. District staff can produce the required outcomes 

if given time, support, technical guidance and follow-up. This is made possible by the ongoing presence 

of ISDS facilitators, good working relationships, technical expertise and understanding of districts. 

The ISDS has been working on two major goals for the past six years. The first is developing and 

strengthening the district health system and the second is in improving 

the quality of primary care services. 

A management team 

without the authority to 

make and implement 

decisions, is a recipe for 

no or little progress. 

The role of provincial and 

national health 

departments should be 

one of guidance, support 

and nurturing of their 

districts. 

The ISDS has worked in all provinces and in all types of districts ranging 

from the most well resourced metropolitan districts to the poorest of 

rural districts. Currently the ISDS is working mainly in the 13 most 

disadvantaged rural districts in South Africa. This work is part of the 

Integrated Sustainable Rural Development Programme (ISRDP), a 

presidential lead project, aimed at improving the lives of the most needy. 

This document highlights some of the lessons that have been gathered 

by working with mainly the management structures of the districts and 

sub-districts, but also from our interactions with senior management at 

provincial and national level.

Introduction 

There are a great many lessons reflecting the diversity of the districts. We highlight the most important 

lessons as well as those which are not only applicable to the local circumstances but which are 

generic to improvement of primary health care around the country. 

There are two overarching lessons which are applicable to every district in the country and which we 

consider fundamental to improving the quality of primary health care and the health of the people 

within the district. 

The first is that without a permanently appointed management team, which is given full responsibility 

and accountability for being in charge of the health services in the district, it is difficult to make 

sustainable changes for improvement. Having a management team without the authority to make 

and implement decisions is a recipe for no or little progress. This has been seen in numerous districts 

in different provinces. 

The second lesson is that the role of the national and provincial health departments should be one of 

guidance, protection from undue pressure, support and nurturing of their districts. 

We have seen countless incidents where national and provincial senior managers are disrespectful of 

district managers’ diaries and ad hoc meetings are called at short notice causing cascading disruption 

through the district. This usually affects the least resourced districts the most as the district managers 

from these districts have to spend the most time travelling to the provincial capital. 

National and provincial programme managers pass on policies and requests for tasks to districts 

without ensuring that they have the means to implement these. It is imperative that especially those 

districts with the greatest needs, (paradoxically usually those with the least resources), are given support 

by the relevant managers. These managers should visit the districts to discuss with them in their own 

setting what their constraints are and how these can possibly be overcome. 

The case studies have been kept short as they serve as a vehicle to illustrate the main lessons that we 

wish to share. Each case study includes the “lessons learnt” and has recommendations. The lessons 

and recommendations are generic in nature, and can apply to any health district in a similar situation. 

The case studies have been divided into three main areas or chapters. 

1. THE DISTRICT HEALTH SYSTEM 

The first section deals with strengthening the district health system (DHS). For the sustainable 

development and improvement of primary health care, a decentralised system is essential. South 

Africa has endorsed the DHS as the vehicle for implementation of primary health care and the lessons 

in this section deal with issues related to the governance and management of the DHS.

Introduction 

2. SUPPORT SERVICES 

Improvements in primary health care are as much dependent on the support systems underlying 

programmes, as on improvements in the programmes themselves. The second set of case studies 

deals with issues of finance, drug supplies and information systems, all of which underpin the good 

functioning of the health system. 

3. QUALITY OF CARE ISSUES 

The third section deals with improvements in the actual quality of care. The ultimate aim of any 

intervention is to improve the quality of care provided and the health of people who use the services. 

In this section there are case studies dealing with the importance of supervision, and others deal with 

the important priority health programmes of TB, sexually transmitted infections (STIs) and maternal 

health.

Capacity Building of Health Councillors in 

Kgalagadi District Municipality, North West & 

Northern Cape 

Following the local government elections in December 2000, a number 

of health councillors serve on the health committee and are expected to 

participate meaningfully in health issues through working with health 

managers. Most of these councillors do not have a health background. 

Situation 

Councillors are a force to be 

recognised in health and 

development. The councillors 

in Kgalagadi have made 

strides to improve health 

services in the district. Their 

interest and commitment 

(irrespective of political 

affiliation) has contributed to 

the successes in the district. 

Kgalagadi District Municipality includes three local municipalities, Ga- 

Segonyana, Gamagara, Moshaweng. Each of these is served by at least 

six health councillors. HST facilitated a capacity building project to inform 

and educate them on health policies, health services management, priority 

health programmes and community involvement. In addition, forums were 

established to enable health councillors and managers to interact meaningfully. The specific objectives 

were: 

➢ 

➢ 

➢ 

For health councillors to share their experiences with other stakeholders in the district 

To clarify the role of health councillors in health and community development 

To emphasise the involvement of the community. 

KEY 

Health District 

(C Municipality Boundary) 

B Municipality Boundary 

Provincial Boundary 

Original source - Municipal Demarcation Board. 

Updated through other sources 

KGALAGADI 

DISTRICT 

MUNICIPALITY 

North West 

NW1a1 

Tswalu 


Kimberley 

Indicates cross boundary 


1

1 Strengthening 

the District 

Health System 


Kgalagadi District Municipality, 

North West & Northern Cape 

Approach and Outcomes 

The councillors participated in the following capacity building projects: 

1. An overview of health policies, health services management and priority health 

programmes 

To improve the health background of the councillors, workshops were conducted presenting an 

overview of: 

➢ 

➢ 

➢ 

The Policy on District Health Systems in South Africa 

The Ten Point Plan of the national Department of Health (DOH) 

The Primary Health Care approach focusing on the priority health programmes of STIs, HIV, 

TB, and Maternal and Child Health. 

2. Conducting a situation analysis in the Kgalagadi District Municipality 

The situation analysis of health services in Kgalagadi district was conducted and completed in June 

2002. The health councillors were involved in discussions around the framework to be used, data 

collection and verification and report writing. As part of the situation analysis, the team completed a 

mapping exercise of health facilities in the district showing hospitals, clinics, mobile points, police 

stations, schools and roads. 

The resulting benefits were that: 

➢ 

➢ 

➢ 

Each municipality was provided with a comprehensive map of how facilities were located 

within their areas 

This is the first time that councillors understood the issues surrounding access and nonaccess 

of services and duplication of services, caused particularly by the cross-boundary 

with both provinces running services independently 

The analysis also gave them an idea about the degree of availability of basic services such as 

water and sanitation. 

3. Improving the quality of care 

A review of the TB Control Programme was conducted and completed in May 2003 and presented to 

the health councillors. Some positive findings and a number of challenges were highlighted in the 

review. 

The benefits were: 

➢ 

➢ 

The councillors acknowledged and adopted the report 

Through their input, they challenged the district management team on identified gaps, and 

demanded a speedy response to improve the situation 

2



North West & Northern Cape 




➢ 

➢ 

Councillors now carry out clinic visits to support the clinic nurses and to gain deeper insight 

into the problems that the clinic nurses encounter 

Through the pressure applied by the councillors, the district manager on the North West 

side of Kgalagadi responded positively by acting immediately to the recommendations 

made by the review team. 

4. Improving management systems 

A district health expenditure review (DHER) was conducted and completed in May 2003. The councillors 

participated in the long process of data collection and continuous verification. This was an opportunity 

for councillors to understand the link between finance, population and services. A number of questions 

were asked especially around workload indicators. This has assisted councillors to respond with insight 

on issues such as shortage of staff. 


