Primary Health Care in Mpumalanga - Health Systems Trust
Primary Health Care in Mpumalanga - Health Systems Trust
Primary Health Care in Mpumalanga - Health Systems Trust
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<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> <strong>in</strong> <strong>Mpumalanga</strong>:<br />
Highveld<br />
Lowveld<br />
Eastern Highveld<br />
Guide to district-based action
T<br />
Written and produced by the Department of <strong>Health</strong>,<br />
Welfare and Gender Affairs, <strong>Mpumalanga</strong>:<br />
Dept. of <strong>Health</strong>, Welfare and Gender Affairs<br />
Private Bag X11285 • Nelspruit 1200<br />
Tel: (013) 7528085 • Fax: (013) 7554698<br />
Published by the <strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
S<br />
H<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
504 General Build<strong>in</strong>g • Cnr Smith and Field Streets • Durban 4001<br />
Tel: (031) 3072954 • Fax: (031) 304 0775 • E-Mail: hst@wn.apc.org<br />
ISBN: 0-9584110-5-0<br />
First Edition: October 1996<br />
Designed, Typeset and Pr<strong>in</strong>ted by Kwik Kopy Pr<strong>in</strong>t<strong>in</strong>g, Durban
FOREWORD<br />
Our prov<strong>in</strong>ce has adopted <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> (PHC) as the ma<strong>in</strong> strategy<br />
for develop<strong>in</strong>g and promot<strong>in</strong>g the health of our communities, us<strong>in</strong>g the<br />
District <strong>Health</strong> System as the vehicle for facilitat<strong>in</strong>g its implementation. The<br />
services to be rendered to each community must necessarily be based on<br />
their needs; acceptable to them; and delivered <strong>in</strong> a manner that is<br />
accountable to them and with their full participation.<br />
S<strong>in</strong>ce adopt<strong>in</strong>g PHC, my prov<strong>in</strong>cial and regional teams have worked<br />
tirelessly to establish a health system based on a district, first by conduct<strong>in</strong>g<br />
a situation analysis which was followed by development of the district health<br />
plans. The preparation of this handbook is yet a further <strong>in</strong>itiative aimed at<br />
consolidat<strong>in</strong>g the development of the District <strong>Health</strong> System. The book will<br />
be used both as a reference and a guide to successful implementation of<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> <strong>in</strong> the prov<strong>in</strong>ce.<br />
It is important to note that the handbook is not a prescriptive document.<br />
Each District <strong>Health</strong> Management Team and other users should adapt its<br />
use to their chang<strong>in</strong>g environment.<br />
Each DHMT should strive to deliver primary health care services on the basis<br />
of equal accessibility; build<strong>in</strong>g on exist<strong>in</strong>g structures; <strong>in</strong>tegrat<strong>in</strong>g the PHC<br />
programmes <strong>in</strong>to an implementable package; optimis<strong>in</strong>g the<br />
public-private sector mix; and empower<strong>in</strong>g the users to participate <strong>in</strong> service provision and governance. Let<br />
us aim at provid<strong>in</strong>g a high quality, compassionate and car<strong>in</strong>g service founded on availability and accessibility<br />
of a well organised referral network <strong>in</strong>volv<strong>in</strong>g all levels of care, i.e. community, cl<strong>in</strong>ic, health care and hospital;<br />
availability of f<strong>in</strong>ancial and material resources; provision of timely logistical support systems; and development<br />
of a culture that recognises the health worker as an important resource. It is our responsibility, to ensure that<br />
the systems and resources are <strong>in</strong> place. The prov<strong>in</strong>cial team together with the regional staff are committed<br />
to provid<strong>in</strong>g the necessary technical support to the districts to make the implementation of <strong>Primary</strong> <strong>Health</strong><br />
<strong>Care</strong> a reality.<br />
May I take this opportunity to congratulate all members who contributed to the production of this handbook<br />
and the support from the National Department of <strong>Health</strong>. The enthusiasm demonstrated is a true reflection<br />
of the commitment of our staff to transform<strong>in</strong>g the health care delivery system to address the needs of the<br />
people.<br />
The usefulness of the handbook, however, will only be realised when we beg<strong>in</strong> see<strong>in</strong>g positive changes <strong>in</strong> the<br />
health status of our people.<br />
Hon. Candith K. Mashego (Ms)<br />
MEC<br />
<strong>Health</strong>, Welfare and Gender Affairs,<br />
<strong>Mpumalanga</strong> Prov<strong>in</strong>ce<br />
i
ACKNOWLEDGEMENTS<br />
The MEC and Management of the <strong>Mpumalanga</strong> Department of <strong>Health</strong>, Welfare and Gender Affairs wishes<br />
to thank the follow<strong>in</strong>g persons, as well as those that may have been <strong>in</strong>adverterly omitted for their vision,<br />
<strong>in</strong>sight and commitment <strong>in</strong> develop<strong>in</strong>g this handbook. We also wish to thank David Harrison for edit<strong>in</strong>g and<br />
plann<strong>in</strong>g the layout of this handbook.<br />
This has truly been an example where divergent views have been embroided <strong>in</strong>to synergy.<br />
Maureen Beck<br />
Coenie Bekker<br />
Kelv<strong>in</strong> Bell<strong>in</strong>ghurst<br />
Leon Bonnet<br />
Clara Chiloane<br />
Deon Cloete<br />
Dave Durrheim<br />
Danie Groenewald<br />
Bernice Harris<br />
Rebecca Hlatshwayo<br />
Felicity Gibbs<br />
John Gear<br />
Nobayeni Dladla<br />
David Harrison<br />
David Mametja<br />
Joan Matji<br />
Eddie Mhlanga<br />
Eddie McGrath<br />
Mandi Mzimba<br />
Sam Kazibwe<br />
William Okedi<br />
V<strong>in</strong>cent Or<strong>in</strong>da<br />
Steve Tollman<br />
Yogan Pillay<br />
Row<strong>in</strong>a Jordaan<br />
Gulam Karim<br />
Judith Lubisi<br />
Elizabeth Malumane<br />
Len Mdluli<br />
Amos Masango<br />
Thalitha Modonsela<br />
Janet Maphanga<br />
Gladness Mathebula<br />
Keith Michael<br />
Writers<br />
Resource Persons<br />
Get Ahead Foundation<br />
Wits Rural Foundation<br />
Department of <strong>Health</strong> (National)<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
UNICEF<br />
Department of <strong>Health</strong> (National)<br />
Department of <strong>Health</strong> (National)<br />
Department of <strong>Health</strong> (National)<br />
AMREF<br />
AMREF<br />
UNICEF<br />
<strong>Health</strong> <strong>Systems</strong> Development Unit<br />
Department of <strong>Health</strong> (National)<br />
Reviewers<br />
Sam Mkhabela<br />
Irene Mkhabela<br />
Pat Mkhwanazi<br />
Coll<strong>in</strong> Mupombwa<br />
Shirley Ngwenya<br />
Sonto Nxumalo<br />
Jabulani Mndebele<br />
Andrew Pond<br />
Christ<strong>in</strong>e Phiri<br />
Andr<strong>in</strong>a Sambo<br />
Alucia Shabangu<br />
Kareen Swart<br />
Lynn Viljoen<br />
Bonnyface Wankya<br />
Milani Wolmarans<br />
Mas<strong>in</strong>gita Zwane<br />
Elise Appel<br />
Peter Barron<br />
Irw<strong>in</strong> Friedman<br />
Lucy Gilson<br />
Arthur Haywood<br />
Peter Long<br />
Lydia Pretorius<br />
William Pick<br />
Laetitia Rispel<br />
Hugh Philpott<br />
National Progressive <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Network<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
National Progressive <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Network<br />
University of the Witwatersrand<br />
University of the Western Cape<br />
National Progressive <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Network<br />
National Disability Desk<br />
University of Witwatersrand<br />
University of the Witwatersrand<br />
Centre for <strong>Health</strong> and Social Studies - University of Natal<br />
ii
Secretariat<br />
Graziela DeSouza<br />
Theresa Knoetze<br />
Irene Mathare<br />
Busi Mathabela<br />
Rose Mgwenya<br />
Anna Nkosi<br />
Lucas Nkosi<br />
Doreen Nkuna<br />
Maritjie Petzer<br />
Michael Skhosana<br />
Co-ord<strong>in</strong>ators<br />
Nomonde Bam<br />
Kathy Kahn<br />
Wynand Nant’ulya<br />
Sam O’ngayo<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> (<strong>Mpumalanga</strong>)<br />
<strong>Health</strong> <strong>Systems</strong> Development Unit<br />
AMREF<br />
AMREF<br />
Editor<br />
David Harrison<br />
<strong>Health</strong> <strong>Systems</strong> <strong>Trust</strong><br />
iii
TABLE OF CONTENTS<br />
Page<br />
FOREWORD<br />
i<br />
ACKNOWLEDGEMENTS<br />
ii<br />
INTRODUCTION 3<br />
CHAPTER 1<br />
HEALTH CARE IN MPUMALANGA:<br />
WHY CHANGE HAD TO COME 9<br />
Background 9<br />
The New Focus 9<br />
CHAPTER 2<br />
AN OVERVIEW OF THE ORGANISATION OF HEALTH SERVICES<br />
IN MPUMALANGA 15<br />
Prov<strong>in</strong>cial <strong>Health</strong> Office 15<br />
Regional <strong>Health</strong> Office 19<br />
District <strong>Health</strong> Office 21<br />
Distribution of Public <strong>Health</strong> Facilities <strong>in</strong> the Prov<strong>in</strong>ce 21<br />
Other <strong>Health</strong> Service Providers 23<br />
CHAPTER 3<br />
A DISTRICT HEALTH SYSTEM AND ITS MANAGEMENT 27<br />
The District <strong>Health</strong> System and Referral Networks 28<br />
The District <strong>Health</strong> Management Team 31<br />
Functions of other members of the DHMT 39<br />
<strong>Health</strong> Facility Management Teams 40
Page<br />
CHAPTER 4<br />
THE ROLE OF COMMUNITIES IN HEALTH DEVELOPMENT 45<br />
Gett<strong>in</strong>g to Know the Community You Serve 46<br />
Forg<strong>in</strong>g L<strong>in</strong>kages and Partnership 47<br />
Community Involvement <strong>in</strong> <strong>Health</strong> <strong>Care</strong> 47<br />
CHAPTER 5<br />
DELIVERING INTEGRATED PRIMARY HEALTH CARE<br />
IN THE DISTRICT 55<br />
The District <strong>Health</strong> for All Package 55<br />
The Need for Integration of PHC Services 56<br />
How the District PHC Package will be co-ord<strong>in</strong>ated 58<br />
Deliver<strong>in</strong>g <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Services to Households 60<br />
<strong>Health</strong> Facility Based PHC Services 62<br />
CHAPTER 6<br />
GOVERNANCE OF THE DISTRICT HEALTH SYSTEM<br />
IN MPUMALANGA 69<br />
The Governance Option for <strong>Mpumalanga</strong> 70<br />
Governance of <strong>Health</strong> Services at Prov<strong>in</strong>cial Level 70<br />
Governance of <strong>Health</strong> Services at District Level 71<br />
Governance of <strong>Health</strong> Services at Facilities 71<br />
Community <strong>Health</strong> Committees 73
Page<br />
CHAPTER 7<br />
PRIMARY HEALTH CARE SERVICE PROGRAMMES 77<br />
<strong>Health</strong> Promotion 78<br />
Maternal, Child and Women’s <strong>Health</strong> 80<br />
Nutrition Programme 83<br />
<strong>Primary</strong> Oral <strong>Health</strong> <strong>Care</strong> 85<br />
Environmental <strong>Health</strong> 86<br />
Communicable Diseases Control 88<br />
Rehabilitation as a Service Programme 90<br />
Emergency <strong>Health</strong> Services 92<br />
Curative, Diagnostic and Medico-Legal Services 93<br />
Mental <strong>Health</strong> and Substance Abuse 95<br />
CHAPTER 8<br />
A DISTRICT HEALTH AND MANAGEMENT INFORMATION SYSTEM 103<br />
<strong>Health</strong> and Management Information Needs 103<br />
Tools and Methods for Collect<strong>in</strong>g and Process<strong>in</strong>g Information 105<br />
Advocat<strong>in</strong>g for the Use of <strong>Health</strong> Information 107<br />
How to Establish a District <strong>Health</strong> and Management Information System 108<br />
CHAPTER 9<br />
MONITORING AND EVALUATION OF HEALTH SERVICES 113<br />
Monitor<strong>in</strong>g 113<br />
Evaluation 117
Page<br />
CHAPTER 10<br />
DEVELOPING AND MANAGING HUMAN RESOURCES 125<br />
Case Study 126<br />
Human Resources Plann<strong>in</strong>g 127<br />
Job Analysis and Job Description 127<br />
Recruitment 128<br />
Public Service Commission 128<br />
Probation 128<br />
Orientation and Induction 128<br />
Performance Appraisal 129<br />
Promotion 130<br />
Discipl<strong>in</strong>e 130<br />
Benefits 130<br />
When Employees Leave (Exit) 130<br />
Tra<strong>in</strong><strong>in</strong>g and Development 131<br />
Annexure of Acronyms 132<br />
District Dictionary 134<br />
Additional References 142
INTRODUCTION
INTRODUCING THIS GUIDE<br />
<strong>Mpumalanga</strong> is one of the n<strong>in</strong>e prov<strong>in</strong>ces of the Republic of South Africa. The population of the prov<strong>in</strong>ce is<br />
about 3 150 000 (1993 estimate). 1 There are 10 prov<strong>in</strong>cial government departments. One of these is the<br />
Department of <strong>Health</strong>, Welfare and Gender Affairs which is responsible for the <strong>Health</strong> portfolio. With<strong>in</strong> this<br />
department, there are two chief directorates: one for health and the other for welfare; and a<br />
sub-directorate of Gender Affairs which gives policy support to all the prov<strong>in</strong>cial departments.<br />
Tremendous change is tak<strong>in</strong>g place <strong>in</strong> the character and organisation of health services <strong>in</strong> <strong>Mpumalanga</strong>.<br />
These changes are <strong>in</strong> accordance with policy guidel<strong>in</strong>es from the National Department of <strong>Health</strong> 2 , and they<br />
<strong>in</strong>volve:<br />
• decentralisation of services to the regions and districts to br<strong>in</strong>g the services close to the people;<br />
• adoption of the district health system as the vehicle for health care delivery <strong>in</strong> the prov<strong>in</strong>ce;<br />
• the choice of primary health care as the strategy for delivery of universal health care to <strong>in</strong>dividuals,<br />
families and communities <strong>in</strong> the prov<strong>in</strong>ce;<br />
• the need to <strong>in</strong>volve stakeholders <strong>in</strong> plann<strong>in</strong>g and delivery of health services to the communities<br />
through mean<strong>in</strong>gful community participation; and<br />
• the need and desire to create a health service that cares for, and is responsive to client needs.<br />
This guide is <strong>in</strong>tended for you (health service managers, providers and consumers) <strong>in</strong> the prov<strong>in</strong>ce.<br />
The purpose of the guide is to:<br />
• help all people <strong>in</strong>volved <strong>in</strong> health care to understand the philosophy underly<strong>in</strong>g the new<br />
developments <strong>in</strong> health care provision <strong>in</strong> the prov<strong>in</strong>ce;<br />
• help those <strong>in</strong>volved <strong>in</strong> health care to def<strong>in</strong>e their own roles and responsibilities; stimulate and guide<br />
all <strong>in</strong>volved <strong>in</strong> health care to translate plans <strong>in</strong>to action and concepts <strong>in</strong>to practice; and<br />
• enable health providers to expla<strong>in</strong> to communities the changes and what the District <strong>Health</strong><br />
System is all about.<br />
The guide will help to accelerate the implementation of <strong>in</strong>tegrated health care services with<strong>in</strong> the<br />
district health system, based on primary health care pr<strong>in</strong>ciples. As the key actions highlighted <strong>in</strong> the guide<br />
are put <strong>in</strong>to practice, the prov<strong>in</strong>ce will be able to achieve its health goals and objectives - <strong>in</strong> l<strong>in</strong>e with the<br />
goals of the Reconstruction and Development Programme and the National Programme of Action for Children<br />
<strong>in</strong> South Africa. The guide provides a detailed description of the health services and should not be seen as<br />
prescriptive, but as provid<strong>in</strong>g guidel<strong>in</strong>es. In apply<strong>in</strong>g the guidel<strong>in</strong>es, you are encouraged to use your <strong>in</strong>itiative<br />
and judgement.<br />
The guide is divided <strong>in</strong>to four parts. The first part, on service organisation and management,<br />
conta<strong>in</strong>s four chapters. The first chapter describes the philosophy beh<strong>in</strong>d the new changes. Chapter 2 sketches<br />
the services presently available <strong>in</strong> the prov<strong>in</strong>ce. The third chapter <strong>in</strong>troduces the district health system, while<br />
chapter 4 describes the role of the communities <strong>in</strong> health development.<br />
Part two of the handbook deals with PHC service delivery and governance and the section conta<strong>in</strong>s three<br />
chapters. Chapter 5 provides the framework for implementation of the PHC services, while chapter 6 focuses<br />
on governance systems for the health services. Chapter 7 describes the 10 (PHC) service programmes.<br />
The third part of the handbook discusses <strong>in</strong>formation, monitor<strong>in</strong>g and evaluation. Chapter 8 discusses the<br />
district health and management <strong>in</strong>formation system (DHMIS) and chapter 9 focuses on monitor<strong>in</strong>g and<br />
evaluation.<br />
Part four of the handbook conta<strong>in</strong>s one chapter which describes the prov<strong>in</strong>cial plans for human<br />
resources development and management.<br />
The process of writ<strong>in</strong>g the handbook took 6 months and it <strong>in</strong>volved:<br />
• rapid assessment of health needs <strong>in</strong> the prov<strong>in</strong>ce<br />
• literature review<br />
• four workshops, a field visit to Ag<strong>in</strong>court, a health centre network <strong>in</strong> Bushbuckridge district, Northern<br />
Prov<strong>in</strong>ce; and<br />
• extensive consultations with National officials, Regional <strong>Health</strong> Directors and District <strong>Health</strong><br />
Managers, NGOs, and private providers.<br />
1<br />
Source: Regional <strong>Health</strong> Management Information System (ReHMIS)<br />
2<br />
A Policy for the Development of a District <strong>Health</strong> System for South Africa, National Department of <strong>Health</strong>, 1994<br />
3
The workshops and consultations provided the department with an opportunity to exam<strong>in</strong>e certa<strong>in</strong><br />
policies, and to th<strong>in</strong>k through the proposed structural and operational frameworks for service delivery. Some<br />
old policies and practices have been revised; new ideas have been <strong>in</strong>troduced; and issues which require<br />
further debate, deliberation and prov<strong>in</strong>cial legislation have been identified.<br />
The ideas presented <strong>in</strong> the text are not fixed; they are <strong>in</strong> evolution and will be redef<strong>in</strong>ed as necessary.<br />
Unresolved issues still rema<strong>in</strong>. The department faces certa<strong>in</strong> constra<strong>in</strong>ts and obstacles. Certa<strong>in</strong> national and<br />
prov<strong>in</strong>cial policies are still to be f<strong>in</strong>alised. Some changes <strong>in</strong> the service structure have already been put <strong>in</strong><br />
place, but others are yet to come. A lot stands to be learnt dur<strong>in</strong>g the first few years of implement<strong>in</strong>g this new<br />
system. The lessons learnt will be put to use <strong>in</strong> improv<strong>in</strong>g the quality of health care for all <strong>in</strong>dividuals, families<br />
and communities <strong>in</strong> the prov<strong>in</strong>ce and <strong>in</strong> mak<strong>in</strong>g future revisions to the handbook. The handbook does not<br />
provide all the answers - but we had to start somewhere. We are sure that this handbook will be of <strong>in</strong>terest to<br />
the other prov<strong>in</strong>ces, too.<br />
<strong>Mpumalanga</strong> Prov<strong>in</strong>ce<br />
<strong>Health</strong> Regions<br />
Highveld Region<br />
Lowveld Region<br />
R E G I O N<br />
Eastern Highveld<br />
Eastern Highveld Region<br />
Highveld region<br />
Lowveld region<br />
N<br />
0 25 50<br />
Kilometers<br />
4
PART 1<br />
Service Organisation and Management
HEALTH CARE IN MPUMALANGA:<br />
WHY CHANGE HAD TO COME<br />
CHAPTER 1
Chapter 1<br />
HEALTH CARE IN MPUMALANGA:<br />
WHY CHANGE HAD TO COME<br />
The objective of this chapter is to provide background <strong>in</strong>formation that will help you to understand why the<br />
change <strong>in</strong> health service delivery became necessary.<br />
After read<strong>in</strong>g this chapter, you will be able to:<br />
• visualise the background to health services <strong>in</strong> the prov<strong>in</strong>ce;<br />
• understand factors lead<strong>in</strong>g to changes <strong>in</strong> the health delivery system;<br />
• appreciate the need for change;<br />
• identify key elements <strong>in</strong> the new focus for health care <strong>in</strong> the prov<strong>in</strong>ce; and<br />
• understand the rationale for decentralisation of health services to the districts.<br />
BACKGROUND<br />
The Department of <strong>Health</strong>, Welfare and Gender Affairs <strong>in</strong> <strong>Mpumalanga</strong> <strong>in</strong>herited a health system which was<br />
fragmented; <strong>in</strong>accessible to the majority of the citizens of the prov<strong>in</strong>ce; and was also curative<br />
oriented and hospital based.<br />
The hospital based, curative health services consumed the bulk of health resources of the prov<strong>in</strong>ce at the<br />
expense of preventive and promotive health services. As a result, patients with preventable<br />
conditions overloaded the hospital services. Prom<strong>in</strong>ent amongst these conditions were communicable<br />
diseases, diseases of childhood, nutritional deficiencies and manageable complications of pregnancy. For<br />
most of these conditions, prevention, easy treatment and control measures exist.<br />
The overload<strong>in</strong>g of hospitals by patients with preventable conditions created a vicious cycle which led to a<br />
greater demand for more hospitals. Huge <strong>in</strong>vestments were put <strong>in</strong>to the construction and equipp<strong>in</strong>g of hospitals<br />
and the tra<strong>in</strong><strong>in</strong>g of sophisticated health workers, with little or no allocation of resources for the development<br />
of a <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> system. Moreover, health care was available to only small numbers of the population,<br />
ma<strong>in</strong>ly those with the ability to pay and with easy access to hospitals and other facilities situated ma<strong>in</strong>ly <strong>in</strong> the<br />
cities and urban areas.<br />
The other feature of the system <strong>in</strong>herited was the unequal distribution of resources along geographic and<br />
other l<strong>in</strong>es. <strong>Health</strong> care facilities were concentrated <strong>in</strong> urban areas. This unequal distribution of health facilities<br />
led to disparities <strong>in</strong> health care coverage. The old strategy was thus <strong>in</strong>appropriate for the health care needs<br />
of the majority of people.<br />
THE NEW FOCUS<br />
The goal of the Department is to change, <strong>in</strong> four major ways, the manner <strong>in</strong> which health services are delivered<br />
<strong>in</strong> the prov<strong>in</strong>ce by:<br />
• design<strong>in</strong>g a health service delivery system which can reach the majority of people;<br />
• employ<strong>in</strong>g measures to prevent and treat preventable diseases and conditions<br />
• redirect<strong>in</strong>g the thrust of health care <strong>in</strong> the broader context of development; and<br />
• provid<strong>in</strong>g a car<strong>in</strong>g, compassionate service.<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Strategy<br />
The Department is <strong>in</strong> the process of implement<strong>in</strong>g a new strategy which will change the fragmented health<br />
system <strong>in</strong>to a comprehensive and <strong>in</strong>tegrated health system based on <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> (PHC). This<br />
9
strategy is derived from the National <strong>Health</strong> Bill, the Reconstruction and Development Programme (RDP), the<br />
official policy of the National Department of <strong>Health</strong> and the National Programme of Action for Children<br />
(NPA). Central to this strategy is commitment to a system of health care that is accessible and affordable and<br />
addresses the socio-economic issues which impact on health, through community participation and<br />
<strong>in</strong>tersectoral collaboration<br />
Def<strong>in</strong>ed simply, primary health care is affordable, susta<strong>in</strong>able, and universal essential health care for all<br />
<strong>in</strong>dividuals, families and communities <strong>in</strong> the district, rendered <strong>in</strong> accordance with the people’s health needs,<br />
acceptance and their full participation. 1<br />
Enshr<strong>in</strong>ed <strong>in</strong> the primary health care strategy are the concepts of keep<strong>in</strong>g people healthy <strong>in</strong> their homes and<br />
car<strong>in</strong>g for them <strong>in</strong> health facilities when they become unwell. This strategy uses the district as the centre for<br />
plann<strong>in</strong>g, implement<strong>in</strong>g and evaluat<strong>in</strong>g PHC services. The comprehensive primary health care approach<br />
<strong>in</strong>corporates a broad def<strong>in</strong>ition of health; the nature and role of health services; and the relationship between<br />
health services and other <strong>in</strong>terventions which improve the health status of the people.<br />
Decentralisation of <strong>Health</strong> Services<br />
<strong>Health</strong> services <strong>in</strong> the prov<strong>in</strong>ce are decentralised to the districts, giv<strong>in</strong>g the District <strong>Health</strong> Managers appropriate<br />
powers <strong>in</strong> respect of personnel and f<strong>in</strong>ancial controls. This will <strong>in</strong>crease responsibility,<br />
accountability and efficiency of the service. It will also boost staff morale and encourage local <strong>in</strong>itiative and<br />
flexibility <strong>in</strong> deal<strong>in</strong>g with chang<strong>in</strong>g local circumstances<br />
The purpose for decentralis<strong>in</strong>g health services to the district level is to:<br />
• allow primary health care services to be brought nearer to all communities <strong>in</strong> the district so as to<br />
allow decisions to be taken at the operational level;<br />
• promote participation by communities <strong>in</strong> plann<strong>in</strong>g and delivery of health services;<br />
• ensure responsiveness of health services to the health needs of the communities;<br />
• create an environment for transparency and accountability of the services to the communities;<br />
and<br />
• facilitate collaboration with other government sectors that have a bear<strong>in</strong>g on health.<br />
Characteristics of the New Service<br />
The Department aims to transform health care <strong>in</strong> <strong>Mpumalanga</strong> <strong>in</strong>to a car<strong>in</strong>g, compassionate service that is<br />
responsive to local health needs and is accountable to its community. The service will put emphasis on<br />
health promotion, disease prevention, early diagnosis and treatment to prevent complications, communitybased<br />
rehabilitation of people with chronic disabilities and palliative therapy. The key<br />
elements of the new delivery system are briefly discussed below.<br />
Quality Service<br />
The follow<strong>in</strong>g factors are regarded as important and will be assured <strong>in</strong> all health facilities:<br />
• care should be technically sound and <strong>in</strong> accordance with national standards of practice;<br />
• the general environment of the health facility, <strong>in</strong>clud<strong>in</strong>g cleanl<strong>in</strong>ess, attitude and approach of<br />
staff should be car<strong>in</strong>g;<br />
• client satisfaction and happ<strong>in</strong>ess should be a prime consideration; and<br />
• health services should be responsive to the broader problems of the community e.g. lack of food,<br />
water and sanitation; and illiteracy.<br />
Good quality health care <strong>in</strong>cludes:<br />
• ensur<strong>in</strong>g that the patient’s and health provider’s rights are protected <strong>in</strong> accordance with the<br />
provisions of Chapter 2 of the National <strong>Health</strong> Act;<br />
• m<strong>in</strong>imis<strong>in</strong>g wait<strong>in</strong>g time for the patient/client;<br />
• hav<strong>in</strong>g a pleasant staff and a hospitable environment;<br />
• respect<strong>in</strong>g the client’s/patient’s dignity, culture and values;<br />
• giv<strong>in</strong>g full explanation to the patient/client as well as to relatives about his/her condition;<br />
• ensur<strong>in</strong>g availability of drugs; and<br />
• organis<strong>in</strong>g open<strong>in</strong>g and clos<strong>in</strong>g time to meet the needs of the community.<br />
1<br />
Adapted from Alma Ata Declaration<br />
10
Integrated, Comprehensive Services<br />
The District <strong>Health</strong> Management Teams (DHMTs) will have an effective service delivery strategy that<br />
m<strong>in</strong>imises wastage and maximises benefits to the people. All activities will be <strong>in</strong>tegrated and the health care<br />
system organised to focus on PHC. The DHMTs will plan, deliver and manage an <strong>in</strong>tegrated and<br />
comprehensive service both at household and facility levels.<br />
Effectiveness and Efficiency<br />
The DHMTs should target resources appropriately <strong>in</strong> order to obta<strong>in</strong> demonstrable health benefits and maximise<br />
health ga<strong>in</strong>s at the lowest possible cost. This will need careful plann<strong>in</strong>g, implementation and<br />
monitor<strong>in</strong>g of health activities. Use of services will be rationalised such that only services that cannot be<br />
provided at lower levels of health care are rendered at the higher levels, with a clearly established referral<br />
system.<br />
Equity and Accessibility<br />
Service plann<strong>in</strong>g will ensure that underserved communities benefit from a system that promotes equity <strong>in</strong><br />
the provision of services. This system will be developed and put <strong>in</strong> place by direct<strong>in</strong>g resources<br />
accord<strong>in</strong>g to need, with emphasis on disadvantaged communities. Any person who needs access to<br />
primary health care services will obta<strong>in</strong> them without restrictions from the health authorities.<br />
Community Participation and Local Accountability<br />
In order to promote ownership of health development, the communities, through their representatives and<br />
<strong>in</strong>terest groups, will be encouraged to participate <strong>in</strong> the plann<strong>in</strong>g, provision, control and monitor<strong>in</strong>g of health<br />
services. Communities will be represented <strong>in</strong> governance structures at community and district levels.<br />
Mechanisms are be<strong>in</strong>g developed for ensur<strong>in</strong>g that staff and service <strong>in</strong> a district or local area with<strong>in</strong> the<br />
district are accountable to the local communities they serve. Cont<strong>in</strong>u<strong>in</strong>g dialogue between the communities,<br />
health service providers and relevant sectors will be essential <strong>in</strong> establish<strong>in</strong>g the mechanisms.<br />
Intersectoral Approach to <strong>Health</strong> Development<br />
Intersectoral collaboration, <strong>in</strong>formation shar<strong>in</strong>g and jo<strong>in</strong>t efforts are essential for health promotion and<br />
prevention of ill health. Partnership is the key to empower<strong>in</strong>g communities and <strong>in</strong>dividuals to take<br />
responsibility for the promotion and ma<strong>in</strong>tenance of their health. While carry<strong>in</strong>g out their tasks, health workers<br />
will give due recognition to the role and place of other players and facilitate their participation.<br />
Susta<strong>in</strong>ability of Services<br />
As DHMTs attempt to put new systems <strong>in</strong> place, they should develop ways and means of ensur<strong>in</strong>g that<br />
services are susta<strong>in</strong>able. In this regard the districts will need to establish a secure f<strong>in</strong>ancial base to allow for<br />
long-term plann<strong>in</strong>g.<br />
In this chapter you have read about the background lead<strong>in</strong>g to changes <strong>in</strong> the way health services are<br />
delivered <strong>in</strong> the prov<strong>in</strong>ce. These changes affect you - the consumer, health provider or service manager.<br />
Implementation and management of change is difficult. In order for the changes to be successfully<br />
implemented, all stakeholders have a role to play. This calls for conviction, commitment, dedication and<br />
understand<strong>in</strong>g.<br />
Where there is a will there is a way!<br />
11
AN OVERVIEW OF THE HEALTH SERVICES IN<br />
MPUMALANGA<br />
CHAPTER 2
Chapter 2<br />
AN OVERVIEW OF THE HEALTH<br />
SERVICES IN MPUMALANGA<br />
In chapter one, you read about the circumstances lead<strong>in</strong>g to changes <strong>in</strong> the delivery of health care <strong>in</strong> the<br />
prov<strong>in</strong>ce. This chapter describes the organisational structure of health services <strong>in</strong> <strong>Mpumalanga</strong> Prov<strong>in</strong>ce and<br />
the functional relationships between various service levels <strong>in</strong> the prov<strong>in</strong>ce.<br />
After read<strong>in</strong>g the chapter, you will be able to:<br />
• understand how health services are organised <strong>in</strong> the prov<strong>in</strong>ce;<br />
• know how the prov<strong>in</strong>ce is divided <strong>in</strong>to regions and districts;<br />
• understand the roles of the prov<strong>in</strong>cial, regional and district health offices; and<br />
• appreciate the functional l<strong>in</strong>kages between different service levels.<br />
National and prov<strong>in</strong>cial levels of health care <strong>in</strong> many countries (particularly those which are geographically<br />
large or have large populations) are too far removed from the community to be responsive to local health<br />
needs. In <strong>Mpumalanga</strong>, the system of delivery and management of health services has been decentralised<br />
<strong>in</strong> accordance with Government guidel<strong>in</strong>es, <strong>in</strong> an attempt to br<strong>in</strong>g both the services and service<br />
management closer to the people, thereby enabl<strong>in</strong>g them to respond more effectively to local needs.<br />
The health services <strong>in</strong> the prov<strong>in</strong>ce are therefore structured <strong>in</strong> three levels: prov<strong>in</strong>cial, regional and district.<br />
Each level will be discussed below:<br />
PROVINCIAL HEALTH OFFICE<br />
The political head of the prov<strong>in</strong>cial Department of<br />
<strong>Health</strong>, Welfare and Gender Affairs is the Member<br />
of the Executive Council (MEC) with the Deputy<br />
Director-General (DDG) as the chief executive of the<br />
department.<br />
There are two Chief Directorates <strong>in</strong> the department:<br />
<strong>Health</strong> and Welfare. Gender Affairs is an<br />
<strong>in</strong>dependent sub-directorate that gives gender<br />
policy support to the two Chief Directorates and all<br />
the departments <strong>in</strong> the prov<strong>in</strong>ce (see Figure 2.1).<br />
The Chief Directorate receives adm<strong>in</strong>istrative support<br />
from the Directorate of Adm<strong>in</strong>istration which also<br />
serves the Chief Directorate for Welfare and the<br />
Gender Affairs Sub-Directorate (see Figures 2.1 & 2.2).<br />
The specific functions of the Directorate of<br />
Adm<strong>in</strong>istration are:<br />
The MEC for F<strong>in</strong>ance Mr J. Modipane adm<strong>in</strong>isters polio vacc<strong>in</strong>e<br />
• formulation of policies <strong>in</strong> respect of general adm<strong>in</strong>istration and f<strong>in</strong>ancial matters;<br />
• determ<strong>in</strong>ation of norms and standards; and<br />
• handl<strong>in</strong>g of matters perta<strong>in</strong><strong>in</strong>g to personnel adm<strong>in</strong>istration, transport and auxiliary services, f<strong>in</strong>ance,<br />
provision<strong>in</strong>g and procurement.<br />
15
Figure 2.1<br />
The Organisational Structure of the Department of <strong>Health</strong>, Welfare and Gender Affairs<br />
Directorate:<br />
<strong>Primary</strong><br />
<strong>Health</strong><br />
Chief<br />
Directorate:<br />
<strong>Health</strong><br />
Directorate:<br />
Secondary<br />
Services<br />
Member of the Executive Council<br />
Deputy Director-General<br />
Chief<br />
Directorate:<br />
Welfare<br />
Directorate:<br />
Policy, Plann<strong>in</strong>g<br />
& Information<br />
Directorate:<br />
Adm<strong>in</strong>istration<br />
Directorate:<br />
Social<br />
Work<br />
Directorate:<br />
Social<br />
Security<br />
Sub-Directorate:<br />
Population and<br />
Development<br />
Sub-Directorate:<br />
Gender<br />
Affairs<br />
16
The Prov<strong>in</strong>cial <strong>Health</strong> Office derives its authority from the <strong>Health</strong> Act, the National Constitution<br />
and other relevant health related legislation. The purpose of the Prov<strong>in</strong>cial <strong>Health</strong> Office is to<br />
ensure that national and prov<strong>in</strong>cial health policies are translated <strong>in</strong>to action.<br />
How is the Prov<strong>in</strong>cial <strong>Health</strong> Office Structured?<br />
The Prov<strong>in</strong>cial <strong>Health</strong> Office (see Figure 2.2) consists of:<br />
• The Chief Directorate;<br />
• 3 Support Directorates:<br />
- <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Services<br />
- Secondary <strong>Health</strong> <strong>Care</strong> Services<br />
- Policy, Plann<strong>in</strong>g and Information Services;<br />
• 3 Regional Directorates:<br />
- Lowveld Region<br />
- Highveld Region<br />
- Eastern Highveld Region;<br />
• The Nurs<strong>in</strong>g College; and<br />
• Prov<strong>in</strong>cial Pharmaceutical Services and Medic<strong>in</strong>es Control Unit.<br />
Figure 2.2<br />
The Organisational Structure of the Prov<strong>in</strong>cial <strong>Health</strong> Office<br />
Chief Directorate:<br />
<strong>Health</strong><br />
Directorate:<br />
<strong>Primary</strong> <strong>Health</strong><br />
<strong>Care</strong> Services<br />
Directorate:<br />
Secondary<br />
<strong>Health</strong> Services<br />
Directorate:<br />
Policy, Plann<strong>in</strong>g<br />
and Information<br />
Services<br />
Directorate:<br />
Adm<strong>in</strong>istration<br />
*Nurs<strong>in</strong>g<br />
College<br />
Pharmaceutical<br />
Services &<br />
Medic<strong>in</strong>es<br />
Control Unit<br />
Regional<br />
Directorate:<br />
Lowveld<br />
Regional<br />
Directorate:<br />
Highveld<br />
Regional<br />
Directorate:<br />
Eastern<br />
Highveld<br />
* The Nurs<strong>in</strong>g College will rema<strong>in</strong> a l<strong>in</strong>e function of the Chief Directorate until a national decision is made as to whether the<br />
tra<strong>in</strong><strong>in</strong>g of nurses will be the responsibility of General Education or <strong>Health</strong>. If this does not happen, the possibility of sett<strong>in</strong>g up<br />
satellite colleges <strong>in</strong> each region will be looked <strong>in</strong>to.<br />
17
The Functions of the Chief Directorate<br />
The specific responsibilities of the Chief Directorate are:<br />
• development of policy guidel<strong>in</strong>es, norms and standards, <strong>in</strong> accordance with national policy<br />
framework;<br />
• provision of professional support to plann<strong>in</strong>g, development and implementation of primary and<br />
secondary health care programmes and services as well as an <strong>in</strong>formation service;<br />
• provision of support to plann<strong>in</strong>g, development and implementation of the district health system;<br />
• monitor<strong>in</strong>g and evaluation of the health services;<br />
• national and <strong>in</strong>ter-prov<strong>in</strong>cial liaison; and<br />
• procurement, distribution and control of pharmaceuticals and medic<strong>in</strong>es.<br />
Functions of the Support Directorates<br />
The 3 Directorates (<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong>; Secondary <strong>Health</strong> Services; and Policy, Plann<strong>in</strong>g and Information<br />
Services) have no l<strong>in</strong>e functions. They provide support to the Chief Directorate. Their specific functions are<br />
given <strong>in</strong> Table 2.1<br />
Table 2.1<br />
Functions of the Support Directorates<br />
Directorate:<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Services<br />
Purpose:<br />
To provide service development<br />
support function to the Chief<br />
Directorate of <strong>Health</strong> <strong>in</strong> respect of<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Services (PHC<br />
Programmes and Community<br />
Services)<br />
Functions:<br />
1. Formulate policy for <strong>Primary</strong><br />
<strong>Health</strong> <strong>Care</strong> Services.<br />
2. Determ<strong>in</strong>e norms and<br />
standards.<br />
3. Plan and develop <strong>Primary</strong><br />
<strong>Health</strong> <strong>Care</strong> Services and<br />
Programmes and provide<br />
service support to regional<br />
directors.<br />
4. Provide support <strong>in</strong> plann<strong>in</strong>g<br />
and development of a District<br />
<strong>Health</strong> System.<br />
5. Monitor and evaluate <strong>Primary</strong><br />
<strong>Health</strong> <strong>Care</strong> Services.<br />
6. Provide support to human<br />
resources development <strong>in</strong><br />
respect of primary health<br />
care<br />
Directorate:<br />
Secondary <strong>Health</strong> Services<br />
Purpose:<br />
To provide service development<br />
support function to the Chief<br />
Directorate of <strong>Health</strong> <strong>in</strong> respect of<br />
Secondary <strong>Health</strong> <strong>Care</strong> Services<br />
(curative and related programmes,<br />
emergency health, laboratory and<br />
associated health services).<br />
Functions:<br />
1. Formulate policy for curative<br />
and secondary health<br />
programmes.<br />
2. Determ<strong>in</strong>e norms and<br />
standards.<br />
3. Monitor and evaluate<br />
curative and secondary health<br />
programmes.<br />
4. Provide support to Secondary<br />
<strong>Health</strong> Services.<br />
5. Provide support to human<br />
resources development <strong>in</strong><br />
respect of Secondary <strong>Health</strong><br />
Sevices.<br />
Directorate:<br />
Policy, Plann<strong>in</strong>g and Information<br />
Purpose:<br />
To provide service development<br />
support function to the Chief<br />
Directorate of <strong>Health</strong> <strong>in</strong> respect of<br />
General <strong>Health</strong> Policy, Plann<strong>in</strong>g<br />
and Information Services (<strong>in</strong>clud<strong>in</strong>g<br />
<strong>Health</strong> Information).<br />
Functions:<br />
1. Co-ord<strong>in</strong>ate policy formulation<br />
<strong>in</strong> support of the directorates<br />
for primary and secondary<br />
health services.<br />
2. Determ<strong>in</strong>e norms and standards<br />
for policy, plann<strong>in</strong>g and<br />
<strong>in</strong>formation.<br />
3. Plan, develop and <strong>in</strong>tegrate<br />
policy, plann<strong>in</strong>g and <strong>in</strong>formation<br />
services.<br />
4. Provide support to regional<br />
directors <strong>in</strong> respect of policy,<br />
plann<strong>in</strong>g and <strong>in</strong>formation.<br />
5. Monitor and evaluate policy,<br />
plann<strong>in</strong>g and <strong>in</strong>formation<br />
services.<br />
6. Provide support <strong>in</strong> plann<strong>in</strong>g<br />
and <strong>in</strong>formation development<br />
for the District <strong>Health</strong> System.<br />
18
The policies of the Prov<strong>in</strong>cial <strong>Health</strong> Office are implemented through 3 regional health directorates (Highveld,<br />
Eastern Highveld and Lowveld), a Nurs<strong>in</strong>g College and a prov<strong>in</strong>cial Pharmaceutical and Medic<strong>in</strong>es Control<br />
Unit (see Figure 2.2).<br />
The Nurs<strong>in</strong>g College<br />
The Nurs<strong>in</strong>g College has l<strong>in</strong>e responsibility to the Prov<strong>in</strong>cial <strong>Health</strong> Office with regard to human resources<br />
development <strong>in</strong> the nurs<strong>in</strong>g profession.<br />
Prov<strong>in</strong>cial Pharmaceutical & Medic<strong>in</strong>es Control Unit<br />
The Prov<strong>in</strong>cial Pharmaceutical and Medic<strong>in</strong>es Control Unit will be responsible for:<br />
• procur<strong>in</strong>g and supply<strong>in</strong>g pharmaceuticals and surgical sundries to service po<strong>in</strong>ts;<br />
• implement<strong>in</strong>g and monitor<strong>in</strong>g drug policies, with emphasis on rational use of drugs;<br />
• control and <strong>in</strong>spection of medic<strong>in</strong>es;<br />
• provid<strong>in</strong>g <strong>in</strong>formation and advice on pharmaceuticals to prescribers and users with emphasis on<br />
essential drugs; and<br />
• develop<strong>in</strong>g computer systems for pharmacies with the assistance of the computer division <strong>in</strong> the<br />
adm<strong>in</strong>istration.<br />
THE REGIONAL HEALTH OFFICE<br />
The prov<strong>in</strong>ce has been divided <strong>in</strong>to 3 health regions: the Lowveld, Highveld and Eastern Highveld. The three<br />
regions and their districts are given <strong>in</strong> Figure 2.3. The population of each district is also <strong>in</strong>cluded.<br />
Figure 2.3 The <strong>Health</strong> Regions and Districts <strong>in</strong> <strong>Mpumalanga</strong><br />
<strong>Mpumalanga</strong> Prov<strong>in</strong>ce<br />
HIGHVELD REGION<br />
District Population*<br />
1. Lydenburg 83 961<br />
2. Middelburg 148 837<br />
3. Witbank 184 675<br />
4. Groblersdal 62 005<br />
5. Kwamhlanga 231 076<br />
6. Mmamethlake 111 749<br />
7. Philadelphia 247 264<br />
LOWVELD REGION**<br />
District Population*<br />
1. Barberton 37 599<br />
2. Tonga 314 732<br />
3. Shongwe 307 948<br />
4. Kabokweni 221 346<br />
5. Sabie 31 110<br />
6. Nelspruit 212 855<br />
EASTERN HIGHVELD<br />
District Population*<br />
1. Eerste Hoek 241 396<br />
2. Volkrust 81 967<br />
3. Ermelo 116 632<br />
4. Piet Retief 92 740<br />
5. Delmas 52 105<br />
6. Standerton 133 327<br />
7. Bethal 70 628<br />
8. Highveld Ridge 166 149<br />
Total 1 069 567<br />
Total 1 125 641<br />
Total 954 944<br />
* Source: ReHMIS (1993 figures)<br />
** It is envisaged that Bushbuckridge (presently part of Northern Prov<strong>in</strong>ce) will be <strong>in</strong>corporated <strong>in</strong>to <strong>Mpumalanga</strong> Prov<strong>in</strong>ce. If<br />
that happens it will then be part of the Lowveld Region. It has an estimated population of 500,000<br />
19
The <strong>Health</strong> Regions will be managed through the Regional <strong>Health</strong> Offices (RHOs). The RHOs are responsible<br />
for facilitat<strong>in</strong>g establishment of the district health system and for provid<strong>in</strong>g support to the District <strong>Health</strong><br />
Management Teams <strong>in</strong> render<strong>in</strong>g health care to the communities. The RHO consists of:<br />
• Regional Directorate;<br />
• Sub-Directorate for <strong>Health</strong> Information;<br />
• Sub-Directorate for Adm<strong>in</strong>istration and F<strong>in</strong>ance; and<br />
• Academic Support Unit<br />
