Lesson learnt in the implementation of PHC - Health Systems Trust

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1 Strengthening the District Health System 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 Health District (C Municipality Boundary) B Municipality Boundary Provincial Boundary Durban Original source - Municipal Demarcation Board. Updated through other sources 11
1 Strengthening the District Health System 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
Page 2 and 3: LESSONS LEARNT IN THE IMPLEMENTATIO
Page 4 and 5: Acknowledgements Acronyms Introduct
Page 6 and 7: Introduction There are a great many
Page 8 and 9: Capacity Building of Health Council
Page 10 and 11: Capacity Building of Health Council
Page 12 and 13: Functional Integration in Chris Han
Page 14 and 15: Functional Integration in Chris Han
Page 16 and 17: Structural Management and Support S
Page 20 and 21: Decentralising TB Management from a
Page 22 and 23: 1 Strengthening the District Health
Page 24 and 25: Clinic Supervision in the Sekhukhun
Page 26 and 27: The District Health Expenditure Rev
Page 28 and 29: Improving the Quality of Routine Pr
Page 30 and 31: Improving the Quality of Routine Pr
Page 32 and 33: Drug Supply and Management City of
Page 34 and 35: Improving the Quality of STI Manage
Page 36 and 37: Improving the Quality of STI Manage
Page 38 and 39: 3 Quality of Care The Use of the Di
Page 40 and 41: The Use of the District Quality of
Page 42 and 43: Monitoring Quality of Care in Mater
Page 44 and 45: Monitoring Quality of Care in Mater
Page 46 and 47: Addressing Maternal Mortality Rate
Page 48 and 49: 3 Quality of Care The TB Control Pr
Page 50 and 51: The TB Control Programme, Elundini
Page 52: Primary health care is essentially

Lesson learnt in the implementation of PHC - Health Systems Trust

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