❖ 

❖ 

❖ 

Councillors are a force to be recognised in health and development. The 

councillors in Kgalagadi have made strides to improve health services in 

the district. Their interest and commitment (irrespective of political 

affiliation) has contributed to the successes in the district. 

If one wishes to work with councillors it is crucial to first establish good 

relationships with them. It is a process that requires patience, 

acknowledgement and mutual respect. 

Role clarification of councillors and health managers is important in order 

to ensure that health workers are not threatened by the presence of 

councillors and that councillors do not overstep their role. 


Basic information around primary health care and about specific local 

problems should be provided to all local politicians so that they can use 

their political influence to the benefit of the community. 

3




Functional Integration in Chris Hani District 

Municipality, Eastern Cape 

The joint prioritisation and 

planning process is extremely 

important for team building 

by focusing on common 

health problems and the 

improvement of the quality of 

care of the PHC programmes. 

The Chris Hani District Municipality is one of the biggest district 

municipalities in the Eastern Cape. After the municipal elections in 

November 2000, in line with the new municipal boundaries, a new restructuring 

of the health services took place. The Chris Hani District 

Municipality (Category C) was born, composed of eight local 

municipalities (Category B). 

Based on the size of the population, these eight category B local 

municipalities were combined into 6 health sub-districts by the Eastern 

Cape Department of Health. These are: 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

Inxuba Yethemba 

Lukhanji 

Intsika Yethu 

Emalahleni 

Sakhisizwe 

Engcobo. 

The first 4 health sub-districts have both local government and provincial health workers, whilst the 

last two have only provincial health workers. 


Umtata 

CHRIS HANI 

Port St Johns 

DISTRICT MUNICIPALITY 

Eastern 

Cape 

Eastern Cape 

East London 

KEY 




Port Elizabeth 




4

Functional Integration 

in Chris Hani District Municipality, 

Eastern Cape 




Situation 

When ISDS started work in Chris Hani, there were neither district nor sub-district health management 

structures in place. Integration of different provincial and local government providers of health care is 

an indispensable step in the implementation of the district health system. This is particularly important 

for districts like Chris Hani, which has historically been fragmented and has significant inequities. A 

major achievement of this period has been the initiation of a process of functional integration between 

local government (LG) and province at district municipality and sub-district level. 

Approach 

Functional integration has been used in the absence of a legislative framework as a temporary instrument 

for implementing the district health system. 

The National Department of Health has defined functional integration (FI) as follows: “A structured 

cooperation and collaboration between provincial and local government health rendering authorities 

for the purpose of decreasing fragmentation and duplication, enhancing integrated service provision, 

and increasing efficiency and quality of Primary Health Care (PHC), in the absence of legal, financial 

and administratively integrated governance and management structures.” 

The Chris Hani Interim District Management Team (IDMT) was created out of a need to manage and 

improve the health of the population of the district. It was agreed that sub-district management teams 

should form the foundation of this structure. The challenge was that in four of the six sub-districts, 

there were both local and provincial government health providers and management. The solution 

was the establishment of joint interim health management structures. These structures were to resolve 

the daily problems and implement joint operational plans to improve the health of the population at 

local and district level. 

Outcomes at district municipality level 

Regular monthly meetings take place with good attendance and participation. Interim managerial 

issues are discussed. The first task of the district management team was to undertake a situation 

analysis regarding health and health related issues. The situation analysis was finalised in April 2002. 

Outcomes at sub-district level 

The results of the situation analysis were utilised for the establishment of the six interim sub-district 

management teams. Information pertinent to each sub-district was extracted and presented to the 

sub-district staff and managers. It illustrated the current situation, helped define local priorities and was 

utilised in the development of plans. 

The mandate and frequency of meetings were defined. An innovative mechanism was developed to 

monitor commitment to the process. A notice board in each sub-district shows the names of the 

members and graphically monitors the attendance of each member at the IDMT meetings on a 

monthly basis to ensure continuity. 

5






Eastern Cape 

Evaluating progress in the implementation of Functional Integration 

In 2003 the checklist of the Functional Integration Guidelines published by the National Department 

of Health was utilised and the results concluded that progress had been made in the district. 


❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

It is possible to develop a team spirit in a district through a collective, 

inclusive, participatory process of institutional and organisational 

restructuring of the management of health services. 

A situation analysis enables the team to acknowledge their strengths and 

weaknesses with an evidence based document that will be used to measure 

progress. 

The joint prioritisation and planning process is extremely important for 

team building by focusing on common health problems and the 

improvement of the quality of care of the primary health care programmes. 

Team members are often confronted by a dilemma when they have to 

implement activities planned by the district and at the same time those 

planned by the province, that are not based on their priorities. 

The process of functional integration leads to effective sharing of human 

resources. So for example, Inxuba Yethemba and Lukhanji have decided to 

share their supervisors and develop an integrated supervisory system. Local 

government and provincial supervisors are therefore allocated according 

to need, regardless of which authority provides the services, thus avoiding 

duplication and gaps. 

Functional integration is based not only on service agreements. The 

commitment and support of all parties, based on good faith, is essential. 

This bottom-up approach needs to be complemented by top-down support 

and guidance from the province for functional integration initiatives to be 

successful. 

6



Eastern Cape 





For functional integration to be an effective means of improving services, 

it is important that monthly strategic meetings are held between local 

government and provincial health officials. 

7




Parallel lines of accountability 

by doctors, pharmacists or 

clerks to someone else in their 

profession (be it for their 

performance or discipline), 

instead of to the facility 

manager, limits the facility 

manager’s ability to manage 

the facility. 

Structural Management and Support Services - 

Cape Town Metro, Western Cape 

This case study arises out of a project that aimed to increase the 

operational efficiency of a community health centre (CHC) in the Cape 

Town Metro region. The CHC has had to deal with two management 

challenges that made it difficult for the facility manager to manage the 

facility effectively. One challenge was that of human resource matters 

relating to disciplining of employees. The second challenge was due to 

a management structure that uses parallel lines of accountability, which 

bypass the authority of the facility manager. 

Situation 

A rapid appraisal of the CHC was carried out. One problem area identified was that of long patient 

waiting times. Solutions to this and other problems included better utilisation of staff; the immediate 

appointment of a facility manager; the establishment of a facility management team; and doing away 

with parallel lines of accountability in management of staff. 

KEY 








Western Cape 

Paarl 

UNICITY 

CAPE TOWN 

METRO 

Hermanus 

George 

8

Structural Management and Support Services – 





Approach 

Following the recommendations of the rapid appraisal: 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

A facility manager was appointed, together with administrative support 

A facility management team was formed with the heads of sub-sections 

An operational plan with key performance areas (KPAs) was drawn up. One of the KPAs was 

to reduce patient waiting time 

The facility manager attended a management course for improving service delivery to assist 

with identifying operational problems such as bottlenecks in patient flow 

A study on waiting times showed that the main bottlenecks were in the reception and the 

pharmacy 

The solutions to speed up service and reduce waiting time mainly involved changes in 

scheduling for both patient flow and staff. 

Problems arose in trying to implement these solutions. These fall into two categories: support services 

and line management problems. 

1. Support Service Problems 

Procurement and Information Technology: 

The implementation of plans for technical improvements to speed up service experienced excessively 

long delays. This was due to a long bureaucratic procurement cycle and lack of efficiency from the 

support services which are centralised at the metro head office. 