Functions of the Regional Directorate<br />
Report<strong>in</strong>g directly to the Chief Directorate, the Regional Directorates are to:<br />
• translate prov<strong>in</strong>cial health policies and strategies <strong>in</strong>to operational plans;<br />
• co-ord<strong>in</strong>ate regional health programmes and activities;<br />
• provide support to districts <strong>in</strong> development of health plans and service delivery.<br />
• promote and co-ord<strong>in</strong>ate <strong>in</strong>ter-sectoral collaboration <strong>in</strong> health promotion and development<br />
activities;<br />
• promote and co-ord<strong>in</strong>ate liaison between the health services <strong>in</strong> the region and relevant academic<br />
<strong>in</strong>stitutions;<br />
• ensure provision of referral health services to all districts by their designated referral hospitals;<br />
• co-ord<strong>in</strong>ate emergency services <strong>in</strong> the region; and<br />
• oversee the functions of regional referral hospitals.<br />
The Sub-Directorate for <strong>Health</strong> Information<br />
This Sub-Directorate provides support to districts <strong>in</strong> development of health and management <strong>in</strong>formation<br />
systems.<br />
The Sub-Directorate for Adm<strong>in</strong>istration and F<strong>in</strong>ance is to:<br />
• ensure the provision of support services <strong>in</strong>clud<strong>in</strong>g laundry and cater<strong>in</strong>g to the districts;<br />
• provide support to the districts <strong>in</strong> development of budgets and f<strong>in</strong>ance management; and<br />
• provide support to the districts <strong>in</strong> staff development and management.<br />
The Academic Support Unit<br />
The prov<strong>in</strong>ce has entered <strong>in</strong>to agreements with the Medical University of Southern Africa (MEDUNSA), the<br />
University of Pretoria and the University of the Witwatersrand through which it is envisaged that the follow<strong>in</strong>g<br />
will take place:<br />
• appo<strong>in</strong>tment of personnel to support the cl<strong>in</strong>ical, research, human resource development, and<br />
management needs of the prov<strong>in</strong>ce through jo<strong>in</strong>t contracts;<br />
• provision of access to all health facilities <strong>in</strong> the prov<strong>in</strong>ce to under-and post-graduate students for<br />
service attachment;<br />
• provision of advice to the regional manager on norms, standards, protocols and managerial <strong>in</strong>puts by<br />
the academic support representative; and<br />
• provision of opportunities for jo<strong>in</strong>t development of community-based and problem-oriented learn<strong>in</strong>g.<br />
Referral Hospitals<br />
Regional Services and Facilities<br />
It is envisaged that there will be a referral hospital complex <strong>in</strong> each Region. A referral hospital should have<br />
the follow<strong>in</strong>g specialities:<br />
Full time: Surgery, Obstetrics & Gynaecology, Paediatrics; Internal Medic<strong>in</strong>e; Family<br />
Medic<strong>in</strong>e; Orthopaedics; Radiology; Anaesthesiology; Community <strong>Health</strong>.<br />
Part-time: Ophthalmology; Ear, Nose and Throat Surgery; Dermatology; Psychiatry; Urology<br />
The specialists will also provide support to the lower levels of health facilities.<br />
20
Tuberculosis Hospitals<br />
There are also 3 hospitals run by the South African National Tuberculosis Association (SANTA) and subsidised<br />
by the state. They are:<br />
• Barberton (SANTA) - Lowveld;<br />
• Standerton (SANTA)- Eastern Highveld; and<br />
• Witbank (SANTA)- Highveld.<br />
They are regionally controlled and supervised. There is also a chronic care facility <strong>in</strong> the Lowveld Region<br />
(Bongani Hospital) and a small local authority tuberculosis (TB) hospital (Sesifuba) <strong>in</strong> the Eastern Highveld<br />
Region. With the <strong>in</strong>crease <strong>in</strong> TB and the HIV epidemic, the Department <strong>in</strong>tends to ma<strong>in</strong>ta<strong>in</strong> one TB hospital<br />
per region.<br />
A Multiple Drug Resistance Unit (MDRU) will be established <strong>in</strong> one TB hospital <strong>in</strong> the prov<strong>in</strong>ce for standardised<br />
therapy and monitor<strong>in</strong>g of all multiple drug resistance tuberculosis (MDR TB) patients under supervision of the<br />
prov<strong>in</strong>cial TB specialist.<br />
THE DISTRICT HEALTH OFFICE<br />
At present the prov<strong>in</strong>ce is divided <strong>in</strong>to 21 health districts: 7 <strong>in</strong> the Highveld; 8 <strong>in</strong> the Eastern Highveld; and 6 <strong>in</strong><br />
the Lowveld. The boundaries between districts are not fixed, they are “soft.” This means that the exist<strong>in</strong>g<br />
boundaries could still be re-def<strong>in</strong>ed, by creat<strong>in</strong>g new health districts or abolish<strong>in</strong>g exist<strong>in</strong>g ones. The National<br />
<strong>Health</strong> Bill provides powers to the MEC to create new health districts or abolish exist<strong>in</strong>g ones.<br />
The criteria for establishment of a health district <strong>in</strong>clude the follow<strong>in</strong>g:<br />
• health needs;<br />
• population size and distribution;<br />
• communication network (roads, telephones);<br />
• social and economic factors;<br />
• political factors (coterm<strong>in</strong>ous with local government/magisterial boundaries);<br />
• physical barriers; and<br />
• susta<strong>in</strong>ability.<br />
Functions of a District <strong>Health</strong> Office<br />
The health district is managed through the District <strong>Health</strong> Office. The generic functions of a district health<br />
office are to:<br />
• ensure health service delivery to the communities <strong>in</strong> the district;<br />
• ensure proper management and utilisation of resources allocated to the health district;<br />
• manage and develop health personnel serv<strong>in</strong>g <strong>in</strong> the district; and<br />
• develop, ma<strong>in</strong>ta<strong>in</strong> and manage the district health <strong>in</strong>formation system.<br />
These functions are described <strong>in</strong> detail <strong>in</strong> chapter 3.<br />
Distribution of Public <strong>Health</strong> Facilities <strong>in</strong> the Prov<strong>in</strong>ce<br />
There are 27 hospitals, 22 community health centres, 199 cl<strong>in</strong>ics, 97 mobile cl<strong>in</strong>ics and 3570 visit<strong>in</strong>g po<strong>in</strong>ts <strong>in</strong><br />
the prov<strong>in</strong>ce. The distribution of these facilities <strong>in</strong> the districts is given <strong>in</strong> Table 2.2. The task fac<strong>in</strong>g the DHMT is<br />
to organise the health facilities <strong>in</strong>to a district health system by:<br />
• identify<strong>in</strong>g primary and secondary catchment areas;<br />
• rationalis<strong>in</strong>g facility distribution accord<strong>in</strong>g to the health needs which might mean that some facilities<br />
are down graded or upgraded;<br />
• ensur<strong>in</strong>g that patients do not walk more than 5 kilometres to a cl<strong>in</strong>ic;<br />
• ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g a balance between primary care and secondary care (this may mean a conscious and<br />
determ<strong>in</strong>ed action to shift resources from secondary to primary care level);<br />
• restructur<strong>in</strong>g the district staff establishments to reflect needs at all levels of care; and<br />
• rationalis<strong>in</strong>g the distribution of personnel accord<strong>in</strong>g to PHC needs at various levels.<br />
21
Table 2.2 Distribution of Public <strong>Health</strong> Facilities <strong>in</strong> the Prov<strong>in</strong>ce<br />
1. Eastern Highveld Region<br />
Type of Facility<br />
District Cl<strong>in</strong>ics <strong>Health</strong> Centres Hospitals Mobile Cl<strong>in</strong>ics Visit<strong>in</strong>g Po<strong>in</strong>ts<br />
1 Bethal 6 0 1 4 205<br />
2 Delmas 2 2 1 4 144<br />
3 Eerstehoek 16 1 2 3 144<br />
4 Ermelo 9 0 2(1TB) 4 193<br />
5 Highveld Ridge 6 1 1 2 71<br />
6 Piet Retief 5 0 1 4 210<br />
7 Standerton 10 0 1(TB) 5 229<br />
8 Volksrust 7 0 1 6 230<br />
Sub-Total<br />
Eastern Highveld 61 4 10 32 1426<br />
2. Highveld Region<br />
Type of Facility<br />
District Cl<strong>in</strong>ics <strong>Health</strong> Centres Hospitals Mobile Cl<strong>in</strong>ics Visit<strong>in</strong>g Po<strong>in</strong>ts<br />
1 Groblersdal 1 0 1 6 727<br />
2 Kwa-Mhlanga 17 3 1 1 4<br />
3 Lydenburg 13 0 3 7 246<br />
4 Middelburg 9 0 1 3 145<br />
5 Mmamethlake 13 4 1 2 12<br />
6 Philadelphia 10 3 1 5 21<br />
7 Witbank 10 1 2(1TB) 7 236<br />
Sub-Total<br />
Highveld 73 11 10 31 1391<br />
3. Lowveld Region<br />
Type of Facility<br />
District Cl<strong>in</strong>ics <strong>Health</strong> Centres Hospitals Mobile Cl<strong>in</strong>ics Visit<strong>in</strong>g Po<strong>in</strong>ts<br />
1 Barberton 4 2 2(1TB) 4 231<br />
2 Kabokweni 18 0 2(1TB) 5 26<br />
3 Nelspruit 8 3 1 4 168<br />
4 Tonga 11 2 0 12 118<br />
5 Shongwe 16 0 1 8 117<br />
6 Sabie-Mathibidi 8 0 1 1 93<br />
Sub-Total Lowveld 65 7 7 34 753<br />
Prov<strong>in</strong>cial Total 199 22 27 97 3570<br />
22
OTHER HEALTH SERVICE PROVIDERS<br />
Local Authorities<br />
Apart from the Prov<strong>in</strong>cial <strong>Health</strong> Department, various authorities are responsible for the provision of<br />
health services e.g. Transitional Local Councils (TLCs), Transitional Rural Councils (TRCs) and District<br />
Councils (DCs). In the past, local authorities provided ma<strong>in</strong>ly preventive health<br />
services. This will, however, change so that all local authorities are <strong>in</strong>volved <strong>in</strong> deliver<strong>in</strong>g<br />
comprehensive primary health care to their residents. The Department of <strong>Health</strong>, Gender and Welfare<br />
Affairs together with the respective local authorities will br<strong>in</strong>g change by:<br />
• elim<strong>in</strong>at<strong>in</strong>g the duplication of services e.g. where a prov<strong>in</strong>cial and a local authority cl<strong>in</strong>ic are<br />
operat<strong>in</strong>g next to each other, the district will negotiate with stakeholders and rationalise the services<br />
by clos<strong>in</strong>g down one of them; and<br />
• provid<strong>in</strong>g all local authorities with medic<strong>in</strong>es on the essential drug list free of cost.<br />
Successful implementation of this will require:<br />
• work<strong>in</strong>g towards harmonised conditions of service; and<br />
• deliver<strong>in</strong>g a comprehensive PHC package at the local authority cl<strong>in</strong>ics based on needs of the<br />
community.<br />
Private Sector<br />
It is envisaged that the District <strong>Health</strong> Authority (DHA) 1 will be directly responsible for the provision of<br />
all public sector primary health care services <strong>in</strong> the district. The DHA will also be the mechanism through<br />
which l<strong>in</strong>ks are established with other health care providers <strong>in</strong> the district, <strong>in</strong>clud<strong>in</strong>g the private health<br />
care providers and non-governmental organisations.<br />
The National <strong>Health</strong> Plan for Universal Access to <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> envisages a district health system based<br />
primarily on the public health sector, but provid<strong>in</strong>g for contractual relationships between the<br />
district health authority and accredited private providers with<strong>in</strong> the district. These private providers will<br />
complement the public sector service provided by the DHA.<br />
Non-government Organisations<br />
A variety of non-governmental <strong>in</strong>itiatives <strong>in</strong>clud<strong>in</strong>g community based organisations (CBOs), religious<br />
organisations and other non-governmental organisations are active <strong>in</strong> a variety of health-related<br />
development and service activities. These activities are important <strong>in</strong> mobilis<strong>in</strong>g effective community<br />
participation and promot<strong>in</strong>g <strong>in</strong>tersectoral action for health development.<br />
This service is already available <strong>in</strong> the form of:<br />
Part-time Medical Officers<br />
Part-time Services<br />
The part-time Medical Officer (or specialist) performs duties on a session basis as described <strong>in</strong> the Public<br />
Adm<strong>in</strong>istration Standards manual. The sessions referred to are a period of duty performed on a cont<strong>in</strong>uous<br />
basis. One session equals one hour per week duty over a year, i.e. 52 hours per year.<br />
The part-time Medical Officer is appo<strong>in</strong>ted on a temporary basis aga<strong>in</strong>st a vacant post or sessions provided<br />
for on the establishment of the <strong>in</strong>stitution where duty is rendered. The duties assigned to the part-time Medical<br />
Officer may consist of regular duties performed dur<strong>in</strong>g normal work<strong>in</strong>g hours or duties performed after hours<br />
on a more irregular basis. The temporary and part-time appo<strong>in</strong>tment means that he/she is not entitled to the<br />
benefits accorded to full-time employees such as paid annual leave, membership of pension fund and<br />
medical aid.<br />
1<br />
See Chapter 3 for structure and functions of DHA<br />
23
Part-Time District Surgeon (PTDS)<br />
The part-time District Surgeon renders duties for the follow<strong>in</strong>g services:<br />
Personal <strong>Health</strong> <strong>Care</strong>:<br />
Forensic Medical Duties:<br />
Ex-officio Duties:<br />
These are ma<strong>in</strong>ly curative cl<strong>in</strong>ical duties performed for certa<strong>in</strong> categories of<br />
patients.<br />
These are duties performed at the request of government officers charged with<br />
the responsibility of <strong>in</strong>vestigat<strong>in</strong>g activities of a crim<strong>in</strong>al nature and other fact<br />
f<strong>in</strong>d<strong>in</strong>g processes of the law. This <strong>in</strong>cludes the performance of post-mortems,<br />
exam<strong>in</strong>ation of persons <strong>in</strong>volved <strong>in</strong> cases of assault, rape or other crim<strong>in</strong>al activities.<br />
These are duties that are ma<strong>in</strong>ly performed on behalf of other state departments<br />
and <strong>in</strong>cludes the exam<strong>in</strong>ation of persons for disability, determ<strong>in</strong>ation of age,<br />
admitted and discharged prisoners or persons <strong>in</strong> custody, and the certification<br />
of persons under the Mental <strong>Health</strong> Act.<br />
The part-time District Surgeon is currently appo<strong>in</strong>ted on a contractual basis, with the contract detail<strong>in</strong>g the<br />
duties and obligations of the District Surgeon as well as the employer (the Prov<strong>in</strong>ce). Legal op<strong>in</strong>ion is currently<br />
be<strong>in</strong>g sought on the exact position the part-time District Surgeon has and whether he/she should be regarded<br />
as a contract worker or as an official.<br />
The remuneration of the part-time District Surgeon is largely determ<strong>in</strong>ed by the activities result<strong>in</strong>g from his<br />
duties. The activities are converted <strong>in</strong>to hours per week equall<strong>in</strong>g sessions as paid to the part-time Medical<br />
Officer. The sessions are adjusted on a regular basis accord<strong>in</strong>g to statistics of activities.<br />
This service will be restructured and <strong>in</strong>tegrated <strong>in</strong>to the <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> System to achieve an <strong>in</strong>tegrated<br />
community health service. All cl<strong>in</strong>ical aspects of their service will be provided at cl<strong>in</strong>ics or health centres.<br />
Medico-legal services for assaults, rape, drunkenness, etc will be referred to the health centre or district<br />
hospital. Prison medical services and Forensic Pathology (i.e. post mortems, exhumations) will for the time<br />
be<strong>in</strong>g rema<strong>in</strong> with the PTDS.<br />
The Traditional Healers<br />
In some districts there is already a close work<strong>in</strong>g relationship with the traditional healers. The department<br />
supports this relationship and District <strong>Health</strong> Managers are encouraged to strengthen this relationship so that<br />
they can <strong>in</strong>volve Traditional Healers <strong>in</strong> the delivery of PHC services.<br />
This chapter has described the decentralisation of services to the district level and the structure, composition<br />
and functions at the various levels. You have also read about the distribution of health facilities <strong>in</strong> the prov<strong>in</strong>ce<br />
and the service providers. The management of the services at various levels is discussed <strong>in</strong> the next chapter.<br />
24
THE DISTRICT MANAGER<br />
A DISTRICT HEALTH SYSTEM AND ITS<br />
MANAGEMENT<br />
CHAPTER 3
Tonga<br />
Chapter 3<br />
A DISTRICT HEALTH SYSTEM<br />
AND ITS MANAGEMENT<br />
The previous chapter discussed the organisation of health services <strong>in</strong> the prov<strong>in</strong>ce and the rationale for their<br />
decentralisation. This chapter aims at present<strong>in</strong>g to you the concept of a District <strong>Health</strong> System, its various<br />
components, functional <strong>in</strong>ter-relationships and management.<br />
After read<strong>in</strong>g the chapter, you will be able to:<br />
• understand the concept of a District <strong>Health</strong> System;<br />
• appreciate a District <strong>Health</strong> System as a vehicle for delivery of primary health care;<br />
• identify the elements that constitute a District <strong>Health</strong> System;<br />
• understand the importance of the facility and service referral network <strong>in</strong> a District <strong>Health</strong><br />
System;<br />
• understand the methods for delivery of health services <strong>in</strong> facility catchment areas; and<br />
• understand the management system for District <strong>Health</strong> Office and its component health<br />
facilities.<br />
<strong>Mpumalanga</strong><br />
<strong>Health</strong> Districts<br />
Mmamethlake<br />
Philadelphia<br />
Bushbuckridge<br />
Sabie<br />
Groblersdal<br />
Kabokweni<br />
KwaMhlanga<br />
Lydenburg<br />
Nelspruit<br />
Shongwe<br />
Middelburg<br />
Barberton<br />
Witbank<br />
Carol<strong>in</strong>a<br />
Delmas<br />
R E G I O N<br />
Highveld Ridge<br />
Bethal<br />
Ermelo<br />
Eastern Highveld<br />
Highveld region<br />
Standerton<br />
Lowveld region<br />
Volksrust<br />
Piet Retief<br />
N<br />
0 25 50<br />
Kilometers<br />
27
If you are a health service manager, health worker or a service beneficiary, you need to know the range of<br />
health facilities <strong>in</strong> your district; what health services are rendered at each health facility, and by who. You<br />
need to know also the referral system that l<strong>in</strong>ks the various health service levels. Ultimately you need to know<br />
how these services and facilities relate to you.<br />
THE DISTRICT HEALTH SYSTEM AND REFERRAL NETWORKS<br />
What is a District <strong>Health</strong> System?<br />
The World <strong>Health</strong> Organization def<strong>in</strong>es a District <strong>Health</strong> System as follows:<br />
A District <strong>Health</strong> System based on <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> is a more or less conta<strong>in</strong>ed segment of<br />
the National <strong>Health</strong> System. It comprises, first and foremost, a well-def<strong>in</strong>ed population, liv<strong>in</strong>g<br />
with<strong>in</strong> a clearly del<strong>in</strong>eated adm<strong>in</strong>istrative and geographical area, whether urban or rural. It<br />
<strong>in</strong>cludes all <strong>in</strong>stitutions and <strong>in</strong>dividuals provid<strong>in</strong>g health care <strong>in</strong> the district, whether governmental,<br />
social security, non-governmental, private, or traditional. A District <strong>Health</strong> System, therefore,<br />
consists of a large variety of <strong>in</strong>ter-related elements that contribute to health <strong>in</strong> homes, schools,<br />
work places, and communities, through the health and other related sectors. It <strong>in</strong>cludes self<br />
care and all health care workers and facilities, up to and <strong>in</strong>clud<strong>in</strong>g the hospital at the first<br />
referral levels, and the appropriate laboratory, other diagnostic, and logistic support services.<br />
A district health system is thus a network of health facilities, services and providers, all cater<strong>in</strong>g for the same<br />
ultimate goal of promot<strong>in</strong>g the health of a def<strong>in</strong>ed population <strong>in</strong> the district.<br />
In <strong>Mpumalanga</strong>, the district health system comprises the district health office, district hospital, community<br />
health centres, cl<strong>in</strong>ics and smaller facilities such as mobile units and visit<strong>in</strong>g po<strong>in</strong>ts, operated by both the<br />
prov<strong>in</strong>cial department, local authorities, the private sector, non-governmental organisations (NGOs) and<br />
community based organisations (CBOs).<br />
<strong>Health</strong> Service Levels <strong>in</strong> the District <strong>Health</strong> System<br />
In <strong>Mpumalanga</strong> the District <strong>Health</strong> System is based on a five-level network of functional units which <strong>in</strong>cludes:<br />
• households;<br />
• visit<strong>in</strong>g po<strong>in</strong>ts;<br />
• cl<strong>in</strong>ics;<br />
• health centres; and<br />
• the district hospital.<br />
Each of these services is described below.<br />
Household<br />
The household level is the focus for health development <strong>in</strong> <strong>Mpumalanga</strong> and the start<strong>in</strong>g po<strong>in</strong>t for health<br />
care. Household members require adequate <strong>in</strong>formation based upon which they can make decisions and<br />
adopt appropriate health seek<strong>in</strong>g behaviour. Community based health workers/promoters are essential <strong>in</strong><br />
the empowerment of households with the necessary <strong>in</strong>formation and skills.<br />
Visit<strong>in</strong>g Po<strong>in</strong>t<br />
This is a service delivery po<strong>in</strong>t where the health providers render primary health care services to the community<br />
as an outreach activity. The providers visit the facility at <strong>in</strong>termittent but regular <strong>in</strong>tervals.<br />
Cl<strong>in</strong>ic<br />
This is a fixed structure <strong>in</strong> which basic health services are provided, usually by nurses. It should open 12 hours<br />
a day for five days <strong>in</strong> a week. It is the facility <strong>in</strong> the referral system which l<strong>in</strong>ks the community to the formal<br />
health facility referral network. It renders primary health care services to the communities around it. This area<br />
of jurisdiction is known as the catchment area.<br />
28
<strong>Health</strong> Centre<br />
The health centre is a fixed structure which provides comprehensive primary health care to the immediate<br />
community around it. It is also a referral centre for the cl<strong>in</strong>ics. However, the primary health care services<br />
rendered to the immediate community around should, wherever possible, be provided at a po<strong>in</strong>t different<br />
from the outpatient department which should receive the referrals from the cl<strong>in</strong>ics.<br />
District Hospital<br />
The district hospital is the non-specialist facility to which patients from cl<strong>in</strong>ics or health centres may be referred.<br />
The district hospital provides comprehensive PHC services to the community around it. However, this service<br />
should be rendered at a service po<strong>in</strong>t different from the outpatient department which should be reserved for<br />
receiv<strong>in</strong>g referrals from health centres and cl<strong>in</strong>ics <strong>in</strong> the district.<br />
The <strong>Health</strong> Facility Catchment Area<br />
Figure 3.1. depicts the concept of health facility catchment areas.<br />
Figure 3.1<br />
The Catchment areas for Various Levels of <strong>Health</strong> Facilities<br />
KEY: Catchment areas for:<br />
District hospital<br />
<strong>Health</strong> centre<br />
Cl<strong>in</strong>ic<br />
Each health facility <strong>in</strong> the network is expected to render comprehensive primary health care services to the<br />
communities <strong>in</strong> a def<strong>in</strong>ed geographic area around the facility, referred to as the catchment area. The<br />
health facility is responsible for the health of all people <strong>in</strong> the catchment area and not only those who attend<br />
the facility for care. Whereas every health cl<strong>in</strong>ic will serve the population with<strong>in</strong> a def<strong>in</strong>ed geographic area<br />
29
around it, a health centre will cover both the community around it as well as several catchment areas catered<br />
for by the cl<strong>in</strong>ics for which the health centre serves as a referral facility.<br />
A district hospital will serve as a referral facility for all the health centres and cl<strong>in</strong>ics with<strong>in</strong> the district. Hence its<br />
catchment area is the district.<br />
How The Referral System Will Work<br />
In the past the various health facilities and services <strong>in</strong> the prov<strong>in</strong>ce were <strong>in</strong>dependent of one another. In the<br />
transformed health organisation, a simple common <strong>in</strong>tegrated system is envisaged and will be emphasised<br />
<strong>in</strong> order to br<strong>in</strong>g together a number of separate systems and adm<strong>in</strong>istrations.<br />
In the District <strong>Health</strong> System model, all the facilities <strong>in</strong> the district form a clear referral network of health<br />
services from household ➮ community ➮ cl<strong>in</strong>ic ➮ health centre ➮ hospital with <strong>in</strong>creas<strong>in</strong>g service capacity<br />
from one level to the next, <strong>in</strong> terms of the range and complexity of services rendered. The referral hierarchy<br />
however does not mean that the higher health care levels are superior <strong>in</strong> terms of benefits and resource<br />
allocation (see Figure 3.2).<br />
Figure 3.2<br />
The District <strong>Health</strong> Facility Network<br />
OTHER<br />
COMMUNITY<br />
HOUSEHOLDS<br />
HEALTH<br />
FACILITIES<br />
Collaboration<br />
with other<br />
providers<br />
DISTRICT HEALTH OFFICE<br />
Intersectoral<br />
Collaboration<br />
OTHER<br />
SECTORS<br />
HOUSEHOLDS<br />
HOUSEHOLDS VISITING<br />
POINTS<br />
HOUSEHOLDS COMMUNITY<br />
CLINICS<br />
HOUSEHOLDS HEALTH<br />
CENTRES<br />
HOUSEHOLDS DISTRICT<br />
HOSPITAL<br />
Key: The arrows <strong>in</strong>dicate the referral network <strong>in</strong>volv<strong>in</strong>g health facilities, district health office and other sectors<br />
Adapted from Monekosso GL<br />
30
The referral system <strong>in</strong> the District <strong>Health</strong> System will entail:<br />
• know<strong>in</strong>g what condition needs to be referred;<br />
• know<strong>in</strong>g where to refer to;<br />
• know<strong>in</strong>g when to refer;<br />
• establish<strong>in</strong>g the procedures for referral; and<br />
• tra<strong>in</strong><strong>in</strong>g the staff on manag<strong>in</strong>g the referral system.<br />
Ideally the entry po<strong>in</strong>t for the referral system is the lower level facility, namely the cl<strong>in</strong>ic.<br />
At the community level, the community based health workers (CBHWs/promoters) advise clients/patients to<br />
seek health care at the cl<strong>in</strong>ic. At the cl<strong>in</strong>ic, the manager may refer a patient/client to a health centre or<br />
hospital clearly <strong>in</strong>dicat<strong>in</strong>g the reason for referral. At the health centre, the manager or any appropriate staff<br />
may refer a patient/client to the district hospital for emergency or regular cl<strong>in</strong>ics. Patients/clients requir<strong>in</strong>g<br />
specialised treatment will be screened at the district hospital and referred to regional referral hospitals. Higher<br />
levels of care may also refer patients/clients to the lower levels for ma<strong>in</strong>tenance therapy or follow-up. Only <strong>in</strong><br />
emergencies can patients enter at any level (see Figure 3.1). It is envisaged that patients/clients who do not<br />
follow the referral system will be liable to a by-pass fee.<br />
A critical element <strong>in</strong> the referral system is communication. An appropriate referral tool (form) and protocol<br />
will be developed by the prov<strong>in</strong>cial health office.<br />
With<strong>in</strong> the multi-level health service structure <strong>in</strong> your district there are a number of systems that need to work<br />
effectively. Such systems <strong>in</strong>clude:<br />
• systems for diagnosis, referral, treatment and care of patients;<br />
• systems for identify<strong>in</strong>g and tackl<strong>in</strong>g the community’s major health problems;<br />
• transport and communication systems;<br />
• management systems related to staff recruitment, selection, tra<strong>in</strong><strong>in</strong>g, supervision, support and<br />
performance appraisal;<br />
• systems for the procurement and distribution of drugs, pharmaceuticals, equipment and other<br />
supplies;<br />
• systems for management of f<strong>in</strong>ance;<br />
• systems for health <strong>in</strong>formation management; and<br />
• systems for monitor<strong>in</strong>g and evaluation of the health services.<br />
Good management of these systems is critical for effective service delivery <strong>in</strong> the district.<br />
Each Service Level i.e. the cl<strong>in</strong>ic, community health centre, district or referral hospital and district health<br />
office will be managed by a specific management team, namely, the:<br />
• District <strong>Health</strong> Management Team for the district health office;<br />
• Hospital Management Team for the district hospital;<br />
• <strong>Health</strong> Centre Management Team for the health centre; and<br />
• Cl<strong>in</strong>ic Management Team for the cl<strong>in</strong>ic.<br />
The composition and functions of each management team are discussed separately below:<br />
THE DISTRICT HEALTH MANAGEMENT TEAM (DHMT)<br />
Each health district will be managed by a District <strong>Health</strong> Management (DHMT) which will have overall<br />
responsibility for provision and management of the district health services. The organogram illustrat<strong>in</strong>g the<br />
relationships between the various staff positions of the DHMT is given <strong>in</strong> Figure 3.3.<br />
Figure 3.3<br />
Composition of a District <strong>Health</strong> Management Team<br />
DISTRICT HEALTH MANAGER<br />
DISTRICT<br />
HEALTH<br />
INFORMATION<br />
MANAGER<br />
DISTRICT<br />
PHARMACIST<br />
FINANCE AND<br />
ADMINISTRATION<br />
MANAGER<br />
HUMAN<br />
RESOURCES<br />
DEVELOPMENT<br />
MANAGER<br />
DISTRICT<br />
PRIMARY<br />
HEALTH CARE<br />
CO-ORDINATOR<br />
ACADEMIC<br />
SUPPORT<br />
REPRESENTATIVE<br />
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Members of the District <strong>Health</strong> Management Team (DHMT) (see Figure 3.3) are:<br />
• District <strong>Health</strong> Manager<br />
• District <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Co-ord<strong>in</strong>ator<br />
• Adm<strong>in</strong>istration & F<strong>in</strong>ance Manager<br />
• <strong>Health</strong> Information Manager<br />
• Human Resources Development Manager<br />
• District Pharmacist<br />
• Academic Support Representative<br />
The District <strong>Health</strong> Manager<br />
As District <strong>Health</strong> Manager, you are responsible for the development, provision and supervision of health<br />
services <strong>in</strong> the district, <strong>in</strong>clud<strong>in</strong>g monitor<strong>in</strong>g and evaluation of coverage, efficiency and effectiveness. In<br />
particular you are expected to:<br />
• co-ord<strong>in</strong>ate the development and implementation of the district health plan;<br />
• ensure delivery of comprehensive primary health care to the communities <strong>in</strong> the district;<br />
• ensure access to referral health services;<br />
• purchase, via prov<strong>in</strong>cial procurement system, pharmaceuticals and surgical sundries;<br />
• ensure registration and ma<strong>in</strong>tenance of district health assets;<br />
• appo<strong>in</strong>t, evaluate, discipl<strong>in</strong>e and promote staff <strong>in</strong> the district, subject to powers delegated by the<br />
Prov<strong>in</strong>cial <strong>Health</strong> Office;<br />
• control the district capital and recurrent health budget;<br />
• purchase services from <strong>in</strong>dependent providers <strong>in</strong> the district where appropriate e.g. accredited<br />
private practitioners, environmental services, local authorities, NGOs, etc;<br />
• take responsibility for ensur<strong>in</strong>g that decisions made by the DHMT are implemented; and<br />
• ensure a car<strong>in</strong>g, quality service.<br />
The District <strong>Health</strong> Manager carries a very important responsibility especially at this critical phase<br />
<strong>in</strong> the development and establishment of a district health system. The task will require establish<strong>in</strong>g<br />
a management culture based on the pr<strong>in</strong>ciples of management by objectives which are<br />
described below:<br />
Management by Objectives<br />
Management by objectives is a cont<strong>in</strong>uous process that requires you to:<br />
• critically review and even re-state the long-term and short-term health plans of the district;<br />
• clarify with each manager and the PHC team their roles, responsibilities and key outcome areas;<br />
• agree with each manager, PHC team on “targets” and “action plans” based on identified health<br />
problems and resources available; and<br />
• provide the right work<strong>in</strong>g atmosphere <strong>in</strong> which other team members can achieve their objectives, for<br />
example through tra<strong>in</strong><strong>in</strong>g and support where necessary.<br />
This approach seeks to <strong>in</strong>tegrate three th<strong>in</strong>gs:<br />
• the achievement of the aim and purposes of the district plan (as expressed <strong>in</strong> the Policy Guidel<strong>in</strong>es<br />
on District <strong>Health</strong> <strong>Systems</strong>, the National <strong>Health</strong> Act and your own district health plan);<br />
• <strong>in</strong>corporation of <strong>in</strong>dividual plans of all health service managers with<strong>in</strong> the district to the overall district<br />
health plan; and<br />
• development of skills <strong>in</strong> your own sphere of work and those who work with you.<br />
For you and your service managers to be successful, you need to agree on broad objectives and targets<br />
with other people, thereby benefitt<strong>in</strong>g from their ideas. Such an exercise also helps to strengthen the<br />
commitment of all concerned. You should as much as possible attempt to l<strong>in</strong>k new programme objectives to<br />
ongo<strong>in</strong>g and planned health and health related <strong>in</strong>terventions and support systems <strong>in</strong> the district.<br />
Used sensibly, management by objectives is a technique which helps the District Manager, service managers<br />
and the PHC team to tackle the day to day work and the future development of the district <strong>in</strong> a systematic<br />
way.<br />
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Standards<br />
Standards are the expected levels of work performance and will be central to your work as a District <strong>Health</strong><br />
Manager, service manager and the PHC team. As a manager you will have to set high standards for yourself<br />
and constantly work to improve those standards. If you do this, you will be <strong>in</strong> a position to require high standards<br />
of work from the others. However, those standards should be realistic and should be agreed upon and<br />
accepted by those whose duty it is to implement.<br />
Promot<strong>in</strong>g Team Work<br />
The success of the health activities <strong>in</strong> the district depends to a large extent on people work<strong>in</strong>g well together<br />
<strong>in</strong> small groups and relat<strong>in</strong>g to a common goal, which is the co-ord<strong>in</strong>ation of efforts to br<strong>in</strong>g about an<br />
improvement <strong>in</strong> the health status of the community as a whole.<br />
Def<strong>in</strong>ition of tasks will help you to plot out exactly where activities need to be co-ord<strong>in</strong>ated. It will be your<br />
responsibility to ensure effective work<strong>in</strong>g teams by:<br />
• def<strong>in</strong><strong>in</strong>g a clear purpose and common task which everyone <strong>in</strong> your team understands and is<br />
committed to. Each one of your service managers will need to be helped to appreciate what the<br />
function of his/her unit is and how it fits <strong>in</strong>to the overall work of the District;<br />
• ensur<strong>in</strong>g that each member of the team has a clear idea of his/her own job and how it relates to the<br />
work of the other team members;<br />
• ensur<strong>in</strong>g that <strong>in</strong>dividual members with<strong>in</strong> each of the teams understand the work and duties of others,<br />
particularly where there is an overlap of functions;<br />
• ensur<strong>in</strong>g flexibility amongst members so that the work of the team does not collapse when one<br />
person is absent;<br />
• ensur<strong>in</strong>g that leadership with<strong>in</strong> the team is clearly identifiable and that the team leader is the<br />
person <strong>in</strong> charge;<br />
• ensur<strong>in</strong>g stability and cont<strong>in</strong>uity - but remember that a group that never changes may become set <strong>in</strong><br />
its own ways and also become complacent;<br />
• allocat<strong>in</strong>g sufficient resources to carry out tasks and clear work<strong>in</strong>g methods and procedures which<br />
are well understood; and<br />
• ensur<strong>in</strong>g l<strong>in</strong>kages amongst teams so that teams are not so cohesive as to become exclusive.<br />
Communication Channels<br />
With<strong>in</strong> the District <strong>Health</strong> System, all efforts should be made to streaml<strong>in</strong>e communication channels between<br />
you, your service managers and communities. Further, you should establish effective communication l<strong>in</strong>ks<br />
with all the role players <strong>in</strong> your district <strong>in</strong>clud<strong>in</strong>g non-governmental organizations, community based<br />
organisations and with other sectors.<br />
Management of Change<br />
Profound changes are go<strong>in</strong>g to be needed <strong>in</strong> the balance between hospital and primary health care. You<br />
will have the primary responsibility of br<strong>in</strong>g<strong>in</strong>g about this change <strong>in</strong> your district. It is go<strong>in</strong>g to be important for<br />
you to organise and create opportunities for all <strong>in</strong>volved or who will be affected to be <strong>in</strong>formed about the<br />
change and what they will now be expected to do. You will have to draw up the tasks and responsibilities for<br />
each worker and the skills that will be needed. The tasks should clearly spell out what the health worker is<br />
expected to do, when and <strong>in</strong> what areas of work.<br />
It will be your responsibility to consult and work with them on:<br />
• what they need to learn <strong>in</strong> order to be effective;<br />
• how best to help them learn; and<br />
• how to support them dur<strong>in</strong>g the transition.<br />
You can expect resistance to change. It may not be overt but it could be shown through:<br />
• be<strong>in</strong>g less <strong>in</strong>terested <strong>in</strong> the work;<br />
• people sometimes opt<strong>in</strong>g out of their responsibilities;<br />
• refus<strong>in</strong>g to accept that change is go<strong>in</strong>g to take place;<br />
• compla<strong>in</strong><strong>in</strong>g about their work;<br />
• becom<strong>in</strong>g antagonistic at times to supervisors or those who are try<strong>in</strong>g to br<strong>in</strong>g about the changes;<br />
• cont<strong>in</strong>u<strong>in</strong>g to do th<strong>in</strong>gs <strong>in</strong> the same way as before, particularly if it is a long established practice; and<br />
• a number of <strong>in</strong>dividuals feel<strong>in</strong>g threatened by change, and strengthen<strong>in</strong>g themselves as a group to<br />
resist the change.<br />
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How do you handle this?<br />
• attempt to understand the feel<strong>in</strong>gs of the health workers<br />
• create an atmosphere of confidence and trust, <strong>in</strong>crease understand<strong>in</strong>g and secure co-operation;<br />
• communicate and expla<strong>in</strong> why transformation and restructur<strong>in</strong>g are tak<strong>in</strong>g place and discuss with<br />
them the problems;<br />
• <strong>in</strong>volve them <strong>in</strong> the plann<strong>in</strong>g so as to promote participation;<br />
• do not make the change long drawn out;<br />
• set reasonable time frames;<br />
• reassure personnel that tra<strong>in</strong><strong>in</strong>g and support will be available to enable them to cope with the change;<br />
and<br />
• aim to achieve success, even if only <strong>in</strong> limited areas to build confidence <strong>in</strong> the process.<br />
Manag<strong>in</strong>g Conflict<br />
Change is threaten<strong>in</strong>g, it may also br<strong>in</strong>g about conflict. Try not to be <strong>in</strong>volved <strong>in</strong> “fire fight<strong>in</strong>g” as this will take<br />
up a lot of your time and energy. Set up a team which will be responsible for problem-solv<strong>in</strong>g. Do not avoid<br />
or ignore conflict. Unresolved conflicts tend to get worse, so try to be constantly listen<strong>in</strong>g to the first signs of<br />
major difficulties so that conflicts can be dealt with sooner rather than later.<br />
Giv<strong>in</strong>g Support to Supervisors<br />
You will be responsible for provid<strong>in</strong>g support to service managers and supervisors at the facility level as well as<br />
at the community level. This is key as it will result <strong>in</strong> improved quality of health services.<br />
Supervisors might need support <strong>in</strong> the follow<strong>in</strong>g areas:<br />
• plann<strong>in</strong>g the work of their department/section/health facility;<br />
• co-ord<strong>in</strong>at<strong>in</strong>g work and services;<br />
• sett<strong>in</strong>g and ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g standards;<br />
• communicat<strong>in</strong>g with workers, communities and other sectors;<br />
• motivat<strong>in</strong>g, tra<strong>in</strong><strong>in</strong>g and support for their teams;<br />
• problem solv<strong>in</strong>g;<br />
• improv<strong>in</strong>g their performance skills;<br />
• creat<strong>in</strong>g and ensur<strong>in</strong>g good physical and social work<strong>in</strong>g environment;<br />
• develop<strong>in</strong>g policy mak<strong>in</strong>g skills and functions at a level which is closest to workers and communities;<br />
• develop<strong>in</strong>g and mak<strong>in</strong>g budgets; and<br />
• personal support, advice and praise.<br />
Personnel Management and Staff Development<br />
Issues deal<strong>in</strong>g with plann<strong>in</strong>g, job analysis and description, recruitment, orientation/<strong>in</strong>duction, appraisal,<br />
promotion, discipl<strong>in</strong>e, benefits, exit, retirement and staff development are discussed <strong>in</strong> Chapter 10.<br />
F<strong>in</strong>ance<br />
It is your responsibility to ensure that each specific programme gets the amount of money as budgeted <strong>in</strong> the<br />
district health plan, with a bias towards PHC but without compromis<strong>in</strong>g the quality of referral services. Your<br />
district health care plans and programmes will need to be translated <strong>in</strong>to f<strong>in</strong>ancial plans concerned with<br />
estimated capital and revenue expenditure for both long-term strategic plann<strong>in</strong>g and shorter term operational<br />
plann<strong>in</strong>g. As capital expenditure is concerned with expensive items of build<strong>in</strong>gs or equipment, the expenditure<br />
is often spread over a number of years and can be shown <strong>in</strong> the form of a capital plan. An example of this is<br />
shown below:<br />
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Table 3.1 Capital Expenditure<br />
Name of District: Tiurpslen<br />
Year Type of Construction Cost<br />
1997 Outpatient Department R1,000,000<br />
1998 Water Tank R 50,000<br />
1999 Laboratory R 300,000<br />
An expenditure plan relates to the day to day runn<strong>in</strong>g of services. The f<strong>in</strong>ancial plan will show the amounts<br />
allocated for the current f<strong>in</strong>ancial year, as well as for future years. Your estimates and forecasts for future<br />
years will need to take <strong>in</strong>to account <strong>in</strong>flation and proposed changes <strong>in</strong> the levels of services to be provided<br />
and <strong>in</strong>come expected from various sources.<br />
Operat<strong>in</strong>g Budget<br />
Operat<strong>in</strong>g budgets are concerned with the application of health plan for the current year. Although the<br />
DHMT will have overall control of the health budget, the <strong>in</strong>dividual service managers will be accountable for<br />
funds utilised <strong>in</strong> their specific service areas. These <strong>in</strong>clude health centres, cl<strong>in</strong>ics and mobile cl<strong>in</strong>ics who will all<br />
be responsible for the control of their own budgets. Each one of them will be <strong>in</strong>volved <strong>in</strong> prepar<strong>in</strong>g, controll<strong>in</strong>g<br />
and manag<strong>in</strong>g that part of the budget that is their responsibility whilst the members of the District <strong>Health</strong><br />
Management Team reta<strong>in</strong> overall budget responsibility.<br />
The method of budget<strong>in</strong>g which will be used is programme budget<strong>in</strong>g. Money will be allocated to specific<br />
programmes with<strong>in</strong> the District <strong>Health</strong> Plan e.g. Communicable Disease Control. The weight<strong>in</strong>g of health<br />
programmes is to be viewed as part of an overall health plan designed to achieve def<strong>in</strong>ed and measurable<br />
objectives and outputs of the whole health plan of the district.<br />
The allocation of funds to programmes will be done <strong>in</strong> such a way that the programmes likely to contribute<br />
more substantially to the realisation of the aims and objectives of the District <strong>Health</strong> Plan are given first<br />
priority. This enables scarce funds to be distributed more rationally (a weight<strong>in</strong>g formula will be supplied by<br />
the prov<strong>in</strong>cial office).<br />
Programme plann<strong>in</strong>g and budget<strong>in</strong>g will compel you and your District health staff to plan your health<br />
activities carefully with well def<strong>in</strong>ed and measurable objectives. There must be justification of resources needed<br />