Human Resources Management: 

Reception staff resisted rescheduling to improve their efficiency. Certain employees continued to be 

a disruptive influence and actively attempted to undermine the authority of the facility manager. The 

next level of management at the metro office did not have the capacity to assist the facility manager 

to discipline staff effectively. 

The pharmacy posed the major bottleneck in patient waiting time. Rescheduling to allow the pharmacy 

to stay open over lunchtime and to reschedule chronic patients to the afternoon was resisted. In 

addition, poor staff discipline in the pharmacy was not effectively addressed by the HR section. 

2. Line Management Problems 

Various categories of staff (doctors, pharmacists, nurses, clerks) are technically supervised by a senior 

member (e.g. chief pharmacist) of that category based outside of the facility. The problems caused by 

such parallel lines of accountability contribute to and complicate the disciplinary cases and procurement 

problems mentioned above. For example, when a doctor is performing poorly, this is addressed 

9




Structural Management and Support Services – 


through the chief medical officer in the sub-district and not through the facility manager. The result is 

that the facility manager does not have full authority over staff performance. In addition, the facility 

manager position is not a formal position. These factors limit the ability of the facility manager to 

manage effectively. 

Outcome 

Following an evaluation and report back to senior management about the problems of support services 

and management, some aspects are receiving attention. The interventions that are being considered 

at senior level are: 

➢ 

➢ 

➢ 

Establishing a central team of HR experts that will deal with the backlog of serious disciplinary 

cases 

Improving procurement by shortening the procurement cycle 

Creating formal facility management posts for the 24 hour community health centres. 


❖ 

❖ 

Effective management by a facility manager depends on the formal authority 

and control the manager has over staff. Operational efficiency at facility 

level can be compromised by inefficiencies of support services at district 

and provincial level. 

Parallel lines of accountability by doctors, pharmacists or clerks to someone 

else in their profession (be it for their performance or discipline), instead 

of to the facility manager, will always limit the facility manager’s ability to 

effectively manage the facility. 


Each facility should have one “boss” and all health workers should know 

clearly the extent of the authority vested in this person in charge. 

10




Decentralising TB Management from a Hospitalcentred 

System to a Primary Health Care Level in 

Umkhanyakude District, KwaZulu-Natal 

The process of decentralising TB management in KwaZulu-Natal has been 

slow, especially in uMkhanyakude District. TB management at 

uMkhanyakude was centralised to such an extent, that in some sub-districts 

the DOT system and patient drug collection was carried out in hospitals 

instead of in clinics. 

Situation 

The resistance to decentralise TB management to a primary health care 

level was mostly due to the majority of district doctors not having bought 

into the national TB control programme. Doctors thought that their current 

system was working well enough. The ISDS facilitator was left with the 

dilemma of not knowing where and how to start improving the quality of 

care given in TB. In addition there was pressure from the Provincial 

Department of Health to decentralise TB management. 

Plan for implementation in a 

detailed manner and track 

loopholes along the way. The 

role of the Provincial 

Department of Health is not 

only to dictate change but 

also to support change. This 

should be in the form of : 

➢ Providing clear guidelines 

➢ Unpacking the policy 

specifically for that district 

➢ Providing extra resources if 

necessary. 

Free State 

Mpumalanga 

KwaZulu-Natal 

KwaZulu-Natal 

UMKHANYAKUDE 

DISTRICT 

MUNICIPALITY 

UMKHANYAKUDE 

DISTRICT 

MUNICIPALITY 

Ulundi 

Richards Bay 

KEY 





Durban 



11




Decentralising TB Management from a 

Hospital-centred System to a Primary Health Care 

Level in Umkhanyakude District, KwaZulu-Natal 

Approach 

Strategies which did not work 

➢ 

➢ 

➢ 

In a number of initial meetings the doctors’ viewpoints were challenged. This resulted in 

heated arguments and deadlocks without trying to find a way towards agreement or solution. 

The issue here was that the district health management team looked at TB from a programme 

performance point of view that did not acknowledge the clinical issues that were of real 

concern to doctors. 

The national TB control programme was introduced, with the assumption that everybody 

would automatically understand and implement it 

The communicable disease coordinator (CDC) went ahead and trained all primary health 

care nurses on TB management. However, only 3 out of 5 sub-districts allowed some 

nurses to partially manage TB. The consequence of this was that six months down the line, 

there was a division between the nurses who wanted to start managing TB, and the doctors 

who did not want this to happen. Nevertheless, these nurses started managing TB patients 

on their own. Unfortunately the whole programme fell apart because they had no systems 

in place and they were not yet well equipped or able to manage the job on their own. 

Strategies that worked 

➢ 

Fostering cooperative management between doctors and CDCs 

In the primary site where the ISDS facilitator worked, an in-depth analysis of the TB programme 

was conducted. An action plan was formulated by the task team which included sub-district 

management, PHC management, TB coordinators and doctors. The role of the CDC was to 

allow for further discussions and reduce the animosity that had existed. 

➢ 

Learning from a neighbouring district about decentralising TB management 

A site visit was undertaken in Bergville (DC23). Bergville is a KwaZulu-Natal rural area known 

for having improved TB quality of care through decentralisation. The CDC, sub-district TB 

coordinators, PHC matrons and community doctors all visited Bergville. After this visit each 

sub-district had to submit a detailed plan of their own decentralisation strategy, including 

setting-up systems such as transport. They also had to indicate the kind of support that they 

would provide to PHC nurses. This site visit helped with getting consensus on the need to 

decentralise TB. 

➢ 

Doctors’ buy-in to the NTCP policy 

The TB clinical and policy specialists conducted a workshop for doctors. This workshop 

convinced doctors about the importance of diagnosing by sputum microscopy and measuring 

critical indicators such as smear conversion and cure rate. 

12







➢ 

The supportive and monitoring role of the CDC 

Outcome 

The TB plan was adopted for the whole district and is being monitored by the CDC through 

monthly sub-district coordinator meetings. These meetings ensure the sustainability of the 

programme by supporting the sub-district coordinators to effectively deal with problems. 

An agreement from all parties to work in harmony was reached in April 2003. Having orientated the 

system to decentralised management, the problems of defaulting patients, poor tracing mechanisms 

and poor recording and statistics are apparent - but there is continuous problem solving taking place. 

There are signs of improvement for example, the microscopy coverage is nearing 80% and case 

finding is increasing. Moreover, the smear conversion rate and cure rate have also improved. 


❖ 

❖ 

❖ 

❖ 

❖ 

Buy-in from key stakeholders is critical. More time should be dedicated to 

familiarise stakeholders, such as doctors, with the policy. 

Cooperative management (i.e. the belief that we depend on each other for 

success) should be reinforced by the Department of Health, rather than 

having an authoritarian position (saying you shall do as requested because 

the policy or department says so). This would allow managers to be more 

innovative and willing to facilitate change, rather than resist it. 

Policy implementation requires stepwise systems change, phasing of 

interventions, and rationalisation of resources. The details of systems are 

not explicitly set out in the policy (for example the requirement of a vehicle 

to collect sputum every 2nd day from all clinics) and are often overlooked. 

Plan for implementation in a detailed manner and track loopholes along 

the way. The role of the Provincial Department of Health is not only to 

dictate change but also to support change through providing clear 

guidelines, unpacking the policy for the particular district and providing 

extra resources (if necessary). 

Close monitoring of a new system and on-going problem solving is 

important. Changing systems should be treated as an opportunity for 

healthcare workers to learn through designing those systems that are 

suitable for their circumstances and to learn from their mistakes. 