<strong>in</strong> each programme. Therefore every programme must have clearly def<strong>in</strong>ed objectives and a detailed<br />
budget show<strong>in</strong>g expected revenues and expenditure. In this way your budget will become a management<br />
tool which will provide you with feedback for the redef<strong>in</strong><strong>in</strong>g of your objectives should this be necessary.<br />
F<strong>in</strong>ancial Management<br />
One of your responsibilities is to ensure that the required funds for implement<strong>in</strong>g planned activities at various<br />
levels are available. Once <strong>in</strong> place, you should set up a monitor<strong>in</strong>g system that enables you to obta<strong>in</strong><br />
<strong>in</strong>formation on the current f<strong>in</strong>ancial situation for each programme.<br />
<strong>Systems</strong> of monitor<strong>in</strong>g are essential means of detect<strong>in</strong>g deviation from the budget early enough so that<br />
remedial action can be taken to ensure not only that the budget is not exceeded, but that such action is<br />
taken <strong>in</strong> a measured way, consistent with the objectives of the service plans.<br />
Budget management statements such as the one shown <strong>in</strong> Table 3.2 provide you with the means of monitor<strong>in</strong>g<br />
expenditure.<br />
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Table 3.2 Monthly F<strong>in</strong>ancial Management Monitor<strong>in</strong>g<br />
Item Budget Expenditure Budget Variance % Projected Variance<br />
to date (+ under, Year-end<br />
- over Expenditure<br />
Expenditure)<br />
R000 R000 R000 R000 R000 R000<br />
Personnel 120 10* 30 +20 +66 40 +66<br />
Drugs 80 40 + 20 -20 -100 160 -100<br />
Transport 40 20 ++ 10 -10 -100 80 -100<br />
Utilities 12 1** 3 +2 +66 4 +66<br />
252 71 63 -8 -13 284 -13<br />
Budget Notes:<br />
* Personnel: recruitments slow for new posts at beg<strong>in</strong>n<strong>in</strong>g of year<br />
+ Drugs: early stock-tak<strong>in</strong>g<br />
++ Transport: Overspent due to petrol price-<strong>in</strong>crease<br />
** Utilities: Water strike - no bill received<br />
The above shows a monthly management statement after 3 months of the year. The budget to-date column<br />
shows what might be expected to have been spent one quarter of the way through the year. It is assumed<br />
here that spend<strong>in</strong>g will be equal each month (which is unlikely); more sophisticated estimates could be<br />
made. The variance columns show the relative (not actual) over-or underspend<strong>in</strong>g.<br />
F<strong>in</strong>ancial monitor<strong>in</strong>g may detect two variations from the set budget - a likely over- or under-expenditure.<br />
Such variations are likely to be the result of:<br />
• poor <strong>in</strong>itial estimation;<br />
• <strong>in</strong>itial misallocation between budget items;<br />
• unplanned change <strong>in</strong> volume of activity;<br />
• unexpected change <strong>in</strong> prices; or<br />
• change <strong>in</strong> efficiency levels.<br />
It is important, therefore, to be clear as to what is the cause of the deviation, as this may lead to different<br />
responses from managers, and planners. A change <strong>in</strong> activity level may have been unavoidable if it came<br />
about, for example, as a result of an epidemic. Inefficient use of resources, however, should be discouraged<br />
through budgetary mechanisms. An ideal f<strong>in</strong>ancial management and budget system should aim to discourage<br />
both <strong>in</strong>efficiency and unplanned activity-level changes. It should also not encourage end-of-year ‘spend<strong>in</strong>gup’,<br />
a common phenomenon when budget residues cannot be carried forward or budgets are related to<br />
the previous year’s expenditure.<br />
Corrective F<strong>in</strong>ancial Actions<br />
The options to a manager fac<strong>in</strong>g over-or under-expenditure can be summarised as:<br />
• virement between different items;<br />
• a request for supplementary funds;<br />
• improvements <strong>in</strong> efficiency;<br />
• a reduction <strong>in</strong> activity levels; and<br />
Each of these is outl<strong>in</strong>ed briefly below.<br />
Virement Between Different Items<br />
Virement is the process of transferr<strong>in</strong>g funds from one budget l<strong>in</strong>e to another. Where the likely over-expenditure<br />
is only <strong>in</strong> one item, and is compensated for by an underspend<strong>in</strong>g <strong>in</strong> another item, then a transfer of funds<br />
from one l<strong>in</strong>e item (such as transport) to another (such as drugs) may be possible. F<strong>in</strong>ancial control systems<br />
usually have restrictions on the ability of a budget-manager to make such virement between certa<strong>in</strong> items.<br />
A Request for Supplementary Funds<br />
A second option is to seek additional fund<strong>in</strong>g. This may under certa<strong>in</strong> circumstances be possible <strong>in</strong> the form<br />
of a supplementary vote of funds from the next level up <strong>in</strong> the health service (the region or prov<strong>in</strong>ce for<br />
36
example), or from central government. The possibilities of this and the appropriateness of such action will<br />
depend both on the availability of funds, either through a cont<strong>in</strong>gency budget or through underspend<strong>in</strong>g<br />
elsewhere, and on the cause of the overspend<strong>in</strong>g. Unanticipated <strong>in</strong>creases <strong>in</strong> the levels of activity (for example<br />
through an emergency) may be seen as reasonable cause for supplementary fund<strong>in</strong>g.<br />
Efficiency Improvements<br />
The most attractive option for deal<strong>in</strong>g with potential over-expenditure is an <strong>in</strong>crease <strong>in</strong> efficiency, allow<strong>in</strong>g<br />
the same level of service activity to be provided, at the same quality, for less resources. Striv<strong>in</strong>g for improved<br />
efficiency should, of course, be a concern of all managers at all times, and not just <strong>in</strong> situations of potential<br />
over-expenditure. Possible techniques which may help to identify areas of <strong>in</strong>efficiency <strong>in</strong>clude economic<br />
appraisal techniques, or, even more simply, an exam<strong>in</strong>ation of cost structures. Efficiency may, <strong>in</strong> general, be<br />
improved <strong>in</strong> three ways. Firstly, by achiev<strong>in</strong>g the same ends by a completely different approach. Secondly,<br />
by look<strong>in</strong>g for areas where economies of scale can be achieved, perhaps by shar<strong>in</strong>g resources such as<br />
transport. And lastly, efficiency improvements may be achieved by negotiat<strong>in</strong>g a reduction <strong>in</strong> the price of<br />
<strong>in</strong>puts, such as drugs. It should be noted though, that often efficiency improvements take some time to filter<br />
through <strong>in</strong>to budgets, and thus may not provide an easy solution to short-term over-expenditure problems.<br />
There are also efficiency traps which can lure the unsuspect<strong>in</strong>g manager <strong>in</strong>to worse situations. It is worth<br />
remark<strong>in</strong>g that undue attention spent on attempt<strong>in</strong>g to improve efficiency may be counter-productive, and<br />
may divert attention away from more important managerial and plann<strong>in</strong>g issues.<br />
A Reduction <strong>in</strong> Activity Levels<br />
A fourth option <strong>in</strong>volves reduc<strong>in</strong>g the levels of service activity, which, <strong>in</strong> contrast with the previous option,<br />
may lead to budget sav<strong>in</strong>gs, but possibly also to lower levels of efficiency. Reduction of activity is rarely easy<br />
managerially, as there is likely to be understandable resistance to it from health professionals and the<br />
community. It may, however, be preferable to other options, or the only option available.<br />
L<strong>in</strong>e Item Control<br />
The previous options have all dealt with alternative ways of reduc<strong>in</strong>g expenditure. In many situations this may<br />
be the only realistic option open to a cash-limited budget-manager. An alternative approach, commonly<br />
followed, starts with the exist<strong>in</strong>g l<strong>in</strong>e item budgets (such as transport or drugs) and looks for sav<strong>in</strong>gs <strong>in</strong> these.<br />
Such an approach is a useful way of <strong>in</strong>volv<strong>in</strong>g other functional managers. However, it is important to recognise<br />
that this and the previous approaches are closely l<strong>in</strong>ked. Any change <strong>in</strong> such l<strong>in</strong>e items will always result <strong>in</strong> a<br />
change <strong>in</strong> either the efficiency, the quality, or the levels of activity of services. Similarly, any change <strong>in</strong> efficiency,<br />
quality, or quantity can only be realised through changes <strong>in</strong> the actual budget l<strong>in</strong>es.<br />
Build<strong>in</strong>gs<br />
These are <strong>in</strong> the form of cl<strong>in</strong>ics, health centres, hospitals and are a normal part of the health care set-up.<br />
As a district health manager, you will have to th<strong>in</strong>k carefully before decid<strong>in</strong>g to spend money on new build<strong>in</strong>gs<br />
and extensions of exist<strong>in</strong>g ones. The first question that you should always ask yourself is “How can I develop a<br />
health plan that makes maximum use of exist<strong>in</strong>g build<strong>in</strong>gs?”<br />
Supplies and Stores<br />
You will need an effective supplies systems for the smooth runn<strong>in</strong>g of your district. Your district supplies system<br />
will essentially deal with requisition<strong>in</strong>g, order<strong>in</strong>g, purchas<strong>in</strong>g receipts, storage and issue of supplies to users.<br />
You will need a centralised store at the district level which will be managed by a stores manager with expertise<br />
<strong>in</strong> the various stages of supplies management. All members of the District <strong>Health</strong> Team should be familiar with<br />
the way the system operates, so as to ensure that the essential requirements for the district are <strong>in</strong> regular<br />
supply.<br />
Factors to be taken <strong>in</strong>to consideration when determ<strong>in</strong><strong>in</strong>g how much stock to keep will be:<br />
• monthly, quarterly or annual requirement for each item;<br />
• price of items; and<br />
• time taken between plac<strong>in</strong>g an order and receiv<strong>in</strong>g goods.<br />
Stores records are important. The follow<strong>in</strong>g records will be used:<br />
• an <strong>in</strong>ventory register;<br />
• a standard requisition form;<br />
• a store ledger and a tally card;<br />
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• a stores issue voucher; and<br />
• a stores issue book.<br />
Your team must clearly understand the supplies procedures <strong>in</strong> order to ensure that goods are ordered and<br />
obta<strong>in</strong>ed before stocks run down. You need to put <strong>in</strong> place a system of periodic stock tak<strong>in</strong>g and audit<strong>in</strong>g to<br />
ensure that goods are not stolen, lost, misappropriated and/or deteriorate through poor storage. Where<br />
certa<strong>in</strong> goods are used frequently you will have to develop a “topp<strong>in</strong>g up” system whereby a top limit e.g. of<br />
not less than 50% of stock are held at any one time and once stocks reach this limit they are replenished.<br />
To avoid abuses however, you will have to set an upper limit. You will also have to become skilled <strong>in</strong> us<strong>in</strong>g<br />
locally available resources and technology and not depend on imported expensive supplies and equipment.<br />
Transport and Communication<br />
Transport will be an essential part of your communication system <strong>in</strong> your district. It will be necessary for:<br />
• supervision and support;<br />
• distribution of drugs and supplies;<br />
• mobile teams;<br />
• health promotion workers;<br />
• programme co-ord<strong>in</strong>ators;<br />
• referral of patients to cl<strong>in</strong>ics, health centres and hospitals; and<br />
• adm<strong>in</strong>istration.<br />
Transport, if not properly organised and co-ord<strong>in</strong>ated will consume a large part of your<br />
district health budget, because of the high costs of vehicles, ma<strong>in</strong>tenance and fuel.<br />
You will need to properly co-ord<strong>in</strong>ate your transport and communication needs. (The prov<strong>in</strong>cial transport<br />
policy document will provide you with guidel<strong>in</strong>es).<br />
Whenever possible you will have to use multi-purpose vehicles which can be used by teams rather than<br />
<strong>in</strong>dividuals. Apart from transport you are expected to ensure control and economic use of other<br />
communication systems <strong>in</strong>clud<strong>in</strong>g telephone, fax, radio communication and mail.<br />
Delegat<strong>in</strong>g and Motivat<strong>in</strong>g Others<br />
Whilst it is important for you to understand your district function holistically, you cannot carry out all the activities<br />
alone. You are dependent on others to do some of the work. As a district health manager you must be able<br />
to delegate work to others, motivate them and w<strong>in</strong> over their commitment. You and your team will be provided<br />
with tra<strong>in</strong><strong>in</strong>g and professional support by the prov<strong>in</strong>cial and regional offices to enable you to perform your<br />
duties more effectively.<br />
It will be important for those that you delegate to, to know that they will get your support whenever they<br />
make decisions with<strong>in</strong> their own area of delegated responsibility. Even where bad decisions are made, it is<br />
important that they are supported, whilst be<strong>in</strong>g given help to address the situation and guidance on how to<br />
make better decisions <strong>in</strong> the future. It is better for the occasional mistake to be made than for supervisors to<br />
be afraid of mak<strong>in</strong>g any decisions.<br />
Some of your duties and responsibilities will be delegated to other managers and supervisors <strong>in</strong> the follow<strong>in</strong>g<br />
offices:<br />
• Adm<strong>in</strong>istration and F<strong>in</strong>ance<br />
• Human Resources Development Unit<br />
• PHC Co-ord<strong>in</strong>ation<br />
• District Pharmacist’s Office<br />
• District <strong>Health</strong> Information Unit<br />
• Management Teams at various facilities<br />
It will be however important for you to ensure that the different parts of the health systems are well coord<strong>in</strong>ated,<br />
so that they do not work <strong>in</strong> isolation but work together towards a common goal.<br />
In delegat<strong>in</strong>g you have to make it clear where authority and responsibility lie. Accountability however cannot<br />
be delegated and you as the manager holds the utmost responsibility and accountability.<br />
38
FUNCTIONS OF OTHER MEMBERS OF THE DHMT<br />
District <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Co-ord<strong>in</strong>ator<br />
As a District <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> (PHC) Co-ord<strong>in</strong>ator, you will be responsible for develop<strong>in</strong>g, <strong>in</strong>tegrat<strong>in</strong>g and<br />
ensur<strong>in</strong>g delivery of PHC services at all the service levels <strong>in</strong> the district.<br />
Your responsibility is to:<br />
• develop plans for implementation of primary health care service programmes <strong>in</strong> the district<br />
• ensure <strong>in</strong>tegration of the PHC service programme components <strong>in</strong>to appropriate packages for the<br />
various service levels;<br />
• provide technical and logistical support to the PHC service providers;<br />
• identify <strong>in</strong>puts for the PHC service programmes;<br />
• monitor implementation, coverage, effectiveness, efficiency and impact of PHC service programmes;<br />
and<br />
• set up community structures for promot<strong>in</strong>g participation of communities <strong>in</strong> PHC service delivery.<br />
In this role you will be assisted by programme co-ord<strong>in</strong>ators who will be responsible for:<br />
• assist<strong>in</strong>g service implementors <strong>in</strong> plann<strong>in</strong>g, implementation, supervision, monitor<strong>in</strong>g and evaluation of<br />
services;<br />
• advis<strong>in</strong>g the DHMT on health matters affect<strong>in</strong>g the district; and<br />
• advis<strong>in</strong>g policy makers at regional and prov<strong>in</strong>cial levels <strong>in</strong> matters relat<strong>in</strong>g to their areas of expertise.<br />
Adm<strong>in</strong>istration and F<strong>in</strong>ance Manager<br />
The support from Adm<strong>in</strong>istration and F<strong>in</strong>ance is meant to be a non-prescriptive support service which sets<br />
free the health managers and their technical personnel to function <strong>in</strong> a cost effective and targeted manner.<br />
In each district the hospital secretary will become the adm<strong>in</strong>istration officer. As Adm<strong>in</strong>istration and F<strong>in</strong>ance<br />
Manager you will play the follow<strong>in</strong>g supportive role:<br />
Personnel: You will deal with all staff matters <strong>in</strong> the health district. This <strong>in</strong>cludes matters perta<strong>in</strong><strong>in</strong>g to leave<br />
forms, merit reports, salary and pension queries and hous<strong>in</strong>g subsidies.<br />
Transport and auxiliary services: Transport officers deal with the transport needs of the DHMT, their staff as<br />
well as cl<strong>in</strong>ic, health centre and hospital requirements <strong>in</strong> the district. This <strong>in</strong>cludes supply<strong>in</strong>g Government and<br />
subsidised vehicles. This section is responsible for process<strong>in</strong>g all transport claims and forward<strong>in</strong>g them to<br />
F<strong>in</strong>ance.<br />
F<strong>in</strong>ance: Budgets and expenditure at the District <strong>Health</strong> Office are controlled by the District <strong>Health</strong> Manager<br />
concerned. However, the District Adm<strong>in</strong>istration and F<strong>in</strong>ance Manager processes payments and distributes<br />
cheques.<br />
Provision<strong>in</strong>g and stores: Purchases of stationery and equipment, the acquisition of premises, and rental of<br />
labour sav<strong>in</strong>g devices is done on behalf of the District <strong>Health</strong> Manager and is controlled and distributed from<br />
the District Adm<strong>in</strong>istration and F<strong>in</strong>ance Manager’s Office.<br />
Provision of adm<strong>in</strong>istrative support personnel: The adm<strong>in</strong>istrative office supplies the required support to the<br />
District <strong>Health</strong> Office on request. This <strong>in</strong>cludes advertisement and acquisition of new personnel.<br />
District <strong>Health</strong> Information Manager<br />
Work<strong>in</strong>g <strong>in</strong> the districts, you may f<strong>in</strong>d yourself isolated by geographic and communication circumstances. To<br />
manage the services and health resources available to you, it is necessary that you gather, analyse and put<br />
to use the health and management data available to you.<br />
As District <strong>Health</strong> Information Manager, you will assist the DHMT and other stakeholders <strong>in</strong> the follow<strong>in</strong>g way:<br />
• develop and ma<strong>in</strong>ta<strong>in</strong> a register of <strong>in</strong>formation on the health status of the communities <strong>in</strong> the district;<br />
• analyse and provide feedback to the service managers and relevant communities about the<br />
conclusions and lessons from the data gathered;<br />
• facilitate communities and service managers <strong>in</strong> apply<strong>in</strong>g the data <strong>in</strong> plann<strong>in</strong>g of resources and<br />
services;<br />
39
• develop and ma<strong>in</strong>ta<strong>in</strong> a register of <strong>in</strong>formation on health service management itself i.e. how the<br />
services are rendered and by who, how effective are the services at all levels, what are the constra<strong>in</strong>ts<br />
<strong>in</strong> the service etc;<br />
• develop tools for monitor<strong>in</strong>g progress and achievements of services;<br />
• provide tools for mobilisation of communities to take actions that promote their own health; and<br />
• ma<strong>in</strong>ta<strong>in</strong> a cont<strong>in</strong>uous and up to date audit of all district resources.<br />
Human Resources Development Manager<br />
It is often forgotten that health workers and health service managers <strong>in</strong> the district constitute a resource that<br />
needs support and tra<strong>in</strong><strong>in</strong>g, cont<strong>in</strong>u<strong>in</strong>g education, cont<strong>in</strong>uous appraisal and recognition (read chapter 10).<br />
In a departure from the past the District <strong>Health</strong> Management Team is to ensure that this is done, through the<br />
Human Resources Development Unit <strong>in</strong> the follow<strong>in</strong>g way:<br />
• advise on deployment of appropriately tra<strong>in</strong>ed personnel <strong>in</strong> health facilities;<br />
• develop tools for support supervision of personnel <strong>in</strong> all health facilities;<br />
• develop tools for personnel appraisal;<br />
• provide cont<strong>in</strong>u<strong>in</strong>g education and tra<strong>in</strong><strong>in</strong>g to health personnel <strong>in</strong> the district; and<br />
• develop career guidel<strong>in</strong>es for health personnel <strong>in</strong> the district.<br />
Academic Support Representative<br />
The academic support unit supports and advises the District <strong>Health</strong> Management Team on issues perta<strong>in</strong><strong>in</strong>g<br />
to service delivery, tra<strong>in</strong><strong>in</strong>g monitor<strong>in</strong>g and research. The academic support representative has a functional<br />
e.g. cl<strong>in</strong>ical role <strong>in</strong> the district and also participates <strong>in</strong> activities implemented by the District <strong>Health</strong> Management<br />
Team (DHMT). He/she also co-ord<strong>in</strong>ates academic activities with<strong>in</strong> the district and liaises with the relevant<br />
academic <strong>in</strong>stitution.<br />
The unit will be established <strong>in</strong> a phased approach as districts employ personnel on the jo<strong>in</strong>t establishments<br />
mentioned <strong>in</strong> chapter 2.<br />
The functions of a district pharmacist are:<br />
District Pharmacist<br />
• to purchase, via the prov<strong>in</strong>cial procurement system, pharmaceuticals and surgical sundries for the<br />
district;<br />
• to provide pharmaceuticals and surgical sundries to all the public sector health facilities <strong>in</strong> the district;<br />
and<br />
• to monitor and ensure compliance of usage of pharmaceuticals <strong>in</strong> the district <strong>in</strong> accordance with<br />
policy guidel<strong>in</strong>es.<br />
The DHMT will need to monitor how the services are be<strong>in</strong>g implemented <strong>in</strong> the district. Therefore, the DHMT<br />
would be <strong>in</strong>terested <strong>in</strong> know<strong>in</strong>g how effective the management support has been <strong>in</strong> areas such as: plann<strong>in</strong>g<br />
of services; management of personnel; tra<strong>in</strong><strong>in</strong>g of staff; supervision of health personnel; management of<br />
f<strong>in</strong>ance; management of logistics; health <strong>in</strong>formation and community organisation. For more <strong>in</strong>formation on<br />
monitor<strong>in</strong>g and evaluation you should read chapter 9.<br />
HEALTH FACILITY MANAGEMENT TEAMS<br />
All facilities will be managed by management teams<br />
The Hospital Management Team (HMT)<br />
A hospital has its own management team for runn<strong>in</strong>g the day-to-day bus<strong>in</strong>ess. This management team is<br />
known as the Hospital Management Team.<br />
Composition<br />
The Hospital Management Team consists of:<br />
• Hospital Manager/Medical Super<strong>in</strong>tendent;<br />
40
• Heads of Departments (Unit Heads); and<br />
• Elected representatives from each unit.<br />
Functions<br />
If you are a member of the Hospital Management Team, you are expected to support the Hospital Manager<br />
to carry out the follow<strong>in</strong>g:<br />
• provide technical support to health centres and cl<strong>in</strong>ics;<br />
• manage and ma<strong>in</strong>ta<strong>in</strong> all the non-human resources of the hospital;<br />
• identify resource requirements for support<strong>in</strong>g the hospital;<br />
• render curative and diagnostic services to the health district;<br />
• provide referral services for the lower level health facilities and as a referral source for higher level<br />
facilities <strong>in</strong> the district; and<br />
• participate <strong>in</strong> human resources development, <strong>in</strong>clud<strong>in</strong>g technical support to the cl<strong>in</strong>ics and health<br />
centres <strong>in</strong> the district.<br />
District Managers are expected to meet regularly (at least quarterly) with health centre, cl<strong>in</strong>ic and hospital<br />
managers to review and plan strategies for health service delivery <strong>in</strong> the district.<br />
The <strong>Health</strong> Centre Management Team (HCMT)<br />
In a District <strong>Health</strong> system, a health centre has its own management team: The <strong>Health</strong> Centre Management<br />
Team (HCMT).<br />
Composition<br />
The <strong>Health</strong> Centre Management Team is made up of the follow<strong>in</strong>g:<br />
• The <strong>Health</strong> Centre Manager<br />
• Unit Heads at the <strong>Health</strong> Centre<br />
• District <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Co-ord<strong>in</strong>ator<br />
Functions<br />
The health centre is a k<strong>in</strong>gp<strong>in</strong> <strong>in</strong> the health care system. It is a unit for steer<strong>in</strong>g development of health <strong>in</strong> its<br />
catchment area. As a member of the <strong>Health</strong> Centre Management Team, you are expected to support the<br />
<strong>Health</strong> Centre Manager <strong>in</strong>:<br />
• provid<strong>in</strong>g both primary and secondary health care services to communities <strong>in</strong> its catchment area;<br />
• provid<strong>in</strong>g referral service to the cl<strong>in</strong>ics and serv<strong>in</strong>g as a referral source for the district;<br />
• establish<strong>in</strong>g l<strong>in</strong>kages with other sectors <strong>in</strong> matters perta<strong>in</strong><strong>in</strong>g to health promotion and development;<br />
• promot<strong>in</strong>g l<strong>in</strong>kages with community based health development <strong>in</strong>itiatives by CBOs, NGOs, local<br />
authorities and private sector;<br />
• supervis<strong>in</strong>g and ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g the health centre based health <strong>in</strong>formation system;<br />
• identify<strong>in</strong>g resource requirements for support to the health centre; and<br />
• provid<strong>in</strong>g technical support to satellite cl<strong>in</strong>ics with<strong>in</strong> its catchment area.<br />
The <strong>Health</strong> Centre Manager is expected to meet regularly (at least once a month) with managers of the<br />
cl<strong>in</strong>ics <strong>in</strong> the health centre catchment area together with the PHC Co-ord<strong>in</strong>ator, to share <strong>in</strong>formation and to<br />
plan and evaluate the services for the catchment area.<br />
The Cl<strong>in</strong>ic Management Team (CMT)<br />
A community health cl<strong>in</strong>ic also has its own management team, the Cl<strong>in</strong>ic Management Team (CMT)<br />
Composition<br />
The Cl<strong>in</strong>ic Management Team comprises:<br />
• The Cl<strong>in</strong>ic Manager<br />
• Representatives of Units based at the cl<strong>in</strong>ic<br />
41
Functions<br />
The cl<strong>in</strong>ic represents the first formal structure of the health service <strong>in</strong> the community. It thus has an important<br />
role to play <strong>in</strong> promot<strong>in</strong>g the health of the community. The Cl<strong>in</strong>ic Management Team is expected to uphold<br />
and promote this role. Specifically the team is to support the Cl<strong>in</strong>ic Manager to render the follow<strong>in</strong>g services<br />
to the community <strong>in</strong> the catchment area:<br />
• provide quality primary health care services to the communities;<br />
• facilitate and encourage community based health development <strong>in</strong>itiatives;<br />
• promote <strong>in</strong>tersectoral collaboration <strong>in</strong> community based health development <strong>in</strong>itiatives;<br />
• participate <strong>in</strong> establishment, implementation and ma<strong>in</strong>tenance of a community based <strong>Health</strong> and<br />
Management Information System;<br />
• provide a source for referral to the health centre; and<br />
• promote l<strong>in</strong>kage with community health development <strong>in</strong>itiatives by CBOs, NGOs, local authorities<br />
and private sector.<br />
You have read, <strong>in</strong> this chapter, about the District <strong>Health</strong> System for <strong>Mpumalanga</strong> and how it will be used as a<br />
vehicle for facilitat<strong>in</strong>g the delivery of <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong>. The chapter has also discussed the referral system<br />
that provides l<strong>in</strong>kage from one service level to another. In addition the management system for the District<br />
<strong>Health</strong> System has been discussed <strong>in</strong> detail, highlight<strong>in</strong>g the responsibilities of various management teams.<br />
An important l<strong>in</strong>k <strong>in</strong> the District <strong>Health</strong> System is the people. The role of communities <strong>in</strong> ensur<strong>in</strong>g ownership<br />
and susta<strong>in</strong>ability of community based health development <strong>in</strong>itiative is discussed <strong>in</strong> the next chapter.<br />
42
THE ROLE OF COMMUNITIES IN<br />
HEALTH DEVELOPMENT<br />
CHAPTER 4
Chapter 4<br />
THE ROLE OF COMMUNITIES IN<br />
HEALTH DEVELOPMENT<br />
The purpose of this chapter is to discuss the importance of <strong>in</strong>volv<strong>in</strong>g local communities <strong>in</strong> plann<strong>in</strong>g,<br />
implementation, monitor<strong>in</strong>g and evaluation of health development activities.<br />
After read<strong>in</strong>g this chapter, you will be able to understand:<br />
• the need for community participation <strong>in</strong> health plann<strong>in</strong>g and service delivery;<br />
• the requirements/prerequisites for successful community participation;<br />
• common obstacles to community participation;<br />
• strategies to promote/enhance community participation; and<br />
• the importance of monitor<strong>in</strong>g and evaluat<strong>in</strong>g participation by communities <strong>in</strong><br />
health development.<br />
Through decentralisation the health services <strong>in</strong> the prov<strong>in</strong>ce have been brought closer to the people to<br />
facilitate mean<strong>in</strong>gful participation by communities <strong>in</strong> plann<strong>in</strong>g and delivery of health services (refer to chapters<br />
1-3). This promotes responsiveness of the services to the local health needs, ownership by accountability of<br />
the services to the communities. However, community participation <strong>in</strong> health services should be orderly and<br />
well co-ord<strong>in</strong>ated. How would you achieve this?<br />
Community participation means a lot of different<br />
th<strong>in</strong>gs to different people. For us <strong>in</strong> <strong>Mpumalanga</strong>,<br />
community participation is taken as the process of<br />
<strong>in</strong>volv<strong>in</strong>g communities <strong>in</strong> sett<strong>in</strong>g the health priorities,<br />
plann<strong>in</strong>g, implementation and evaluation of activities<br />
relat<strong>in</strong>g to improvements <strong>in</strong> their own health status.<br />
The process itself is empower<strong>in</strong>g, and it builds skills and<br />
confidence <strong>in</strong> the people <strong>in</strong>volved. It is also a<br />
mechanism of mobilis<strong>in</strong>g human and material<br />
resources at local level for health and development<br />
efforts.<br />
Community participation is not the sporadic and<br />
superficial consultations with “not-so-representative<br />
community forums”, nor does it imply abdication by<br />
the Department on its responsibilities <strong>in</strong> provid<strong>in</strong>g<br />
health services.<br />
The community is the core of the District <strong>Health</strong> Strategy as all health functions and tasks have a community<br />
component. Local people are the greatest resource and by work<strong>in</strong>g closely with them it can be ensured that<br />
the health care system is part of their responsibility.<br />
It is important for you to remember that there is more than one degree of community participation, namely:<br />
• nom<strong>in</strong>at<strong>in</strong>g representatives to sit on committees;<br />
• a truly democratic dialogue with the community or its elected leaders; and<br />
• active participation <strong>in</strong> service delivery activities.<br />
The Department supports the option of democratic dialogue with communities because not only is community<br />
<strong>in</strong>volvement a democratic right, it should be seen also as part of the broader social development and utilisation<br />
of human potential envisioned and propagated <strong>in</strong> the Reconstruction and Development Plan (RDP) as well<br />
as <strong>in</strong> the National <strong>Health</strong> Plan for South Africa.<br />
45
It is clearly stated <strong>in</strong> the RDP document that “development is not about the delivery of goods to a passive<br />
society, it is about active <strong>in</strong>volvement and grow<strong>in</strong>g empowerment”<br />
For many health workers, work<strong>in</strong>g together with a community is a new experience. Remember, this is true for<br />
communities as well. You will be learn<strong>in</strong>g together. The degree to which the community is <strong>in</strong>volved will depend<br />
<strong>in</strong>itially on the extent of community organisations already <strong>in</strong> existence, as well as the relationship with the<br />
health service. Involvement will be built up from there, <strong>in</strong>creas<strong>in</strong>g as the community develops capacity to<br />
participate <strong>in</strong> health development.<br />
GETTING TO KNOW THE COMMUNITY YOU SERVE<br />
The process of gett<strong>in</strong>g to know the community is not easy. It will vary with different communities and the<br />
health worker should guard aga<strong>in</strong>st concentrat<strong>in</strong>g on the elite and the vocal and forgett<strong>in</strong>g the silent majority<br />
(see Figure 4.1).<br />
Figure 4.1:<br />
Characteristics of Community Representation<br />
1<br />
2<br />
3<br />
Key:<br />
1. The elite (big leaders) who presume they represent the community;<br />
2. The “better off” members of the community;<br />
3. The silent majority (community): marg<strong>in</strong>alised and dom<strong>in</strong>ated; usually the last to be consulted or<br />
contacted.<br />
As one gets to know the communities <strong>in</strong> the catchment area served by the cl<strong>in</strong>ic, health centre or hospital,<br />
one will come to realise that the status of their health is <strong>in</strong>timately <strong>in</strong>fluenced by many social determ<strong>in</strong>ants.<br />
Important determ<strong>in</strong>ants <strong>in</strong>clude socio-economic status, life style choices, health seek<strong>in</strong>g behaviour, cultural<br />
beliefs and practices, religious beliefs, education and general awareness. Without address<strong>in</strong>g these needs,<br />
health <strong>in</strong>terventions can be a very frustrat<strong>in</strong>g experience.<br />
<strong>Health</strong> professionals have the technical knowledge and skills but the communities have the knowledge about<br />
their culture and social organisation. That knowledge needs to be tapped <strong>in</strong> design<strong>in</strong>g and implement<strong>in</strong>g<br />
health programmes which will be acceptable to the community.<br />
Acceptance of health <strong>in</strong>terventions by the community will ensure not only the success of the <strong>in</strong>tervention but<br />
also susta<strong>in</strong>ability of the effects and impact of the <strong>in</strong>tervention. Community participation will also allow health<br />
programmes to access other resources <strong>in</strong> the community such as the human resources which would not<br />
otherwise be available.<br />
46
FORGING LINKAGES AND PARTNERSHIPS<br />
Intersectoral collaboration is simply the connection between statutory and non-statutory sectors shar<strong>in</strong>g<br />
common <strong>in</strong>terests <strong>in</strong> the promotion of health, prevention of diseases and conditions, cur<strong>in</strong>g of health ailments<br />
and rehabilitation.<br />
Partnerships between the community, health service, and other sectors need to be established. It is advisable<br />
to beg<strong>in</strong> by:<br />
• identify<strong>in</strong>g staff who are go<strong>in</strong>g to drive this process (The Prov<strong>in</strong>cial <strong>Health</strong> Office will assist you <strong>in</strong><br />
establish<strong>in</strong>g governance and management structures, whilst the PHC team will support community<br />
<strong>in</strong>volvement <strong>in</strong> service programmes);<br />
• identify<strong>in</strong>g exist<strong>in</strong>g community structures, eg. church, women’s, and youth groups, NGOs, CBOs,<br />
Reconstruction and Development Councils (RDCs), traditional group<strong>in</strong>gs, political organisations,<br />
labour movements;<br />
• identify<strong>in</strong>g additional structures which need to be formed, <strong>in</strong>clud<strong>in</strong>g representative community<br />
structures;<br />
• identify<strong>in</strong>g <strong>in</strong>tersectoral l<strong>in</strong>kages, particularly with the departments of works, water affairs, safety and<br />
security, education and agriculture;<br />
• collaborat<strong>in</strong>g with statutory bodies such as local government;<br />
• br<strong>in</strong>g<strong>in</strong>g different groups together to promote l<strong>in</strong>kages and formalise networks;<br />
• rais<strong>in</strong>g awareness of health issues, <strong>in</strong> community and other sector forums ;<br />
• shar<strong>in</strong>g <strong>in</strong>formation with other agencies; and<br />
• facilitat<strong>in</strong>g formation of representative community structures, eg. community health committees.<br />
A database (descriptive <strong>in</strong>ventory) of all potentially health-related structures with<strong>in</strong> the district, <strong>in</strong>clud<strong>in</strong>g<br />
RDCs, local government councils, NGOs, and community groups of various k<strong>in</strong>ds, should be built up through<br />
the district health <strong>in</strong>formation unit. The Regional National Progressive <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Network (NPPHCN)<br />
already has this <strong>in</strong>formation.<br />
The importance of <strong>in</strong>tersectoral collaboration<br />
Many health problems have multiple underly<strong>in</strong>g causes. Their solutions may, therefore, require <strong>in</strong>terventions<br />
from a number of different sectors. Depend<strong>in</strong>g on the problems you have prioritised, you may need to<br />
develop l<strong>in</strong>ks not only with the community but also with other development sectors e.g. education, water<br />
supply, agriculture, social welfare and gender affairs, safety and security, and correctional services operat<strong>in</strong>g<br />
<strong>in</strong> that community.<br />
It is most useful if your health team, representatives of the community health committee, and the other sector<br />
structures sit together, agree on a common goal, and plan the <strong>in</strong>tervention jo<strong>in</strong>tly. Each player would then<br />
contribute to the implementation accord<strong>in</strong>g to his or her particular role.<br />
The pr<strong>in</strong>ciples to be borne <strong>in</strong> m<strong>in</strong>d <strong>in</strong>clude:<br />
• identification of common ground/<strong>in</strong>terests;<br />
• official, mean<strong>in</strong>gful consultation;<br />
• commitment from each sector towards a shared goal; and<br />
• effective, efficient feedback mechanisms for all sectors.<br />
COMMUNITY INVOLVEMENT IN HEALTH CARE<br />
Communities need to be <strong>in</strong>volved at all stages of the development and implementation of health <strong>in</strong>itiatives.<br />
These <strong>in</strong>clude:<br />
• identification of health needs;<br />
• sett<strong>in</strong>g of priorities;<br />
• design<strong>in</strong>g of <strong>in</strong>terventions;<br />
• implementation of the <strong>in</strong>terventions; and<br />
• monitor<strong>in</strong>g and evaluation of the <strong>in</strong>terventions and their impacts.<br />
47
The health worker, <strong>in</strong> cultivat<strong>in</strong>g the <strong>in</strong>volvement of communities should ensure that:<br />
• all stakeholders <strong>in</strong> the community and health service are well <strong>in</strong>formed;<br />
• all stakeholders are consulted from the very beg<strong>in</strong>n<strong>in</strong>g (needs assessment);<br />
• a participatory approach is employed <strong>in</strong> gather<strong>in</strong>g detailed <strong>in</strong>formation about the problems;<br />
• feedback <strong>in</strong>formation is supplied to all stakeholders, us<strong>in</strong>g this as an opportunity for network<strong>in</strong>g with<strong>in</strong><br />
and between communities;<br />
• the collected <strong>in</strong>formation is used to advocate for new service;<br />
• a community support group is established;<br />
• available resources are brought as close to the community as possible and that exist<strong>in</strong>g resources are<br />
utilised for the benefit of community members;<br />
• the community is <strong>in</strong>volved <strong>in</strong> support<strong>in</strong>g/ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g these resources;<br />
• awareness is raised <strong>in</strong> the community through occasions such as health days, competitions etc; and<br />
• an appropriate communication system is used to convey health messages.<br />
Communities should also be encouraged to take responsibility for their own health through healthy lifestyle<br />
and healthy behaviour.<br />
The follow<strong>in</strong>g case study illustrates several pr<strong>in</strong>ciples <strong>in</strong> community participation.<br />
Case Study<br />
The Speak<strong>in</strong>g Gardens of Makoko<br />
Somewhere <strong>in</strong> the year 1984, Agnes, a midwife was transferred from a hospital to a very remote cl<strong>in</strong>ic. The people<br />
of the area were referred to as “Bonjobe Njobeni”mean<strong>in</strong>g the illiterate. They were plagued with a host of different<br />
but preventable diseases - <strong>in</strong>clud<strong>in</strong>g malnutrition and other diseases that came as result of not tak<strong>in</strong>g a<br />
balanced diet. People depended on the traditional food crops grown <strong>in</strong> their gardens: maize and ground nuts.<br />
Although she was born <strong>in</strong> the area, she had lived away for a long time and was practically a stranger to the area.<br />
She was unfamiliar to the people and was treated as a different species because of her education. She realised<br />
that to succeed <strong>in</strong> her work , she had to work her way <strong>in</strong>to the hearts of the people. She had to show that she<br />
belonged to and was a person of the people. She spoke the language well, attended the traditional meet<strong>in</strong>gs and<br />
gather<strong>in</strong>gs, Amongst the other th<strong>in</strong>gs she did to w<strong>in</strong> the community was work<strong>in</strong>g <strong>in</strong> her garden like every body else;<br />
keep<strong>in</strong>g chickens <strong>in</strong> her fowlrun and participat<strong>in</strong>g <strong>in</strong> traditional craft mak<strong>in</strong>g . Her identification with the community<br />
paid off , for she gradually became accepted.<br />
She understood the local jargon for describ<strong>in</strong>g childhood diseases. She knew, for <strong>in</strong>stance, that “Isifo Sabe Sotho”was<br />
noth<strong>in</strong>g but kwashiorkor. In her own exemplary way of fight<strong>in</strong>g malnutrition, Agnes began educat<strong>in</strong>g the community<br />
on what to do about kwashiorkor . Women admired her garden which she expla<strong>in</strong>ed as the tool for fight<strong>in</strong>g<br />
kwashiorkor . They decided to give it a try and see if it was the answer to their sick children.<br />
They gathered themselves and requested Agnes to teach them how to do garden<strong>in</strong>g. This she turned <strong>in</strong>to an<br />
enjoyable experience for women. They planted their own little plots with nutritious vegetables. Gett<strong>in</strong>g water to<br />
irrigate their gardens was not an easy task, but they made it enjoyable by s<strong>in</strong>g<strong>in</strong>g traditional songs as they went<br />
down to the river . They also had to fight off goats and other livestock that grazed <strong>in</strong> their crops. They further<br />
promoted togetherness by engag<strong>in</strong>g <strong>in</strong> group activities after work<strong>in</strong>g <strong>in</strong> the garden. After many seasons of battl<strong>in</strong>g<br />
crop failures, the group became progressively successful and became an example of success through hard work<br />
and perseverance. More women jo<strong>in</strong>ed the group and more land was cultivated. They won public recognition<br />
and assistance. Maheshe from Spr<strong>in</strong>g M<strong>in</strong>istry donated water tanks for the group. The Department of Agriculture<br />
provided fenc<strong>in</strong>g material to protect the gardens.<br />
The group grew from strength to strength. They entered a local agricultural competition and won. This was an<br />
<strong>in</strong>centive for even harder work. However, the most important reward was a reduction <strong>in</strong> malnutrition.<br />
This was the success story of “The Speak<strong>in</strong>g Gardens of Makoko”.<br />
48
Lessons Learnt from the Case Study:<br />
Agnes was quick to appreciate the need to be identified with the community and be accepted by them.<br />
Agnes realised the need to have certa<strong>in</strong> skills <strong>in</strong> order to further develop the community. She learnt how to write<br />
project proposals <strong>in</strong> order to get assistance from other organisations and she was able to sell her ideas to other<br />
sectors.<br />
Work<strong>in</strong>g with the community requires certa<strong>in</strong> skills. You, like Agnes, will need to empower yourself with the ability to<br />
recognise :<br />
• the characteristics and values of the community you work <strong>in</strong>;<br />