13








All new policies should have an implementation plan. This plan should be 

regularly monitored, especially in the initial phase, to ensure that problems 

are overcome. If necessary, the policy needs to be modified to take into 

account local circumstances and requirements. 

14




Clinic Supervision in the Sekhukhune District, 

Limpopo and Mpumalanga 

Sekhukhune District is a cross-boundary district between Mpumalanga 

and Limpopo provinces. The district has five health sub-districts which 

coincide with the local municipalities of Makhudu Thamaga, Fetakgomo, 

Greater Marble Hall, Greater Tubatse and Greater Groblersdal. 

The Clinic Supervision Manual is used in the Makhudu Thamaga and 

Fetakgomo sub-districts. This manual is a collection of tools that guides 

the supervision of clinics. Amongst other things it describes who a 

supervisor is, what and how to supervise, when and how often to do it. 

The tools in the clinic 

supervision manual can 

identify problems that 

can be addressed at clinic, 

sub-district, district and 

provincial levels. 

Situation 

At the time of this intervention, Makhudu Thamaga had an interim district 

management team consisting of 8 people who coordinated different 

programmes such as HIV/AIDS and TB and who also supervised clinics. There were 19 fixed clinics 

and 6 mobile clinics. Fetakgomo sub-district had 11 clinics and 3 mobile teams. Clinic supervision was 

identified as a problem in the entire Sekhukhune district. It was agreed to pilot the manual in two subdistricts 

before extending its use to the others. 

Limpopo 

Groblersdal 

SEKHUKHUNE 

DISTRICT 

MUNICIPALITY 

Mpumalanga 

KEY 



Nelspruit 







15

2 Support 

Systems 



Approach 

A three-day workshop was organised per sub-district and involved clinic managers, clinic supervisors 

and programme managers at district level. It focused on the nuts and bolts of clinic supervision, the 

various components of the Clinic Supervision Manual, and the preparation for visiting selected clinics. 

To increase the objectivity of the exercise managers visited clinics they were not currently supervising. 

A report back on the clinic visits included a description of what they experienced during their visits, 

the tools that were used and what their findings were. A follow up workshop was carried out four 

months later to review the progress made in trying to address the challenges that were identified. 

Outcome of the clinic supervision intervention 

The following are some highlights of the challenges that were identified in both sub-districts: 

Infrastructure 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

Water shortages 

Lack of electricity and/or power failure with no back up system 

Lack of transport 

One clinic was almost falling apart 

Lack of communication systems like telephone/radiophone 

Lack of and broken equipment. 

Management 

➢ 

➢ 

➢ 

➢ 

➢ 

Lack of treatment protocols 

Lack of, or outdated, job descriptions 

Lack of stationery 

Poor or lack of supervision with unstructured visits 

High staff absenteeism and no monitoring of time registers. 

Systems and structural issues 

➢ 

➢ 

Poor referral system 

Lack of teamwork between primary health care and environmental health officers. 

Training needs identified 

➢ 

➢ 

How to conduct a physical examination 

How to manage patients with TB and STIs. 

16



2 Support 


The use of the Clinic Supervision Manual assisted in identifying longstanding problems that needed 

attention. It helped the clinic staff to critically look into their daily practice and identify challenges 

affecting quality of care. It assisted them in developing an action plan to resolve the issues without 

external support and also to refer those problems they could not deal with, to the appropriate people. 

Some of the problems have been addressed. For example, the structurally unsound clinic was included 

into the following year’s capital budget and a new one was built. Other problems such as support 

structures for the supervision of clinics have not been addressed. 


❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

Clinic supervision can be successful where there is a structure in place to 

conduct supervision like in Makhudu Thamaga, but fails where no 

supervisory structures exist. 

The support of management at district and sub-district level is crucial for 

supervision to be effective and the process should be driven locally. 

It is not worth conducting training where there are inadequate human 

resources and no support systems in place to implement what was learnt. 

When conducting clinic supervision, it is important to consider each clinic 

as being unique. The problems experienced vary from one clinic to the 

next. 

The tools in the clinic supervision manual can identify problems that can 

be addressed at clinic, sub-district, district and provincial levels. 

Clinic managers can use these tools to manage the clinic on a daily basis. 

It would enhance problem solving and address day-to-day challenges. 


The Clinic Supervision Manual is a structured way of assessing the support 

required by clinics. All clinics should have a monthly structured supervision 

visit with a written report. 

17

2 Support 


The District Health Expenditure Review, 

Kgalagadi District Municipality, North West and 


It is difficult to make sense 

of the financial status when 

the quality of financial data, 

records and record keeping 

is incomplete and very poor. 

The aim of a district health expenditure review (DHER) is to document 

the available resources in the district and how resources are used and 

distributed. The review integrates financial, service and population data, 

thereby establishing it as an important source of information for 

population-based health planning. The DHER in Kgalagadi focused on 

the provincial financial year 2001-2002. 

Situation 

The findings of the DHER in Kgalagadi, showed that the current resources 

are not equitably distributed with wide variations in how efficiently 

resources are spent. For instance: 

➢ 

➢ 

➢ 

The recurrent district expenditure per capita for primary healthcare services is on average 

R109, which is well below the national average of around R150 per capita 

The district spent 60% of its’ annual budget on hospital services whilst 26% was spent on 

primary health care 

A ten-fold variation existed across clinics in the cost per visit, with some clinics having a cost 

per visit of R10 and others more than R100 per visit. This probably represents a real problem 

of equity as well as a problem of accurate information. 

KEY 







KGALAGADI 

DISTRICT 

MUNICIPALITY 

North West 

NW1a1 

Tswalu 


Kimberley 



18

The District Health Expenditure Review, 


North West and Northern Cape 

2 Support 


Approach 

These findings and suggestions for improvement were presented at the interim joint district management 

committee meeting, where information was shared with other stakeholders. 

Outcome 

The district municipality is using the information as a benchmark for what the cost for primary health 

care services could be. However, the district municipality has also been made aware of the poor 

information and financial systems. The DHER exercise assisted the district management teams to 

realise the problems and gaps in their records, which highlighted irregularities particularly with data 

within the human resource and transport sections. 


❖ 

❖ 

❖ 

❖ 

The district health expenditure review (DHER) is a key tool for planning as 

it indicates where money is being spent on services. 

Poor financial data gives an incomplete and inaccurate picture of financial 

indicators of the district. 

Each facility needs to be made into an individual cost centre if accurate 

financial data is required. 

The DHER process highlighted the lack of appropriate skills in the district, 

for example in areas such as financial analysis, computer skills (word 

processing) and writing skills. However, the process also provided an 

opportunity to identify the potential of some team members to learn and 

improve. 


Both service and financial information need to be brought together, so 

that indicators (such as cost per patient per visit) can be used for 

management purposes. 

19

2 Support 


Information is not a vertical 

programme but merely a 

tool to assist with planning, 

implementation and 

monitoring. It can be used to 

improve quality of care and 

to identify problems. 

Improving the Quality of Routine Primary Health 

Care Data at Facility Level in Lejweleputswa 

District Municipality, Free State 

Lejweleputswa is one of five district municipalities in the Free State. It 

consists of 5 local municipalities and was the first district municipality in 

the province to appoint an interim district management team (IDMT). 

During 1999 and 2000, ISDS assisted this district in establishing a minimum 

data set as well as with the implementation of a district health information 

system. The district information officer, the district management and 

programme managers participated actively in the process. 