• the needs and root causes of the problems <strong>in</strong> the community;<br />
• solutions to the problems; and<br />
• the opportunities with<strong>in</strong> the community for participatory action to solv<strong>in</strong>g the problem.<br />
Requirements for effective community participation<br />
There are four basic conditions which must be met if community participation is to be more than just lip<br />
service. These are:<br />
1. Political commitment to support community <strong>in</strong>volvement <strong>in</strong> health service programmes and community<br />
based health development programmes.<br />
2. Reorientation and retra<strong>in</strong><strong>in</strong>g of health care providers, <strong>in</strong> terms of attitudes and skills <strong>in</strong> <strong>in</strong>teractions with<br />
communities.<br />
3. Support for community-based activities <strong>in</strong> the form of effective decentralisation of services, logistical<br />
support, and <strong>in</strong>tersectoral co-ord<strong>in</strong>ation ( <strong>in</strong> other words, a well established and function<strong>in</strong>g district health<br />
system as already expla<strong>in</strong>ed <strong>in</strong> chapter 3).<br />
4. Empower<strong>in</strong>g communities to enhance their participation <strong>in</strong> health plann<strong>in</strong>g and development. This<br />
<strong>in</strong>cludes supply<strong>in</strong>g <strong>in</strong>formation on:<br />
• health issues, their causes, appropriate preventive and promotive measures;<br />
• how to plan, implement, monitor and evaluate programmes;<br />
• management skills, <strong>in</strong>clud<strong>in</strong>g fundrais<strong>in</strong>g, bookkeep<strong>in</strong>g; available resources with<strong>in</strong> the community,<br />
government, and non-governmental sectors;<br />
• methods of access<strong>in</strong>g these resources; advocacy; and related health and development groups with<strong>in</strong><br />
the community.<br />
At prov<strong>in</strong>cial and district level, there is commitment and support for community participation. Empower<strong>in</strong>g<br />
communities to participate mean<strong>in</strong>gfully needs to occur at the local level, and this should be made possible<br />
through affirmative action by the DHMT.<br />
Common obstacles to community participation <strong>in</strong> health development<br />
Significant obstacles may be met when attempt<strong>in</strong>g to <strong>in</strong>volve communities <strong>in</strong> health development. These<br />
are some of the obstacles that may be encountered:<br />
• <strong>in</strong>adequate empowerment to facilitate mean<strong>in</strong>gful community participation <strong>in</strong> their health care;<br />
• lack of a mechanism for jo<strong>in</strong>t decision mak<strong>in</strong>g. This may frustrate efforts of the communities;<br />
• <strong>in</strong>adequate funds allocated for community development;<br />
• lack of representation <strong>in</strong> community structures;<br />
• <strong>in</strong>adequate skills among health professionals <strong>in</strong> work<strong>in</strong>g with communities;<br />
• lack of appropriate tools such as an operational manual or guidel<strong>in</strong>e on community-based health<br />
development;<br />
• reluctance to co-operate <strong>in</strong>tersectorally;<br />
• resistance to change from a curative and facility based health system to one that is health<br />
development-oriented and community based;<br />
• community members pursu<strong>in</strong>g <strong>in</strong>dividual <strong>in</strong>terests; and<br />
• negative political <strong>in</strong>fluence.<br />
49
Monitor<strong>in</strong>g and Evaluat<strong>in</strong>g Community Participation<br />
It is necessary to monitor and evaluate community <strong>in</strong>volvement <strong>in</strong> order to assess whether you are succeed<strong>in</strong>g<br />
<strong>in</strong> enlist<strong>in</strong>g their support <strong>in</strong> health development.<br />
You will know if you are succeed<strong>in</strong>g by the:<br />
• number or percentage of community members who state that PHC services are accessible, and<br />
convenient;<br />
• number or percentage of community members who state that the PHC services are acceptable and<br />
relevant to their needs;<br />
• number or percentage of community committees that meet regularly;<br />
• number or percentage of communities participat<strong>in</strong>g <strong>in</strong> health activities; and<br />
• number or percentage of health units with an affiliated health committee or community organisation.<br />
This chapter has stressed the importance of <strong>in</strong>volv<strong>in</strong>g the communities <strong>in</strong> plann<strong>in</strong>g and delivery of primary<br />
health care services. In addition, it has expla<strong>in</strong>ed the ways by which this could be achieved and has identified<br />
some of the common obstacles that you could encounter <strong>in</strong> enlist<strong>in</strong>g the participation of communities <strong>in</strong><br />
service delivery.<br />
The chapter that follows describes the services to be rendered to the communities and the manner <strong>in</strong> which<br />
they will be delivered.<br />
50
PART 1i<br />
Service Delivery and Governance
Ag nee Willem!<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong><br />
means more than be<strong>in</strong>g a<br />
barefoot doctor!<br />
DELIVERING INTEGRATED<br />
PRIMARY HEALTH CARE<br />
CHAPTER 5
Chapter 5<br />
DELIVERING INTEGRATED<br />
PRIMARY HEALTH CARE<br />
This chapter describes the comprehensive PHC services to be rendered at various levels of health care and<br />
the mechanisms for deliver<strong>in</strong>g the services to households and communities <strong>in</strong> the district.<br />
After read<strong>in</strong>g this chapter, you will be able to:<br />
• appreciate the need for <strong>in</strong>tegrated primary health care (PHC) services;<br />
• def<strong>in</strong>e the m<strong>in</strong>imum <strong>in</strong>tegrated PHC service packages for various health service levels;<br />
• recognise the important role of the community-based health worker <strong>in</strong> PHC services;<br />
• appreciate the need for co-ord<strong>in</strong>ation of PHC services <strong>in</strong> the district;<br />
• understand the role of programme co-ord<strong>in</strong>ators.<br />
• def<strong>in</strong>e the support needed at various health facility levels; and<br />
• def<strong>in</strong>e the staff<strong>in</strong>g requirements for each service level.<br />
THE DISTRICT “HEALTH FOR ALL” PACKAGE<br />
Achiev<strong>in</strong>g the goal of “health for all” <strong>in</strong> the prov<strong>in</strong>ce calls for strategies that will address the health problems<br />
of <strong>in</strong>dividuals of all age groups as households and community members. This will be done through<br />
implementation of an <strong>in</strong>tegrated “health for all” package based on <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong>. The district health<br />
for all package <strong>in</strong>cludes:<br />
• basic health care <strong>in</strong>terventions; and<br />
• health related <strong>in</strong>terventions<br />
55
Such <strong>in</strong>terventions will <strong>in</strong>clude:<br />
Basic <strong>Health</strong> <strong>Care</strong> Interventions<br />
• control and prevention of communicable diseases, <strong>in</strong>clud<strong>in</strong>g STD/HIV;<br />
• immunisation aga<strong>in</strong>st major <strong>in</strong>fectious diseases, especially those <strong>in</strong>cluded <strong>in</strong> the expanded programme<br />
of immunisation;<br />
• promotion of maternal, child and women’s health, <strong>in</strong>clud<strong>in</strong>g family plann<strong>in</strong>g;<br />
• provision of education on prevail<strong>in</strong>g health problems as well as basic public health activities for<br />
disease prevention and control;<br />
• provision of appropriate treatment of common diseases and <strong>in</strong>juries viz; curative care, <strong>in</strong>clud<strong>in</strong>g early<br />
diagnosis, treatment and prevention of medical, surgical, mental, dental and other common<br />
problems;<br />
• early rehabilitation to prevent complications and disabilities;<br />
• provision of essential drugs; and<br />
• provision of district health emergency and first aid.<br />
These basic health care <strong>in</strong>terventions are <strong>in</strong> l<strong>in</strong>e with the PHC priority service programmes which are to be<br />
implemented <strong>in</strong> the prov<strong>in</strong>ce. The priority programmes are:<br />
• <strong>Health</strong> Promotion<br />
• Maternal, Child and Women’s <strong>Health</strong><br />
• Nutrition<br />
• Oral <strong>Health</strong><br />
• Environmental <strong>Health</strong><br />
• Communicable Diseases Control<br />
• Rehabilitation<br />
• Emergency Medical Service<br />
• Curative, Diagnostic and Medico-Legal Services<br />
• Mental <strong>Health</strong> and Substance Abuse<br />
Each of these programmes is discussed <strong>in</strong> chapter 7.<br />
<strong>Health</strong> Related Interventions<br />
<strong>Health</strong> related <strong>in</strong>terventions <strong>in</strong>clude adult health literacy, household food security, water supply and sanitation.<br />
These will be organised <strong>in</strong> health facilities and other locations <strong>in</strong> collaboration with the departments responsible<br />
for Education, Agriculture, Hous<strong>in</strong>g, Works, Water Affairs and Forestry. <strong>Health</strong> workers will co-operate with<br />
their counterparts <strong>in</strong> these departments to facilitate community access to health related needs.<br />
These elements will accelerate atta<strong>in</strong>ment of health for all and contribute significantly to promot<strong>in</strong>g health<br />
as a determ<strong>in</strong>ant factor for achiev<strong>in</strong>g socio-economic development at district level. Utilis<strong>in</strong>g these elements,<br />
district health authorities will def<strong>in</strong>e objectives and targets for district health plans, organise activities for<br />
implementation by health management teams, and collect data locally for monitor<strong>in</strong>g progress.<br />
THE NEED FOR INTEGRATION OF PHC SERVICES<br />
Case Study<br />
A young couple from the Mhluzi district, <strong>in</strong> <strong>Mpumalanga</strong>, has four children aged 5, 4, 3, and 2 years. They are also<br />
expect<strong>in</strong>g another child <strong>in</strong> 5 months. The first child appears mentally handicapped; the second child has dental<br />
caries; the third and fourth look small for their age. The husband, a casual labourer <strong>in</strong> a neighbour<strong>in</strong>g urban centre,<br />
has not been to work for one week due to fever.<br />
The neighbour th<strong>in</strong>ks that he might have typhoid because three people <strong>in</strong> the neighbourhood have been treated<br />
for it. How would you deliver primary health care to this family and to the community they live <strong>in</strong>?<br />
56
Table 5.1 Analysis of <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> (PHC) required by the family <strong>in</strong> the case study.<br />
Services required by the family<br />
Antenatal; maternity; postnatal; family plann<strong>in</strong>g<br />
Immunisation<br />
Growth monitor<strong>in</strong>g; nutritional therapy<br />
<strong>Health</strong> education <strong>in</strong> oral hygiene; management<br />
of dental caries<br />
Evaluation, management and rehabilitation<br />
of mentally handicapped child<br />
PHC Service Programme Involved<br />
Maternal <strong>Health</strong>; <strong>Health</strong> Promotion<br />
Child <strong>Health</strong>; <strong>Health</strong> Promotion; Nutrition<br />
Communicable Diseases Control<br />
Nutrition; Child <strong>Health</strong>; <strong>Health</strong> Promotion<br />
Oral health; <strong>Health</strong> promotion; Curative and<br />
Diagnostic Services;<br />
Mental <strong>Health</strong>; Rehabilitation; Curative and<br />
Diagnostic Services; <strong>Health</strong> Promotion<br />
Investigation of typhoid epidemic;<br />
Investigation of water safety and sanitation<br />
Ambulance service for possible complications<br />
at 5th delivery<br />
Communicable Diseases Control;<br />
Environmental <strong>Health</strong>;<br />
Curative and Diagnostic Services;<br />
<strong>Health</strong> Promotion<br />
Environmental <strong>Health</strong>; <strong>Health</strong> Promotion<br />
facilities; <strong>Health</strong> education; Communicable<br />
Disease Control<br />
Emergency Services; Maternal <strong>Health</strong>;<br />
<strong>Health</strong> Promotion<br />
This case study illustrates many <strong>in</strong>terest<strong>in</strong>g and practical questions which are relevant to the manner <strong>in</strong> which<br />
PHC services should be organised at the operational level such as:<br />
• What PHC services would be needed by this family?<br />
• What co-ord<strong>in</strong>ation mechanism will ensure that the necessary services are rendered to the family and<br />
community?<br />
• At what level would <strong>in</strong>tegration of the PHC service programmes occur, and who would be responsible<br />
for this?<br />
• What support would be made available at various health service levels?<br />
• What referral system would ensure accessibility of appropriate PHC services to the family at various<br />
service levels?<br />
• What category of health worker should be at the front-l<strong>in</strong>e (i.e. <strong>in</strong>terface with the community?)<br />
• How many staff should be at the front-l<strong>in</strong>e: a multidiscipl<strong>in</strong>ary team of health workers or one<br />
multi-skilled health worker?<br />
• How will other sectors be engaged <strong>in</strong> jo<strong>in</strong>t promotion of health <strong>in</strong> this community?<br />
The case study illustrates the po<strong>in</strong>t that primary health care is about real health problems of <strong>in</strong>dividuals and<br />
families <strong>in</strong> a community. Their health problems usually will require the services of more than one primary<br />
health care programme. The choice you have to make is that you either <strong>in</strong>tegrate all the PHC programmes<br />
<strong>in</strong>to one specific service package or you deliver the services as <strong>in</strong>dividual vertical programmes. In the case<br />
study cited it is not cost effective to mobilise a team of different health workers, each represent<strong>in</strong>g a different<br />
vertical programme, to descend on this household! The programmes are better <strong>in</strong>tegrated <strong>in</strong>to one package<br />
that can be delivered at different service levels (household, cl<strong>in</strong>ic, health centre, hospital) us<strong>in</strong>g different<br />
categories of health workers with different skills.<br />
The <strong>Mpumalanga</strong> choice is for:<br />
• <strong>in</strong>tegrated services with specific service packages for each service level: community, cl<strong>in</strong>ic, health<br />
centre and hospital;<br />
• delivery of primary health care services to the household with<strong>in</strong> the community where the family lives,<br />
us<strong>in</strong>g health promotion as the strategy; and<br />
• use of community based health worker (CBHW) as the first contact with the health service. This worker<br />
will provide health promotion and l<strong>in</strong>k the community with the formal health service.<br />
57
HOW THE DISTRICT PHC SERVICE PACKAGE WILL BE<br />
CO-ORDINATED<br />
The prov<strong>in</strong>ce has taken a decision to do away with prov<strong>in</strong>cially-based and vertically run programmes which<br />
normally take little account of local health needs. This decision, therefore, <strong>in</strong>volves strengthen<strong>in</strong>g district level<br />
programme plann<strong>in</strong>g and co-ord<strong>in</strong>ation through a team of co-ord<strong>in</strong>ators based at the health centres and<br />
supported and supervised by the District PHC Co-ord<strong>in</strong>ator. Posts will be identified for full time programme<br />
co-ord<strong>in</strong>ators, accord<strong>in</strong>g to the identified health needs <strong>in</strong> a district. In the meantime, capacity is already<br />
be<strong>in</strong>g built <strong>in</strong> the districts by utilis<strong>in</strong>g professionals from exist<strong>in</strong>g services to perform programme co-ord<strong>in</strong>ation<br />
work <strong>in</strong> identified key programme areas e.g. Communicable Diseases Control, Nutrition, Maternal Child and<br />
Women’s <strong>Health</strong> and Environmental <strong>Health</strong><br />
To ensure that they do not develop <strong>in</strong>to vertical programmes, all new health care <strong>in</strong>itiatives (projects) should<br />
be developed with<strong>in</strong> the framework of the District PHC Package. For example the Prov<strong>in</strong>cial Community<br />
Sanitation Initiative which focuses on health and hygiene education promotion will <strong>in</strong>tegrate with the follow<strong>in</strong>g<br />
programmes:<br />
• child health component of the maternal, child and women’s health programme;<br />
• diarrhoeal diseases control component of the communicable diseases control programme<br />
• diagnostic and curative services programme; and<br />
• health promotion programme.<br />
The <strong>in</strong>volvement of other sectors is also important. These will <strong>in</strong>clude:<br />
• Water Affairs and Forestry;<br />
• Education;<br />
• Environment Affairs and Tourism;<br />
• Prov<strong>in</strong>cial Affairs; and<br />
• Hous<strong>in</strong>g.<br />
Together with the District PHC Co-ord<strong>in</strong>ator, the Programme Co-ord<strong>in</strong>ators will constitute the district PHC<br />
team. The PHC team will form the technical nucleus for plann<strong>in</strong>g and co-ord<strong>in</strong>at<strong>in</strong>g primary health care<br />
service programmes <strong>in</strong> the district. The PHC team will provide support to the service providers at all levels of<br />
health care and to the District <strong>Health</strong> Management Team. While hav<strong>in</strong>g a jo<strong>in</strong>t responsibility for the district as<br />
a whole, however, each team member will reta<strong>in</strong> responsibility as a resource for his/her own area of<br />
specialisation.<br />
The responsibilities of the District PHC team will be:<br />
• to assist service implementors <strong>in</strong> the community and <strong>in</strong> health facilities to plan, implement,<br />
monitor and evaluate primary health care services by:<br />
- identify<strong>in</strong>g the priority problems and their root causes;<br />
- identify<strong>in</strong>g a range of solutions to each prioritised problem;<br />
- plann<strong>in</strong>g implementation activities based on the prioritised solutions;<br />
- design<strong>in</strong>g an <strong>in</strong>tegrated PHC service package for the district;<br />
- monitor<strong>in</strong>g and evaluat<strong>in</strong>g service implementation; and<br />
- repeat<strong>in</strong>g the whole cycle for the same problems<br />
(depend<strong>in</strong>g on success or failure) or start<strong>in</strong>g afresh with other problems us<strong>in</strong>g the<br />
above steps (see figure 5.1).<br />
58
Figure 5.1<br />
Programme Plann<strong>in</strong>g and Co-ord<strong>in</strong>ation Cycle<br />
Identify<strong>in</strong>g and select<strong>in</strong>g<br />
problems<br />
Outcome:<br />
a list of problems <strong>in</strong> order of<br />
priority<br />
Evaluat<strong>in</strong>g the impact of the solutions<br />
Outcome:<br />
Assessment of whether the <strong>in</strong>tervention<br />
strategy is work<strong>in</strong>g or not and feed<strong>in</strong>g<br />
this <strong>in</strong>to the plann<strong>in</strong>g process<br />
Analys<strong>in</strong>g the problems<br />
Outcome:<br />
A precise description of the problem<br />
and its root causes<br />
Implement<strong>in</strong>g the solutions to the<br />
problems<br />
Outcome:<br />
Implementation of the activity's<br />
various components e.g. health<br />
promotion, prevention, cure,<br />
rehabilitation at a particular level<br />
of service delivery<br />
Suggest<strong>in</strong>g Solutions<br />
Outcome:<br />
A description of the activities which<br />
would solve the problem<br />
Adapted from Amondo-Lartson R etal<br />
Other responsibilities will be:<br />
• advis<strong>in</strong>g the DHMT as <strong>in</strong>dividuals <strong>in</strong> their areas of expertise;<br />
• serv<strong>in</strong>g as a resource for advice to policy makers at regional and prov<strong>in</strong>cial levels;<br />
• identify<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g needs and organis<strong>in</strong>g appropriate tra<strong>in</strong><strong>in</strong>g for PHC service implementors;<br />
• assist<strong>in</strong>g the PHC co-ord<strong>in</strong>ator <strong>in</strong> identify<strong>in</strong>g resource <strong>in</strong>puts for PHC services;<br />
• ensur<strong>in</strong>g <strong>in</strong>tegration of PHC service components <strong>in</strong>to community based health development<br />
<strong>in</strong>itiatives; and<br />
• carry<strong>in</strong>g out such other duties as may from time to time be assigned by the PHC Co-ord<strong>in</strong>ator.<br />
In order to enable them to carry out the above responsibilities, the programme co-ord<strong>in</strong>ators will receive <strong>in</strong>service<br />
tra<strong>in</strong><strong>in</strong>g <strong>in</strong> programme plann<strong>in</strong>g.<br />
Implementation of Programme Co-ord<strong>in</strong>ation<br />
Three districts <strong>in</strong> each region have been selected as model sites for <strong>in</strong>tegration and co-ord<strong>in</strong>ation of the<br />
follow<strong>in</strong>g <strong>in</strong>itiatives:<br />
• well child <strong>in</strong>itiative <strong>in</strong>clud<strong>in</strong>g components of maternal and reproductive health;<br />
• sanitation project;<br />
• communicable diseases control;<br />
• community based nutrition; and<br />
• <strong>in</strong>itiative for sub-district support.<br />
Experiences learnt from the model districts will be transferred to other districts.<br />
59
DELIVERING PRIMARY HEALTH CARE SERVICES<br />
TO HOUSEHOLDS<br />
Who is the first contact person <strong>in</strong> a case of illness? Different types of people provide health advice and health<br />
care. Depend<strong>in</strong>g on where you are, the first person who is consulted when illness strikes is not usually a health<br />
worker. It is either a “gogo”, “mkhulu”, “mama”, “baba”, a neighbour or a friend, etc.<br />
After consult<strong>in</strong>g any one of the above mentioned, the next type of person consulted will depend on what<br />
the family, relatives etc th<strong>in</strong>k are the causes of illness and which service they th<strong>in</strong>k may be able to help. The<br />
next level, therefore, could be the “spaza shop”, traditional or spiritual healer, private health worker or<br />
pharmacy or the health services.<br />
From the above, it becomes clear that the first level of advice and care takes place <strong>in</strong> the community<br />
and it is by the community. It also follows that when equipped with the right <strong>in</strong>formation, this first l<strong>in</strong>e<br />
consultation will have a far-reach<strong>in</strong>g effect on the health of <strong>in</strong>dividuals and families <strong>in</strong> the community.<br />
Household <strong>Health</strong> Promotion Service<br />
The aim of the Department is to empower households to take correct decisions concern<strong>in</strong>g the health of<br />
their members through a household health promotion service, us<strong>in</strong>g a community based health worker (CBHW).<br />
This service already exists <strong>in</strong> the districts but at present it is highly fragmented, non-homogeneously distributed<br />
and too limited to function optimally. In the various areas where it is provided, the providers <strong>in</strong>clude: the<br />
public sector services, non-governmental organisations, the private sector, local authorities, community based<br />
organisations, etc.<br />
The aim of this service is to l<strong>in</strong>k the health service with households <strong>in</strong> the prov<strong>in</strong>ce, thus facilitat<strong>in</strong>g the l<strong>in</strong>kage<br />
between health and socio-economic development.<br />
The ma<strong>in</strong> advantages of this service are two fold:<br />
• <strong>in</strong>formation and health education is provided to the household which will empower families to take<br />
charge of their own health;<br />
• the household health promotion worker will provide valuable <strong>in</strong>formation to the facility based<br />
services. This <strong>in</strong>formation will enable the DHMT to plan and prioritise services which are responsive to<br />
the people’s needs.<br />
Implementation<br />
Implementation of the household health promotion service will be <strong>in</strong> phases, start<strong>in</strong>g with the most<br />
disadvantaged areas with<strong>in</strong> a district. The DHMTs are encouraged to give priority to exist<strong>in</strong>g voluntary workers<br />
when recruit<strong>in</strong>g community based health workers. Initially each worker will look after a specified number of<br />
households.<br />
The department will develop a standard tra<strong>in</strong><strong>in</strong>g curriculum and establish the capacity for tra<strong>in</strong><strong>in</strong>g which will<br />
take place <strong>in</strong> the community. Two specialised auxiliary services assistants (SASAs) from each sub-region have<br />
already been identified to undergo tra<strong>in</strong><strong>in</strong>g as tra<strong>in</strong>ers of tra<strong>in</strong>ers for the CBHWs. The department will also<br />
provide technical support to the household health promotion service. However, supervision and control of<br />
the service will be the responsibility of the communities through identified community structures. This will ensure<br />
that the workers are accountable to the community. Before establish<strong>in</strong>g this service <strong>in</strong> the district, the district<br />
manager will be required to submit a specific proposal to the Chief Director for approval.<br />
The community based health worker will act as a catalyst for development by mobilis<strong>in</strong>g resources and<br />
community capabilities to carry out those activities which will improve the status of the community. In this<br />
area he/she will be work<strong>in</strong>g with other development agents <strong>in</strong> the community.<br />
PHC Service Package for Community/Household Level <strong>Health</strong> Promotion<br />
The PHC package for household level health care focuses on empowerment of communities to promote<br />
and protect their health; prevent common illnesses which afflict the community; identify common illnesses<br />
for referral to health facilities for treatment; and rehabilitate their members who may have suffered chronic<br />
disabilities. The full package is given below:<br />
60
The PHC Package for Community/household Level <strong>Health</strong> <strong>Care</strong><br />
Individuals and families <strong>in</strong> the community will be enabled through provision of the necessary<br />
<strong>in</strong>formation (awareness) of the problems which affect their health and the tools (knowledge)<br />
and means (resources) required to:<br />
• promote and protect their own health aga<strong>in</strong>st health problems <strong>in</strong> their community; e.g.<br />
through health education;<br />
• prevent common diseases that affect them and their community; e.g. through<br />
immunisation, change of behaviour;<br />
• identify common ailments <strong>in</strong> the community and refer them to the nearest cl<strong>in</strong>ic for<br />
early management so as to prevent complications and disabilities;<br />
• give support to, and rehabilitate, their members who may have mental, physical or<br />
other disabilities; and<br />
• mobilise communities to take responsibility of their own health, emphasis<strong>in</strong>g <strong>in</strong> particular<br />
improvement of <strong>in</strong>dividual life styles, reproductive practices of families and environmental<br />
management of communities.<br />
Community based health care will be given maximum emphasis. The support from the cl<strong>in</strong>ics, health centre<br />
and the district hospital will:<br />
• ensure that community based <strong>in</strong>terventions are rendered efficiently and effectively <strong>in</strong> a co-ord<strong>in</strong>ated,<br />
controlled way; and<br />
• provide a referral service for the level of health care that is not available at the lower facilities.<br />
In carry<strong>in</strong>g out their duties <strong>in</strong> the community, the community based health workers will need support from<br />
staff from the nearest health facility (cl<strong>in</strong>ic or health centre) <strong>in</strong> the form of:<br />
• technical support;<br />
• supplies<br />
• referral support; and<br />
• supervision.<br />
The Cl<strong>in</strong>ic Manager who will be a member of the Community <strong>Health</strong> Committee (see chapter 6) is well<br />
placed to provide support to and co-ord<strong>in</strong>ate all community based health care and development activities<br />
with<strong>in</strong> the cl<strong>in</strong>ic catchment area, <strong>in</strong>clud<strong>in</strong>g support supervision of the community based health workers <strong>in</strong><br />
that area.<br />
Outreach <strong>Health</strong> Promotion Services to Communities<br />
In its broader catchment area, the health centre, plays an important role <strong>in</strong> support<strong>in</strong>g community health<br />
care services <strong>in</strong> its catchment areas, apart from serv<strong>in</strong>g as a referral centre for the cl<strong>in</strong>ics.<br />
Effective coverage of cl<strong>in</strong>ic and health centre catchment areas will call for the organisation of outreach<br />
sessions (campaigns), e.g. for vacc<strong>in</strong>ation and maternal and child health, surveillance for populations liv<strong>in</strong>g<br />
far away from health facilities. This makes the promotive health services accessible to the population. This<br />
method of primary health care delivery reaches out to people <strong>in</strong> the catchment area who live far from the<br />
facility. This will assume <strong>in</strong>creas<strong>in</strong>g importance as service delivery shifts emphasis from curative to preventive<br />
and promotive care.<br />
Implementation<br />
A special category of outreach health workers <strong>in</strong> the form of Specialised Auxiliary Services Assistants (SASAs),<br />
Specialised Auxiliary Services Officers (SASOs), health educators and health promoters will play a key role <strong>in</strong><br />
this service. The DHMT will restructure and harmonise this service as it has an important role to play <strong>in</strong> the<br />
promotion of the health of households and prevention of illnesses. Some of these workers are already skilled<br />
<strong>in</strong> health promotion work and are a resource that, with proper plann<strong>in</strong>g and co-ord<strong>in</strong>ation, can immediately<br />
render an effective support and supervision to health promotion and rehabilitation services. Initially this<br />
category of health workers will operate from a community health centre under the supervision of a liaison<br />
officer. The liaison officer will be accountable to the <strong>Health</strong> Centre Manager, and will work closely with other<br />
development agencies. The ideal situation is that this category of workers should be based at the cl<strong>in</strong>ic level.<br />
Though these workers are government employees, <strong>in</strong> future, the community will have a role <strong>in</strong> their recruitment<br />
61
and selection. <strong>Care</strong> will, however, be taken that the partnership between communities and government are<br />
clearly def<strong>in</strong>ed, so that these workers do not serve “two masters”. The implementation of the statutory district<br />
health authority will solve this problem.<br />
The facility based community health promotion workers, cl<strong>in</strong>ic and health centre managers and health<br />
committees will be <strong>in</strong>volved <strong>in</strong> mobilis<strong>in</strong>g local populations for outreach and other community-based activities.<br />
Co-ord<strong>in</strong>ation of PHC services <strong>in</strong> the broader catchment area of the health centre and its<br />
satellite cl<strong>in</strong>ics will be undertaken by the outreach services team compris<strong>in</strong>g:<br />
• Programme Co-ord<strong>in</strong>ators<br />
• <strong>Health</strong> Centre Manager<br />
• Cl<strong>in</strong>ic Managers<br />
This team will ensure enlist<strong>in</strong>g necessary support from the district hospital and the participation<br />
of other development sectors <strong>in</strong> community development <strong>in</strong>itiatives.<br />
The Outreach Services Team will:<br />
• provide support to preventive services e.g. immunisation, oral rehydration therapy for diarrhoea, health<br />
promotion, STDs and HIV/AIDS, nutrition, hygiene and environmental sanitation etc;<br />
• provide support to the community based health workers and community health activities.<br />
• provide tra<strong>in</strong><strong>in</strong>g to the community based health workers; and<br />
• serve as a l<strong>in</strong>k with other government departments, NGOs and the private sector.<br />
The reason for l<strong>in</strong>kage of the outreach services to the public health sector is that <strong>Primary</strong> <strong>Health</strong><br />
<strong>Care</strong> is part and parcel of the health service. This l<strong>in</strong>kage will ensure <strong>in</strong>tegration of PHC<br />
programme activities <strong>in</strong>to one health service. PHC services are <strong>in</strong>timately l<strong>in</strong>ked with other<br />
levels of the health care system i.e. the community, cl<strong>in</strong>ic, health centre, and hospital levels.<br />
HEALTH FACILITY BASED PHC SERVICES<br />
<strong>Primary</strong> health care services are delivered at all health facilities. This means that people come to the visit<strong>in</strong>g<br />
post, cl<strong>in</strong>ic, health centre or hospital for the services. Some of them may have been referred to the facility<br />
(health centre, hospital) from the facilities at lower level. The types of service packages rendered at each<br />
level of facility are described below.<br />
PHC Service Package at Visit<strong>in</strong>g Posts<br />
The visit<strong>in</strong>g post is the most peripheral unit which serves as a regular (at least every fortnight) outreach<br />
service. It is organised from various health facility levels <strong>in</strong>volv<strong>in</strong>g various health providers.<br />
The ma<strong>in</strong> PHC package for this level is:<br />
• health education, health campaigns and immunisation;<br />
• treatment of simple <strong>in</strong>juries and common diseases; and<br />
• referral of those who need further care.<br />
Staff<strong>in</strong>g Pattern<br />
The staff mix <strong>in</strong> visit<strong>in</strong>g mobile units is quite variable because it depends on the health provider that is servic<strong>in</strong>g<br />
the post. However, it usually <strong>in</strong>volves a nurse and community health workers. The staff number is determ<strong>in</strong>ed<br />
by the number of activities and service demand.<br />
The PHC Service Package at Cl<strong>in</strong>ic Level<br />
The cl<strong>in</strong>ic is a one-stop station for primary health care services. It is a facility provided accord<strong>in</strong>g to the needs<br />
of the community; a jo<strong>in</strong>t venture between the communities and the providers to ensure maximum<br />
acceptability and accessibility to the community.<br />
62
The ma<strong>in</strong> role of a cl<strong>in</strong>ic is to re-enforce the PHC services rendered <strong>in</strong> the community and to support and<br />
supervise activities of the community health workers. It is necessary to emphasise that the PHC service package<br />
at the cl<strong>in</strong>ic level is not <strong>in</strong>dependent of the services rendered <strong>in</strong> the community. It supports and supplements<br />
the community level service package as an <strong>in</strong>tegrated service for, and with the community.<br />
Personnel<br />
Promotive and Protective:<br />
PHC service package for the cl<strong>in</strong>ic level<br />
• child care (<strong>in</strong>clud<strong>in</strong>g immunisation and growth monitor<strong>in</strong>g); maternal care (<strong>in</strong>clud<strong>in</strong>g<br />
antenatal care, post natal and family plann<strong>in</strong>g); women’s health (screen<strong>in</strong>g for<br />
cervical and breast cancer, health education);<br />
• promotion of breastfeed<strong>in</strong>g and nutrition education;<br />
• recognition, treatment and control of communicable diseases;<br />
• tra<strong>in</strong><strong>in</strong>g and supervision of community health workers;<br />
• provision of outreach/mobile services <strong>in</strong>clud<strong>in</strong>g school health services; and<br />
• provision of health education on oral health.<br />
Curative and Diagnostic:<br />
• treatment of common diseases and basic emergencies;<br />
• handl<strong>in</strong>g normal deliveries;<br />
• follow-up of patients who are on ma<strong>in</strong>tenance therapy for chronic diseases; and<br />
• referral of patients to community health workers for follow-up or to health centres and<br />
hospital for more appropriate care.<br />
Rehabilitative<br />
• rehabilitation of people with disabilities and render<strong>in</strong>g of counsell<strong>in</strong>g services to<br />
<strong>in</strong>dividuals and families <strong>in</strong> need <strong>in</strong> the community;<br />
Palliative therapy for the term<strong>in</strong>ally ill.<br />
A cl<strong>in</strong>ic is staffed by at least one registered nurse, enrolled nurse and nurs<strong>in</strong>g assistant. The cl<strong>in</strong>ic should<br />
provide a 12 hour service each day. The support staff <strong>in</strong>clude watchmen, gardeners and cleaners. The actual<br />
staff<strong>in</strong>g level is determ<strong>in</strong>ed by service demand. At present, our cl<strong>in</strong>ics are under staffed, and the Prov<strong>in</strong>ce<br />
has proposed a new staff establishment based on the district health system.<br />
PHC Service Package for <strong>Health</strong> Centre Level<br />
A health centre is a vital facility <strong>in</strong> health care development <strong>in</strong> the districts. It is the level <strong>in</strong> the service where<br />
the technical and staff mix has the necessary multi-discipl<strong>in</strong>ary <strong>in</strong>tegration and co-ord<strong>in</strong>ation of primary<br />
health care service programmes occurs. It is also the level at which <strong>in</strong>tersectoral collaboration is co-ord<strong>in</strong>ated.<br />
The staff mix at the health centre is a reflection of functions at the facility and its supportive role to the satellite<br />
cl<strong>in</strong>ics and communities.<br />
The health centre offers all the PHC services which are offered at the community and cl<strong>in</strong>ic levels. It is important<br />
to emphasise that the health centre PHC service package is meant to enhance the health <strong>in</strong>itiatives of the<br />
communities themselves and the support provided to them by community health workers and staff at satellite<br />
cl<strong>in</strong>ics.<br />
63
PHC Service Package for <strong>Health</strong> Centre Level<br />
The full PHC package for health centre level offers the same services as those rendered by the<br />
cl<strong>in</strong>ic, but <strong>in</strong> addition it offers the follow<strong>in</strong>g:-<br />
• manages rehabilitation services;<br />
• provides ambulance services;<br />
• serves as a referral centre for all the satellite cl<strong>in</strong>ics; and referral source for the district<br />
hospital;<br />
• monitors and provides technical guidance to the satellite cl<strong>in</strong>ics;<br />
• monitors community health services <strong>in</strong> all the catchment areas of its satellite cl<strong>in</strong>ics;<br />
• promotes self help groups/care groups;<br />
• promotes <strong>in</strong>tersectoral collaboration;<br />
• provides basic curative services, with laboratory 1 and x-ray facilities and may also<br />
have facilities for do<strong>in</strong>g m<strong>in</strong>or surgery and management of uncomplicated fractures;<br />
• provides <strong>in</strong>patient care for normal deliveries, short illnesses requir<strong>in</strong>g observation (to a<br />
maximum of 48 hours) and care, before and after hospital admission, as and when<br />
necessary; and<br />
• serves as a focus for co-ord<strong>in</strong>ation of PHC services <strong>in</strong> the catchment area of the health<br />
centre and its satellite cl<strong>in</strong>ics.<br />
Staff mix at a health centre<br />
• Nurs<strong>in</strong>g Profession: • Pharmacy Assistant<br />
- Nurse Cl<strong>in</strong>ician • Environmental <strong>Health</strong> Officer<br />
- Nurse/Midwife<br />
- Psychiatric Nurse • Therapists:<br />
- Enrolled Nurse<br />
• Programme Co-ord<strong>in</strong>ators<br />
• Social Worker - Occupational Therapist<br />
• Laboratory Technician/Technologist - Physiotherapist<br />
• Support Staff - Dental Therapist/oral hygienist<br />
- Gardener - Nutritionist/Dietician<br />
- Watchman<br />
- Cleaner<br />
The draft “Report of the Committee on Human Resources for <strong>Health</strong>” which was published <strong>in</strong> December 1994<br />
recommends that there should be one staff for each of the categories identified for every population of<br />
30,000 people. Therefore, the number of staff of each category <strong>in</strong> your health centre will be determ<strong>in</strong>ed by<br />
the population the health centre is serv<strong>in</strong>g (catchment population).<br />
District Hospital Referral Services<br />
A district hospital is the ultimate referral po<strong>in</strong>t for the District <strong>Health</strong> System. It will provide essential<br />
back-up services and will act as a support to the community based activities, health centres and<br />
cl<strong>in</strong>ics which are <strong>in</strong> more direct contact with <strong>in</strong>dividuals, families and communities.<br />
Hospital support to PHC entails its <strong>in</strong>tegration <strong>in</strong>to the district health system as a referral unit. A district<br />
hospital provides comprehensive care (promotive, protective, preventive, curative and rehabilitative)<br />
on a 24 hour basis. Its bed capacity is approximately 200 and may have a few specialised health<br />
service beds (e.g. psychiatric unit).<br />
1 The directorate of <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> has been given the responsibility of sett<strong>in</strong>g up PHC laboratories <strong>in</strong> health centres (1<br />
health centre per district) <strong>in</strong> conjunction with the South African Institute for Medical Research (SAIMR).<br />
64
PHC package at district hospital level<br />
• diagnosis and treatment of common diseases and <strong>in</strong>juries, with a resident doctor<br />
service;<br />
• casualty service for the immediate treatment of <strong>in</strong>juries, medical and surgical<br />
emergencies, with a resident medical officer;<br />
• basic diagnostic theatre and Central Sterile Supplies services to enable the<br />
performance of common surgical procedures;<br />
• social work services, oral health, mental health, basic rehabilitation services, <strong>in</strong>clud<strong>in</strong>g<br />
physiotherapy, counsell<strong>in</strong>g, eye care etc which may be provided on a permanent or<br />
<strong>in</strong>termittent basis depend<strong>in</strong>g on the size of the community served; and<br />
• <strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g of health workers <strong>in</strong> the service to upgrade their skills and knowledge.<br />
Staff at district hospital<br />
• Medical Practitioners • Social Worker<br />
• Nurs<strong>in</strong>g Profession<br />
- Advanced Midwives • Therapists:<br />
- Nurse Cl<strong>in</strong>icians - occupational<br />
- Psychiatric Nurse - physiotherapist<br />
- Enrolled Nurses - speech and hear<strong>in</strong>g<br />
- Nurs<strong>in</strong>g Auxiliaries - Nutritionist/Dietician<br />
- Hospital Infection Control - Oral Hygienist/dental therapists<br />
Nurse<br />
• Pharmacy • Laboratory<br />
- Pharmacist Technician/Technologist<br />
- Pharmacy Assistants<br />
• Support Staff<br />
- Driver<br />
- Watchman<br />
- Cleaner<br />
- Gardener<br />
- Handyman<br />
The Report of the Committee on Human Resources for <strong>Health</strong> recommends that there should be one referral<br />
health team for every ten frontl<strong>in</strong>e teams (health centre teams).<br />
In this chapter you have read about the district “health for all” PHC package and how it will be delivered <strong>in</strong><br />
the district <strong>in</strong> an <strong>in</strong>tegrated and co-ord<strong>in</strong>ated manner. The chapter has also discussed the importance of<br />
community based health promotion and the ways <strong>in</strong> which health facilities will support the community based<br />
health <strong>in</strong>itiatives.<br />
The governance system that will facilitate and also ensure that PHC services are delivered <strong>in</strong> the district is the<br />
subject for discussion <strong>in</strong> the chapter that follows.<br />
65
GOVERNANCE OF THE DISTRICT HEALTH<br />
SYSTEM<br />
CHAPTER 6
Chapter 6<br />
GOVERNANCE OF THE DISTRICT<br />
HEALTH SYSTEM<br />
The previous chapters have described how health services <strong>in</strong> the prov<strong>in</strong>ce are organised (chapter 2); the<br />
District <strong>Health</strong> System as a mechanism for facilitat<strong>in</strong>g PHC service delivery <strong>in</strong> the district (chapter 3); the role<br />
of communities <strong>in</strong> plann<strong>in</strong>g and delivery of health services (chapter 4); and the <strong>in</strong>tegration and<br />
co-ord<strong>in</strong>ation of the district health for all PHC package (chapter 5).<br />
The purpose of this chapter is to describe the manner <strong>in</strong> which the various service levels of the District <strong>Health</strong><br />
System will be governed.<br />
After read<strong>in</strong>g the chapter, you will be able to:<br />
• clearly understand the option for governance of health services <strong>in</strong> this prov<strong>in</strong>ce;<br />
• appreciate the reasons for this choice;<br />
• identify the composition and functions of governance structures for each service level; and<br />
• appreciate the degree and role of community representation <strong>in</strong> governance of their health<br />
services.<br />
Governance describes the structure, functions, powers and <strong>in</strong>ter-relationships between the various levels of<br />
authority and control of an establishment.<br />
The National Department of <strong>Health</strong> has set out <strong>in</strong> its policy guidel<strong>in</strong>es to the prov<strong>in</strong>ces three options for<br />
governance of the District <strong>Health</strong> System, giv<strong>in</strong>g each prov<strong>in</strong>ce the full authority to choose its <strong>in</strong>itial option 1 .<br />
Briefly described, the three options are:<br />
1. A prov<strong>in</strong>ce can choose to run the health services <strong>in</strong> all its districts, delegat<strong>in</strong>g limited powers to<br />
the District <strong>Health</strong> Managers. The role of the “District <strong>Health</strong> Authority”, as a governance<br />