Situation 

Following the implementation of the minimum data set, a review on the quality of data collected as 

well as the use of information for management was conducted. 

Approach 

A series of workshops, aimed at building capacity around data management, were held. This included 

data collection, validation, analysis, presentation and interpretation. The development of operational 

plans at facility level, based on local information and in line with district, provincial and national plans 

KEY 



FS204 


FS203 




North West 

FS201 

Free State 

FS205 

FS185 

FS183 

LEJWELEPUTSWA 

DISTRICT MUNICIPALITY 

FS184 

Welkom 

FS193 

FS194 

FS182 

FS191 

FS192 

FSDMA19 

FS181 

Bloemfontein 

FS161 

FS172 

FS173 

20

Improving the Quality of Routine Primary 

Health Care Data at Facility Level in 

Lejweleputswa District Municipality, 

Free State 

2 Support 


were also dealt with. Participants used their own data to practice methods of validating data, calculating 

indicators and developing hand-drawn graphs. All group-work was preceded by theory and the 

group was encouraged to seek their own solutions for problems. On the last day, consensus was 

reached on the way forward. This included the development of specific action plans with targets and 

timeframes. 

One of the most important functions of these workshops was to ensure that every facility allocated a 

dedicated person to manage information. The main functions of this person include: 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

Ensuring a common understanding of data and indicator definitions 

Collating data as received from individual staff in the facility 

Validating data for completeness, correctness and consistency and do necessary corrections 

as needed 

Using local data to calculate key indicators 

Preparing and update yearly graphs (to be displayed in the facilities’ waiting area) 

Giving feedback to staff on quality of data 

Ensuring that the progress towards local targets is assessed at facility meetings. 

Outcome 

Subsequent to the workshops 

➢ 

➢ 

➢ 

➢ 

➢ 

Data quality has improved remarkably and is submitted on time 

Staff are able to measure the impact of service on health status of the community 

Facility staff make their own decisions with local information 

Graphs are used in health education / promotion activities 

Communities have became involved in health and have joined hands with the facility staff 

to improve their own health status, and reach local health targets. 

21

2 Support 





Free State 


Comparison of quality of data: Lejweleputswa and rest of Free State Province 

800 

700 

600 

500 

Units 

400 

300 

200 

100 

0 

2000 2001 2002 

Data errors - Lejweleputswa 

Missing records - Lejweleputswa 

Data errors - province average 

Missing records - province average 

22




Free State 

2 Support 



❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

In order to improve quality of data, there needs to be a focus on the point 

of data collection at facility level. 

Each facility should have a specific person who is responsible for 

information such as a facility information coordinator who is an existing 

staff member. 

When staff analyse their own data, they become aware of the impact that 

poor quality data has on the monitoring process. 

Information used at local level can be used to assess progress towards 

local, district, provincial and national objectives and targets. 

Information used at facility level can be used to improve quality and 

coverage of services. 

Information is not a vertical programme but merely a tool to assist with 

planning, implementation and monitoring. It can be used to improve quality 

of care and to identify problem areas and priorities. By involving the 

facilities in the planning process, common objectives and targets are set. 

It is essential to give feedback to the facilities on their performance. This 

helps to acknowledge their work and to challenge any irregularities. 

Recommendations 

❖ 

❖ 

❖ 

A shift in perception is needed from focusing on the use of software to 

the use of information for management. 

Data definitions must be known and understood by all who are involved 

with the data. 

District information officers need to visit facilities regularly. They should 

spend at least 60% of their time on training and support of facility 

staff. 

23

2 Support 


In order to improve drug 

supply and management, 

a situation analysis is an 

essential first step in 

identifying problem areas. 

The reality of the situation 

analysis must be discussed 

with all interested parties. 


City of Tshwane, Gauteng 

Tshwane is one of three metropolitan municipalities in Gauteng. It 

incorporates the old city of Pretoria (urban) and parts of North West 

province’s Odi and Moretele health districts (peri-urban / rural). An ISDS 

facilitator was introduced to the district in May 2001 to assist with the 

development of the health district. Both provincial and local authority 

management identified drug supply and management as a focus area. 

Situation 

As Tshwane is a cross-boundary district between Gauteng and North 

West Provinces, facilities in Odi and Moretele are supplied with stock 

by the North West provincial pharmaceutical depot, and different standard 

operating procedures are in use. In the Gauteng parts of the metro 

area, a dual drug supply management was in operation, with both provincial and local government 

health departments operating a depot from which their own facilities were being supplied. This caused 

a duplication of efforts, facilities, staff and transport. There had also been “over-expenditure” in the 

drug budget, mainly at local authority facilities over a number of years. 

Approach 

In order to strengthen drug supply and management, the Joint Health District Management Team 

KEY 





North West 



TSHWANE 

MUNICIPALITY 

Pretoria 



Gauteng 

Johannesburg 

24



2 Support 


formed a task team, comprising pharmaceutical services management and staff from all authorities. 

The task team undertook to do a situation analysis, the results of which would help guide management 

in the future. 

Outcome 

➢ 

➢ 

➢ 

➢ 

➢ 

Teamwork and cooperation between officials from different authorities was fostered. An 

external, non-partisan facilitator helped promote participation. 

Immediate feedback was provided to the facility manager and the persons responsible for 

drug supply and management on the findings and recommendations 

The recommendations of the Drug Supply and Management report were discussed and 

accepted by the task team. They prioritised the recommendations to aid implementation. 

The report was also discussed at a workshop with all relevant staff, and a shared implementation 

plan of the recommendations was developed 

Each facility received a copy of the situation analysis report. 


❖ 

❖ 

❖ 

❖ 

❖ 

In order to improve drug supply and management, a situation analysis is 

essential in identifying problem areas. The situation analysis must be 

discussed with all relevant staff. 

A representative team of health officials should lead this process and an 

external facilitator can add value to the process. 

Clear joint leadership and vision from management is imperative to facilitate 

implementation of the recommendations. 

Because the task team was involved throughout, the findings and 

recommendations were accepted and endorsed as a common way forward. 

Communication with facilities is imperative and especially when it comes 

to giving immediate feedback to facilities on health information. This applies 

to data collection relevant to that facility. 

25

2 Support 





Where the supply and management of drugs is thought to be a problem, 

carrying out a situation analysis will pinpoint the problems and generate 

possible solutions. 

26

Improving the Quality of STI Management 

Using the DISCA Tool, City of Tshwane, Gauteng 

Tshwane is one of three metropolitan municipalities in Gauteng. A local 

authority health manager was appointed in September 2001 who 

encouraged any interventions that would improve the quality of services. 

Situation 

Although an assessment of STI management had never been done before, 

staff were convinced that STIs were being managed very well. Provincial 

and local authority facilities were managed separately, with little interaction 

between the supervisors from the different authorities. 

Improvements were achieved 

without additional training 

of clinicians. Although 

training remains important, 

supervision is more 

important in sustaining 

improvements in practice. 

Approach 

The first joint assessment of STI care in Centurion was conducted in 

November 2001 using the District STI Quality of Care Assessment (DISCA) 1 tool. This is a quality 

assessment tool, approved by the Department of Health, which measures key input, process and 

outcome indicators related to STI care. The ISDS facilitator introduced the tool and discussed its use 

with the team to gain a common understanding. 