structure, <strong>in</strong> this option is only advisory. Executive powers are reta<strong>in</strong>ed by the Prov<strong>in</strong>cial <strong>Health</strong><br />
Office. This is known as Option 1.<br />
2. The second option is that of full powers be<strong>in</strong>g delegated to the District <strong>Health</strong> Authority. In this<br />
option (Option 2 or the Statutory District <strong>Health</strong> Authority), the District <strong>Health</strong> Authority takes<br />
over all the public health services <strong>in</strong> the district; becomes the employer of all public health<br />
personnel; and is responsible for management of all public health resources. The role of the<br />
Prov<strong>in</strong>cial <strong>Health</strong> Office would then be to set policy, norms and standards, and to monitor and<br />
evaluate the services.<br />
3. In the third option (the Local Authority option or Option 3), responsibility for provision and<br />
management of health services is vested <strong>in</strong> the local authorities. This means that <strong>in</strong> a health<br />
district there would be one local authority. Here too the role of the Prov<strong>in</strong>cial <strong>Health</strong> Office<br />
would be to set policy, norms and standards, and to monitor and evaluate the services.<br />
Regardless of the <strong>in</strong>itial option chosen by a prov<strong>in</strong>ce, the long-term aim will be Option 3. Each prov<strong>in</strong>ce will<br />
determ<strong>in</strong>e its own pace <strong>in</strong> the move towards the f<strong>in</strong>al option. This will be <strong>in</strong>fluenced by the evolutionary<br />
process currently tak<strong>in</strong>g place <strong>in</strong> local government.<br />
THE GOVERNANCE OPTION FOR MPUMALANGA<br />
The prov<strong>in</strong>ce has chosen to start with the prov<strong>in</strong>cial option or Option one. This decision is based on the fact<br />
that the prov<strong>in</strong>ce does not yet have the necessary <strong>in</strong>frastructure and capacity <strong>in</strong> the districts for any of the<br />
alternative options to work well.<br />
1<br />
A policy for the Development of a District <strong>Health</strong> System for South Africa.<br />
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In this option, the Prov<strong>in</strong>cial <strong>Health</strong> Office is responsible for the adm<strong>in</strong>istration and provision of health services<br />
<strong>in</strong> the prov<strong>in</strong>ce. Each district will have an Interim District <strong>Health</strong> Authority, which is to be established by prov<strong>in</strong>cial<br />
legislation. Its role will be advisory to the District <strong>Health</strong> Manager who is an employee of the Prov<strong>in</strong>cial <strong>Health</strong><br />
Office.<br />
The Governance Structures<br />
There will be an <strong>in</strong>terim health authority at each level of the health service. Although <strong>in</strong>itially advisory, the<br />
<strong>in</strong>terim health authorities are <strong>in</strong>tended, <strong>in</strong> time, to take full responsibility for health services.<br />
The purpose of these structures is to:<br />
• ensure that health services are responsive to the needs of communities;<br />
• l<strong>in</strong>k health services more closely to improvements <strong>in</strong> the health of communities;<br />
• f<strong>in</strong>d ways of mak<strong>in</strong>g partnerships between health services and communities so<br />
that jo<strong>in</strong>t plann<strong>in</strong>g can be undertaken to address genu<strong>in</strong>ely shared concerns.<br />
The composition, powers and functions for the governance structures at various levels of the health service<br />
are described below:<br />
GOVERNANCE OF HEALTH SERVICES AT PROVINCIAL LEVEL<br />
The prov<strong>in</strong>cial-level governance structure is the Interim Prov<strong>in</strong>cial <strong>Health</strong> Authority (IPHA) which will be chaired<br />
by the Member of the Executive Council (MEC).<br />
The IPHA will comprise:<br />
Composition<br />
• Chairpersons of the <strong>in</strong>terim District <strong>Health</strong> Authorities;<br />
• Deputy Director-General; and<br />
• Chief Director, <strong>Health</strong> Services (ex-officio).<br />
Powers and Functions<br />
The Interim Prov<strong>in</strong>cial <strong>Health</strong> Authority will be an advisory body to ensure community participation <strong>in</strong> the<br />
governance of health services at various levels <strong>in</strong> the prov<strong>in</strong>ce. It will provide advice that will enable the MEC<br />
to carry out the follow<strong>in</strong>g functions:<br />
• def<strong>in</strong>e guidel<strong>in</strong>es for resource allocation to districts based on allocation to all the districts<br />
<strong>in</strong> the prov<strong>in</strong>ce;<br />
• approve health plans and budget;<br />
• approve capital expenditure via the prov<strong>in</strong>cial capital works programme and tender system;<br />
• re-allocate revenue from Revenue Equalisation Fund accord<strong>in</strong>g to district needs;<br />
• set limits for expenditure requir<strong>in</strong>g prov<strong>in</strong>cial approval;<br />
• approve creation and abolition of posts <strong>in</strong> the prov<strong>in</strong>cial health service.<br />
GOVERNANCE OF THE HEALTH SERVICES AT DISTRICT LEVEL<br />
The Interim District <strong>Health</strong> Authority (IDHA) will be an advisory body meant to enlist community participation<br />
at the various health service levels <strong>in</strong> the district. However, with time, this body will evolve towards a formal<br />
statutory one namely, the District <strong>Health</strong> Authority once the necessary <strong>in</strong>frastructure and capacity have<br />
been developed <strong>in</strong> the districts. In other words, the objective is that, <strong>in</strong> time, the district health service will be<br />
accountable to the District <strong>Health</strong> Authority or Local Authority. The District <strong>Health</strong> Authority or Local Authority<br />
will hold responsibility for local health service governance, local policy issues and also be accountable for<br />
the use of f<strong>in</strong>ancial resources.<br />
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Composition<br />
The composition of the Interim District <strong>Health</strong> Authority will be:<br />
• Equal numbers of:<br />
- members appo<strong>in</strong>ted by the local or other authority or authorities with<strong>in</strong> the health district;<br />
- members represent<strong>in</strong>g organisations with an <strong>in</strong>terest <strong>in</strong> the health of the communities resident<br />
with<strong>in</strong> the health district and appo<strong>in</strong>ted by the relevant MEC;<br />
• District <strong>Health</strong> Manager (as ex-officio representative of Prov<strong>in</strong>cial <strong>Health</strong> Office);<br />
• F<strong>in</strong>ancial management expert appo<strong>in</strong>ted by the IDHA; and<br />
• Representation of personnel employed by the IDHA.<br />
Powers and Functions of the Interim District <strong>Health</strong> Authority<br />
The Interim District <strong>Health</strong> Authority will meet regularly at <strong>in</strong>tervals determ<strong>in</strong>ed by the MEC. Its role will be<br />
advisory to the District <strong>Health</strong> Management Team. The specific functions are given below:<br />
• def<strong>in</strong>e requirements for capital and recurrent expenditure based on national and prov<strong>in</strong>cial<br />
guidel<strong>in</strong>es and local needs;<br />
• develop, together with the District <strong>Health</strong> Manager, annual plans and budget with<strong>in</strong> allocation awarded<br />
• generate additional revenue for the district health services;<br />
• monitor and evaluate the provision of health services <strong>in</strong> the light of community needs and advise<br />
accord<strong>in</strong>gly.<br />
GOVERNANCE OF HEALTH SERVICES AT FACILITIES<br />
Each health facility level with<strong>in</strong> the district will have its own governance structure, with its particular composition<br />
and functions.<br />
Governance of a District Hospital<br />
The governance structure for a district hospital will be the District Hospital Board.<br />
Composition<br />
The composition of the District Hospital Board will be:<br />
• Two representatives from the Interim District <strong>Health</strong> Authority (IDHA);<br />
nom<strong>in</strong>ated by the IDHA itself (one from NGO/CBO; one from private sector);<br />
• Hospital Manager/Hospital Super<strong>in</strong>tendent (ex-officio);<br />
• One member from each cl<strong>in</strong>ic and health centre governance structure;<br />
• District <strong>Health</strong> Manager (ex-officio)<br />
• <strong>Health</strong> Centre Managers.<br />
Powers and Functions of a District Hospital Board<br />
The functions and powers of the District Hospital Board are given below:<br />
• advocate on behalf of community and provide <strong>in</strong>put <strong>in</strong>to management of the hospital;<br />
• raise additional funds for the hospital and its activities; and<br />
• ensure co-ord<strong>in</strong>ation between the hospital and other health facilities <strong>in</strong> the district.<br />
Referral Hospital Governance<br />
There are hospitals <strong>in</strong> the prov<strong>in</strong>ce which have been designated a referral status (see Chapter 2).<br />
Governance of a referral hospital will be by the Referral Hospital Board.<br />
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Composition<br />
The Referral Hospital Board will consist of:<br />
• Regional <strong>Health</strong> Director from the relevant region (ex-officio);<br />
• Hospital Manager/Hospital Super<strong>in</strong>tendent;<br />
• Hospital Adm<strong>in</strong>istrator Representation from IDHAs of communities served by the referral hospital;<br />
• 2 members nom<strong>in</strong>ated by MEC from CBO/NGO/private sector.<br />
Powers and Functions of a Referral Hospital Board<br />
The powers and functions of the Referral Hospital Board will be to:<br />
• advocate on behalf of the communities served and provide <strong>in</strong>put <strong>in</strong> management of the hospital;<br />
• raise additional funds for the referral hospital and its activities; and<br />
• ensure co-ord<strong>in</strong>ation of referral services <strong>in</strong> the region.<br />
Governance of Services at <strong>Health</strong> Centre<br />
The <strong>Health</strong> Centre will have a governance structure which represents the local <strong>in</strong>terests of the<br />
communities served by the <strong>Health</strong> Centre. This governance structure is the <strong>Health</strong> Centre Committee.<br />
Composition<br />
The composition of the <strong>Health</strong> Centre Committee will be as follows:<br />
• <strong>Health</strong> Centre Manager; and<br />
• Representatives from cl<strong>in</strong>ic committees served by the <strong>Health</strong> Centre.<br />
Powers and Functions of the <strong>Health</strong> Centre Committee<br />
The powers and functions of the <strong>Health</strong> Centre Committee will be to:<br />
• advocate on behalf of the community and provide <strong>in</strong>put <strong>in</strong> management of services at the <strong>Health</strong><br />
Centre and <strong>in</strong> its catchment area;<br />
• ensure co-ord<strong>in</strong>ation between the health centre and cl<strong>in</strong>ics;<br />
• participate <strong>in</strong> needs assessment, plann<strong>in</strong>g and implementation of PHC;<br />
• elect 2 members to serve on the local Reconstruction and Development Committee (RDC).<br />
Governance of a Community Cl<strong>in</strong>ic<br />
Governance of a community cl<strong>in</strong>ic will be by the Cl<strong>in</strong>ic Committee.<br />
Composition<br />
The composition of a Cl<strong>in</strong>ic Committee is given below:<br />
• Cl<strong>in</strong>ic Manager (ex-officio); and<br />
• Representation from the communities served by the cl<strong>in</strong>ic.<br />
Powers and Functions<br />
The powers and functions of the Cl<strong>in</strong>ic Committee are given below:<br />
• advocate on behalf of community and provide <strong>in</strong>put <strong>in</strong> management of services at the cl<strong>in</strong>ic and<br />
<strong>in</strong> its catchment area;<br />
• ensure co-ord<strong>in</strong>ation between the cl<strong>in</strong>ic and health centre;<br />
• participate <strong>in</strong> needs assessment, plann<strong>in</strong>g and implementation of PHC; and<br />
• elect 2 members to serve on the local RDC.<br />
The Chairperson of the Cl<strong>in</strong>ic Committee will come from the<br />
community and will be elected by the committee.<br />
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COMMUNITY HEALTH COMMITTEES<br />
There will be a Community <strong>Health</strong> Committee for each community. The Manager of the cl<strong>in</strong>ic serv<strong>in</strong>g the<br />
community will be an ex-officio member.<br />
The role of community health committees will be to:<br />
Powers and Functions<br />
• participate <strong>in</strong> the needs analysis, plann<strong>in</strong>g and implementation of primary health care services <strong>in</strong><br />
the community;<br />
• participate <strong>in</strong> community mobilisation for health development;<br />
• elect/nom<strong>in</strong>ate representatives to the Cl<strong>in</strong>ic <strong>Health</strong> Committee;<br />
• create awareness <strong>in</strong> the community of its responsibility for its own health.<br />
This chapter has described the system for governance of health services which is to be established dur<strong>in</strong>g<br />
1997 <strong>in</strong> <strong>Mpumalanga</strong>. The composition and functions of the authorities at various levels have been expla<strong>in</strong>ed.<br />
Also covered <strong>in</strong> the same chapter is a discussion on the importance of community representation as well as<br />
the mechanisms for that representation. It has further expla<strong>in</strong>ed that people’s participation promotes ownership<br />
and ensures acceptance and susta<strong>in</strong>ability of health care <strong>in</strong>terventions.<br />
The PHC service programmes are described <strong>in</strong> the next chapter.<br />
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PRIMARY HEALTH CARE SERVICE<br />
PROGRAMMES<br />
CHAPTER 7
Chapter 7<br />
PRIMARY HEALTH CARE<br />
SERVICE PROGRAMMES<br />
The purpose of this chapter is to outl<strong>in</strong>e the <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> service programmes that make up the<br />
m<strong>in</strong>imum package to be delivered <strong>in</strong> all districts <strong>in</strong> the prov<strong>in</strong>ce.<br />
After read<strong>in</strong>g this chapter, you will be able to:<br />
• describe the PHC service programmes to be implemented <strong>in</strong> the districts<br />
• understand the goal and objectives of each service programme<br />
• plan and implement activities <strong>in</strong> each programme area<br />
• identify some of the <strong>in</strong>dicators for assess<strong>in</strong>g programme performance.<br />
As you have read <strong>in</strong> chapter 1, <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> is affordable, susta<strong>in</strong>able and universal essential health<br />
care for all <strong>in</strong>dividuals, families and communities <strong>in</strong> the district rendered <strong>in</strong> accordance with the people’s<br />
health needs - and with their full acceptance and participation. In <strong>Mpumalanga</strong>, PHC services will be provided<br />
through service programmes, each of which will address identified community health problems and their<br />
causes.<br />
The development and implementation of service programmes signifies a major shift <strong>in</strong> health service delivery,<br />
<strong>in</strong> that the focus will now be on the health of each <strong>in</strong>dividual and family. Each health programme will have<br />
several components, namely:<br />
– health promotion<br />
– prevention of health problems<br />
– cure<br />
– rehabilitation<br />
– palliation, where necessary<br />
Depend<strong>in</strong>g on the skill needed, the activity could be implemented <strong>in</strong> the homes, at community locations<br />
(schools, factories, offices, etc), cl<strong>in</strong>ics, health centres or hospitals.<br />
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Ten priority PHC programmes have been selected for implementation <strong>in</strong> the prov<strong>in</strong>ce. The choice was based<br />
on the results from a situation analysis carried out throughout the districts. The order of priority for the<br />
programmes <strong>in</strong> each district will vary and will be <strong>in</strong>fluenced by differences <strong>in</strong> the prevalence of health problems.<br />
The programme goals, objectives and strategies are <strong>in</strong> accordance with national policies outl<strong>in</strong>ed <strong>in</strong><br />
documents such as the National Programme of Action for Children (NPA); Year 2000 <strong>Health</strong> Goals, Objectives,<br />
Strategies and Indicators for South Africa; and the National <strong>Health</strong> Plan for South Africa. The essence of each<br />
programme is discussed below.<br />
HEALTH PROMOTION<br />
Goal<br />
<strong>Health</strong> promotive activities should enable <strong>in</strong>dividuals, households and communities to ga<strong>in</strong> and ma<strong>in</strong>ta<strong>in</strong><br />
good health through improved knowledge and skills.<br />
Although it is presented here as a programme, health promotion will form an important strategy <strong>in</strong> all PHC<br />
provision. The <strong>Health</strong> Promotion programme will ensure communication, <strong>in</strong>formation exchange and health<br />
promotional support to all the service programmes <strong>in</strong> the districts.<br />
The objectives of this programme are to:<br />
Objectives<br />
• provide people with the knowledge to live healthy lives<br />
• encourage and support people <strong>in</strong> keep up healthy lifestyles<br />
• encourage national, prov<strong>in</strong>cial, district and community leaders to promote health <strong>in</strong><br />
all development policies and activities<br />
• encourage government to enact legislation that promotes, rather than constra<strong>in</strong>s good health.<br />
Opportunities for <strong>Health</strong> Promotion<br />
Opportunities for health promotion exist at various service levels: the community, health facility and the<br />
district health office.<br />
The community level offers a tremendous opportunity for empower<strong>in</strong>g <strong>in</strong>dividuals, households and communities<br />
to be pro-active role <strong>in</strong> promot<strong>in</strong>g their own health, because health promotional messages are delivered<br />
right where the problems exist.<br />
At the health facility level, opportunities present <strong>in</strong> the form of contact between the health worker and the<br />
client/patient. At that time of first contact, the patient/client is most receptive to health promotional messages.<br />
You can take maximum advantage by <strong>in</strong>volv<strong>in</strong>g all health workers <strong>in</strong> health promotion at a time when<br />
<strong>in</strong>dividuals are particularly receptive.<br />
The district health office also offers unique opportunities for health promotion because decisions <strong>in</strong> health<br />
service design made here have district-wide application. In addition, the District <strong>Health</strong> Office is the most<br />
effective level for <strong>in</strong>tersectoral collaboration and mobilisation of resources and technologies for health<br />
<strong>in</strong>terventions.<br />
Strategies<br />
You should take advantage of these opportunities by develop<strong>in</strong>g effective health promotion and<br />
communication strategies which target different groups. Your strategies should:<br />
• upgrade the communication and counsell<strong>in</strong>g skills of health workers, who have an important role<br />
<strong>in</strong> shar<strong>in</strong>g health <strong>in</strong>formation with mothers, fathers, grandparents, youth, teachers, leaders, church<br />
leaders etc<br />
• tra<strong>in</strong> community members, <strong>in</strong>clud<strong>in</strong>g community-based health workers, who will contribute<br />
towards health education and mobilisation of communities<br />
• adopt a research-based approach to identify <strong>in</strong>formation needs <strong>in</strong> the communities, develop<br />
effective messages which are well targeted, and assess impact of health promotion activities.<br />
• establish <strong>in</strong>formation resource centres at the district level, to facilitate dissem<strong>in</strong>ation of <strong>in</strong>formation<br />
through the district health <strong>in</strong>formation unit.<br />
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Table 7.1. <strong>Health</strong> Promotion - Major Activities at Various Service Levels<br />
Household/Community Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Mobilise communities to take an active • Provide <strong>in</strong>formation • Plan health • Provide support to<br />
<strong>in</strong>terest <strong>in</strong> health-related development feedback to promotion service health centres<br />
• Assist communities identify health and communities with<strong>in</strong> <strong>in</strong> its catchment and cl<strong>in</strong>ics <strong>in</strong><br />
development problems and health needs the respective area design<strong>in</strong>g health<br />
• Assist communities improve their knowledge catchment areas • Establish l<strong>in</strong>kages promotion<br />
of the causes of ill health and how good • Organise and with mass and materials and<br />
health can be ma<strong>in</strong>ta<strong>in</strong>ed conduct tra<strong>in</strong><strong>in</strong>g for traditional media messages<br />
• Mobilise community resources to enhance community based for support<strong>in</strong>g<br />
self help for health improvements with a health workers health promotion<br />
special focus on community groups • Provide technical activities <strong>in</strong> the<br />
• Strengthen public participation <strong>in</strong> support to community <strong>in</strong> the catchment<br />
development-related activities based health workers area<br />
• Tra<strong>in</strong> health workers <strong>in</strong> community • Provide support to<br />
organisation,communication and cl<strong>in</strong>ics <strong>in</strong> health<br />
counsell<strong>in</strong>g skills promotion activities<br />
• Provide support to community based <strong>in</strong>clud<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g<br />
services e.g. immunisation, oral rehydration<br />
therapy for diarrhoea, health education and<br />
counsell<strong>in</strong>g <strong>in</strong> priority areas such as maternal<br />
and child health, STDs and HIV/AIDS, nutrition,<br />
hygiene and environmental sanitation, etc.<br />
• Provide tra<strong>in</strong><strong>in</strong>g and educational<br />
opportunities to the community based<br />
health worker<br />
• Empower communities to realise their own<br />
role <strong>in</strong> promot<strong>in</strong>g their own health<br />
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Activities<br />
The district health office will do the follow<strong>in</strong>g:<br />
• identify district and community tra<strong>in</strong><strong>in</strong>g needs <strong>in</strong> health education and community health skills and<br />
co-ord<strong>in</strong>ate necessary tra<strong>in</strong><strong>in</strong>g<br />
• advocate for cross-sectoral policies which will support improved community health<br />
• oversee the development of appropriate health education materials and community based health<br />
education <strong>in</strong> support of all PHC programmes<br />
• commission and oversee the research required to ensure that health education materials and<br />
activities are culturally appropriate<br />
• co-ord<strong>in</strong>ate and organise district health promotion activities<br />
• establish structures for <strong>in</strong>ter-district exchange of <strong>in</strong>formation and knowledge;<br />
• establish structures for <strong>in</strong>tersectoral collaboration<br />
• establish l<strong>in</strong>kages with mass and traditional media for support<strong>in</strong>g health promotion activities<br />
• help establish health promotion/communication resource centres.<br />
Some of the major health promotion activities at various service levels are given <strong>in</strong> Table 7.1.<br />
How to judge the success of your programme<br />
You will know your programme is work<strong>in</strong>g well when:<br />
• the number of health workers tra<strong>in</strong>ed <strong>in</strong> health promotion and communication skills <strong>in</strong>creases<br />
• more health workers use health promotion techniques such as role-play<strong>in</strong>g and demonstration<br />
• your target groups show greater knowledge of your key health education messages<br />
• more survey respondents state that they practise healthy lifestyles def<strong>in</strong>ed by your health education<br />
objectives<br />
• your district has an active, effective health promotion resource centre.<br />
MATERNAL, CHILD AND WOMEN’S HEALTH<br />
Goal<br />
The goal of the Maternal, Child and Women’s <strong>Health</strong> programme<br />
<strong>in</strong> your district is to reduce sickness and death <strong>in</strong> mothers, children,<br />
adolescents and women.<br />
Objectives<br />
The programme focuses on health protection, promotion and development of children and women. The<br />
programme aims to:<br />
• provide accessible, comprehensive services <strong>in</strong> antenatal, delivery, postnatal and reproductive health<br />
for mothers<br />
• provide accessible, quality, preventive health care services to children<br />
• reduce illness and death <strong>in</strong> children aris<strong>in</strong>g from preventable conditions<br />
• provide accessible, health care services to adolescents to address problems of substance abuse,<br />
depression, teenage pregnancies and sexually transmitted diseases<br />
• ma<strong>in</strong>ta<strong>in</strong> the health status of the elderly and their access to health services.<br />
Strategies<br />
Some of the strategies your team will use to atta<strong>in</strong> the goal of less morbidity and mortality for each group are<br />
to:<br />
Maternal <strong>Health</strong><br />
• ensure access to quality antenatal care, quality care dur<strong>in</strong>g and after delivery to mothers and their<br />
babies - and encourage the use of these services<br />
• implement a system of service delivery for mothers and their babies which strives to achieve agreed<br />
objectives<br />
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• ensure that all maternity facilities are mother and baby friendly<br />
• provide comprehensive family plann<strong>in</strong>g services to families and <strong>in</strong>dividuals requir<strong>in</strong>g them.<br />
Child <strong>Health</strong><br />
• establish capacity for management of common illnesses that affect children<br />
• establish services for low birth weight babies<br />
• reduce mortality due to diarrhoea, measles and acute respiratory <strong>in</strong>fections <strong>in</strong> children, through<br />
appropriate disease management activities<br />
• <strong>in</strong>crease immunisation coverage among children of one year of age aga<strong>in</strong>st diphtheria, pertussis,<br />
tetanus, measles, poliomyelitis, hepatitis and tuberculosis<br />
• provide oral rehydration therapy (ORT) and cont<strong>in</strong>ued feed<strong>in</strong>g for children suffer<strong>in</strong>g from diarrhoeal<br />
disorders<br />
• ensure regular growth monitor<strong>in</strong>g for all pre-school children<br />
• encourage breastfeed<strong>in</strong>g<br />
• <strong>in</strong>troduce nutrition-supportive strategies with<strong>in</strong> health facilities and the community<br />
• ensure adequate management of malnourished children<br />
• ensure appropriate wean<strong>in</strong>g practices and nutritional rehabilitation of vulnerable children.<br />
Adolescent <strong>Health</strong><br />
• provide teenager support programmes aimed at reduc<strong>in</strong>g substance abuse, teen pregnancies and<br />
<strong>in</strong>tentional and un<strong>in</strong>tentional <strong>in</strong>juries among adolescents<br />
• provide peer group education for sexuality and life skills.<br />
Women’s <strong>Health</strong><br />
• support education and literacy programmes for girls and women<br />
• provide <strong>in</strong>formation on sexuality and reproduction<br />
• provide confidential services for the diagnosis, management and counsell<strong>in</strong>g of HIV/AIDS/STD<br />
for girls and women<br />
• implement a plan for health education, screen<strong>in</strong>g and treatment of cervical and breast cancer.<br />
Activities<br />
Some of the major activities to be implemented at various service levels are given <strong>in</strong> Table 7.2.<br />
How to judge the success of your programme<br />
You will know this programme is work<strong>in</strong>g well when:<br />
Child health<br />
• fewer babies are born with low weights<br />
• immunisation coverage <strong>in</strong>creases<br />
• there are fewer deaths from preventable diseases<br />
• fewer children are stunted or wasted<br />
• fewer children have severe malnutrition<br />
Adolescent health<br />
• there are fewer cases of adolescent <strong>in</strong>jury and suicide<br />
• less adolescents abuse drugs and alcohol<br />
• there are fewer teenage pregnancies<br />
Women’s health<br />
• there is a decrease <strong>in</strong> the fertility rate<br />
• more women have access to antenatal care<br />
• more health facilities have health workers tra<strong>in</strong>ed to recognise high risk pregnancies<br />
• more women receive postnatal care from health care workers<br />
• more facilities provide screen<strong>in</strong>g services for women’s cancer<br />
• more health care <strong>in</strong>itiatives target women’s health.<br />
• more women tak<strong>in</strong>g <strong>in</strong>formed decisions about their sexuality and fertility<br />
81
Table 7.2. Maternal, Child and Women’s <strong>Health</strong> Programme - Major Activities at Various Service Levels<br />
Community Level Cl<strong>in</strong>ic Level <strong>Health</strong> Centre District Hospital<br />
• Empower households through health • Provide antenatal, • Provide services for • Provide referral<br />
promotion to make the right decisions maternal and antenatal, maternal services for the<br />
to ensure safe motherhood postnatal care and postnatal care lower levels eg.<br />
• Provide tra<strong>in</strong><strong>in</strong>g for TBAs (Traditional Birth • Provide family • Provide family - delivery of high<br />
Attendants) plann<strong>in</strong>g services plann<strong>in</strong>g services risk cases <strong>in</strong>cl.<br />
• Provide <strong>in</strong>formation on ORT (oral-rehydration • Provide tra<strong>in</strong><strong>in</strong>g for • Provide screen<strong>in</strong>g Caesarean section;<br />
therapy) TBAs (Traditional service for high-risk - manag<strong>in</strong>g congenital<br />
• Empower households through health Birth Attendants) cases for referral to abnormalities<br />
promotion to prevent home <strong>in</strong>juries • Provide screen<strong>in</strong>g hospital and premature<br />
• Provide counsell<strong>in</strong>g aga<strong>in</strong>st child abuse of high risk antenatal • Manage simple post mature babies;<br />
• Promote breast feed<strong>in</strong>g cases for referral to partum complications - screen<strong>in</strong>g for<br />
• Empower households through health health centre/ and abortions cervical and<br />
promotion to seek immunisation and hospital • Provide care for breast cancer;<br />
growth monitor<strong>in</strong>g services at health • Undertake post-natal normal and sick new- - render<strong>in</strong>g <strong>in</strong>fertility<br />
facilities follow-ups borns services.<br />
• Provide education and counsell<strong>in</strong>g to • Provide growth • Provide counsell<strong>in</strong>g<br />
youth groups and schools regard<strong>in</strong>g monitor<strong>in</strong>g services aga<strong>in</strong>st child abuse<br />
sexuality, unwanted pregnancies, • Provide diagnosis and • Provide service for<br />
substance abuse, abortions, sexual treatment of m<strong>in</strong>or monitor<strong>in</strong>g develophealth<br />
(HIV/STDs) ailments ment milestones<br />
• Empower women through health • Provide ORT • Provide health<br />
promotion to seek screen<strong>in</strong>g service • Provide counsell<strong>in</strong>g promotion services<br />
for cervical and breast cancer aga<strong>in</strong>st child abuse <strong>in</strong> support of school<br />
• Empower households through health • Provide health health<br />
promotion to be gender conscious promotion services • Provide screen<strong>in</strong>g<br />
• Provide services for <strong>in</strong>fertility <strong>in</strong> support of school service for cervical<br />
health (pap smear) and<br />
• Provide screen<strong>in</strong>g breast cancer<br />
service for cervical • Provide good<br />
(pap smear) and quality immunisation<br />
breast cancer services and <strong>in</strong>crease<br />
• Provide good quality public awareness<br />
immunisation services about its benefits<br />
and <strong>in</strong>crease public<br />
awareness about its<br />
benefits<br />
82
NUTRITION PROGRAMME<br />
Goal<br />
This programme seeks to ensure good nutrition for everyone <strong>in</strong> <strong>Mpumalanga</strong><br />
Objectives<br />
The nutrition programme aims to:<br />
• reduce the prevalence of underweight, stunt<strong>in</strong>g and severe<br />
malnutrition among children under the age of six<br />
• prevent severe malnutrition of pregnant and lactat<strong>in</strong>g women<br />
• reduce the prevalence of micro-nutrient deficiency i.e. vitam<strong>in</strong> A,<br />
iod<strong>in</strong>e and iron<br />
• promote exclusive breast feed<strong>in</strong>g for 4-6 months and establish breast feed<strong>in</strong>g support groups<br />
• promote baby friendly hospital <strong>in</strong>itiatives<br />
• prevent diseases of lifestyle<br />
• provide specialised therapy to nutrition related diseases<br />
• give support to community-based nutrition surveillance and rehabilitation programmes.<br />
Strategies<br />
The strategies for achiev<strong>in</strong>g the objectives of the nutrition programme <strong>in</strong>clude:<br />
• Provision of preventive, curative, rehabilitative and promotive services;<br />
• Promotion of <strong>in</strong>tersectoral collaboration and community participation<br />
• Development of an effective referral system.<br />
Components<br />
The ma<strong>in</strong> components of the nutrition programme are:<br />
• nutrition promotion and education<br />
• nutrition surveillance<br />
• nutrition therapy and rehabilitation.<br />
Activities<br />
Some of the major activities of this programme are given <strong>in</strong> Table 7.3.<br />
How to judge the success of your programme<br />
You will know your programme is do<strong>in</strong>g well when:<br />
• more children up to 23 months of age are still breastfeed<strong>in</strong>g;<br />
• fewer children are wasted or stunted<br />
• people <strong>in</strong> more households consume adequately iodised salt<br />
• more mothers know how to <strong>in</strong>terpret growth charts.<br />
83
Table 7.3. Nutrition Programme - Major Activities at Various Service Levels<br />
Community Level Cl<strong>in</strong>ic Level <strong>Health</strong> Centre District Hospital<br />
• Promote household food security, correct eat<strong>in</strong>g<br />
habits and hygiene<br />
• Promote, support and participate <strong>in</strong> breastfeed<strong>in</strong>g<br />
<strong>in</strong>itiative<br />
• Form support groups for lactation management<br />
at baby friendly <strong>in</strong>stitutions/facilities<br />
• Monitor, evaluate and upgrade nutrition education<br />
programme<br />
• Provide health workers with skills on promotion of<br />
health/nutrition<br />
• Tra<strong>in</strong> communities to assess/analyse and take<br />
action on specific or identified needs<br />
• Implement primary school nutrition programme<br />
• Empower households through health promotion<br />
to recognise and refer nutrition related cases/<br />
diseases to the health facility for treatment or<br />
specialised care<br />
• Empower households to manage and rehabilitate<br />
members with nutrition related conditions<br />
• Provide nutrition<br />
education, guidance<br />
and demonstrations to<br />
target groups<br />
• Provide support to<br />
breastfeed<strong>in</strong>g <strong>in</strong>itiative<br />
• Provide support to<br />
communities to plan<br />
nutrition projects<br />
• Monitor nutritional status<br />
especially children under<br />
6 years<br />
• Implement micronutrient<br />
supplementation<br />
• Give support to<br />
monitor<strong>in</strong>g and<br />
evaluation of nutrition<br />
<strong>in</strong>terventions such as<br />
breastfeed<strong>in</strong>g and<br />
iod<strong>in</strong>e deficiency<br />
disorders control<br />
• Participate <strong>in</strong> rout<strong>in</strong>e<br />
data collection through<br />
<strong>Health</strong> Information<br />
System<br />
• Provide supervisory<br />
support to cl<strong>in</strong>ics<br />
• Plan and support<br />
nutrition campaigns<br />
• Give support to tra<strong>in</strong><strong>in</strong>g<br />
activities<br />
• Give support to communities<br />
to plan projects<br />
• Provide support <strong>in</strong><br />
compil<strong>in</strong>g of community<br />
profile<br />
• Provide support and<br />
ma<strong>in</strong>ta<strong>in</strong> referral and<br />
support system for<br />
follow-up<br />
• Provide specialised<br />
treatment of diseases of<br />
lifestyle<br />
• Provide diet therapy<br />
• Develop special nutrition<br />
<strong>in</strong>terventions<br />
• Implement Baby Friendly<br />
Hospital Initiative<br />
• Collect and collate data<br />
from referr<strong>in</strong>g cl<strong>in</strong>ics and<br />
communities<br />
• Monitor nutritional status<br />
of children under 6 years<br />
• Provide specialised<br />
prevention, cure and<br />
rehabilitation of<br />
malnutrition<br />
• Implement Baby Friendly<br />
Hospital Initiative<br />
• Formulate special<br />
therapeutic diets<br />
• Conduct nutrition<br />
related research<br />
84
PRIMARY ORAL HEALTH CARE<br />
Goal<br />
This programme aims to promote oral health <strong>in</strong> children and adults.<br />
<strong>Primary</strong> Oral <strong>Health</strong> <strong>Care</strong> (POHC) means the control and prevention of oral diseases without expensive<br />
restorative procedures for teeth. The programme focuses on diagnosis and prevention of oral diseases us<strong>in</strong>g<br />
local technology wherever possible, with the full co-operation and participation of the community.<br />
The objectives of primary oral health care are to:<br />
Objectives<br />
• reduce the <strong>in</strong>cidence of oral diseases <strong>in</strong> children and adults; and<br />
• promote proper oral health practices.<br />
Strategies <strong>in</strong>clude:<br />
Strategies<br />
• advocat<strong>in</strong>g for the fluoridation of public dr<strong>in</strong>k<strong>in</strong>g water where necessary<br />
• us<strong>in</strong>g alternatives to water fluoridation<br />
• prophylactic fissure seal<strong>in</strong>g of occlusal pit and fissures of posterior teeth of high-risk patients<br />
• provision of oral health education<br />
• provision of oral hygiene <strong>in</strong>formation, with emphasis on the role of plaque <strong>in</strong> caus<strong>in</strong>g oral disease.<br />
Components<br />
• personal primary health care services (basic oral health services, <strong>in</strong>clud<strong>in</strong>g treatment of pa<strong>in</strong> and<br />
sepsis); and<br />
• non personal primary health care services (health education and promotion activities aimed at groups<br />
and communities.<br />
For the oral health programme to be successful <strong>in</strong> your district, it needs to be <strong>in</strong>tegrated <strong>in</strong>to general health<br />
promotion strategies, as it will require full co-operation and active participation by the community.<br />
How to judge the success of your programme<br />
You will know this programme is effective when:<br />
• more children under six are free of caries<br />
• fewer twelve year olds have decayed, miss<strong>in</strong>g or filled teeth<br />
• more health units have dental facilities.<br />
85
ENVIRONMENTAL HEALTH<br />
Goal<br />
This programme should ensure a healthy environment for all<br />
communities <strong>in</strong> the prov<strong>in</strong>ce.<br />
This programme should:<br />
Objectives and strategies<br />
• ensure that safe, clean water and basic sanitation is available:<br />
- monitor and advocate the use of safe dr<strong>in</strong>k<strong>in</strong>g water<br />
- promote personal hygiene<br />
- prevent water and environmental pollution<br />
- promote good and safe hous<strong>in</strong>g<br />
• reduce health risks related to food, water and sanitation,<br />
labell<strong>in</strong>g and import<strong>in</strong>g of consumer goods, hazardous<br />
substances, <strong>in</strong>dustrial and occupational hygiene, and port<br />
health:<br />
- implement environmental health education<br />
- promulgation of related legislation and regulations<br />
- control smok<strong>in</strong>g<br />
- promote <strong>in</strong>dustrial and occupational safety<br />
• improve accessibility for all <strong>in</strong> the district to a comprehensive environmental health service:<br />
- <strong>in</strong>vestigate communicable and environment related diseases<br />
- control disease vectors<br />
• promote quality assurance of environmental health programmes through operations research<br />
• establish an effective environmental health <strong>in</strong>formation system.<br />
Activities<br />
The major activities carried out <strong>in</strong> this programme are listed <strong>in</strong> Table 7.4.<br />
How to judge the success of your programme<br />
You will know your programme is work<strong>in</strong>g well when:<br />
• people live with<strong>in</strong> 15 m<strong>in</strong>utes walk of a safe source of water<br />
• households use a safe form of waste disposal<br />
• people know the importance of wash<strong>in</strong>g hands after us<strong>in</strong>g the toilet<br />
• food outlets meet hygiene standards<br />
• safe dump<strong>in</strong>g sites are proclaimed<br />
• the frequency of epidemics caused by contam<strong>in</strong>ated water, food and other substances<br />
decreases<br />
• households <strong>in</strong> malaria areas are adequately sprayed.<br />
86
Table 7.4 Environmental <strong>Health</strong> Programme - Major Activities at Various Service Levels<br />
Community Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Empower communities to<br />
recognise and take protective<br />
action aga<strong>in</strong>st environmental<br />
health hazards<br />
• Tra<strong>in</strong> households <strong>in</strong> personal<br />
hygiene<br />
• Advocate environmental health<br />
development eg. the provision of<br />
safe hous<strong>in</strong>g, water, sanitation<br />
• Mobilise communities for<br />
environmental health action<br />
• Promote <strong>in</strong>tersectoral<br />
collaboration<br />
• Collect <strong>in</strong>formation on<br />
environmental health <strong>in</strong> the<br />
communities<br />
• Carry out environmental<br />
sampl<strong>in</strong>g of milk, soil,<br />
water and food<br />
• Provide education on<br />
environmental health<br />
• Advocate personal<br />
hygiene<br />
• Support community<br />
environmental health<br />
<strong>in</strong>itiatives<br />
• Collect relevant data<br />
• Monitor and evaluate<br />
environmental health programme<br />
at community and cl<strong>in</strong>ic levels<br />
• Support and provide tra<strong>in</strong><strong>in</strong>g to<br />
community health workers <strong>in</strong><br />
environmental health<br />
• Carry out surveillance of<br />
environmental health programme<br />
eg. food outlets<br />
• Monitor the implementation of<br />
relevant legislation<br />
• Inspect government and nongovernment<br />
facilities<br />
• Promote safe work<strong>in</strong>g environment<br />
• Inspect/monitor food hygiene and<br />
food handl<strong>in</strong>g <strong>in</strong> public facilities<br />
• Give support to and monitor vector<br />
control programme<br />
• Collect relevant data<br />
• Provide referral services<br />
e.g. monitor<strong>in</strong>g of safety<br />
of food outlets<br />
• Conduct operational<br />
research <strong>in</strong><br />
environmental health<br />
Key Notes<br />
* Functions of the Environmental <strong>Health</strong> Programme are governed by acts of Parliament, many of which are presently under revision:<br />
• <strong>Health</strong> Act of 1977 (Under revision)<br />
• National Build<strong>in</strong>g Regulations (Act 103 of 1977)<br />
• Food Cosmetics and dis<strong>in</strong>fectants act (Act 54 of 1972)<br />
• Water Act (Act 54 of 1956) (Under revision)<br />
• Act on Hazardous Substances (Act 28 of 1975)<br />
• The Occupational <strong>Health</strong> and Safety Act (Act of 1993)<br />
* Revisions of stand<strong>in</strong>g legislation may impact on the legal responsibility of environmental health services at the various levels<br />
87
The MEC for <strong>Health</strong>, Welfare & Gender Affairs, Ms Candith Mashego,<br />
promotes an immunisation campaign<br />
COMMUNICABLE DISEASES CONTROL<br />
Goal<br />
This programme aims to prevent exposure to and risk from endemic and epidemic communicable diseases<br />
which currently account for 70% of the morbidity and mortality burden <strong>in</strong> <strong>Mpumalanga</strong>.<br />
The programme aims to achieve:<br />
Objectives<br />
• 90% coverage of 7 major vacc<strong>in</strong>es (diphtheria, pertussis, tetanus, hepatitis B, polio, tuberculosis,<br />
measles) before 2 years of age<br />
• 85% cure of sputum smear positive tuberculosis patients<br />
• 90% completion of multiple drug therapy by leprosy patients<br />
• 95% correct syndromic treatment for sexually transmitted diseases<br />
• <strong>in</strong>creased knowledge <strong>in</strong> at least 90% of households on how to treat acute respiratory <strong>in</strong>fections (ARI)<br />
and diarrhoeal diseases (DD) and when to refer<br />
• reduction <strong>in</strong> the malaria mortality rate to less than 0.5%.<br />
Strategy<br />
This programme should achieve effective and efficient control of priority communicable diseases us<strong>in</strong>g<br />
appropriate and proven <strong>in</strong>terventions (Table 7.5).<br />
Components<br />
The components of the Communicable Diseases Control programme are:<br />
• expanded programme on immunisation<br />
• control of tuberculosis/leprosy<br />
• control of HIV/AIDS and sexually transmitted diseases<br />
• control of diarrhoeal diseases<br />
• control of acute respiratory <strong>in</strong>fections<br />
• control of vector borne and parasitic diseases and zoonoses outbreaks.<br />
88
Table 7.5 Communicable Diseases Control Programme - Major Activities at Various Service Levels<br />
Community Level Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Provide education on value of<br />
health <strong>in</strong>terventions<br />
• Mobilise communities for special<br />
activities<br />
• Tra<strong>in</strong> communities on lay<br />
def<strong>in</strong>itions of diseases<br />
• Encourage communities to br<strong>in</strong>g<br />
animals for vacc<strong>in</strong>ations<br />
• Recruit treatment supporters<br />
• Develop life skills and mobilise<br />
<strong>in</strong>terest and youth groups<br />
• Communicate simple, accurate<br />
messages<br />
• Supply condoms<br />
• Support home based care<br />
• Tra<strong>in</strong> on prevention, especially<br />
environmental health measures<br />
• Provide health education<br />
• Co-ord<strong>in</strong>ate special local outreach efforts<br />
• Provide day-to-day services to suit<br />
community needs<br />
• Order, supply and manage vacc<strong>in</strong>es,<br />
drugs and consumables<br />
• Set local coverage targets<br />
• Liaise with local community-based health<br />
workers on ways to make service more<br />
relevant to community needs<br />
• Record and <strong>in</strong>terpret practice <strong>in</strong> l<strong>in</strong>e with<br />
targets<br />
• Counsell<strong>in</strong>g on contacts and importance<br />
of complet<strong>in</strong>g therapy<br />
• Treat with appropriate medication on<br />
syndromic basis<br />
• Refer complicated/non-responsive cases<br />
to next level<br />
• Notify Communicable Diseases Control<br />
Co-ord<strong>in</strong>ators of suspected cases of<br />
contagious diseases (outbreaks)<br />
• Initiate prompt response for control of<br />
contagious conditions<br />
• Develop mechanisms for contact<strong>in</strong>g<br />
local state veter<strong>in</strong>arians<br />
• Ma<strong>in</strong>ta<strong>in</strong> close contact with local<br />
Environmental <strong>Health</strong> Staff for dual<br />
community based <strong>in</strong>terventions<br />
• Provide <strong>Health</strong> Education<br />
• Co-ord<strong>in</strong>ate special local<br />
outreach efforts<br />
• Provide day-to-day services to suit<br />
community needs<br />
• Order, supply and manage vacc<strong>in</strong>es<br />
drugs and consumables<br />
• Set local coverage targets<br />
• Liaise with local community-based<br />
health workers on ways to make<br />
services more relevant to community<br />
needs<br />
• Record and <strong>in</strong>terpret practice <strong>in</strong> l<strong>in</strong>e<br />
with targets<br />
• Conduct tra<strong>in</strong><strong>in</strong>g of all staff <strong>in</strong> the<br />
catchment area<br />
• Counsell<strong>in</strong>g on contacts and<br />
importance of complet<strong>in</strong>g therapy<br />
• Treat with appropriate medication on<br />
syndromic basis<br />
• Refers complicated/non-responsive<br />
cases<br />
• Provide service to referred cases (eg.<br />
STDs) or complicated cases (eg.<br />
abscess follow<strong>in</strong>g vacc<strong>in</strong>ation)<br />
• Notify Communicable Diseases Control<br />
Co-ord<strong>in</strong>ators of suspected cases of<br />
contagious diseases (outbreaks)<br />
• Initiate prompt response for control of<br />
contagious conditions<br />
• Develop mechanisms for contact<strong>in</strong>g<br />
local state veter<strong>in</strong>arians<br />
• Ma<strong>in</strong>ta<strong>in</strong> close contact with local<br />
Environmental <strong>Health</strong> for dual<br />
community based <strong>in</strong>terventions<br />
• Treatment of the<br />
referral cases<br />
• Treatment of<br />
<strong>in</strong>fectious diseases<br />
merit<strong>in</strong>g hospital<br />
level management<br />
89
Activities<br />
Some of the major activities of the programme are given <strong>in</strong> Table 7.5<br />
How to judge the success of your programme<br />
You will know the programme is work<strong>in</strong>g well when:<br />
• fewer children under five are hospitalised with acute respiratory <strong>in</strong>fection<br />
• fewer health units experience stock shortages of antibiotics<br />
• more mothers know how to prepare and adm<strong>in</strong>ister oral rehydration salt (ORS) solution<br />
• more children aged 12-23 months are fully immunised with BCG, DPT, measles, and polio vacc<strong>in</strong>es<br />
• more people know how TB is spread and how to prevent <strong>in</strong>fection<br />
• more people have the correct knowledge about ways to prevent HIV/STD transmission.<br />
REHABILITATION AS A SERVICE PROGRAMME<br />
Goal<br />
The goal of this programme is to prevent disabilities, detect disabilities early and provide rehabilitation services.<br />
Strategy<br />
The strategy of community-based rehabilitation (CBR) places rehabilitation with<strong>in</strong> a community development<br />
context, <strong>in</strong> which rehabilitation services are delivered by community based rehabilitation workers<br />
supervised by professional staff. It <strong>in</strong>cludes equalisation of opportunities and social <strong>in</strong>tegration of people with<br />
disabilities. For the strategy of CBR to succeed, referral to and support from specialized rehabilitation centres<br />
at secondary level is essential.<br />
All people with physical and mental disabilities should be enabled to make decisions about appropriate<br />
health care, education, vocational tra<strong>in</strong><strong>in</strong>g and re-<strong>in</strong>tegration <strong>in</strong>to society. This highlights the need for<br />
<strong>in</strong>tersectoral collaboration <strong>in</strong>volv<strong>in</strong>g education, welfare, labour, transport, sport and recreation and hous<strong>in</strong>g.<br />
Rehabilitation focuses on the follow<strong>in</strong>g:<br />
• visual difficulties;<br />
• hear<strong>in</strong>g and speak<strong>in</strong>g difficulties;<br />
• movement difficulties;<br />
• mood and behaviour disorders;<br />
• learn<strong>in</strong>g difficulties; and<br />
• epilepsy.<br />
Components<br />
Activities<br />
Some of the major activities of the programme are listed <strong>in</strong> Table 7.6<br />
How to judge the success of your programme<br />
You will know the programme is effective when:<br />
• more disabled children enrol <strong>in</strong> special schools<br />
• fewer adults are disabled<br />
• more disabled children have access to appropriate health services<br />
• more health workers can identify signs and symptoms associated with disabilities<br />
• more mothers with disabled children know how to prevent a similar disability.<br />
90
Table 7.6 Rehabilitation Programme - Major Activities at Various Service Levels<br />
Community Level Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Identify people with disabilities<br />
• Carry out basic assessment of<br />
people with disabilities to the<br />
relevant resources<br />
• Select appropriate rehabilitation<br />
procedure, <strong>in</strong>clud<strong>in</strong>g health<br />
promotion and prevention<br />
• Promote social rehabilitation<br />
• Work towards community<br />
development and<br />
empowerment of disabled<br />
people<br />
• Support and strengthen<br />
community <strong>in</strong>itiatives such as<br />
self help groups and care groups<br />
for disabled children<br />
• Provide emotional and <strong>in</strong>formational<br />
support<br />
• Encourage normal development <strong>in</strong><br />
disabled<br />
• Encourage normal activities <strong>in</strong> disabled<br />
adults<br />
• Assist with the acquisition of assistive devices<br />
• L<strong>in</strong>k the disabled with appropriate<br />
resources<br />
• Refer people with disabilities to appropriate<br />
rehabilitation services<br />
• Provide <strong>in</strong>tensive rehabilitation with<br />
emphasis on disability<br />
• Support community-based<br />
rehabilitation workers<br />
• Act as resource for communities<br />
• Provide community outreach visits<br />
especially to the areas where no<br />
community based rehabilitation<br />
programme exists<br />
• Provide referral<br />
rehabilitation services<br />
with emphasis on the<br />
provision of early<br />
phases of rehabilitation<br />
<strong>in</strong>clud<strong>in</strong>g a<br />
spectrum of<br />
therapeutic services,<br />
early detection and<br />
prevention disabilities<br />
follow<strong>in</strong>g illness or<br />
trauma<br />
91
EMERGENCY HEALTH SERVICES<br />
Goal<br />
The goal of this programme is to provide a quick response to emergencies, and tra<strong>in</strong> communities to deal<br />
with emergencies and disasters.<br />
This programme aims to:<br />
Objectives<br />
• facilitate speedy and safe transport of the seriously ill or <strong>in</strong>jured patient from the site of <strong>in</strong>jury or illness<br />
to the appropriate health facility, or between facilities.<br />
• develop capacity of the health facilities to attend to medical, surgical, paediatric, obstetric and all<br />
other emergencies <strong>in</strong> the district;<br />
• sensitise the communities to risk-tak<strong>in</strong>g behaviour and the potential for disasters<br />
• put <strong>in</strong> place an early warn<strong>in</strong>g system at community level<br />
• re<strong>in</strong>force preventive and disease control measures to m<strong>in</strong>imise risks to people<br />
• co-ord<strong>in</strong>ate emergency preparedness activities with<strong>in</strong> the community<br />
• prepare a health emergency plan which mobilises available local resources<br />
• ensure that the tra<strong>in</strong><strong>in</strong>g for community health workers <strong>in</strong>cludes health emergencies<br />
• improve first aid and improve exist<strong>in</strong>g district emergency plans and the state of read<strong>in</strong>ess of<br />
emergency teams<br />
• empower households to manage domestic <strong>in</strong>juries<br />
• promote safe use of roads <strong>in</strong> order to reduce traffic accidents<br />
• prevent domestic <strong>in</strong>juries.<br />
Strategies<br />
In order to accomplish the programme objectives, the prov<strong>in</strong>cial health office will:<br />
• ensure sufficient programme coverage <strong>in</strong> the prov<strong>in</strong>ce<br />
• make available vehicles equipped with all relevant resuscitation equipment<br />
• ensure that all emergency vehicles and stations are staffed with adequately skilled personnel<br />
• <strong>in</strong>form all communities and health facilities of the service po<strong>in</strong>ts for ambulance services <strong>in</strong> the<br />
prov<strong>in</strong>ce<br />
• market the service through media.<br />
• develop and implement first aid tra<strong>in</strong><strong>in</strong>g programmes.<br />
Components<br />
The components of this programme are to:<br />
• manage medical emergencies<br />
• evacuate emergencies and referral<br />
• tra<strong>in</strong> “at risk” groups <strong>in</strong> disaster preparedness<br />
• educate people about First Aid management of emergencies.<br />
The Prov<strong>in</strong>cial <strong>Health</strong> Office has contracted out the emergency services to the District Council (old regional<br />
services board) at the Lowveld, the Highveld and Eastern Highveld. The Lowveld has a control room <strong>in</strong> Nelspruit<br />
and <strong>in</strong>formation about the service po<strong>in</strong>ts to cover the whole of the Lowveld Region can be obta<strong>in</strong>ed from<br />
the Nelspruit office.<br />
The Highveld Control room is <strong>in</strong> Middelburg and <strong>in</strong>formation about service po<strong>in</strong>ts to cover the whole of the<br />
Highveld region, can be obta<strong>in</strong>ed from there.<br />
Eastern Highveld Region has a control room at Secunda from where <strong>in</strong>formation about service po<strong>in</strong>ts and<br />
location of ambulances may be obta<strong>in</strong>ed.<br />
Disasters/Epidemics<br />
A body known as the Medical Jo<strong>in</strong>t Operations Command (MJOC) exists which co-ord<strong>in</strong>ates <strong>in</strong>terventions<br />
<strong>in</strong>tersectorally <strong>in</strong> cases of epidemics and disasters.<br />
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The MJOC comprises representatives from the departments of <strong>Health</strong>, South African Medical Services, Welfare<br />
and NGOs. The MJOC liaises with the Prov<strong>in</strong>cial Jo<strong>in</strong>t Operations Command (PJOC) which has broader<br />
representation <strong>in</strong>clud<strong>in</strong>g the police services, armed forces and local government. The services of these<br />
bodies are <strong>in</strong>itiated through the regional and prov<strong>in</strong>cial health offices.<br />
Personnel Skills-Mix<br />
Each region has set up tra<strong>in</strong><strong>in</strong>g colleges for purposes of tra<strong>in</strong><strong>in</strong>g and retra<strong>in</strong><strong>in</strong>g all ambulance personnel <strong>in</strong><br />
transport<strong>in</strong>g and First Aid management of the acutely ill/<strong>in</strong>jured while <strong>in</strong> transit to hospitals. Suitably qualified<br />
and/or tra<strong>in</strong>ed staff have been absorbed from former Homelands Governments and Transvaal Prov<strong>in</strong>cial<br />
Adm<strong>in</strong>istration to constitute the New <strong>Mpumalanga</strong> Medical Emergency Staff.<br />
Telephone numbers of the ambulance stations and/or control room contact telephone numbers are available<br />
<strong>in</strong> the appropriate phone books <strong>in</strong> each region or can be obta<strong>in</strong>ed on request from Post Office telephone<br />
operators or from the Police Stations nearest to the client.<br />
National emergency numbers <strong>in</strong> the prov<strong>in</strong>ce are be<strong>in</strong>g <strong>in</strong>troduced.<br />
How to judge the success of your programme<br />
You will know the programme is work<strong>in</strong>g well when:<br />
• less time passes between occurrence of <strong>in</strong>jury and emergency response<br />
• safety regulations are implemented and enforced <strong>in</strong> a work place or other high-risk environment<br />
• more community-based workers, factory or plant cadres, and traditional practitioners are tra<strong>in</strong>ed <strong>in</strong><br />
<strong>in</strong>jury care<br />
• more health care facilities offer 24 hour emergency care services<br />
• people <strong>in</strong> more households are tra<strong>in</strong>ed <strong>in</strong> the management of <strong>in</strong>juries<br />
CURATIVE, DIAGNOSTIC AND MEDICO-LEGAL SERVICES<br />
Goal<br />
The goal of this programme is early diagnosis, treatment and management of diseases to prevent diseases<br />
progress<strong>in</strong>g to a chronic state, disability or death.<br />
Objectives<br />
The long-term objectives of the programme <strong>in</strong>clude ensur<strong>in</strong>g that:<br />
• communities have access to health facilities and health workers<br />
• service programme coverage such as curative diagnostic and medico-legal are adequate<br />
• sufficient capacity for cl<strong>in</strong>ical skills exists at each service level<br />
• a well function<strong>in</strong>g referral system is built with<strong>in</strong> the district health system<br />
• accurate and reliable medical records of <strong>in</strong>dividual patients, disease profile, <strong>in</strong>clud<strong>in</strong>g <strong>in</strong>cidents of<br />
patient-health worker contacts, for patient follow-ups, plann<strong>in</strong>g, monitor<strong>in</strong>g and evaluation and<br />
operational research, are kept<br />
• treatment, management and control of disease is carried out us<strong>in</strong>g given therapeutic protocols<br />
appropriate for different service levels and by prescrib<strong>in</strong>g strictly essential drugs<br />
• sufficient supply of essential drugs and treatment protocols are <strong>in</strong> stock <strong>in</strong> all primary health care<br />
facilities.<br />
The strategies for this programme <strong>in</strong>clude:<br />
Strategies<br />
• development of protocols and provision of <strong>in</strong>-service tra<strong>in</strong><strong>in</strong>g for the early diagnosis and treatment of<br />
simple ailments <strong>in</strong> homes, public <strong>in</strong>stitutions and community based facilities (first aid and primary<br />
curative <strong>in</strong>terventions), through the community based health workers, outreach services,<br />
community cl<strong>in</strong>ics<br />
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Table 7.7<br />
Curative, Diagnostic and Medico-Legal Services Programme - Major Activities at Various<br />
Service Levels<br />
Community Level Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Provide support to people with<br />
chronic illnesses e.g. AIDS (Home<br />
<strong>Care</strong>); Diabetes (<strong>in</strong>sul<strong>in</strong><br />
adm<strong>in</strong>istration) and cancer<br />
• Distribution drugs to <strong>in</strong>dividuals<br />
who cannot access them at<br />
health facility eg. disabled, old<br />
people<br />
• Provide care for term<strong>in</strong>ally ill<br />
• Provide <strong>in</strong>formation and health<br />
education on 5 priority cancers<br />
- cancer of the uter<strong>in</strong>e cervix<br />
- cancer of oesophagus<br />
- liver cancer<br />
- lung cancer<br />
- breast cancer<br />
• Empower communities to<br />
recognise and manage common<br />
illnesses eg. malaria, vomit<strong>in</strong>g and<br />
diarrhoea <strong>in</strong> children, m<strong>in</strong>or<br />
domestic <strong>in</strong>juries<br />
• Empower households to seek<br />
health services <strong>in</strong> cases of<br />
assault, sexual abuse, rape, dog<br />
bites, etc.<br />
• Provide counsell<strong>in</strong>g services for:<br />
rapes, assault, sexual abuse, HIV<br />
• Provide treatment and<br />
management of m<strong>in</strong>or<br />
and chronic illnesses<br />
and <strong>in</strong>juries<br />
• Provide counsell<strong>in</strong>g<br />
services eg. (HIV/AIDS)<br />
• Exam<strong>in</strong>e and treat some<br />
assault cases<br />
• Provide referral services<br />
for: sexual abuse, rape,<br />
dog bites<br />
• Provide medico-legal<br />
services to clients for<br />
old age pensions and<br />
disability grants<br />
• Diagnose and manage m<strong>in</strong>or illnesses<br />
<strong>in</strong>clud<strong>in</strong>g m<strong>in</strong>or surgery, manage<br />
emergencies and refer to hospital<br />
those requir<strong>in</strong>g higher level care<br />
• Provide two-way referral po<strong>in</strong>t from<br />
cl<strong>in</strong>ic/community to hospital; and<br />
referral to cl<strong>in</strong>ic/community<br />
• Provide diagnostic exam<strong>in</strong>ation of<br />
specimens both from the community<br />
and cl<strong>in</strong>ics<br />
• Exam<strong>in</strong>e and treat some assault cases<br />
and refer those requir<strong>in</strong>g higher level<br />
care<br />
• Exam<strong>in</strong>e and treat rape cases, sexual<br />
abuse, dog bites<br />
• Provide medico-legal services to clients<br />
requir<strong>in</strong>g, disability grants, board<strong>in</strong>g,<br />
complet<strong>in</strong>g medico-legal forms;<br />
issu<strong>in</strong>g of death certificates<br />
• Provide treatment for major ailments<br />
(referral level component), medical<br />
and surgical emergencies<br />
• Initiate treatment and supervised<br />
management of chronic diseases<br />
(diabetes, hypertension)<br />
• Provide diagnostic services;<br />
- x-ray<br />
- laboratory<br />
- histology<br />
- endoscopy<br />
- ultra-sound<br />
- laparoscopy<br />
• Exam<strong>in</strong>e, treat and issue reports for<br />
rape, sexually abused and serious<br />
dog bites<br />
• Provide medico-legal services to<br />
clients such as exam<strong>in</strong>ation for old<br />
age, pensions/disability grants,<br />
issu<strong>in</strong>g of death certificates, post<br />
mortem exam<strong>in</strong>ations<br />
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• auxiliary management of chronic diseases like tuberculosis, heart, hypertension, diabetes, mental<br />
health and cancer<br />
• provision of laboratory and radiographic services <strong>in</strong> support of cl<strong>in</strong>ical services, patient management<br />
and surveillance of diseases<br />
• timely supply and management of medic<strong>in</strong>es, re agents and other chemicals to support early<br />
diagnosis and effective treatment<br />
• provision of timely and accessible services for post mortem, medico-legal exam<strong>in</strong>ations and <strong>in</strong>jury<br />
assessment, medical board<strong>in</strong>g and medical testimony, visit<strong>in</strong>g justice for the prisons (forensic and<br />
medico-legal)<br />
• establishment of an effective referral system <strong>in</strong> support of the PHC services that ensures equity and<br />
accessibility to quality service at secondary and tertiary levels.<br />
Activities<br />
Your team should ensure that adequate services are provided at various levels. Some of the activities the<br />
staff will be implement<strong>in</strong>g at various levels are mentioned <strong>in</strong> Table 7.7<br />
How to judge the success of your programme<br />
You will know your programme is do<strong>in</strong>g well when:<br />
• illnesses are diagnosed earlier<br />
• health facilities have adequate diagnostic capabilities;<br />
• households have the ability to recognise and take appropriate action for the common illnesses <strong>in</strong> the<br />
community;<br />
• primary health workers have the knowledge and management skills for local common conditions and<br />
illnesses;<br />
• health workers know the criteria for referr<strong>in</strong>g patients to a higher level of health care<br />
• health facilities have <strong>in</strong> stock the essential drugs at any given time.<br />
MENTAL HEALTH AND SUBSTANCE ABUSE PROGRAMME<br />
Goal<br />
The goal of the programme is quality mental health services for all the prov<strong>in</strong>ce’s people.<br />
The objectives of this programme are to:<br />
Objectives<br />
• reduce and prevent mental illness and substance abuse<br />
• promote social re-<strong>in</strong>tegration of people with mental disabilities.<br />
The follow<strong>in</strong>g are the strategies of the programme:<br />
Strategies<br />
• identify mental ill health at an early stage and treat appropriately to avoid complications<br />
• identify those who need rehabilitation and refer them<br />
• establish rehabilitation services at all levels<br />
• promote mental health with<strong>in</strong> the communities e.g. through campaigns<br />
• encourage community and family participation <strong>in</strong> mental health programmes<br />
• establish community network<strong>in</strong>g<br />
• establish a child mental health programme;<br />
• establish effective management of mental illness at all levels of care<br />
• establish an effective referral system through all the levels of care.<br />
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Components<br />
The components of this programme are:<br />
• adult mental health;<br />
• adolescent mental health;<br />
• child mental health; and<br />
• geriatric mental health.<br />
Activities<br />
Some of the major activities of this programme are given <strong>in</strong> Table 7.8<br />
How to judge the success of your programme<br />
You will know the programme is runn<strong>in</strong>g well when:<br />
• fewer people with a psychiatric diagnosis are deta<strong>in</strong>ed <strong>in</strong> police cells<br />
• fewer people with a psychiatric diagnosis are admitted to hospital<br />
• fewer children and adults have mental disorders<br />
• cases of child abuse/family violence are reported and managed effectively<br />
• people who are abused seek help and are helped<br />
• fewer people commit suicide<br />
• more victims of rape, child abuse, women abuse receive psychological/social counsell<strong>in</strong>g<br />
A lot of effort will be required from your team to put mental health services <strong>in</strong> place. In the past mental health<br />
was limited to treat<strong>in</strong>g the mentally ill <strong>in</strong> a few facilities. It is of utmost importance that mental health services<br />
form an <strong>in</strong>tegral part of PHC services. Rehabilitation of people with mental conditions need to be developed<br />
extensively. The strategy of community-based rehabilitation should be employed <strong>in</strong> address<strong>in</strong>g this issue.<br />
This chapter has described the goals, objectives, strategies and activities of the 10 PHC service programmes<br />
which are to be implemented <strong>in</strong> the district, together with ways <strong>in</strong> which you can judge the success of each<br />
of the service programmes. The chapter that follows describes the management and health <strong>in</strong>formation<br />
system which will enable the health workers and service managers to plan, implement, monitor and<br />
evaluate the service programmes.<br />
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Table 7.8 Mental <strong>Health</strong> Programme -Activities at Various Service Levels<br />
Community Level Cl<strong>in</strong>ic <strong>Health</strong> Centre District Hospital<br />
• Empower households to recognise<br />
health risks of substance abuse<br />
and violence and to take the<br />
necessary action<br />
• Provide counsell<strong>in</strong>g services eg.<br />
marriage guidance, etc.<br />
• Provide life skills tra<strong>in</strong><strong>in</strong>g eg. how<br />
to cope with death <strong>in</strong> the family<br />
or chronic disease with<strong>in</strong> a family<br />
• Build capacity of households to<br />
identify early mental ill health for<br />
referral to health facilities<br />
• Provide ma<strong>in</strong>tenance therapy<br />
• Resocialise prisoners and chronic<br />
mentally ill patients follow<strong>in</strong>g long<br />
<strong>in</strong>stitutional admission<br />
• Establish support groups eg. youth<br />
groups<br />
• Establish counsell<strong>in</strong>g centres<br />
• Provide counsell<strong>in</strong>g<br />
services<br />
• Empower households to<br />
recognise health causes<br />
of mental illness and<br />
how to prevent it<br />
• Provide ma<strong>in</strong>tenance<br />
therapy<br />
• Provide support for<br />
community based<br />
mental health<br />
programmes<br />
• Initiate <strong>in</strong>dividual, group<br />
and family therapy<br />
• Provide pyschotherapy<br />
• Provide advanced counsell<strong>in</strong>g services<br />
• Provide tra<strong>in</strong><strong>in</strong>g to counsellors, basic<br />
life skills educators<br />
• Conduct specialised screen<strong>in</strong>g eg.<br />
screen<strong>in</strong>g for slow learner children<br />
• Assist <strong>in</strong> screen<strong>in</strong>g for disability grant<br />
• Supervise services at cl<strong>in</strong>ics<br />
• Provide diagnostic and treatment<br />
services for patients suffer<strong>in</strong>g from<br />
mental illness<br />
• Establish mental health forum<br />
• Assist <strong>in</strong> the rehabilitation of the<br />
mentally sick<br />
• Provide advanced psychotherapy<br />
• Manage acutely ill patients<br />
• Provide specialised therapy eg. drug,<br />
alcohol withdrawal and advanced<br />
counsell<strong>in</strong>g services<br />
• Provide advanced diagnostic<br />
services<br />
• Conduct research with assistance<br />
from regional office<br />
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PART 1iI<br />
Information, Programme Monitor<strong>in</strong>g and<br />
Evaluation
A DISTRICT HEALTH AND MANAGEMENT<br />
INFORMATION SYSTEM<br />
CHAPTER 8
Chapter 8<br />
A DISTRICT HEALTH AND<br />
MANAGEMENT INFORMATION<br />
SYSTEM<br />
The previous chapter described the PHC service programmes which are to be implemented <strong>in</strong> the district.<br />
Chapter 8 aims at equipp<strong>in</strong>g the health worker with knowledge on the importance of health and<br />
management <strong>in</strong>formation <strong>in</strong> facilitat<strong>in</strong>g plann<strong>in</strong>g and implementation of health services.<br />
After read<strong>in</strong>g this chapter, you will be able to:<br />
• identify what makes up the District <strong>Health</strong> and Management Information <strong>Systems</strong>;<br />
• state health and management <strong>in</strong>formation needs at district level;<br />
• identify tools and methods for collect<strong>in</strong>g and process<strong>in</strong>g data;<br />
• describe what is <strong>in</strong>volved <strong>in</strong> data analysis, <strong>in</strong>terpretation, presentation and report<strong>in</strong>g;<br />
• advocate for the use of <strong>in</strong>formation; and<br />
• identify the resources and management support needed to develop a District <strong>Health</strong> and<br />
Management Information System.<br />
The District <strong>Health</strong> and Management Information System (DHMIS) is made up of human resources, f<strong>in</strong>ancial<br />
resources and equipment that result <strong>in</strong> collect<strong>in</strong>g, process<strong>in</strong>g, analys<strong>in</strong>g, stor<strong>in</strong>g, retriev<strong>in</strong>g, dissem<strong>in</strong>at<strong>in</strong>g<br />
and us<strong>in</strong>g data for the purpose of efficient and effective management of health services <strong>in</strong> the district. There<br />
are two components of the DHMIS; one is <strong>in</strong>formation on management and the other is health <strong>in</strong>formation.<br />
The management component deals with <strong>in</strong>formation that helps your team handle management issues, and<br />
the health <strong>in</strong>formation component focuses on <strong>in</strong>formation deal<strong>in</strong>g with the health status of the community<br />
and health programmes.<br />
The DHMIS must not be seen as the end <strong>in</strong> itself. It is a tool you will use to improve health. At whatever level you<br />
work, the DHMIS will make it possible for your team to:<br />
• assist <strong>in</strong> the carry<strong>in</strong>g out of day-to-day PHC operations and provide quality services to clients; and<br />
• make health services more effective through improved plann<strong>in</strong>g, more efficient use of resources, and<br />
systematic monitor<strong>in</strong>g and evaluation.<br />
The purpose of a district health <strong>in</strong>formation system is to provide <strong>in</strong>formation that can help<br />
improve the plann<strong>in</strong>g, implementation and evaluation of all activities, <strong>in</strong>clud<strong>in</strong>g those <strong>in</strong><br />
sectors other than health, that will directly lead to an improvement <strong>in</strong> the health status of the<br />
district population.<br />
HEALTH AND MANAGEMENT INFORMATION NEEDS<br />
In order to enable you and your team to better plan and manage the district health services, you will require<br />
<strong>in</strong>formation cover<strong>in</strong>g a wide range of areas. Therefore, your team will be required to have some <strong>in</strong>formation<br />
<strong>in</strong> each of the follow<strong>in</strong>g six categories:<br />
Socio-economic and Environmental Information<br />
The <strong>in</strong>formation needed <strong>in</strong> this category <strong>in</strong>cludes:<br />
• communication network (roads, transportation etc);<br />
• physical features (the terra<strong>in</strong>, mounta<strong>in</strong>s, rivers etc);<br />
• climate (ra<strong>in</strong>fall, temperature, seasonal pattern); and<br />
• organisation of local government and adm<strong>in</strong>istration.<br />
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Your knowledge of the general socio-economic conditions and the environment under which you are operat<strong>in</strong>g,<br />
helps you better understand your district. You should consult local authorities, rural councils and local<br />
leaders.<br />
In this category you obta<strong>in</strong> <strong>in</strong>formation on:<br />
Demographic Information<br />
• population size, age and sex structure;<br />
• population distribution between rural and urban areas;<br />
• population distribution <strong>in</strong> various geographical areas <strong>in</strong> the district;<br />
• births, deaths, migration patterns and population growth rate; and<br />
• family size and composition<br />
The DHMT must know the population with<strong>in</strong> the district catchment area so that the team can<br />
determ<strong>in</strong>e target populations for programme coverage and accessibility of services to the<br />
people. The same <strong>in</strong>formation guides your team <strong>in</strong> resource allocation and serves as a denom<strong>in</strong>ator<br />
when calculat<strong>in</strong>g rates, such as birth and death rates, population growth rates and<br />
disease prevalence.<br />
Your team should obta<strong>in</strong> <strong>in</strong>formation on:<br />
<strong>Health</strong> Status Patterns and Trends<br />
• common causes of illness, disability, mortality;<br />
• frequency of common lifestyle risk factors for communicable and other diseases e.g. promiscuity and<br />
HIV/AIDS; smok<strong>in</strong>g and lung cancer; m<strong>in</strong><strong>in</strong>g and lung disease;<br />
• frequency of use of harmful substances <strong>in</strong>clud<strong>in</strong>g cigarette smok<strong>in</strong>g, alcohol, drugs;<br />
• problems associated with food availability, hous<strong>in</strong>g, water supply and excreta disposal; and<br />
• health care seek<strong>in</strong>g behaviour through knowledge, attitudes, practice and behaviour (KAPB).<br />
Your knowledge of health status helps your team to: determ<strong>in</strong>e health priorities, evaluate<br />
effectiveness of PHC programmes, control measures for epidemics, determ<strong>in</strong>e met and unmet<br />
needs and describe the level of community well be<strong>in</strong>g.<br />
Access, Utilisation, Coverage and<br />
Quality of <strong>Health</strong> <strong>Care</strong><br />
Under this category the <strong>in</strong>formation required <strong>in</strong>cludes:<br />
• safe motherhood (family plann<strong>in</strong>g, antenatal, delivery,<br />
and postnatal care);<br />
• nutrition (breastfeed<strong>in</strong>g, growth monitor<strong>in</strong>g,<br />
malnutrition);<br />
• immunisation;<br />
• environmental health (water supplies, hous<strong>in</strong>g),<br />
household hygiene, excreta disposal);<br />
• control of communicable and non communicable<br />
diseases (risk factors, cases diagnosed, control<br />
activities implemented);<br />
• utilisation of outpatient and <strong>in</strong>patient health care<br />
facilities for acute and chronic diseases; and<br />
• utilisation of diagnostic services (laboratory, x-ray).<br />
This <strong>in</strong>formation enables the DHMT to determ<strong>in</strong>e case<br />
work load(volume), coverage and quality of care<br />
provided <strong>in</strong> the facilities. It also allows your team to<br />
assess the effectiveness and efficiency of the service<br />
programmes.<br />
104
Resource Mobilisation, Allocation and Utilisation<br />
The <strong>in</strong>formation required here <strong>in</strong>cludes:<br />
• number, capacity and distribution of facilities (Government, NGO, private);<br />
• number and distribution of personnel by qualification (Government, NGO, private);<br />
• distribution of programmes (Government, NGO, private);<br />
• sources of fund<strong>in</strong>g, budget allocation;<br />
• expenditure on various programmes; and<br />
• availability and performance of management support (supervision, transport, logistics and supplies).<br />
With this <strong>in</strong>formation , your DHMT is <strong>in</strong> a position to: determ<strong>in</strong>e resources available for health<br />
programmes; estimate future resource requirements; account for use of resources; and<br />
calculate programme efficiency.<br />
District <strong>Health</strong> System Management Process<br />
In this category, we need <strong>in</strong>formation to assist the manager <strong>in</strong>:<br />
• decision mak<strong>in</strong>g;<br />
• plann<strong>in</strong>g (implementation of national and prov<strong>in</strong>cial policies, strategies, plans);<br />
• co-ord<strong>in</strong>ation (collaboration with<strong>in</strong> programme implementors and co-ord<strong>in</strong>ators, <strong>in</strong>tersectoral health<br />
and development activities, the role of communities and the private sector); and<br />
• monitor<strong>in</strong>g and evaluation (extent to which <strong>in</strong>dicators decided by the district health system are used).<br />
Successful plann<strong>in</strong>g and implementation of PHC programmes <strong>in</strong> your district requires support<br />
from prov<strong>in</strong>cial level. Your team must identify areas where they need support and then ask for<br />
guidance. Equally important is the <strong>in</strong>volvement of communities and other health development<br />
agencies <strong>in</strong> health development. The role of monitor<strong>in</strong>g and evaluation is to improve the<br />
management of PHC at all levels as you will f<strong>in</strong>d out <strong>in</strong> chapter 9.<br />
TOOLS AND METHODS FOR COLLECTING AND PROCESSING<br />
INFORMATION<br />
What are the sources of data at district level?<br />
The <strong>Health</strong> Information System (HIS) will collect its data from different sources. Some of these are:<br />
• rout<strong>in</strong>e records of patients, clients and activities <strong>in</strong> health facilities;<br />
• public health programmes e.g. malaria control;<br />
• population based records such as the national censuses;<br />
• ad hoc surveys that are carried out by programmes/projects for monitor<strong>in</strong>g and evaluation purposes;<br />
• vital events such as registration of births and deaths;<br />
• community based health worker with community register; and<br />
• tribal authorities.<br />
In collect<strong>in</strong>g rout<strong>in</strong>e records, the HIS utilises specially designed forms. Once filled by the relevant service<br />
providers, these forms are analysed locally, and the processed <strong>in</strong>formation sent to the District <strong>Health</strong> Information<br />
Office for preparation of district summaries. These are then forwarded to prov<strong>in</strong>cial level and fed back<br />
to the service providers.<br />
The DHIS draws its quantitative data (numbers) from the ma<strong>in</strong>stream of rout<strong>in</strong>e facility-based <strong>in</strong>formation.<br />
This provides a reasonable estimate of the number of activities carried out by the programmes. This is the<br />
<strong>in</strong>formation your team uses <strong>in</strong> estimat<strong>in</strong>g coverage <strong>in</strong>dicators such as percentage of children immunised.<br />
Assessment of direct and <strong>in</strong>direct costs of services and facilities, requires the use of techniques <strong>in</strong> economics.<br />
These skills may also not be readily available <strong>in</strong> your district. Therefore seek guidance from the prov<strong>in</strong>cial<br />
Directorate of Policy, Plann<strong>in</strong>g and Information Services..<br />
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How will you process the data?<br />
The handl<strong>in</strong>g and process<strong>in</strong>g of large volumes of data collected through the rout<strong>in</strong>e health <strong>in</strong>formation<br />
system is made more manageable by us<strong>in</strong>g computers and associated technologies. The prov<strong>in</strong>cial team<br />
should plan to <strong>in</strong>troduce computers <strong>in</strong> all the districts and promote their use. While the prov<strong>in</strong>cial team organises<br />
to have this <strong>in</strong> place, your team has to contend with handl<strong>in</strong>g data manually. This means that you should<br />
design the <strong>in</strong>formation system around carbon papers, calculators, pens and fil<strong>in</strong>g cab<strong>in</strong>ets. Use of telephone/<br />
radiophones will facilitate the ability of your team to share <strong>in</strong>formation with other people.<br />
Data Analysis, Presentation and Report<strong>in</strong>g<br />
The real purpose of collect<strong>in</strong>g data is to transform it <strong>in</strong>to <strong>in</strong>formation that can be used to make rational and<br />
<strong>in</strong>formed decisions. A good <strong>in</strong>formation system enables local level health workers to know whether the health<br />
service is achiev<strong>in</strong>g its objectives. They use <strong>in</strong>formation to set local objectives and targets and this enables<br />
them to see how well they are progress<strong>in</strong>g towards achiev<strong>in</strong>g these targets.<br />
Data becomes <strong>in</strong>formation when it is placed <strong>in</strong> context, and demonstrates that objectives have been met.<br />
For example, the number of children under one year immunised by cl<strong>in</strong>ic A aga<strong>in</strong>st measles only becomes<br />
<strong>in</strong>formation when it is compared to the number of <strong>in</strong>fants <strong>in</strong> the catchment area of cl<strong>in</strong>ic A. The team should<br />
develop reliable and regular <strong>in</strong>formation on major key <strong>in</strong>dicators for various PHC programmes.<br />
How do you present the <strong>in</strong>formation?<br />
Your team should present the <strong>in</strong>formation <strong>in</strong> a manner that promotes wide use. Some of the ways you can<br />
present the <strong>in</strong>formation are outl<strong>in</strong>ed here below:<br />
Tables and Figures<br />
Tables are an essential means of present<strong>in</strong>g organised sets of analysed data, particularly numerical data.<br />
Figures and graphs are also frequently used because they can present visual <strong>in</strong>formation much more clearly<br />
than tables.<br />
Note these important po<strong>in</strong>ts about us<strong>in</strong>g tables and figures:<br />
• titles should always be concise and self-explanatory, express<strong>in</strong>g clearly all the <strong>in</strong>formation that is<br />
be<strong>in</strong>g presented. The mean<strong>in</strong>g of the title should be immediately obvious to the reader;<br />
• rows and columns must be clearly labelled and, where appropriate, all the categories should be<br />
clearly shown;<br />
• Axes of graphs and diagrams should be properly def<strong>in</strong>ed and clearly labelled with their scales;<br />
• Keys or labels are necessary <strong>in</strong> graphs with more than one l<strong>in</strong>e or group. The labels identify the<br />
different groups be<strong>in</strong>g presented for comparison; and<br />
• Footnotes are used to <strong>in</strong>dicate the source of the orig<strong>in</strong>al <strong>in</strong>formation.<br />
Tables<br />
Tables are a common feature <strong>in</strong> most of our reports. If done properly, they are quite easy to construct and<br />
they deliver the message more effectively than the written text. However, there are different types of tables<br />
with vary<strong>in</strong>g levels of complexity. In its simplest form a table can present only one variable, for example,<br />
diseases and their correspond<strong>in</strong>g cases. The complexity of a table rises with the number of variables/items<br />
depicted. Table 8.1 illustrates an example of a table with one variable and Table 8.2 illustrates one with three<br />
variables.<br />
A One Variable Table<br />
Table 8.1 The Top Five Causes of Morbidity <strong>in</strong> Tiursplen District, <strong>Mpumalanga</strong> (Population 412 755)<br />
Disease Number of cases Incidence (%)<br />
Malaria 4786 1.15<br />
Sk<strong>in</strong> disease 18735 4.53<br />
Coughs 35998 8.72<br />
Accidents 6234 1.51<br />
Pneumonia 13735 3.32<br />
TOTAL 79488 -<br />
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A Three Variable Table<br />
Table 8.2:<br />
Population Distribution by Age and Sex <strong>in</strong> Four Wards <strong>in</strong> Tiursplen District, <strong>Mpumalanga</strong><br />
SEX<br />
WARD Males Females<br />
Age
Figure 8.1<br />
District <strong>Health</strong> Plann<strong>in</strong>g Process<br />
1. Where are we now?<br />
(assess<strong>in</strong>g the present<br />
situation, sett<strong>in</strong>g priorities)<br />
4. How will we know that<br />
we have arrived?<br />
(monitor<strong>in</strong>g and<br />
evaluation)<br />
2. Where do we want<br />
to go? (sett<strong>in</strong>g<br />
targets)<br />
3. How will we get there?<br />
(mak<strong>in</strong>g and<br />
implement<strong>in</strong>g an<br />
action plan)<br />
These pr<strong>in</strong>ciples have been used <strong>in</strong> the formulation of the district health plans for the period 1997/98 to<br />
1999/2000. The identification of needs, sett<strong>in</strong>g of objectives and targets was possible because DHMTs used<br />
exist<strong>in</strong>g <strong>in</strong>formation.<br />
Dur<strong>in</strong>g the implementation period, the DHMTs will use the <strong>in</strong>dicators to monitor progress and evaluate<br />
programme achievements.<br />
As your team completes the plann<strong>in</strong>g cycle, this stimulates the need for further <strong>in</strong>formation and reassessment<br />
of the situation. Therefore, all district managers are encouraged to appreciate the value of <strong>in</strong>formation so<br />
that they can give support to collection of quality data that can improve the whole district <strong>in</strong>formation<br />
system.<br />
HOW TO ESTABLISH A DISTRICT HEALTH AND MANAGEMENT<br />
INFORMATION SYSTEM<br />
As your team puts <strong>in</strong> place a health <strong>in</strong>formation system, this should be seen <strong>in</strong> the overall effort to strengthen<br />
the district health system. Therefore, the collection of <strong>in</strong>formation must be viewed <strong>in</strong> terms of its usefulness <strong>in</strong><br />
decision mak<strong>in</strong>g both for your team, prov<strong>in</strong>cial and national decision makers and other <strong>in</strong>terested parties.<br />
General Pr<strong>in</strong>ciples<br />
For collect<strong>in</strong>g <strong>in</strong>formation, you should apply the follow<strong>in</strong>g pr<strong>in</strong>ciples:<br />
• data that is used at the level of collection should be the ma<strong>in</strong> one collected;<br />
• relevant <strong>in</strong>formation that supports decision-mak<strong>in</strong>g should be collected;<br />
• keep the system simple, understandable and with<strong>in</strong> the capability of the resources;<br />
• all data collected must be accessible to all users, managers and decision makers;<br />
• data collected should be accurate, complete and timely;<br />
• data collection <strong>in</strong>struments (forms) must be standardised <strong>in</strong> l<strong>in</strong>e with national and prov<strong>in</strong>cial<br />
guidel<strong>in</strong>es;<br />
• improvements <strong>in</strong> data collection and use should be viewed as improvements <strong>in</strong> service/programme<br />
activities;<br />
• changes <strong>in</strong> data be<strong>in</strong>g collected should be made only if they lead to improvements <strong>in</strong> provision of<br />
care to the communities served; and<br />
• ensure that the data collected is reliable and valid.<br />
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Based on the guidel<strong>in</strong>es from the Prov<strong>in</strong>cial level, the DHMT should implement the District <strong>Health</strong> and<br />
Management Information System follow<strong>in</strong>g the steps suggested below:<br />
Phase I:<br />
Preparatory<br />
• review the proposed National <strong>Health</strong> Information System (NHIS) data collection tools and reconcile<br />
with <strong>in</strong>formation needs for <strong>Mpumalanga</strong> Prov<strong>in</strong>ce;<br />
• develop/modify the tools <strong>in</strong> l<strong>in</strong>e with prov<strong>in</strong>cial guidel<strong>in</strong>es;<br />
• pre-test the data collection and report<strong>in</strong>g forms;<br />
• obta<strong>in</strong> approval to use the modified data collection and report<strong>in</strong>g forms;<br />
• develop tra<strong>in</strong><strong>in</strong>g guidel<strong>in</strong>es for data collection and report<strong>in</strong>g forms;<br />
• pr<strong>in</strong>t the forms and guidel<strong>in</strong>es at prov<strong>in</strong>cial level;<br />
• create awareness of the new system <strong>in</strong> the district (identification of tra<strong>in</strong>ees and tra<strong>in</strong>ers,<br />