KEY 





North West 



TSHWANE 

MUNICIPALITY 

Pretoria 



Gauteng 

Johannesburg 

1. Available from www.hst.org.za. 

27

3 Quality 

of Care 


Using the DISCA Tool, 


Some findings: 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

Equipment for safe examination was adequate at all facilities 

No drug or condom stock-outs were experienced 

Syndromic management protocols were available in all consulting rooms 

All clients with mixed infections were incorrectly treated 

Lack of dildos for condom demonstration 

Lack of educational material in local languages 

Lack of partner notification cards in local languages 

Lack of a system to record partner management 

Speculum examinations were not performed on all female clients with STIs. 

Outcome 

Some of the interventions included: 

➢ 

➢ 

➢ 

➢ 

➢ 

Contact slips were translated into Afrikaans, Sotho and Zulu and made available to all facilities 

Educational material in various languages was sourced and distributed 

A flowchart for mixed infection treatment was developed, disseminated and communicated 

to all staff 

Targeted supervision by facility managers and area managers using the Clinic Supervisor’s 

Manual was introduced 

The number of speculum examinations performed was monitored. 

28




3 Quality 


A second DISCA was conducted in February / March 2003. The graph below compares findings in 

2001 and 2003 

Clinician knowledge of correct treatment 2001 and 2003 

100 

90 

80 

70 

Percentage correct 

60 

50 

40 

30 

20 

10 

0 

male urethral 

discharge 

vaginal 

discharge 

genital ulcer 

disease 

vaginal 

discharge in 

pregnancy 

alternative to 

Doxycycline 

2001 2003 

The graph illustrates that the management of STIs in the district improved between the two assessments. 

29

3 Quality 






❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

To improve the quality of STI it is important that there is local commitment. 

A team that includes key stakeholders should lead the process. 

Include all facilities within an identified geographical area. 

Wherever possible, the team should be trained in the use of the tool and 

should make use of the booklet “A Practical Guide To Using The District 

STI Quality Of Care Assessment” 2 

The analysis of the DISCA findings is best done manually by the team 

themselves using the booklet “Evaluating the quality of STI management 

at Regional level using the DISCA” 3 By calculating the indicators 

themselves, officials are able to gain an understanding of what the findings 

mean, both for service delivery and for their communities. 

Identified weaknesses and gaps need to be addressed through an action 

plan, which needs to be reviewed every quarter. 

Ongoing, focused supervision by supervisors is key to monitoring clinicians’ 

practice. 

Improvements were achieved without additional training of clinicians. 

Although training in itself is important, supervision is more important in 

sustaining improvements in practice. 


Tools, such as DISCA, which can improve quality of care should be 

implemented to identify problems. However, problems can only be 

remedied by ongoing action by practitioners and their supervisors. 

2 & 3 Available from www.hst.org.za 

30

3 Quality 


The Use of the District Quality of Care (DISCA) 

Tool in Mopani District, Limpopo 

In many parts of South Africa, the management of sexually transmitted 

infections (STIs) is of inadequate quality. There are a number of key factors 

affecting the quality of care for clients with STIs. These include incomplete 

treatments, diagnosis not based on syndromic management, nurses not 

using specula, non-compliance in the use of protocols, inadequate testing 

for syphilis and privacy issues. Numerous facilities in Mopani District in 

Limpopo Province were no exception to this pattern. Against this 

background, the ISDS initiated interventions to strengthen the management 

of STIs in this district. 

Clinic managers and local 

area supervisors must ensure 

the use of STI protocols and 

guidelines. 

Approach 

In March 2003, a workshop on STI management was conducted. The 

District Quality of Care Assessment Tool (DISCA) was used as a strategy to strengthen STI management. 

Participants came from all four sub-districts of Mopani (i.e. Ba-Phalaborwa, Greater Giyani, Greater 

Letaba and Greater Tzaneen). 

The objectives of the workshop were to: 

➢ 

➢ 

Assess participants’ awareness of key components of STI management and control 

Clarify the main points around syndromic management of STIs 

KEY 

NP341 



NP342 



NP351 

Limpopo 

NP344 

NP343 



CBDMA4 

NP362 

NP367 

NP352 

Pietersburg 

NP354 

NP355 

NP332 

NP333 

Tzaneen 

MOPANI 

NP331 

DISTRICT 

MUNICIPALITY 

NP334 

NP03A3 

NP04A1 

NP365 

CBLC5 

NP361 

NP366 

NP364 

CBDMA3 

NP03A2 

Mpumalanga 

CBLC6 

31

3 Quality 




➢ 

➢ 

➢ 

Encourage participants to identify the key factors for assessing quality of STI care at primary 

health care clinics 

Introduce participants to the DISCA tool 

Discuss the steps involved in developing a plan for the district regarding STI management. 

Following this workshop, each sub-district started a process of assessing the quality of its STI 

management. The DISCA tool was applied in over 60% of the 82 primary health care facilities. This 

sample was considered adequate to give a wider picture of the quality of STI management in the 

district. 

Outcomes 

Although each sub-district analysed their DISCAs separately, the results showed similar patterns. These 

are outlined below: 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

In all the clinics, consultation rooms provided adequate privacy 

More than 60% of clinicians were trained in STI syndromic management 

None of the clinics had adequate equipment for STI management 

Most clinics did not have ciprofloxacin in stock. During the evaluation workshops it emerged 

that the reason for drug shortages was largely due to poor communication between the 

pharmacy and the clinic staff. 

The knowledge of correct treatment protocols in the district was unsatisfactory 

The turnaround time for the testing for syphilis was more than 7 days 

Patient education material was not available in more than 70% of facilities 

In the month of data collection, about 40% of facilities had run out of condoms 

There was poor record keeping of STIs in most facilities. 

32



3 Quality 



❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

Training does not automatically transfer to good practice. Most professional 

nurses were trained in syndromic management, yet many clients were still 

incorrectly treated. This demonstrated the need for continuous in-service 

training and mentoring. 

The evaluation demonstrated that lack of supervision was one of the main 

contributing factors in the lack of equipment. In most cases the supervisors 

were not aware of the lack of protocols, dildos, condoms, and examination 

equipment such as the specula. 

The shortages of STI drugs indicated that there was a need to develop drug 

control mechanisms and to improve communication between the pharmacy 

and clinic staff. 

Clinic managers and local area supervisors must ensure the use of STI 

protocols and guidelines. 

There is the general assumption that each STI client has only one sexual 

partner, which is not always the case. Thus there is a tendency to give an 

STI client only one partner notification card, with possible missed 

opportunities and potential re-infections. This is caused by poor history 

taking and staff attitude towards clients. 

The DISCA was very useful for: 

– Identifying current quality of STI care at health facilities. 

– Identifying factors that contribute to providing a good service. 

– Identifying problems affecting quality of STI care. 

– Helping the district develop an action plan to improve and monitor 

the quality of STIs. 


Every clinic needs a regular (monthly) written report about supervision 

and support given to that clinic. This report should be filed with the clinic 

and sub-district management team. 

33

3 Quality 


Monitoring Quality of Care in Maternal Health 

Umzinyathi District, KwaZulu-Natal 

Regular auditing both at a 

clinic and maternity ward 

level is essential in improving 

the quality of maternal health 

services. 

Umzinyathi is a rural district in KwaZulu-Natal with a very limited 

infrastructure especially regarding roads, piped water and telephones. A 

situation analysis was carried out which identified maternal health care 

services as a priority area for intervention. 