order<strong>in</strong>g forms, hardware and software, decid<strong>in</strong>g on launch<strong>in</strong>g date); and<br />
• take <strong>in</strong>ventory of who is collect<strong>in</strong>g what <strong>in</strong>formation at district level (<strong>in</strong>clude community health level);<br />
• identify <strong>in</strong>dividuals <strong>in</strong> communities who will be responsible for the community based health register<br />
and tra<strong>in</strong> them; and<br />
• create awareness with<strong>in</strong> the communities on the <strong>in</strong>formation system.<br />
Phase II:<br />
Implementation<br />
• organise and conduct tra<strong>in</strong><strong>in</strong>g of district staff who will be responsible for tra<strong>in</strong><strong>in</strong>g health facility staff<br />
(hospital units, health centres and cl<strong>in</strong>ics) <strong>in</strong> health <strong>in</strong>formation management;<br />
• set the date for start<strong>in</strong>g the implementation of the new <strong>in</strong>formation system throughout the district; and<br />
• promote the use of the new <strong>in</strong>formation system.<br />
Phase III: Review of System and Consolidation<br />
• review the system with a view to mak<strong>in</strong>g corrections where necessary; and<br />
• consolidate the system.<br />
Technical support will be provided by the Policy, Plann<strong>in</strong>g and Information Directorate. It is however, important<br />
that each DHMT outl<strong>in</strong>es the k<strong>in</strong>d of support it requires from this office. This <strong>in</strong>cludes requests for assistance <strong>in</strong><br />
determ<strong>in</strong><strong>in</strong>g the district’s needs <strong>in</strong> this area.<br />
Monitor<strong>in</strong>g and Evaluation of the DHMIS<br />
Indicators of how well the system is work<strong>in</strong>g will <strong>in</strong>clude assessment of <strong>in</strong>puts, processes, outputs and impact<br />
of the system (see Table 8.3).<br />
Table 8.3:<br />
Examples of Indicators for Monitor<strong>in</strong>g the Information System<br />
Type of Indicator<br />
Assessment<br />
Inputs - number of tra<strong>in</strong>ed (skillful) personnel <strong>in</strong> the district<br />
health facilities<br />
- availability of hardware<br />
- availability of software<br />
- availability of data collection tools/forms<br />
- establishment of district health <strong>in</strong>formation office<br />
Processes - use of <strong>in</strong>formation at various levels<br />
- number of people us<strong>in</strong>g <strong>in</strong>formation at various levels<br />
- <strong>in</strong>formation flow from various levels<br />
Outputs - number of communities tra<strong>in</strong>ed on data collection and<br />
use<br />
- number of health workers tra<strong>in</strong>ed <strong>in</strong> data collection,<br />
analysis and use<br />
Impact (based on situation prior to<br />
implementation of the system) - number of staff us<strong>in</strong>g <strong>in</strong>formation for decision mak<strong>in</strong>g<br />
- number of quality plans developed<br />
- community perceptions and Knowledge, Attitude,<br />
Practice and Behaviour (KAPB) on the system<br />
- number of facilities us<strong>in</strong>g health <strong>in</strong>formation system<br />
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Resources and Management Support for Develop<strong>in</strong>g DHMIS<br />
Decentralisation of health service delivery to district level has given DHMTs the mandate to make decisions<br />
concern<strong>in</strong>g health priorities and the resources needed to implement health programmes. Information will be<br />
a key element <strong>in</strong> this endeavour. To facilitate the development of this system, the districts will require resources<br />
such as tra<strong>in</strong>ed staff, computers and supplies. They will need fund<strong>in</strong>g for systems and staff development as<br />
well.<br />
This k<strong>in</strong>d of support will be provided by the Prov<strong>in</strong>cial and Regional <strong>Health</strong> Offices which will also tra<strong>in</strong> DHMTs<br />
<strong>in</strong> plann<strong>in</strong>g and management of health services. The tra<strong>in</strong><strong>in</strong>g will also cover development and management<br />
of health <strong>in</strong>formation systems with emphasis on use of data. Some DHMT members have to undertake tra<strong>in</strong><strong>in</strong>g<br />
that equips them with basic skills <strong>in</strong> epidemiology, statistics and comput<strong>in</strong>g; all of which are essential for<br />
population based plann<strong>in</strong>g and management. Aga<strong>in</strong> the District <strong>Health</strong> Manager has to take the <strong>in</strong>itiative to<br />
ensure that health workers are tra<strong>in</strong>ed to use statistical data and health <strong>in</strong>dicators <strong>in</strong> their work.<br />
The DHMT should consult the relevant prov<strong>in</strong>cial level unit to work out how the tra<strong>in</strong><strong>in</strong>g can be organised and<br />
conducted. The staff at prov<strong>in</strong>cial level will identify the relevant materials both with<strong>in</strong> and outside the country<br />
that may be used for this type of tra<strong>in</strong><strong>in</strong>g. Further <strong>in</strong>formation on tra<strong>in</strong><strong>in</strong>g is discussed <strong>in</strong> chapter 10.<br />
In this chapter you have read about District <strong>Health</strong> and Management Information System (DHMIS) and how<br />
it will be established and operated. The importance of DHMIS <strong>in</strong> service plann<strong>in</strong>g, has been highlighted. The<br />
chapter that follows discusses the application of DHMIS <strong>in</strong> service monitor<strong>in</strong>g and evaluation.<br />
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MONITORING AND EVALUATION OF HEALTH<br />
DISTRICTS<br />
CHAPTER 9
Chapter 9<br />
MONITORING AND EVALUATION OF<br />
HEALTH SERVICES<br />
The last chapter described what a District <strong>Health</strong> and Management Information System is and how to establish<br />
it <strong>in</strong> a district. This chapter will <strong>in</strong>troduce you to one of the most important uses of DHMIS.<br />
After read<strong>in</strong>g this chapter, you will be able to:<br />
• understand what monitor<strong>in</strong>g and evaluation are;<br />
• identify the types of monitor<strong>in</strong>g;<br />
• expla<strong>in</strong> and evaluate programme activities;<br />
• expla<strong>in</strong> the procedures you will follow <strong>in</strong> monitor<strong>in</strong>g and evaluat<strong>in</strong>g;<br />
• expla<strong>in</strong> the process you will follow to develop a monitor<strong>in</strong>g and evaluation system for<br />
your programmes; and<br />
• identify <strong>in</strong>dicators to be used <strong>in</strong> monitor<strong>in</strong>g and evaluat<strong>in</strong>g your programme.<br />
The District <strong>Health</strong> Management Team (DHMT) will need to monitor and evaluate PHC policies, systems and<br />
programme <strong>in</strong> order to establish whether the <strong>in</strong>tended results are be<strong>in</strong>g accomplished. The f<strong>in</strong>d<strong>in</strong>gs of the<br />
monitor<strong>in</strong>g and evaluation process will assist the DHMT <strong>in</strong> ensur<strong>in</strong>g that <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Programme<br />
activity implementation is address<strong>in</strong>g the set targets and objectives. Monitor<strong>in</strong>g and evaluation are thus<br />
essential functions of programme management (See Figure 8.1. <strong>in</strong> the previous chapter).<br />
MONITORING<br />
One of the functions of the DHMT is monitor<strong>in</strong>g of the implementation of PHC programme activities.<br />
Monitor<strong>in</strong>g is a cont<strong>in</strong>uous process of assess<strong>in</strong>g whether an activity or service is proceed<strong>in</strong>g as<br />
planned. Monitor<strong>in</strong>g is not an activity by itself. It must serve to improve project implementation<br />
and achiev<strong>in</strong>g of expected results.<br />
There are two types of monitor<strong>in</strong>g:<br />
Rout<strong>in</strong>e<br />
Types of Monitor<strong>in</strong>g<br />
This type of monitor<strong>in</strong>g focuses on collect<strong>in</strong>g <strong>in</strong>formation on a regular, ongo<strong>in</strong>g basis for a core set of <strong>in</strong>dicators<br />
which provide the manager with enough <strong>in</strong>formation to track progress <strong>in</strong> programme implementation.<br />
Short-term<br />
This is done for a limited period of time and usually tracks new <strong>in</strong>itiatives or processes. The objective is to<br />
collect <strong>in</strong>formation to help solve a problem after which short term monitor<strong>in</strong>g is <strong>in</strong>corporated <strong>in</strong>to rout<strong>in</strong>e<br />
monitor<strong>in</strong>g.<br />
What You Need to Monitor<br />
There are various aspects or components of a programme that have to be monitored. These are the<br />
programme <strong>in</strong>puts, processes and outputs.<br />
Inputs<br />
Inputs are the resources necessary <strong>in</strong> order to implement the programme. These <strong>in</strong>clude personnel, f<strong>in</strong>ances,<br />
drugs, build<strong>in</strong>gs and equipments. Dur<strong>in</strong>g the plann<strong>in</strong>g stage estimates of the cost of <strong>in</strong>puts to complete each<br />
113
of the activities <strong>in</strong> support of <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> is done and a budget is drawn. The procurement and use<br />
of these resources should be monitored to ensure that you are with<strong>in</strong> the budget and are be<strong>in</strong>g used as<br />
<strong>in</strong>tended.<br />
Processes<br />
Processes <strong>in</strong>volve sett<strong>in</strong>g <strong>in</strong> motion a sequence of events or tasks expected to achieve the desired outputs.<br />
These events should be monitored to ensure they are of the expected quality, are happen<strong>in</strong>g smoothly and<br />
<strong>in</strong> a logical manner. Examples <strong>in</strong>clude; weigh<strong>in</strong>g a child, dispens<strong>in</strong>g drugs, giv<strong>in</strong>g an <strong>in</strong>jection and distribut<strong>in</strong>g<br />
oral rehydration salts.<br />
Outputs<br />
Outputs are products or achievements as a result of the successful completion of a programme. Examples<br />
are: numbers of out-patient attendances, <strong>in</strong>-patient cases or health promotion sessions held. Ask yourself,<br />
what are the results, and why are they different from what was expected or promised? This monitor<strong>in</strong>g of the<br />
performance gap is very essential as it can lead to withdrawal from the programme by the target population<br />
if they are not see<strong>in</strong>g the benefits. The project staff may also become disappo<strong>in</strong>ted and neglect their roles if<br />
they f<strong>in</strong>d their efforts to be futile.<br />
At whatever level you work, you need to monitor your programme activities to ensure that you are with<strong>in</strong> the<br />
time and budget you stipulated. If there are variations, document the reasons as this will assist you to justify<br />
your request for additional resources and time extension. Figure 9.1. shows the relationship between <strong>in</strong>put,<br />
process and outputs.<br />
Figure 9.1<br />
Relationship between <strong>in</strong>put, process, output and impact<br />
Programme<br />
Inputs<br />
set <strong>in</strong><br />
motion<br />
which<br />
which<br />
lead to<br />
lead to<br />
Processes Outputs Impact<br />
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Design<strong>in</strong>g a Monitor<strong>in</strong>g System<br />
At whatever level you work, you need to develop a simple rout<strong>in</strong>e or short-term monitor<strong>in</strong>g system to keep<br />
track of the events happen<strong>in</strong>g. When design<strong>in</strong>g such a system you should consider the follow<strong>in</strong>g:<br />
• select only the key <strong>in</strong>dicators (these are variables that <strong>in</strong>dicate or show a given situation such as 80%<br />
immunisation coverage) that will be used by managers and other key users;<br />
• Do not try to monitor everyth<strong>in</strong>g as this can be very expensive and time consum<strong>in</strong>g;<br />
• do not overburden yourself by collect<strong>in</strong>g too much data. The <strong>in</strong>formation required is for only assist<strong>in</strong>g<br />
to monitor the key <strong>in</strong>dicators you selected above;<br />
• provide feedback to the <strong>in</strong>terested parties <strong>in</strong> good time; and<br />
• report the f<strong>in</strong>d<strong>in</strong>gs <strong>in</strong> a way that is easy to understand and facilitates data <strong>in</strong>terpretation and action.<br />
The DHMT must prepare monitor<strong>in</strong>g reports which should be shared with all <strong>in</strong>terested parties. These reports<br />
must highlight both the success and weakness of the implementation process. The DHMT need not feel shy to<br />
say that they have failed <strong>in</strong> implement<strong>in</strong>g a particular programme as long as the reasons are well documented.<br />
However, learn from factors that resulted <strong>in</strong> failure previously so that when you undertake the implementation<br />
of another project <strong>in</strong> future you do not repeat the same mistakes. Always document the successes and<br />
lessons learnt.<br />
Monitor<strong>in</strong>g Procedures<br />
There are n<strong>in</strong>e steps to activity monitor<strong>in</strong>g. The first four cover the plann<strong>in</strong>g stage of monitor<strong>in</strong>g and seek to<br />
ensure that the <strong>in</strong>formation collected is relevant, specific, feasible to collect, and can be analysed. The next<br />
five steps cover the implementation of monitor<strong>in</strong>g: collect<strong>in</strong>g data, compil<strong>in</strong>g and analys<strong>in</strong>g it, report<strong>in</strong>g and<br />
us<strong>in</strong>g the results for management action. The tenth step suggests tak<strong>in</strong>g a look at the system periodically to<br />
decide whether to cont<strong>in</strong>ue monitor<strong>in</strong>g activities at the current level.<br />
Ten steps <strong>in</strong> activity monitor<strong>in</strong>g:<br />
Step 1:<br />
Step 2:<br />
Step 3:<br />
Specify the monitor<strong>in</strong>g objectives. Indicate what services are go<strong>in</strong>g to be monitored; for what purpose<br />
and who will use the monitor<strong>in</strong>g results. For example your team, at whatever service level, may be<br />
<strong>in</strong>terested <strong>in</strong> monitor<strong>in</strong>g environmental sanitation activities for the purpose of know<strong>in</strong>g whether the<br />
programme is be<strong>in</strong>g implemented as planned. This <strong>in</strong>formation will be used by the Environmental<br />
<strong>Health</strong> Officer and the DHMT <strong>in</strong> f<strong>in</strong>d<strong>in</strong>g out the effectiveness of the programme. The DHMT may wish<br />
to focus on <strong>in</strong>formation that will enable them determ<strong>in</strong>e the percentage of households us<strong>in</strong>g latr<strong>in</strong>es<br />
(effect <strong>in</strong>dicator); number of latr<strong>in</strong>es constructed <strong>in</strong> the past two years (output <strong>in</strong>dicator) and number<br />
of communities/households with access to environmental health officers (<strong>in</strong>put <strong>in</strong>dicator).<br />
Decide on the scope of the monitor<strong>in</strong>g. The DHMT may be <strong>in</strong>terested <strong>in</strong> monitor<strong>in</strong>g activities either<br />
with<strong>in</strong> a smaller area <strong>in</strong> the district or the whole district. Before <strong>in</strong>troduc<strong>in</strong>g rout<strong>in</strong>e monitor<strong>in</strong>g<br />
procedures the team may wish to pilot test them <strong>in</strong> a few places before implement<strong>in</strong>g them <strong>in</strong> all<br />
areas. In this connection the duration that monitor<strong>in</strong>g will take should be specified.<br />
Select <strong>in</strong>dicators and set performance standards. Indicators can be formulated by us<strong>in</strong>g either of<br />
the follow<strong>in</strong>g methods:<br />
• a count (just count<strong>in</strong>g the number of events or objects), for example 1,000 children immunised<br />
• a rate (measure of the frequency with which an event occurs <strong>in</strong> a given period (e.g. children<br />
immunised)<br />
• a ratio (two numbers related to each other <strong>in</strong> a fraction e.g. number of environmental health<br />
officers per population)<br />
• a percentage (a proportion multiplied by 100, e.g. if only 40 out of 200 nurses received tra<strong>in</strong><strong>in</strong>g<br />
<strong>in</strong> family plann<strong>in</strong>g then twenty per cent of the nurses were tra<strong>in</strong>ed <strong>in</strong> family plann<strong>in</strong>g last year)<br />
Performance standards, also called targets, are set for each <strong>in</strong>dicator <strong>in</strong> order to assist the team<br />
determ<strong>in</strong>e whether the activity has been implemented as planned or has been effective. The targets<br />
are usually quantified and this is what enables you to judge actual performance with planned (target)<br />
performance.<br />
The target becomes the denom<strong>in</strong>ator <strong>in</strong> comput<strong>in</strong>g performance while the actual performance is<br />
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the numerator. In the example <strong>in</strong>dicated <strong>in</strong> step one, the DHMT may f<strong>in</strong>d that at the end of the year,<br />
the number of households with access to environmental health officers is 300 while the target may<br />
have been set at 500 households.<br />
The result shows that the programme met only 60 percent of its target. This result is obta<strong>in</strong>ed by<br />
divid<strong>in</strong>g the actual performance (numerator) by the target (denom<strong>in</strong>ator) expressed as a percentage.<br />
Step 4:<br />
Choose <strong>in</strong>formation sources and develop data collection procedures.<br />
Your team has to identify the source and procedures for collect<strong>in</strong>g monitor<strong>in</strong>g data. The rout<strong>in</strong>e<br />
records from your District <strong>Health</strong> Information System is one of the sources from which you can obta<strong>in</strong><br />
data. Most of the <strong>in</strong>put <strong>in</strong>dicators can be obta<strong>in</strong>ed from the rout<strong>in</strong>e records. For the process and<br />
output <strong>in</strong>dicators it may be necessary to develop new tools to collect the data if this is not possible<br />
from exist<strong>in</strong>g sources. Also your team may consider talk<strong>in</strong>g to community leaders, health workers<br />
and other relevant people to obta<strong>in</strong> a general feel<strong>in</strong>g of how the PHC programme is do<strong>in</strong>g.<br />
Step 5:<br />
Collect the Data<br />
The team to collect data must be told the procedures for do<strong>in</strong>g so. If data is not available from<br />
exist<strong>in</strong>g sources, some tra<strong>in</strong><strong>in</strong>g of those <strong>in</strong>volved will be necessary.<br />
Step 6:<br />
Tabulate and Analyse Data<br />
Data can be displayed <strong>in</strong> various ways. You may use lists, tables and graphs because these are not<br />
complicated to make.<br />
Step 7:<br />
Interpret the data<br />
Interpret the data i.e. what the f<strong>in</strong>d<strong>in</strong>gs from the analysis mean.<br />
Step 8:<br />
Present the F<strong>in</strong>d<strong>in</strong>gs<br />
Decide who should receive <strong>in</strong>formation regularly e.g. all DHMT members plus any other <strong>in</strong>dividuals or<br />
agencies <strong>in</strong>volved <strong>in</strong> PHC implementation <strong>in</strong> your district. The prov<strong>in</strong>cial level should because they<br />
need to know some of the problems identified and together with the DHMT work out the solution.<br />
Establish a mechanism for dissem<strong>in</strong>at<strong>in</strong>g <strong>in</strong>formation.<br />
Step 9:<br />
Take Appropriate Action<br />
A very important reason for monitor<strong>in</strong>g is to enable a programme manager or implementor to identify<br />
shortfalls and take corrective action <strong>in</strong> time. This enables a health service provider/manager to be <strong>in</strong><br />
control and to ensure quality services.<br />
When evaluation results have been presented and discussed among the <strong>in</strong>terested parties, you<br />
should organise to use the results. Decide whether action needs to be taken, and if so which action.<br />
Explore the causes and then develop solutions based on what will be easy to implement.<br />
Step 10: Decide whether to cont<strong>in</strong>ue monitor<strong>in</strong>g.<br />
Your team designs monitor<strong>in</strong>g <strong>in</strong> order to meet its needs. Therefore as the needs change, the team<br />
must adjust the frequency, especially if there is improvement <strong>in</strong> programme implementation.<br />
Experience has shown that there is less need for frequent detailed <strong>in</strong>formation on some <strong>in</strong>puts and<br />
outputs, as programmes improve over time.<br />
Therefore, the focus shifts to effect <strong>in</strong>dicators as your PHC programmes show good progress <strong>in</strong><br />
implementation. As the implementation of recommendation takes place for some programmes, the<br />
monitor<strong>in</strong>g cycle starts for others.<br />
Limitations to Monitor<strong>in</strong>g<br />
You and your team should realise that collect<strong>in</strong>g <strong>in</strong>formation on most impact <strong>in</strong>dicators (that is changes <strong>in</strong><br />
health status of the community) that may have taken place as a result of the <strong>in</strong>troduction of a programme,<br />
for example, changes <strong>in</strong> <strong>in</strong>fant mortality is not feasible over a short period of time. Therefore, your team is<br />
encouraged to focus monitor<strong>in</strong>g on <strong>in</strong>put, process, output and effect <strong>in</strong>dicators to establish whether the PHC<br />
services are be<strong>in</strong>g carried out as planned.<br />
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EVALUATION<br />
Evaluation can simply be def<strong>in</strong>ed as assess<strong>in</strong>g or f<strong>in</strong>d<strong>in</strong>g out the value of someth<strong>in</strong>g. Evaluation is carried out<br />
after completion of the activity or project. An evaluation assists <strong>in</strong> determ<strong>in</strong><strong>in</strong>g whether the activity or project<br />
accomplished the objectives it set out to achieve.<br />
Purpose of Evaluation<br />
Evaluation is the process by which programme achievements are exam<strong>in</strong>ed from time to time.<br />
It compares outputs to the set objectives, programme implementation with programme<br />
design. It looks at the organisational set up and the use of resources to determ<strong>in</strong>e the<br />
effectiveness and efficiency of the programme.<br />
The Use of Evaluation<br />
The DHMT will be called upon to evaluate health programmes <strong>in</strong> the district with the aim of seek<strong>in</strong>g answers<br />
to press<strong>in</strong>g questions about the programme’s future such as, should the programme be cont<strong>in</strong>ued, expanded,<br />
or should changes be made <strong>in</strong> its operation? To fully respond to these challeng<strong>in</strong>g questions relat<strong>in</strong>g to the<br />
programme’s future, the DHMT will:<br />
• have to clearly understand the various components of the programme (scope, objectives,<br />
organisation and expected outputs); and<br />
• collect the necessary <strong>in</strong>formation which may assist <strong>in</strong> the evaluation. The <strong>in</strong>formation sought<br />
may concern health and related socio-economic policies, plans, programmes as well as the<br />
extent, scope and use of health systems and <strong>in</strong>stitutions. The monitor<strong>in</strong>g reports, District <strong>Health</strong><br />
Management Information System (DHMIS), district profile and the project document are good<br />
sources of <strong>in</strong>formation for an evaluator. Remember that evaluation has to be based on valid<br />
and relevant data (read chapter 8).<br />
Evaluators use a whole range of research methods and tools to collect <strong>in</strong>formation such as <strong>in</strong>terviews, sampl<strong>in</strong>g<br />
questionnaires, test of knowledge skills and attitude, observations, content analysis of documents, records<br />
and exam<strong>in</strong>ations of physical evidence.<br />
What You Need to Evaluate<br />
There are three key parameters that are of <strong>in</strong>terest to the DHMT <strong>in</strong> the process of evaluation.<br />
• Inputs<br />
One reason for the failure of a project is that for a variety of reasons, resources did not arrive as<br />
planned or they were not available. Another reason may be that the resources were <strong>in</strong>sufficient to<br />
provide the services planned. The evaluator has to f<strong>in</strong>d out whether the resources were transformed<br />
<strong>in</strong>to service or misused.<br />
• Outputs<br />
The evaluator needs to took at whether the services provided were appropriate, relevant and<br />
adequate. In particular, the evaluator needs to look at the quality and quantity of services provided,<br />
efficiency of services, whether the community accepted the programme and its outcomes, and<br />
whether the effects were felt by the targeted population.<br />
• Outcome (effects and impact)<br />
The evaluator should know the objectives of the programme be<strong>in</strong>g evaluated. Perhaps the most<br />
fundamental question to determ<strong>in</strong>e is what the activity be<strong>in</strong>g evaluated was <strong>in</strong>tended to achieve. It<br />
is aga<strong>in</strong>st these benchmarks that the activity’s success or failure will be largely measured.<br />
The evaluator must also look <strong>in</strong>to any other possible effects of the project. Besides the planned effects<br />
of the project, there may have been other effects which were not <strong>in</strong>tended. Assess these impacts. For<br />
example, a family plann<strong>in</strong>g project may have other effects such as a decl<strong>in</strong>e <strong>in</strong> female student dropouts<br />
<strong>in</strong> educational <strong>in</strong>stitutions.<br />
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Another question the evaluator must answer is whether any health improvements were the direct<br />
result of the programme. It is important that any health improvements detected are identified as<br />
be<strong>in</strong>g the direct result of the programme. Otherwise, you may end up glorify<strong>in</strong>g a programme that<br />
did not impact any change at all.<br />
How to Carry Out an Evaluation<br />
Design<strong>in</strong>g an evaluation may be done <strong>in</strong> six steps:<br />
1. Sett<strong>in</strong>g out clearly the questions to be answered.<br />
These have been outl<strong>in</strong>ed <strong>in</strong> general terms above. To answer each of the questions raised under the<br />
section on what you need to evaluate, you must identify <strong>in</strong>dicators which will allow you to compare<br />
what actually took place with what was expected. Four types of <strong>in</strong>formation are likely to be required.<br />
• Basel<strong>in</strong>e Information<br />
Basel<strong>in</strong>e <strong>in</strong>formation will assist you to describe the situation prior to the implementation of the<br />
programme. For example, <strong>in</strong> an oral rehydration programme, you would want to know the<br />
number or percentage of mothers who were us<strong>in</strong>g oral rehydration salts (ORS) or knew how to<br />
prepare ORS solutions prior to the start of the programme.<br />
• Input Information<br />
Input <strong>in</strong>formation will describe the resources used <strong>in</strong> the programme. For example, <strong>in</strong> an<br />
immunisation programme, you may want to know how many fridges or staff were utilised to<br />
provide the service.<br />
• Process Information<br />
Process <strong>in</strong>formation will help you to describe the implementation process of the programme.<br />
For example, <strong>in</strong> an immunisation programme, you will want to know how the immunisation was<br />
organised and conducted.<br />
• Output Information<br />
Output <strong>in</strong>formation will help you describe the situation after implementation of the project. For<br />
example, <strong>in</strong> an immunisation programme, you would like to know the number of children fully<br />
immunised aga<strong>in</strong>st your set objective.<br />
2. Identify<strong>in</strong>g the Sources of Information for Evaluation:<br />
Exist<strong>in</strong>g records, for example, hospital statistics, may be good sources of some <strong>in</strong>formation. Other<br />
<strong>in</strong>formation may not be available and surveys or other methods may have to be conducted to obta<strong>in</strong><br />
it. If the latter is the case you should then design a questionnaire that will capture all the <strong>in</strong>formation<br />
required. Pre-test your questionnaire before embark<strong>in</strong>g on actual evaluation.<br />
3. Collect<strong>in</strong>g the Information<br />
When questionnaires have been developed, pre-tested and the people to adm<strong>in</strong>ister the questionnaire<br />
tra<strong>in</strong>ed, organise how the <strong>in</strong>formation is to be collected from the field.<br />
4. Analys<strong>in</strong>g the Information<br />
Before the <strong>in</strong>formation is collected, you should start mak<strong>in</strong>g arrangements on how the data is to be<br />
analysed and tabulated. Prepare possible tables that you will expect to generate from the data such<br />
as Table 9.2.<br />
Table 9.2 Number of Children Immunised by Facility Type<br />
Before Programme<br />
After Programme<br />
Hospital <strong>Health</strong> Centre Cl<strong>in</strong>ic Others<br />
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5. Prepar<strong>in</strong>g the evaluation report and present<strong>in</strong>g f<strong>in</strong>d<strong>in</strong>gs<br />
The evaluator has to write an evaluation report and present it to other <strong>in</strong>terested parties. The report<br />
should be simple and po<strong>in</strong>t out major recommendations. The programme implementors should be<br />
allowed to contribute on potential causes of and solutions to the problems identified.<br />
6. Tak<strong>in</strong>g appropriate actions.<br />
When evaluation results have been presented and discussed among the various programme<br />
implementors, then you should make arrangements to use these results to decide whether action<br />
needs to be taken, and if so which action. This means that you first explore the causes and then<br />
develop the solutions.<br />
Po<strong>in</strong>ts to note about evaluations<br />
• There are <strong>in</strong>stances where observed changes are caused by someth<strong>in</strong>g other than the programme<br />
<strong>in</strong>tervention. In such cases the evaluator has to determ<strong>in</strong>e what factors brought about these changes,<br />
and not attribute them to the programme.<br />
• Occasionally, there is resistance to accept the evaluation and its results especially if it shows negative<br />
f<strong>in</strong>d<strong>in</strong>gs. Participatory evaluation reduces conflict between evaluators and programme<br />
implementors.<br />
The Prov<strong>in</strong>cial Policy and Plann<strong>in</strong>g Information Directorate will set up specific tra<strong>in</strong><strong>in</strong>g programmes <strong>in</strong><br />
monitor<strong>in</strong>g and evaluation for service providers, programme coord<strong>in</strong>ators and the DHMT.<br />
This chapter has described the pr<strong>in</strong>ciples and elements of monitor<strong>in</strong>g and evaluation and their application <strong>in</strong><br />
programme management. The need to have clear <strong>in</strong>dicators has been stressed and examples given.<br />
Availability of tra<strong>in</strong>ed staff is one of the key elements that will make it possible not only to monitor and evaluate<br />
but also implement and manage the service programmes. Development and management of staff is the<br />
subject of the chapter that follows.<br />
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PART 1V<br />
Human Resources Development
DEVELOPING AND MANAGING HUMAN<br />
RESOURCES<br />
CHAPTER 10
Chapter 10<br />
DEVELOPING AND MANAGING<br />
HUMAN RESOURCES<br />
The previous chapters have described the processes for decentralisation of health services to the districts<br />
and the primary health care packages that are to be implemented at various service levels. Accomplishment<br />
of this process is not possible without tra<strong>in</strong>ed, dedicated personnel.<br />
This chapter describes the development and management of the health worker as a valuable resource for<br />
provid<strong>in</strong>g a car<strong>in</strong>g, compassionate health service.<br />
After read<strong>in</strong>g the chapter, you will be able to:<br />
• understand the pr<strong>in</strong>ciples of human resources development and management;<br />
• identify factors that can affect your performance <strong>in</strong> your work place;<br />
• identify the steps <strong>in</strong> human resources plann<strong>in</strong>g;<br />
• understand the importance of prepar<strong>in</strong>g a job description for each member<br />
of staff;<br />
• understand the procedures for recruit<strong>in</strong>g, promot<strong>in</strong>g and discipl<strong>in</strong><strong>in</strong>g staff;<br />
• understand the importance of staff performance appraisal; and<br />
• understand the importance of tra<strong>in</strong><strong>in</strong>g and develop<strong>in</strong>g staff.<br />
Human resources development and management is the attraction, selection, retention, development and<br />
deployment of staff <strong>in</strong> order to achieve the <strong>in</strong>dividual and organisational objectives. The health sector is<br />
labour-<strong>in</strong>tensive and people are its most important resource. There may be money, equipment, materials<br />
and techniques but without people none of these th<strong>in</strong>gs can perform any task. It is people who make th<strong>in</strong>gs<br />
happen. However, resources are very expensive and staff salaries/wages <strong>in</strong> many develop<strong>in</strong>g countries<br />
account for more than two thirds of the recurrent expenditure. It is, therefore, important that the right people<br />
are recruited, tra<strong>in</strong>ed, reta<strong>in</strong>ed and properly deployed.<br />
Effective human resources development and management contributes <strong>in</strong> a major way to the morale,<br />
motivation, job satisfaction, knowledge and skills of personnel <strong>in</strong> the health service, all of which have a bear<strong>in</strong>g<br />
on the quality of care provided.<br />
Human resources development entails upgrad<strong>in</strong>g and updat<strong>in</strong>g the skills and knowledge of<br />
personnel through education and tra<strong>in</strong><strong>in</strong>g. Human resources development at the prov<strong>in</strong>cial<br />
level is the responsibility of the Directorate of Policy, Plann<strong>in</strong>g and Information <strong>in</strong> liaison with the<br />
Public Service Commission and the National Department of <strong>Health</strong>. At district level the<br />
responsibility falls under the Human Resources Development Unit.<br />
The aim of human resources development is to make you a more car<strong>in</strong>g and effective health worker or<br />
service manager through positive change of attitude, upgrad<strong>in</strong>g of knowledge and improvement of skills<br />
through cont<strong>in</strong>u<strong>in</strong>g education and support supervision.<br />
Human resources management encompasses human resources plann<strong>in</strong>g, job analysis and job<br />
descriptions, staff recruitment, orientation and placement, performance appraisal, discipl<strong>in</strong>e,<br />
benefits and retirement. Human resources management at prov<strong>in</strong>cial level is the responsibility<br />
of the Directorate of Adm<strong>in</strong>istration, while at the district level it is under the F<strong>in</strong>ance and<br />
Adm<strong>in</strong>istration Unit.<br />
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The aim of human resources management is to support and care for you so that you can:<br />
• feel appreciated;<br />
• improve your output;<br />
• get job satisfaction; and<br />
• work <strong>in</strong> a conducive environment.<br />
There are obstacles that are faced by health workers. Some of these are illustrated <strong>in</strong> the follow<strong>in</strong>g case<br />
study.<br />
CASE STUDY<br />
Nonjabulo and Lahliwe both entered the health service as professional nurses, <strong>in</strong> 1990. Nonjabulo rose rapidly<br />
through the ranks and by 1996 she was already dest<strong>in</strong>ed to make it to the top of her career. Lahliwe, on the other<br />
hand, did not do well at all. Six years after enter<strong>in</strong>g the service, she was still languish<strong>in</strong>g at the bottom of the career<br />
path.<br />
What Happened To Lahliwe?<br />
A detailed analysis of her experiences revealed that Lahliwe completed general nurs<strong>in</strong>g and midwifery <strong>in</strong> a<br />
dilapidated, under-equipped and under-staffed hospital, and was sent to work <strong>in</strong> a hospital ward. She enjoyed<br />
talk<strong>in</strong>g to patients <strong>in</strong> order to understand the underly<strong>in</strong>g causes of their problems. Because she spent much time <strong>in</strong><br />
discussion with patients <strong>in</strong> the ward, she was labelled “lazy” by her supervisors and colleagues. She tried to expla<strong>in</strong><br />
her <strong>in</strong>tentions, but the result was that she was now labelled “trouble maker”. She was abruptly posted to the <strong>in</strong>tensive<br />
care unit (ICU) to stop her so called “laz<strong>in</strong>ess”. There she made no progress, so she got bad reports. She got no job<br />
satisfaction <strong>in</strong> the (ICU). Moreover she received no orientation. Furthermore the ICU was poorly equipped. This<br />
environment stifled her <strong>in</strong>terest and <strong>in</strong>itiative. By the third year <strong>in</strong> the ICU Lahliwe was aggressive, defensive, <strong>in</strong>effective<br />
and depressed.<br />
What factors contributed to Lahliwe’s slump to the bottom of the<br />
career path?<br />
The follow<strong>in</strong>g are some of the identifiable factors that may have contributed to Lahliwe’s lack of career<br />
progress:<br />
• be<strong>in</strong>g pushed <strong>in</strong>to a job <strong>in</strong> which she had little <strong>in</strong>terest;<br />
• <strong>in</strong>adequate and <strong>in</strong>appropriate skills for her job;<br />
• lack of support and encouragement from establishment;<br />
• lack of recognition by establishment;<br />
• isolation;<br />
• poor equipment;<br />
• neglect of staff development by establishment; and<br />
• poor <strong>in</strong>frastructure.<br />
What do you learn from Lahliwe’s case study?<br />
Many health workers are <strong>in</strong> Lahliwe’s position. As a health worker:<br />
• you may become demotivated if neglected and misplaced;<br />
• you need to participate actively <strong>in</strong> decisions regard<strong>in</strong>g your professional tra<strong>in</strong><strong>in</strong>g and job placement;<br />
• your personal needs should be balanced with organisational needs;<br />
• you should be deployed accord<strong>in</strong>g to your skills;<br />
• your ideas should be heard and respected, not punished, irrespective of your position <strong>in</strong> the hierarchy;<br />
and<br />
• you require professional development at all stages.<br />
What factors will help Lahliwe to move up the career path?<br />
The follow<strong>in</strong>g are some of the factors that would help Lahliwe to rise up the career path:<br />
• support and encouragement from her supervisors;<br />
• clear and appropriate description of roles;<br />
• delegation of responsibilities that encourage use of broad skills and knowledge;<br />
• career plann<strong>in</strong>g and development;<br />
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• <strong>in</strong>centives e.g. salary, promotion, study opportunities;<br />
• time to reflect, to mend and to discuss;<br />
• job satisfaction; and<br />
• improved work<strong>in</strong>g conditions.<br />
The prov<strong>in</strong>cial Department of <strong>Health</strong>, Welfare and Gender Affairs believes that one of the ways<br />
to achieve a car<strong>in</strong>g health service is to be a car<strong>in</strong>g and supportive employer.<br />
The development of human resources beg<strong>in</strong>s with plann<strong>in</strong>g. The purpose of human resources plann<strong>in</strong>g is to<br />
ma<strong>in</strong>ta<strong>in</strong> and improve the ability of the health service to render effective health care to the people through<br />
the development of strategies that promote staff performance.<br />
HUMAN RESOURCES PLANNING<br />
In plann<strong>in</strong>g human resources for your district, you can use the follow<strong>in</strong>g guidel<strong>in</strong>es:<br />
• Estimate the number and types of jobs to be filled at a future po<strong>in</strong>t. Visualise your district or health<br />
facility at some future po<strong>in</strong>t and estimate numbers and types of jobs that will exist. Ask yourself if<br />
currently you have the right number and mix of staff for: the technology and systems <strong>in</strong> use; and the<br />
service demands and chang<strong>in</strong>g workload based on the population’s health needs.<br />
• The staff<strong>in</strong>g ratios and norms provided by the prov<strong>in</strong>cial level. Make a projection of personnel<br />
requirements for your district. Include all facilities (hospitals, health centres, cl<strong>in</strong>ics) as well as<br />
community based activities.<br />
• Make an <strong>in</strong>ternal audit of the present human resources and their skills. For each member of staff,<br />
compile <strong>in</strong>formation on: age, job title, amount of experience, length of service, education and<br />
special skills.<br />
• Us<strong>in</strong>g the <strong>in</strong>formation obta<strong>in</strong>ed from the Personnel <strong>in</strong>ventory, you can forecast changes which are<br />
likely to occur <strong>in</strong> the present work force <strong>in</strong> terms of entries, exits and movements with<strong>in</strong> your district.<br />
• Your district will experience staff turnover due to, for example, retirement, transfers, discharges, mov<strong>in</strong>g<br />
to greener pastures or promotion to the Prov<strong>in</strong>cial or National levels. The patterns of these losses <strong>in</strong> the<br />
past can be extrapolated to <strong>in</strong>dicate future patterns.<br />
• Develop an action plan to assist the prov<strong>in</strong>ce and your team to fill those human resources needs<br />
through recruit<strong>in</strong>g and hir<strong>in</strong>g new staff or upgrad<strong>in</strong>g (tra<strong>in</strong><strong>in</strong>g and development) of exist<strong>in</strong>g staff.<br />
JOB ANALYSIS AND JOB DESCRIPTION<br />
Job analysis and job description are important tools which form a good basis for select<strong>in</strong>g the right candidate<br />
for vacancies <strong>in</strong> your district.<br />
A job analysis is a description of the types of skills, experiences and tra<strong>in</strong><strong>in</strong>g required for a job. It entails<br />
observ<strong>in</strong>g and study<strong>in</strong>g a job to determ<strong>in</strong>e its contents (duties and responsibilities) and the conditions under<br />
which the work will be performed. Job analysis is useful <strong>in</strong> the follow<strong>in</strong>g areas:<br />
• when recruit<strong>in</strong>g and select<strong>in</strong>g <strong>in</strong>dividuals for jobs;<br />
• when employees are transferred or promoted;<br />
• for career counsell<strong>in</strong>g;<br />
• for staff appraisal;<br />
• for tra<strong>in</strong><strong>in</strong>g; and<br />
• for deal<strong>in</strong>g with grievance and discipl<strong>in</strong>e.<br />
A job description is a summary report of <strong>in</strong>formation relat<strong>in</strong>g to a particular job. The format conta<strong>in</strong>s:<br />
• name of district;<br />
• name of division or section;<br />
• official title of the job;<br />
• purpose of the job;<br />
• a short description of how the job fits <strong>in</strong>to the organisation;<br />
• the job’s ma<strong>in</strong> tasks and standards to be achieved;<br />
• accountable to;<br />
• responsible for;<br />
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• other relationships;<br />
• grade of the job;<br />
• special provisions; and<br />
• terms and conditions.<br />
All staff should have a job description. You, as supervisor should make sure that staff under your supervision<br />
have a job description. If job descriptions do not exist, prepare them with the staff you supervise. Job<br />
descriptions should be revised periodically. You need a job description so as to:<br />
• identify the right <strong>in</strong>dividual employee for the appropriate job;<br />
• recruit and place new staff; and<br />
• tra<strong>in</strong> and develop staff.<br />
In addition to be<strong>in</strong>g useful <strong>in</strong> recruitment, a job description helps you organise work; lets you know clearly the<br />
duties and responsibilities your staff are expected to achieve and helps you to prevent arguments between<br />
staff concern<strong>in</strong>g “who will do what”. A job description however, should not restrict the health worker from<br />
creative development of his/her role.<br />
RECRUITMENT<br />
In <strong>Mpumalanga</strong> the recruitment of senior professional staff is done by the Public Service Commission (PSC)<br />
<strong>in</strong>itiated by the Department of <strong>Health</strong>, Welfare and Gender Affairs. Staff recruitment is not the responsibility of<br />
those who directly supervise and manage those recruited. At the district level, the DHMT, through the regional<br />
director, is responsible for the recruitment of lower cadres of staff.<br />
PUBLIC SERVICE COMMISSION (PSC)<br />
The Public Service Commission is charged with the responsibility for recruitment, promotion, tra<strong>in</strong><strong>in</strong>g,<br />
accreditation (issu<strong>in</strong>g of certificates) and discipl<strong>in</strong>e of Permanent Staff. The commission derives its powers<br />
from the Constitution. The commission may and <strong>in</strong>deed delegates some of its powers to Authorised Officers<br />
particularly the Directors-General and Deputies. Such delegated powers <strong>in</strong>clude the follow<strong>in</strong>g:<br />
• appo<strong>in</strong>tments;<br />
• confirmation of probationary appo<strong>in</strong>tment;<br />
• term<strong>in</strong>ation of probationary appo<strong>in</strong>tment;<br />
• compulsory retirement;<br />
• retirement on medical grounds;<br />
• promotions; and<br />
• discipl<strong>in</strong>e.<br />
PROBATION<br />