Approach 

An intervention strategy was developed with the assistance of people 

skilled in maternal health care. An experienced maternal health care 

practitioner was contracted to carry out the intervention. One of the key 

objectives identified for the ISDS facilitator was to work with the newly 

appointed Maternal, Child and Women’s Health Coordinator (MCWH) 

in: 

➢ 

➢ 

➢ 

➢ 

Prioritising key issues 

Identifying areas for intervention 

Developing strategies for intervention 

Monitoring the implementation of these strategies. 

Two strategies were embarked on to achieve the planned intervention. One was a regular meeting 

with the MCWH coordinators and the second was a series of monthly district maternal health workshops. 

KEY 



Mpumalanga 





KwaZulu-Natal 

Free State 

UMZINYATHI 

DISTRICT 

MUNICIPALITY 

Ulundi 

Richards Bay 

Durban 

34



3 Quality 


Progress of the Intervention 

A key area needing intervention was monitoring the quality of care of the maternal health services in 

Umzinyathi. It soon became apparent that important information for monitoring the quality of maternal 

health services was not being collected. This data has now been included in the monthly data submitted 

by each clinic. Each clinic now records: 

➢ 

➢ 

➢ 

➢ 

The response time for emergency vehicles to arrive at a clinic 

The number of first time ANC visits 

The number of subsequent ANC visits 

The number of ANC visits before 20 weeks gestation. 

The availability of this information on a quarterly basis enables the district management team to 

monitor an important quality of care indicator in the delivery of maternal health care. In addition to 

collecting the information listed above, two further methods were introduced for monitoring the 

quality of care. These are: 

➢ 

➢ 

A monthly peri-natal review meeting in each sub-district 

Audit tools for both ante-natal care and care during labour. 

Peri-natal Review Meetings (PRMs) 

PRMs had not been taking place in Umzinyathi district and needed to be set up by the sub-districts. 

To ensure these PRMs are sustained after the project is finished, the MCWH coordinators is slowly 

taking more responsibility for the planning, organising and conducting of these meetings. In addition, 

the district monitoring tool now includes checking that monthly PRMs take place. 

Peri-natal review meetings are attended by staff involved in ante-natal care and by those who work in 

the maternity wards. Maternal health data and indicators of the preceding 3 months are presented 

and discussed. This is followed by an in-depth presentation and discussion of one or two particular 

cases during the last month. These meetings provide an opportunity for staff to reflect on the quality 

of care of services rendered. Cases demonstrating both good and poor quality of care are discussed 

and lessons learnt are highlighted. Regular monthly peri-natal review meetings are now being held in 

each of the four sub-districts. 

Audit Tools 

Two audit tools were introduced in an attempt to monitor the quality of maternal health services, one 

to monitor the quality of antenatal services and the other to monitor the quality of care delivered to 

women in labour. Both of these have been accepted by the district and will be used quarterly in the 

clinics and the maternity wards. The MCWH coordinator will be responsible for ensuring these audits 

are carried out on a regular basis. 

35

3 Quality 




Outcomes 

Achievements 

➢ 

➢ 

➢ 

➢ 

➢ 

The MCWH coordinator identified, prioritised and documented the key areas for intervention 

in maternal health. Detailed plans to address the areas of intervention were developed. 

Indicators to monitor key areas were identified 

Information essential for the monitoring of quality of care in maternal health services can 

now be calculated as key data elements have been added to the monthly PHC data collection 

tool 

Staff in the PHC clinics and the maternity wards in provincial hospitals have come to realise 

that in order to improve the quality of service, they have to work together as a team 

Management issues have been identified as contributing to poor services in some of the 

cases presented in the peri-natal review meetings. The MCWH coordinator has taken up 

these issues with the relevant hospital managers. 

Challenges 

The initial district workshop was very well attended and subsequent workshops have continued to be 

well attended. Participants of the workshops express much enthusiasm for the information learnt and 

the process undergone. However, this has not translated into a consistent carrying out of the tasks as 

set out at each workshop, in neither the clinics nor the maternity wards. This has limited the scope 

and impact of the intervention. 

36



3 Quality 



❖ 

❖ 

❖ 

❖ 

Continued mentoring and support is essential for the sustainability of the 

intervention. 

Regular auditing both at a clinic and maternity ward level is essential in 

improving the quality of maternal health services. 

Hospital managers, especially maternity matrons, have to be involved in 

local training initiatives so that they remain updated on treatment policies 

and procedures and are aware of the problems occurring in their 

institutions. 

District hospitals and clinics are part of a continuum of care. Health workers 

and managers of these facilities need to work cooperatively. 


The transfer of maternity patients from clinics to hospitals should be 

experienced as a seamless change, moving from one part of the system to 

another. For this to happen hospitals and district managers need to meet 

regularly to solve problems. 

37

3 Quality 


The process of conducting 

peri-natal mortality reviews 

shows that there are many 

issues around poor quality of 

obstetric care that can be 

addressed. 

Addressing Maternal Mortality Rate 

King Sabata Dalindyebo Health Sub-district, 

O R Tambo, Eastern Cape 

Statistics from Umtata General Hospital (which is the referral hospital for 

most parts of the former Transkei), showed that there was a very high 

maternal mortality rate in 2002. Many of the mothers who died, originated 

from the King Sabata Dalindyebo health sub-district (KSD), which is part 

of the OR Tambo district. 

Situation 

An in-depth analysis of the situation in KSD highlighted a number of 

problems: 

➢ Clinics and community health centres were not conducting 

deliveries, which created a very high workload in the referral hospital 

➢ 

➢ 

Clinics often referred cases to the hospital that should be managed at primary health care 

level and often did not send referral letters with the patients 

The metro ambulance service operated with unacceptably long delays, which often resulted 

in life-threatening situations 

Free State 

KwaZulu- 

Natal 

EC05b1 

EC05b2 

EC144 

EC132 

EC128 

EC133 

EC143 

EC142 

Eastern Cape 

EC138 

EC136 

EC134 

EC135 

EC124 

EC137 

EC141 

EC122 

EC156 

EC157 

EC121 

EC152 

O R TAMBO 

EC151 

EC153 

DISTRICT 

EC155 EC154 

Umtata 

Port 

St Johns 

King 

Sabata Dalinyebo 

Health Sub-district 

KEY 







38




3 Quality 


➢ 

➢ 

➢ 

➢ 

➢ 

The district hospital experienced ongoing problems with equipment (CTG machines, 

ultrasound, laryngoscopes), drugs and shortage of stationary (partogram) 

There were staff shortages of medical officers and professional nurses 

Only one medical officer in the district hospital was experienced in Caesarean sections and 

anaesthesia 

The maternity ward used two registers for deliveries, the old “Transkei” register, and the new 

Hospital Information System, creating unnecessary duplication 

Peri-natal mortality and morbidity meetings were not taking place at the district hospital. 

Approach 

In an attempt to address these problems and to improve the quality of maternal care, peri-natal 

mortality review meetings were initiated. Participants included staff from the maternity and paediatric 

wards, the outpatient department, medical officers and professional nurses from the surrounding 

clinics. These meetings took place on a monthly basis and a hospital peri-natal committee was 

elected at the first meeting. 

Outcome 

The committee took ownership of the peri-natal mortality review and discussed cases on a regular 

basis. Gradually participants gained a better understanding in the use of monthly statistics and were 

able to calculate key indicators around obstetric quality of care, as well as compare the data to 

previous months. Initially it was impossible to discuss cases of peri-natal mortality due to severe 

problems with record keeping. This improved dramatically after the first meeting. 