For the officer to be confirmed <strong>in</strong> a position he/she must have served <strong>in</strong> the appo<strong>in</strong>ted position for a specified<br />
period of time dur<strong>in</strong>g which he/she has to:<br />
• clearly demonstrate suitability for the position; and<br />
• has complied with the relevant regulations regard<strong>in</strong>g the pass<strong>in</strong>g of exam<strong>in</strong>ations where applicable.<br />
The authorised officer can extend or term<strong>in</strong>ate a probationary appo<strong>in</strong>tment <strong>in</strong> the <strong>in</strong>terest of the Civil Service.<br />
It is important to note that if an officer has completed the stipulated period of probation and has neither<br />
been confirmed nor <strong>in</strong>formed <strong>in</strong> writ<strong>in</strong>g that the probationary appo<strong>in</strong>tment has been extended, such an<br />
officer is deemed to be confirmed <strong>in</strong> his/her appo<strong>in</strong>tment.<br />
ORIENTATION AND INDUCTION<br />
When new officers get posted or transferred to your district, it is important that you make the new staff feel<br />
welcome, wanted and an important member of your health team. Whether the new officer is a member of<br />
the DHMT or will take up any other position, you should make sure that the newcomer has been given<br />
orientation of the district. Prepare other staff for the arrival of the new comer. Make sure that they know when<br />
he/she is arriv<strong>in</strong>g and what he/she will be do<strong>in</strong>g.<br />
The purpose of the orientation is to provide reassurance through support for the achievement of early and<br />
pleasant familiarisation with the work and its overall context. Arrange to:<br />
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• meet the new staff;<br />
• expla<strong>in</strong> rules and standards of conduct <strong>in</strong>clud<strong>in</strong>g work<strong>in</strong>g hours;<br />
• show him/her the build<strong>in</strong>gs, facilities, departments etc;<br />
• <strong>in</strong>troduce him/her to other staff <strong>in</strong>clud<strong>in</strong>g those <strong>in</strong> other sectors;<br />
• expla<strong>in</strong> how his/her job relevant to others. Describe work<strong>in</strong>g relationships, particularly <strong>in</strong> terms of those<br />
with whom he/she is likely to be <strong>in</strong> direct contact;<br />
• describe the role of the health sector <strong>in</strong> the district, its major activities and the objectives you are try<strong>in</strong>g<br />
to achieve;<br />
• take him/her on a tour of the district’s facilities and projects; and<br />
• organise the work place.<br />
After the new staff has been with you for a week or so, it is a good idea to have discussion with him/her to<br />
check whether he/she has settled well and whether there are any problems that need to be dealt with. Deal<br />
with hous<strong>in</strong>g and any other problems of settl<strong>in</strong>g <strong>in</strong> as quickly as possible.<br />
PERFORMANCE APPRAISAL<br />
As a supervisor or team leader, you assess what subord<strong>in</strong>ates do to determ<strong>in</strong>e how close the staff come to<br />
achiev<strong>in</strong>g their work targets. There must be clear statements of objectives and targets that are:<br />
• relevant to the community’s needs;<br />
• feasible;<br />
• measurable; and<br />
• known and agreed to by the staff whose performance is be<strong>in</strong>g assessed.<br />
When you carry out a staff appraisal, bear <strong>in</strong> m<strong>in</strong>d that the appraisal is beneficial to the organisation, the<br />
<strong>in</strong>dividual worker and to you, the supervisor.<br />
Purpose of the appraisal<br />
• to encourage staff to work towards the highest levels of performance;<br />
• to provide feedback on performance;<br />
• to change th<strong>in</strong>gs to support the employee’s work and improvement;<br />
• to develop and ma<strong>in</strong>ta<strong>in</strong> a climate of trust; and<br />
• to provide a forum of express<strong>in</strong>g mutual expectations.<br />
Who appraises and who is appraised?<br />
• the immediate supervisor appraises the supervisee; and<br />
• self appraisal is encouraged for purposes of br<strong>in</strong>g<strong>in</strong>g out strengths that may have escaped the<br />
attention of the supervisor.<br />
When you appraise, what do you look for?<br />
• how the subord<strong>in</strong>ate is do<strong>in</strong>g and what needs to improve;<br />
• how the job is go<strong>in</strong>g and how it can be improved;<br />
• how the worker can develop;<br />
• what you can do to br<strong>in</strong>g identified changes; and<br />
• positive change <strong>in</strong> performance and behaviour and not personality.<br />
Performance appraisal should not be:<br />
• seen as a chance for the supervisor to punish the supervisee; and<br />
• treated as,or equated to an <strong>in</strong>terview. Treat it as a discussion; a two way communication between<br />
the supervisor and the person be<strong>in</strong>g appraised.<br />
In the Civil Service, staff appraisal is done annually. The period of assessment is from January to December<br />
each calender year unless an officer was appo<strong>in</strong>ted <strong>in</strong> the Government Service <strong>in</strong> the middle of the year.<br />
However, it is better to do it more frequently. Twice a year is advisable but it should be a time to provide<br />
feedback on ongo<strong>in</strong>g observations by the supervisor.<br />
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The report<strong>in</strong>g officer is normally the officer’s immediate supervisor and the Countersign<strong>in</strong>g Officer, will normally<br />
be the immediate supervisor of the report<strong>in</strong>g officer.<br />
For example:<br />
A District <strong>Health</strong> Manager is the report<strong>in</strong>g officer of a <strong>Health</strong> Centre Manager and the<br />
Countersign<strong>in</strong>g Officer is the Regional Director.<br />
Pr<strong>in</strong>ciples underly<strong>in</strong>g performance appraisal<br />
• shared responsibility;<br />
• shared commitment (by supervisor and supervisee to health sector objectives);<br />
• openness (stat<strong>in</strong>g the facts as they are);<br />
• specifics (focuss<strong>in</strong>g on issues of concern);<br />
• agreed work plans;<br />
• build<strong>in</strong>g on strengths; and<br />
• follow-up mechanisms.<br />
PROMOTION<br />
In select<strong>in</strong>g candidates for promotion, the relevant authority empowered to approve the promotion, will<br />
consider:<br />
• efficiency <strong>in</strong> the service;<br />
• merit and ability; and<br />
• experience and relevant qualifications.<br />
There are mechanisms for reward<strong>in</strong>g exceptional service with<strong>in</strong> the public service, for example, “out of turn”<br />
promotions. District <strong>Health</strong> Managers should encourage <strong>in</strong>itiative, <strong>in</strong>novation and excellence among<br />
subord<strong>in</strong>ates with the knowledge that these qualities can be practically and f<strong>in</strong>ancially acknowledged.<br />
DISCIPLINE<br />
Rules govern<strong>in</strong>g discipl<strong>in</strong>e <strong>in</strong> the Civil Service and the procedure to be followed <strong>in</strong> cases of breach of discipl<strong>in</strong>e<br />
can be found <strong>in</strong> the Public Service Commission Regulations. Guidel<strong>in</strong>es for management of discipl<strong>in</strong>ary<br />
cases can be obta<strong>in</strong>ed from the Regional/Prov<strong>in</strong>cial <strong>Health</strong> Office.<br />
BENEFITS<br />
The common benefits to employees <strong>in</strong>clude health <strong>in</strong>surance, medical allowances, pension, <strong>in</strong>surance, leave<br />
allowance. Information on all these benefits and how they apply to you can be obta<strong>in</strong>ed from the District/<br />
Regional/Prov<strong>in</strong>cial health office.<br />
WHEN EMPLOYEES LEAVE (EXIT)<br />
Employees leave employment for reasons such as better job opportunities elsewhere, retirement, discharge<br />
or death. When the member of staff leaves, make sure that there is proper hand<strong>in</strong>g over of any equipment,<br />
keys, files and other records entrusted to the staff. Assist the staff member to process his/her f<strong>in</strong>al dues particularly<br />
his/her pension.<br />
Retirement<br />
Retirement <strong>in</strong> the civil service falls under the follow<strong>in</strong>g categories:<br />
• compulsory retirement at atta<strong>in</strong><strong>in</strong>g specified age;<br />
• voluntary retirement at atta<strong>in</strong><strong>in</strong>g specified age;<br />
• retirement <strong>in</strong> public <strong>in</strong>terest;<br />
• retirement on medical grounds; and<br />
• retirement on abolition of office.<br />
If an officer is confirmed <strong>in</strong> appo<strong>in</strong>tment he/she will be eligible for retirement benefits <strong>in</strong> accordance with the<br />
provisions of the pension legislation of the public service.<br />
An officer leav<strong>in</strong>g the service should be cleared and a clearance certificate issued.<br />
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TRAINING AND DEVELOPMENT<br />
<strong>Health</strong> workers require to have the right attitude, skills and knowledge (ASK) to carry out their duties. Most<br />
basic tra<strong>in</strong><strong>in</strong>g is not by itself enough. Some of the th<strong>in</strong>gs you learnt dur<strong>in</strong>g your basic tra<strong>in</strong><strong>in</strong>g may be irrelevant<br />
to your work but there are th<strong>in</strong>gs that you require to know but were not taught. The job for which you were<br />
tra<strong>in</strong>ed may also have changed due to certa<strong>in</strong> circumstances, for example, new drugs and medical<br />
techniques may have been developed. If you have to keep up with the new technologies and to carry out<br />
your job effectively, the learn<strong>in</strong>g process has to be lifelong. It should not stop at the time of qualification. That<br />
is what is called Cont<strong>in</strong>u<strong>in</strong>g Education (CE). It is that education that beg<strong>in</strong>s where basic education ends.<br />
The Department of <strong>Health</strong>, Welfare and Gender Affairs <strong>in</strong> <strong>Mpumalanga</strong> has conducted a needs assessment<br />
<strong>in</strong> respect of human resources development. The follow<strong>in</strong>g challenges have been identified:<br />
• maldistribution and <strong>in</strong>appropriate utilisation of resources;<br />
• lack of management skills;<br />
• lack of primary health care skills;<br />
• <strong>in</strong>appropriate tra<strong>in</strong><strong>in</strong>g e.g. curative orientation only;<br />
• lack of health <strong>in</strong>formation management skills<br />
• <strong>in</strong>appropriate societal attitudes;<br />
• lack of skills <strong>in</strong> basic epidemiology; and<br />
• lack of plann<strong>in</strong>g skills.<br />
In order to respond to these needs, the Department will:<br />
• develop an action plan that will address the identified challenges; and<br />
• reorient all health professionals <strong>in</strong> PHC.<br />
Tra<strong>in</strong><strong>in</strong>g is important and necessary to the staff because it gives them a feel<strong>in</strong>g of mastery over<br />
their work. The staff become motivated, more productive and improve the quality of their<br />
work. The need is greatest for workers who are isolated <strong>in</strong> the rural sett<strong>in</strong>g away from other<br />
health professionals and who may have limited access to read<strong>in</strong>g materials.<br />
The follow<strong>in</strong>g educational pr<strong>in</strong>ciples will help you when consider<strong>in</strong>g tra<strong>in</strong><strong>in</strong>g programmes:<br />
• team tra<strong>in</strong><strong>in</strong>g/learn<strong>in</strong>g is much more effective than send<strong>in</strong>g <strong>in</strong>dividuals on courses;<br />
• learn<strong>in</strong>g based on actual problems is much more effective than teach<strong>in</strong>g of subjects/discipl<strong>in</strong>es;<br />
• <strong>in</strong>teractive groups learn better than passive classes of students;<br />
• subject matter learnt should be applied/implemented or else it is quickly forgotten; and<br />
• it is best to learn <strong>in</strong> the context where the subject will be applied.<br />
There should be promotion of free movement of staff such that available expertise is shared to the maximum<br />
at district level. In this context the health workers should constitute and operate as a team and plan work<br />
together. Tra<strong>in</strong><strong>in</strong>g activities should be implemented jo<strong>in</strong>tly and network<strong>in</strong>g among facilities should be<br />
encouraged.<br />
This chapter has exposed you as a service manager to most of the human resources development and<br />
management aspects of your work, particularly the practical rules and procedures that govern relationships<br />
between you and the staff. It has emphasised the importance of the health worker as an important resource<br />
that needs to be developed and managed <strong>in</strong> a car<strong>in</strong>g manner <strong>in</strong> order to promote a culture of compassion<br />
and care for the patient/client. You should give them careful attention by motivat<strong>in</strong>g and encourag<strong>in</strong>g<br />
them to work as a team. It is hoped that, you will familiarise yourself with the Code of Regulations and all<br />
amendments made from time to time by the relevant directorates. You should also familiarise yourself with<br />
the regulations of labour and professional bodies. Your regional director will guide you <strong>in</strong> this and other areas<br />
as you strive to provide a car<strong>in</strong>g service through the development and management of the health worker <strong>in</strong><br />
an equally car<strong>in</strong>g manner.<br />
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ANNEXURE OF ACRONYMS<br />
AIDS<br />
ARI<br />
BCG<br />
CBOs<br />
CBR<br />
CDD<br />
CHWs<br />
CBHWs<br />
CMTs<br />
DC<br />
DD<br />
DDG<br />
DHIS<br />
DHMIS<br />
DHMT<br />
DPT<br />
EPI<br />
HC<br />
HCMTs<br />
HMTs<br />
HP<br />
IDHA<br />
IPHA<br />
KAPB<br />
MDR<br />
MDRU<br />
MEC<br />
MEDUNSA<br />
MJOC<br />
NGOs<br />
NPA<br />
NPPHCN<br />
PAS<br />
PHC<br />
Acquired Immune Deficiency Syndrome<br />
Acute Respiratory Infections<br />
Bacille Calmette Guer<strong>in</strong> (TB immunisation)<br />
Community Based Organisations<br />
Community Based Rehabilitation<br />
Control of Diarrhoeal Diseases<br />
Community <strong>Health</strong> Workers<br />
Community Based <strong>Health</strong> Workers<br />
Cl<strong>in</strong>ic Management Teams<br />
District Council<br />
Diarrhoeal Diseases<br />
Deputy Director-General<br />
District <strong>Health</strong> Information System<br />
District <strong>Health</strong> Management Information System<br />
District <strong>Health</strong> Management Team<br />
Diptheria, Pertussis, Tetanus immunisation<br />
Expanded Programme on Immunisation<br />
<strong>Health</strong> Centre<br />
<strong>Health</strong> Centre Management Teams<br />
<strong>Health</strong> Management Teams<br />
<strong>Health</strong> Promoter<br />
Interim District <strong>Health</strong> Authority<br />
Interim Prov<strong>in</strong>cial <strong>Health</strong> Authority<br />
Knowledge, Attitude, Practice and Behaviour<br />
Multiple Drug Resistance<br />
Multiple Drug Resistance Unit<br />
Member of the Executive Council<br />
Medical University of South Africa<br />
Medical Jo<strong>in</strong>t Operations Command<br />
Non-Governmental Organisations<br />
National Programme of Action for Children <strong>in</strong> South Africa<br />
National Progressive <strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Network<br />
Public Adm<strong>in</strong>istration Standards<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong><br />
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PJOC<br />
POHC<br />
PSC<br />
PTDS<br />
RDC<br />
RDP<br />
ReHMIS<br />
SANTA<br />
SASAs<br />
SASOs<br />
SAIMR<br />
STDs<br />
TB<br />
TLCs<br />
TPA<br />
TRCs<br />
Prov<strong>in</strong>cial Jo<strong>in</strong>t Operations Command<br />
<strong>Primary</strong> Oral <strong>Health</strong> <strong>Care</strong><br />
Public Service Commission<br />
Part-time District Surgeons<br />
Reconstruction and Development Council<br />
Reconstruction and Development Programme<br />
Regional <strong>Health</strong> Management Information System<br />
South African National Tuberculosis Association<br />
Specialised Auxiliary Services Assistants<br />
Specialised Auxiliary Services Officers<br />
South Africa Institute for Medical Research<br />
Sexually Transmitted Diseases<br />
Tuberculosis<br />
Transitional Local Councils<br />
Transvaal Prov<strong>in</strong>cial Adm<strong>in</strong>istration<br />
Transitional Rural Councils<br />
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DISTRICT DICTIONARY<br />
Access<br />
Accessibility<br />
Account<br />
Accountable<br />
Accountability<br />
Activity<br />
Adult <strong>Health</strong> Literacy<br />
Ambulatory <strong>Care</strong><br />
Anthropometric Measurement<br />
Audit<br />
Basic <strong>Health</strong> <strong>Care</strong><br />
Budgetary Cycle<br />
Budget<strong>in</strong>g<br />
Capacity build<strong>in</strong>g<br />
Capacity Development<br />
Catalyse<br />
Catchment Area<br />
Checklist<br />
Cl<strong>in</strong>ic<br />
Coherent<br />
Co<strong>in</strong>cident<br />
Ease with which health services may be utilised; encompasses<br />
geographic access (the distance from facilities), f<strong>in</strong>ancial access<br />
(refers to affordability of services) and social access (e.g., attitude<br />
of health workers).<br />
Indicator measur<strong>in</strong>g access to the health centre, based on<br />
distance, time, cost and possibly socio-cultural factors.<br />
A record of money received or money spent, or both.<br />
Liable to be called to account, or to answer for responsibilities and<br />
conduct; people <strong>in</strong> decision-mak<strong>in</strong>g positions are held responsible<br />
for their actions; mechanisms that should be used to ensure this.<br />
Liability to give account of, and answer for, discharge of duties or<br />
conduct; mechanisms to ensure this.<br />
A group of tasks with a common purpose.<br />
Ability to read and understand simple health messages.<br />
<strong>Care</strong> provided to patients who are not conf<strong>in</strong>ed to bed; out-patient<br />
care.<br />
Measur<strong>in</strong>g the size of different parts of the body e.g. arm<br />
circumference, to determ<strong>in</strong>e nutritional state.<br />
A call<strong>in</strong>g to account, usually applied to the use of funds, but also<br />
applied to any function or action that has measurable<br />
consequences; hence “cl<strong>in</strong>ical audit” refers to an evaluation of<br />
the value of a cl<strong>in</strong>ical procedure <strong>in</strong> produc<strong>in</strong>g the desired result or<br />
consequence.<br />
Indispensable medical care and preventive services acceptable<br />
to <strong>in</strong>dividuals, families and communities.<br />
Period of time dur<strong>in</strong>g which estimated expenditures are expected<br />
to be made.<br />
The process of match<strong>in</strong>g proposed expenditures to available<br />
f<strong>in</strong>ancial resources with a view to achiev<strong>in</strong>g desired results.<br />
Improv<strong>in</strong>g ability to undertake certa<strong>in</strong> tasks, roles, etc.<br />
The creation of skills necessary to function more effectively; the<br />
process used is important as it should be empower<strong>in</strong>g.<br />
To cause to happen; to br<strong>in</strong>g about; to <strong>in</strong>spire.<br />
Geographic area that is served by a community health facility, e.g.<br />
health centre or cl<strong>in</strong>ic; a sub-unit of the health district.<br />
A list of items or descriptions of actions to be looked at, one at a<br />
time, to ensure that no item or action is overlooked.<br />
Fixed structure <strong>in</strong> which basic health services are provided, usually<br />
by nurses; l<strong>in</strong>ked to a community health centre.<br />
Th<strong>in</strong>gs that hold together <strong>in</strong> a mean<strong>in</strong>gful way; connected<br />
Occupy<strong>in</strong>g the same place or time.<br />
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Community Development<br />
Community <strong>Health</strong><br />
Community <strong>Health</strong> Centre<br />
Community Involvement<br />
Community Participation<br />
Component<br />
Comprehensive<br />
Constra<strong>in</strong>ts<br />
Cont<strong>in</strong>u<strong>in</strong>g Education<br />
Collaborate<br />
Co-ord<strong>in</strong>ate<br />
Core Activities<br />
Cost Effective<br />
Coterm<strong>in</strong>ous<br />
Coverage<br />
Criterion (plural: criteria)<br />
Crucial<br />
Curative <strong>Care</strong><br />
Decentralisation<br />
The process of <strong>in</strong>volv<strong>in</strong>g a community <strong>in</strong> the identification and<br />
re<strong>in</strong>forcement of the aspects of everyday life, culture and political<br />
activity that are conducive to health; this might <strong>in</strong>clude support for<br />
political action to modify the total environment and strengthen<br />
resources for healthy liv<strong>in</strong>g, as well as re<strong>in</strong>forc<strong>in</strong>g social networks<br />
and social support with<strong>in</strong> a community and develop<strong>in</strong>g the material<br />
resources available to the community.<br />
The organised co-operative efforts of all agencies <strong>in</strong> the community,<br />
directed towards the promotion of health <strong>in</strong> the community; it is<br />
based on the concept that all agencies and <strong>in</strong>dividuals have a<br />
role to play <strong>in</strong> promot<strong>in</strong>g, ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g and improv<strong>in</strong>g the health<br />
and well-be<strong>in</strong>g of people.<br />
Usually a 24 hour health facility provid<strong>in</strong>g a greater variety of services<br />
than is provided at a cl<strong>in</strong>ic.<br />
The active <strong>in</strong>volvement of people liv<strong>in</strong>g together <strong>in</strong> some form of<br />
social organisation and cohesion <strong>in</strong> the plann<strong>in</strong>g, operation and<br />
control of primary health care, us<strong>in</strong>g local, national and other<br />
resources.<br />
A process where people participate <strong>in</strong>dividually and collectively<br />
as part of their right and duty, <strong>in</strong> the plann<strong>in</strong>g, implementation and<br />
control of activities for their health and related social development.<br />
One of the essential parts; synonymous with ‘element’.<br />
The fullest possible range of, for example, primary health services;<br />
the provision of preventive, promotive, curative and rehabilitative<br />
care by a health care facility or authority.<br />
Restrictions or limitations of freedom to act.<br />
Courses of study directed towards ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g and improv<strong>in</strong>g<br />
competence after <strong>in</strong>itial tra<strong>in</strong><strong>in</strong>g.<br />
Work jo<strong>in</strong>tly with others.<br />
To relate (arrange) the activities of different persons <strong>in</strong> the same or<br />
connected programmes with one another <strong>in</strong> such a way that their<br />
common goals can be effectively and efficiently achieved.<br />
Essential activities.<br />
Economical <strong>in</strong> terms of improvements or benefits produced by<br />
money spent.<br />
Shar<strong>in</strong>g similar boundaries.<br />
Indicator measur<strong>in</strong>g the effective access to a particular service.<br />
A guide or standard on which someth<strong>in</strong>g is judged, or which is used<br />
as a basis for mak<strong>in</strong>g a decision, assessment or an evaluation.<br />
Important or essential.<br />
Appropriate medical treatment of common diseases and <strong>in</strong>juries<br />
at a health facility.<br />
The process of shift<strong>in</strong>g responsibility, authority and accountability<br />
for plann<strong>in</strong>g, management and the allocation (and rais<strong>in</strong>g) of<br />
resources to those who are implement<strong>in</strong>g policy at the lowest level;<br />
the transfer of appropriate authority from central government to<br />
prov<strong>in</strong>ces, regional offices, district health authorities, local<br />
governments and/or non-governmental organisations.<br />
135
Delegation<br />
Demography<br />
Deployment (personnel)<br />
Devolution<br />
District Council Area<br />
District <strong>Health</strong> Authority<br />
District <strong>Health</strong> Plan<br />
District <strong>Health</strong> System<br />
District Hospital<br />
Donors<br />
Economies of Scale<br />
Effectiveness<br />
Efficiency<br />
Emergency Preparedness<br />
Ensure<br />
Epidemiological<br />
Equitable<br />
Equity<br />
Essential Drugs<br />
Evaluation<br />
External Partners<br />
Facility<br />
The process of shift<strong>in</strong>g authority and responsibility over specific issues<br />
and def<strong>in</strong>ed functions to other adm<strong>in</strong>istrative structures or<br />
<strong>in</strong>dividuals; responsibility rema<strong>in</strong>s with the delegat<strong>in</strong>g authority.<br />
The study of the characteristics of human populations, such as size,<br />
growth, density, distribution and vital statistics.<br />
Mak<strong>in</strong>g the best use of available personnel.<br />
The creation or strengthen<strong>in</strong>g of sub-national levels of government<br />
(such as local authorities) that are substantially <strong>in</strong>dependent of<br />
national level with respect to a def<strong>in</strong>ed set of functions; there is<br />
normally geographic responsibility for a range of services and the<br />
power to raise revenue; accountability is usually to the electorate.<br />
Area controlled by a district council; may be larger than a health<br />
region; may conta<strong>in</strong> a Transitional Rural Council and Transitional<br />
Local Councils.<br />
Governance structure which is responsible for ensur<strong>in</strong>g the delivery<br />
of all primary health care <strong>in</strong> the health district.<br />
A course of action to be followed <strong>in</strong> order to meet the set objectives<br />
and targets.<br />
All the <strong>in</strong>terrelated elements that contribute to the health of<br />
<strong>in</strong>dividuals, families and communities at district level.<br />
First level non-specialist hospital to which patients from cl<strong>in</strong>ics or<br />
health centres may be referred.<br />
Agencies or <strong>in</strong>dividuals provid<strong>in</strong>g f<strong>in</strong>ancial assistance.<br />
Term used to expla<strong>in</strong> the fact that under certa<strong>in</strong> conditions, it is<br />
more efficient to operate at a higher level e.g. a team of 10 nurses<br />
conduct<strong>in</strong>g mass immunisation campaign is more efficient when<br />
100 children get immunised as compared to only 20 children.<br />
The best possible outcome or result.<br />
The atta<strong>in</strong>ment of the best outcome or result at the lowest possible<br />
cost.<br />
Ability of a community to cope with sudden disasters or epidemics<br />
To make it happen; to co-ord<strong>in</strong>ate.<br />
Frequency and distribution of disease <strong>in</strong> a given community.<br />
Without favour<strong>in</strong>g certa<strong>in</strong> regions, communities or groups of<br />
<strong>in</strong>dividuals, i.e. socially just.<br />
The universal provision of services on the basis of need rather than<br />
any other criterion.<br />
Medic<strong>in</strong>es that are the most needed for treat<strong>in</strong>g the most common<br />
diseases <strong>in</strong> a given population and should therefore be available<br />
at all times.<br />
The measurement of performance, based on established criteria,<br />
to ensure that the objectives are be<strong>in</strong>g met.<br />
Agencies from outside a country, region or district will<strong>in</strong>g to work<br />
jo<strong>in</strong>tly with local agencies or citizens to achieve common goals.<br />
A build<strong>in</strong>g, a room or site that makes an activity possible, e.g. a<br />
cl<strong>in</strong>ic, health centre or hospital.<br />
136
Feedback<br />
Follow-up<br />
Food Security<br />
Frame<br />
Front-l<strong>in</strong>e<br />
Function<br />
Goals<br />
Governance<br />
<strong>Health</strong><br />
<strong>Health</strong> Development<br />
<strong>Health</strong> District<br />
<strong>Health</strong> Problem<br />
<strong>Health</strong> Region<br />
<strong>Health</strong> Services<br />
<strong>Health</strong> Status<br />
<strong>Health</strong> Team<br />
High-risk Pregnancy<br />
Indicators<br />
Indicators (health)<br />
Information which helps to evaluate an activity.<br />
Ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g contact with a person (e.g. patient) or watch<strong>in</strong>g over<br />
the development of a process.<br />
Ensur<strong>in</strong>g availability of basic food required for adequate nutrition;<br />
food hygiene.<br />
The basic outl<strong>in</strong>e or idea.<br />
Where the majority of the population live and work, i.e. at<br />
district(village) level.<br />
A group of activities with a common purpose.<br />
These are large “direction-sett<strong>in</strong>g” wants or needs which provide<br />
overall direction for plann<strong>in</strong>g.<br />
The processes used by govern<strong>in</strong>g structures to make and implement<br />
laws and provide services.<br />
State of complete physical, mental and social well-be<strong>in</strong>g, not only<br />
the absence of disease or <strong>in</strong>firmity.<br />
Process of improv<strong>in</strong>g the state of physical, mental and social wellbe<strong>in</strong>g<br />
of the <strong>in</strong>dividual, the family and the community with<strong>in</strong> the<br />
more general framework of socio-economic development.<br />
Geographic area that is small enough to allow maximal <strong>in</strong>volvement<br />
of community participation so that local health needs are met, but<br />
also large enough to effect economies of scale.<br />
A departure from the accepted norms <strong>in</strong> the health status of a<br />
community; sometimes also an underly<strong>in</strong>g cause of such a<br />
departure.<br />
Geographic area <strong>in</strong>to which a prov<strong>in</strong>ce is divided and with<strong>in</strong> which<br />
secondary hospital services are available to health districts which<br />
may fall with<strong>in</strong> its boundaries.<br />
A system of <strong>in</strong>stitutions, people, technologies and resources<br />
designed to improve the health status of a population.<br />
The degree to which the health of a specified population meets<br />
accepted norms (of mortality, morbidity, etc).<br />
<strong>Health</strong> workers hav<strong>in</strong>g a common goal, with each member<br />
contribut<strong>in</strong>g to its achievement <strong>in</strong> accordance with his or her<br />
competence and skills and <strong>in</strong> co-ord<strong>in</strong>ation with the functions of<br />
the others.<br />
A pregnancy that carries a higher than average risk of illness or<br />
death to the mother or baby. Maternal age, number of children<br />
previously born, chronic illness, previous complications dur<strong>in</strong>g<br />
delivery, etc. are all considered <strong>in</strong> estimat<strong>in</strong>g the risk.<br />
These are observable, quantifiable criteria which would be<br />
measured as part of monitor<strong>in</strong>g and evaluation <strong>in</strong> order to<br />
determ<strong>in</strong>e the extent to which objectives and targets have been<br />
met.<br />
Variable data that help to measure the present state and any<br />
future changes <strong>in</strong> the health status of a community; statistic (usually<br />
expressed as a rate or ratio), e.g. an <strong>in</strong>fant mortality rate of 90/1000<br />
<strong>in</strong>dicates a low level of community health whereas a fall <strong>in</strong> the<br />
neonatal tetanus rate from 40/1000 to 10/1000 <strong>in</strong>dicates an<br />
improvement <strong>in</strong> community health.<br />
137
Information<br />
Information System<br />
Immunisation<br />
Impact<br />
Implementation<br />
Infrastructure (health)<br />
Initiative<br />
Integrate<br />
Interface<br />
Intermediate Level<br />
Intersectoral Action<br />
Intervention<br />
Job Description<br />
Local Authority<br />
Local Government<br />
Logistical Support<br />
Management<br />
Mobile Services<br />
Mobilis<strong>in</strong>g<br />
Monitor<strong>in</strong>g<br />
Morbidity Data<br />
Mortality Data<br />
Motivation<br />
Multidiscipl<strong>in</strong>ary<br />
Multiplier Effect<br />
Data processed for a purpose (e.g. decision mak<strong>in</strong>g).<br />
A group of people, procedures, methods and perhaps mach<strong>in</strong>es<br />
and other equipment for the collection, process<strong>in</strong>g, storage and<br />
reviewal of <strong>in</strong>formation.<br />
Prevent<strong>in</strong>g serious attacks of communicable diseases <strong>in</strong> <strong>in</strong>dividuals<br />
by produc<strong>in</strong>g them <strong>in</strong> a mild form, usually by vacc<strong>in</strong>ation.<br />
Overall effect of a programme on the health status and socioeconomic<br />
development of a community, for example the outcome<br />
of an immunisation <strong>in</strong>tervention is reduced child mortality.<br />
Carry<strong>in</strong>g out a planned activity or programme.<br />
All the facilities, <strong>in</strong>stitutions, organisations, material and resources<br />
required for provid<strong>in</strong>g health care.<br />
Steps taken towards start<strong>in</strong>g a programme or activity.<br />
Putt<strong>in</strong>g different parts together to form a whole. In the field of health<br />
care, it applies to activities, programmes, plans and services.<br />
The place at which <strong>in</strong>dependent systems <strong>in</strong>teract or communicate<br />
with each other.<br />
Prov<strong>in</strong>cial or regional level of adm<strong>in</strong>istration.<br />
Action <strong>in</strong> which various sectors collaborate for the achievements<br />
of a common goal.<br />
Action taken to improve or change a health situation.<br />
A document <strong>in</strong>dicat<strong>in</strong>g what a worker is expected to do, the extent<br />
of his/her authority and work<strong>in</strong>g relationships.<br />
Adm<strong>in</strong>istrative structure that is responsible for the provision of a<br />
service with<strong>in</strong> a local government.<br />
Third tier of government; most suitable for a village, rural sett<strong>in</strong>g,<br />
town or city.<br />
Provid<strong>in</strong>g the means of carry<strong>in</strong>g out an activity, e.g. transportation.<br />
“Gett<strong>in</strong>g th<strong>in</strong>gs done”. Management <strong>in</strong>cludes plann<strong>in</strong>g, organis<strong>in</strong>g,<br />
direct<strong>in</strong>g, monitor<strong>in</strong>g and control, supervision and evaluation.<br />
<strong>Health</strong> care provided to distant populations by us<strong>in</strong>g transport e.g.<br />
vehicles, motor cycles.<br />
Becom<strong>in</strong>g prepared to undertake an activity.<br />
Keep<strong>in</strong>g track of the way activities are be<strong>in</strong>g implemented to meet<br />
the objectives set and undertak<strong>in</strong>g corrective measures, if<br />
necessary.<br />
Statistical <strong>in</strong>formation about the <strong>in</strong>cidence of disease <strong>in</strong> a<br />
community.<br />
Statistical <strong>in</strong>formation about the number of deaths <strong>in</strong> a given time<br />
or place.<br />
Whatever stimulates an <strong>in</strong>dividual to make an effort or take action.<br />
Involv<strong>in</strong>g more than one area of knowledge or tra<strong>in</strong><strong>in</strong>g.<br />
Intensification of an effect through repetition of the process<br />
lead<strong>in</strong>g up to it.<br />
138
National <strong>Health</strong> Service<br />
National <strong>Health</strong> System<br />
Network<br />
Non-governmental Organisations<br />
Objective<br />
Operational Plan<br />
Operational Research<br />
Operational Support<br />
Operational Unit<br />
Orientation<br />
Organis<strong>in</strong>g<br />
Outreach <strong>Health</strong> Services<br />
Package (health)<br />
Parameters<br />
Polychemotherapy<br />
Polyvalent (health workers)<br />
Power-brokers<br />
Pragmatic<br />
Prevention<br />
<strong>Primary</strong> data<br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong><br />
<strong>Primary</strong> <strong>Health</strong> <strong>Care</strong> Approach<br />
<strong>Health</strong> services provided by a country for all its citizens.<br />
The organization of the country’s health service (<strong>in</strong>clud<strong>in</strong>g services<br />
provided by central government, the prov<strong>in</strong>cial governments, local<br />
government, the NGOs/CBOs and the private sector).<br />
An <strong>in</strong>terconnected group of <strong>in</strong>dividuals or <strong>in</strong>stitutions.<br />
An organisation which is <strong>in</strong>dependent of any national authority; a<br />
private agency.<br />
The <strong>in</strong>tended result of the achievement of a programme or activity.<br />
An educational objective def<strong>in</strong>es what students should be able to<br />
do at the end of a learn<strong>in</strong>g period that they could not do beforehand.<br />
Description of action to be undertaken and the resources necessary<br />
to achieve stated goals and objectives.<br />
Application of scientific methods to the study and analysis of<br />
problems.<br />
Assistance with carry<strong>in</strong>g out activities. This could be logistical or<br />
technical.<br />
Where the activity will take place.<br />
Process of becom<strong>in</strong>g acqua<strong>in</strong>ted with the exist<strong>in</strong>g situation,<br />
environment, direction of though or <strong>in</strong>terest.<br />
Process of structur<strong>in</strong>g activities, materials and personnel for<br />
accomplish<strong>in</strong>g assigned tasks.<br />
Provision of health care for populations liv<strong>in</strong>g far away from health<br />
facilities.<br />
Essential medical and public health <strong>in</strong>terventions to be undertaken<br />
to improve the health status of a community.<br />
Characteristics elements.<br />
Treatment of a disease us<strong>in</strong>g several chemical agents at the same<br />
time.<br />
Tra<strong>in</strong>ed or expected to carry out more than one function.<br />
People <strong>in</strong> a position to exert great <strong>in</strong>fluence on account of their<br />
wealth or of the numbers of <strong>in</strong>dividuals they control.<br />
Practical<br />
To ensure that diseases or illnesses do not occur.<br />
Information obta<strong>in</strong>ed by carry<strong>in</strong>g out surveys or censuses.<br />
Essential health care based on practical, scientifically-sound and<br />
socially acceptable methods and technology made universally<br />
accessible to <strong>in</strong>dividuals and families <strong>in</strong> the community through<br />
their full participation and that the community and country can<br />
afford to ma<strong>in</strong>ta<strong>in</strong> at every stage of their development <strong>in</strong> the spirit<br />
of self-reliance and self-determ<strong>in</strong>ation.<br />
The underly<strong>in</strong>g philosophy for the provision of health care services<br />
that are based on the Alma Ata Declaration, i.e., comprehensive<br />
care that <strong>in</strong>cludes curative, preventive, promotive and<br />
rehabilitative care with<strong>in</strong> the context of, amongst others, community<br />
participation and <strong>in</strong>tersectoral collaboration.<br />
139
Priority Sett<strong>in</strong>g<br />
Private <strong>Health</strong> Sector<br />
Programme<br />
Programm<strong>in</strong>g<br />
Promotive Activities<br />
Prophylactic Campaigns<br />
Provide<br />
Public <strong>Health</strong> Sector<br />
Quality Assurance<br />
Quantification<br />
Rationalise<br />
Referral Mechanism<br />
Regional Hospital<br />
Rehabilitation<br />
Render<br />
Reprogramm<strong>in</strong>g<br />
Resources<br />
Resource Mobilisation<br />
Restructure<br />
Revenue<br />
Decid<strong>in</strong>g on relative importance or urgency accord<strong>in</strong>g to given<br />
criteria.<br />
That sector of the health care <strong>in</strong>dustry which treats health and illness<br />
as a commodity; as a patient you must pay usually un-regulated<br />
fees to the health care provider or to the provider via a third party<br />
<strong>in</strong>surer (medical aid scheme, <strong>in</strong>surance company, etc.); the<br />
provider may be self-employed or employed by a non-profit<br />
organisation; most private hospitals belong to companies listed on<br />
the Stock Exchange, which must generate profits for their shareholders.<br />
All the activities directed towards the achievement of def<strong>in</strong>ed goals<br />
and targets.<br />
Formulat<strong>in</strong>g programmes to br<strong>in</strong>g about changes needed <strong>in</strong> a<br />
country’s health situation.<br />
Activities directed towards improv<strong>in</strong>g health.<br />
Series of activities direct<strong>in</strong>g towards encourag<strong>in</strong>g <strong>in</strong>dividuals to<br />
present themselves for vacc<strong>in</strong>ation.<br />
To take fiscal responsibility for the provision of services; to pay for<br />
services.<br />
Services provided by and through government structures (national<br />
or prov<strong>in</strong>cial Departments of <strong>Health</strong>, Local Government), for the<br />
benefit of all citizens.<br />
A management system designed to ensure the provision of services<br />
that are of the highest possible standard.<br />
Measurement of quantity<br />
Process whereby resources are used most effectively and efficiently;<br />
often used to mean, especially <strong>in</strong> the civil service, a cutt<strong>in</strong>g back<br />
or reduction of resources.<br />
Procedures for and ways and means of send<strong>in</strong>g patients to an<br />
appropriate facility, <strong>in</strong>stitute or specialist at the next level of the<br />
health care system.<br />
Usually a secondary hospital to which patients are referred from<br />
the district hospital (i.e. a hospital which services many districts and<br />
at which more specialised services are available); managed by<br />
the prov<strong>in</strong>cial Department of <strong>Health</strong>.<br />
A process aimed at enabl<strong>in</strong>g people with disabilities to reach and<br />
ma<strong>in</strong>ta<strong>in</strong> their optimal physical, emotional and social level of<br />
function<strong>in</strong>g.<br />
To provide services directly.<br />
Revis<strong>in</strong>g a programme if, for <strong>in</strong>stance, it is not go<strong>in</strong>g accord<strong>in</strong>g to<br />
plan or it is not acceptable to the people for whom it is <strong>in</strong>tended.<br />
The available means (personnel, equipment, time, money) to<br />
supply or achieve an objective or goal.<br />
Br<strong>in</strong>g<strong>in</strong>g together the means of achiev<strong>in</strong>g a certa<strong>in</strong> objective<br />
(personnel, equipment, money etc).<br />
To change the organisation or pattern of someth<strong>in</strong>g.<br />
Monies earned; <strong>in</strong>come; usually refers to <strong>in</strong>come earned by a<br />
government or authority, e.g. from taxes, or from user fees collected<br />
by a hospital.<br />
140
Safe Motherhood<br />
S.A.S.A./S.A.S.O.<br />
Satellite <strong>Health</strong> Cl<strong>in</strong>ics<br />
Schedul<strong>in</strong>g<br />
Secondary Data<br />
Sector<br />
Sensitisation<br />
Situation Analysis<br />
Soft Boundaries<br />
Staff<strong>in</strong>g<br />
Strategy<br />
Structure<br />
Susta<strong>in</strong>ability<br />
Target<br />
Target Population<br />
Technical Support<br />
Wellness Approach<br />
Workforce<br />
Child bear<strong>in</strong>g without danger.<br />
Specialised auxiliary services assistant/officer. A post class <strong>in</strong> the<br />
public service.<br />
<strong>Health</strong> cl<strong>in</strong>ics dependent on larger and better equipped facilities,<br />
e.g. a health centre.<br />
Mak<strong>in</strong>g a plan that <strong>in</strong>dicates the time and sequence of each<br />
activity.<br />
Information obta<strong>in</strong>ed from health records, health surveys, reports,<br />
etc. as opposed to primary data.<br />
A dist<strong>in</strong>ctive part of the socio-economic organisation of a country,<br />
e.g. the health sector, the agricultural sector.<br />
Arous<strong>in</strong>g awareness of a situation that needs to be changed.<br />
Description of the present state of affairs.<br />
Boundaries that are subject to change, to take <strong>in</strong>to account<br />
chang<strong>in</strong>g circumstances.<br />
Function of select<strong>in</strong>g and tra<strong>in</strong><strong>in</strong>g workers.<br />
Tactic or technique which could be devised or adopted and<br />
utilised to facilitate the achievement of objectives and targets.<br />
Pattern of organisation.<br />
Capacity to cont<strong>in</strong>ue when external assistance ceases.<br />
A goal to be achieved, with<strong>in</strong> a certa<strong>in</strong> time, and which can be<br />
measured.<br />
Sub-group of the population of a health area def<strong>in</strong>ed as priority<br />
target for a given service.<br />
Assistance <strong>in</strong> connection with special knowledge, skills and<br />
technology.<br />
An approach to the provision of services that places an emphasis<br />
on creat<strong>in</strong>g all the conditions (i.e. not just health services) to<br />
enable people to become, and rema<strong>in</strong> healthy, and thus<br />
contribute to the well-be<strong>in</strong>g of all.<br />
Number of workers available.<br />
141
ADDITIONAL REFERENCES<br />
Dem<strong>in</strong> K. Andrei<br />
Towards a <strong>Health</strong>y Russia: Policy for Promotion and Disease Prevention: Focus on Major Non communicable<br />
Diseases. State Research Centre of Preventive Medic<strong>in</strong>e: M<strong>in</strong>istry of <strong>Health</strong> and Medical Industry of Russian<br />
Federation Moscow 1994.<br />
Monekosso GL.<br />
District <strong>Health</strong> Management Plann<strong>in</strong>g: Implement<strong>in</strong>g and Monitor<strong>in</strong>g a M<strong>in</strong>imum <strong>Health</strong> for all Package:<br />
WHO Regional Office for Africa September 1994<br />
M<strong>in</strong>istry of <strong>Health</strong> and Social Services:<br />
Integrated <strong>Health</strong> <strong>Care</strong> Delivery: The challenge of Implementation.<br />
Republic of Nambia, January 1995<br />
M<strong>in</strong>istry of <strong>Health</strong>, and UNICEF Kenya:<br />
Manual for the District <strong>Health</strong> Management Information System<br />
1st Edition; February 1991<br />
Hospital Strategy Project for the Department of <strong>Health</strong>;<br />
Position paper on the Decentralisation of Hospital Management.<br />
(First draft) December 1995<br />
Amando-Lartson R, Ebrahim GJ, Lovel H.J, Ranken JP<br />
District <strong>Health</strong> <strong>Care</strong>: Challenges for plann<strong>in</strong>g and Evaluation <strong>in</strong> Develop<strong>in</strong>g Countries:<br />
2nd Edition 1992, ELBS with Macmillan<br />
SAMDI: The Tra<strong>in</strong><strong>in</strong>g Task of the Supervisor: A Tra<strong>in</strong><strong>in</strong>g Manual<br />
Fourth Edition: February 1995. Public Service Tra<strong>in</strong><strong>in</strong>g Institute<br />
142