The Peri-natal Problem Identification Programme (PPIP) is a computer programme, installed on the 

hospital computer for collection of obstetric data and review of deaths. The District Information Officer 

trained interested maternity staff in basic computer skills. However ongoing computer training is 

required for staff to use the PPIP accurately. 

The PPIP has provided a format for case discussions which look at causes of death, as well as factors 

contributing to death, be it patient-related, administrative or health personnel related factors. 

The involvement of medical officers in the PPIP was significantly reduced after two were transferred. 

The remaining two could not continue with the PPIP due to lack of knowledge of the software and 

increased workload. The peri-natal mortality review meetings continued without the medical officers. 

39

3 Quality 






❖ 

❖ 

❖ 

❖ 

❖ 

The process of conducting peri-natal mortality reviews shows that there 

are many issues around poor quality of obstetric care that can be addressed. 

PPIP is a user-friendly computer programme but requires basic computer 

skills and a dedicated staff member. 

It is important to understand the basic indicators in order to use information 

to assess the quality of care within an obstetric unit. 

Involving primary health care nurses in peri-natal mortality review 

meetings, provides them with an opportunity update their skills and also 

improves the relationship between service providers at different levels of 

care. 

Medical officers have an important role to play in the peri-natal committee 

of the district hospital as well as in the peri-natal mortality review. 


Every facility that is involved in obstetric care should participate in the 

peri-natal mortality review process. 

40

3 Quality 


The TB Control Programme, Elundini Sub-district, 

Ukhahlamba, Eastern Cape 

Elundini is one of three health sub-districts within the Ukhahlamba district 

in the Eastern Cape province. It has a deep rural component consisting of 

Mount Fletcher, Tsolo and Qumbu. The rest of the sub-district is mainly 

farmland consisting of two urban service areas, Maclear and Ugie. 

Situation 

A rapid appraisal of the district conducted at the beginning of 2002 revealed 

that the TB cure rate in Elundini had decreased from 39% in 1999 to 34% 

in 2000. An in-depth review to find out the causes for this decline was 

conducted by the HST facilitator of the district, the communicable disease 

coordinator (CDC) and clinic supervisors during October and November 

2002. 

Training alone is not sufficient 

to improve quality of care. 

Ongoing mentoring, support 

and monitoring is essential to 

ensure that staff use their 

newly acquired skills. 

The findings of the review: 

➢ 

➢ 

Only one third of clinics were found to manage TB cases and the TB programme was 

centralised in the hospital. The hospital referred patients to clinics mainly to continue their 

medication. 

Even though nurses at clinic level were able to correctly diagnose TB, sputum samples 

could not get to the laboratory for a definitive diagnosis because of the lack of transport 

KEY 





Free State 

Elundini Health 

Sub-district 

KwaZulu-Natal 




UKHAHLAMBA 

DISTRICT 

ELUNDINI 

DISTRICT 

MUNICIPALITY 

Eastern Cape 

Eastern Cape 

Umtata 

Port St Johns 

East London 

41

3 Quality 


The TB Control Programme, 

Elundini Sub-district, Ukhahlamba, Eastern Cape 

➢ 

➢ 

➢ 

➢ 

TB patients from rural clinics were referred to the hospital, where the patients could have 

their sputum tested and treatment initiated. Thereafter patients were referred back to the 

clinic for follow up, but would still need to go back to the hospital for the sputum tests in 

month 2 and 3 and at the end of their treatment. Some patients were unable to get to the 

hospital because of the costs involved, while others simply got lost in the system because 

both clinic and hospital were under the impression that the client was attending at the other 

facility. 

Over 75% of clinics did not have TB protocols or any system in place for sputum collection 

Around half of the clinics were not recording clinical progress on the blue cards 

Staff in the majority of the clinics had received no training on the new TB register. 

Approach 

The results of the in-depth review were presented to the management team and clinic staff. A facilitation 

process to find solutions to these problems was followed. 

Outcome 

➢ 

➢ 

➢ 

➢ 

➢ 

➢ 

A TB committee was formed to plan and implement activities that would improve TB services 

Nurses received training on the preliminary findings of the in-depth TB review, the South 

African National TB Control Programme, the new TB register and quarterly reporting of TB 

indicators 

Outstanding TB stationary was supplied to clinics including TB registers, blue and green 

patient profile cards, National TB control programme guidelines and TB protocols 

Recording TB patient data into the new registers was backdated and completed from July 

2002 

The sub-district manager motivated for a car from the Provincial Department of Health for 

sputum collection. A motorbike was provided and as a result case finding is taking place in 

all clinics. 

The challenges facing the TB programme have been discussed at community level with the 

clinic committees. Volunteers for DOTS support training were selected in communities and 

clinic sisters were trained on how to train DOTS supporters. 

Supervision 

The next step was supporting staff at facility level with emphasis on in-service training specific to 

individual clinic needs. The supervisory system was strengthened by allocating clinics to supervisors. 

The supervisors mentored and trained in the use of the supervision manual and were involved in the 

TB training processes. This enabled them to assist the TB coordinator in supporting and monitoring the 

progress of the clinics. 

42



3 Quality 



The TB committee established that there was nobody trained in TB in the sub-district. The district 

municipality had an experienced TB trainer as well as a person who was well versed in TB indicators. 

Thus, these officials were used to assist the sub-district by conducting workshops in TB, which were 

held for both local and provincial government staff. The TB trainer also provided support to the subdistrict 

TB coordinator. A joint supervisory programme was started in the sub-district with the supervisors 

sharing the clinics equally. The basis for supervision was the distance to the clinic. 

Transport Management 

The need to prioritise clinic supervision within the sub-district assisted the management team to put 

in place a transport management system and to work out a transport plan that prioritised service 

delivery. 


❖ 

❖ 

❖ 

❖ 

❖ 

❖ 

Cooperation and collaboration between local and provincial government 

increased efficiency, specifically in the manner in which TB was handled. 

Training alone is not sufficient to improve quality of care: On-going 

mentoring, support and monitoring is essential to ensure that staff used 

their newly acquired skills. 

Supervisors need support to ensure that their work improves the quality of 

care. Supervisors, in addition to ensuring that the structural and 

administrative sectors within the clinics are functioning efficiently, have 

to provide in-service training to staff at clinic level. We found that 

supervisors and programme managers benefited from monthly supervision 

days where a supervisor / mentor provided training . 

Addressing the different components such as transport, drug supply and 

supervision relating to the TB programme had a positive effect on other 

programmes that also needed these support systems. 

Transportation of sputum remains a problem because of the rugged terrain. 

It is important to change the mindset of the community from believing 

that the best TB treatment is only available at a hospital, to one that 

recognises that equally good treatment is available at clinics. 

43

3 Quality 





Clinics and the staff do not only need training, but specific on-going 

supervision, mentoring and support from the sub-district, district and 

provincial levels. 

44

Primary health care is essentially a very simple concept. However its 

implementation, as demonstrated in these case studies, is often very difficult. 

There is a shadow between the policy and the practice. 

These case studies and lessons have tried to highlight some of the insights that have 

been gained by a diverse group of facilitators working in a range of different health 

districts around South Africa. 

It is hoped that readers will be able to use some of these experiences to assist them 

to find their own “simple solutions” to problems that they are experiencing in 

improving PHC. 

45

Lesson learnt in the implementation of PHC - Health Systems Trust

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