Primary Health Care in Mpumalanga:
Primary Health Care in Mpumalanga:
Primary Health Care in Mpumalanga:
Primary Health Care in Mpumalanga:
Primary Health Care in Mpumalanga:
Guide to district-based action
Guide to district-based action
Guide to district-based action
Guide to district-based action
Guide to district-based action
Eastern Highveld Highveld
Published by the Health Systems Trust
Health Systems Trust
504 General Building • Cnr Smith and Field Streets • Durban 4001 Tel: (031) 3072954 • Fax: (031) 304 0775 • E-Mail: hst@wn.apc.org
ISBN: 0-9584110-5-0 First Edition: October 1996
Designed, Typeset and Printed by Kwik Kopy Printing, Durban
H T S
Written and produced by the Department of Health,
Welfare and Gender Affairs, Mpumalanga:
Dept. of Health, Welfare and Gender Affairs Private Bag X11285 • Nelspruit 1200 Tel: (013) 7528085 • Fax: (013) 7554698
FOREWORD
Our province has adopted Primary Health Care (PHC) as the main strategy for developing and promoting the health of our communities, using the District Health System as the vehicle for facilitating its implementation. The services to be rendered to each community must necessarily be based on their needs; acceptable to them; and delivered in a manner that is accountable to them and with their full participation.
Since adopting PHC, my provincial and regional teams have worked tirelessly to establish a health system based on a district, first by conducting a situation analysis which was followed by development of the district health plans. The preparation of this handbook is yet a further initiative aimed at consolidating the development of the District Health System. The book will be used both as a reference and a guide to successful implementation of Primary Health Care in the province.
It is important to note that the handbook is not a prescriptive document. Each District Health Management Team and other users should adapt its use to their changing environment.
Each DHMT should strive to deliver primary health care services on the basis of equal accessibility; building on existing structures; integrating the PHC programmes into an implementable package; optimising the
public-private sector mix; and empowering the users to participate in service provision and governance. Let us aim at providing a high quality, compassionate and caring service founded on availability and accessibility of a well organised referral network involving all levels of care, i.e. community, clinic, health care and hospital; availability of financial and material resources; provision of timely logistical support systems; and development of a culture that recognises the health worker as an important resource. It is our responsibility, to ensure that the systems and resources are in place. The provincial team together with the regional staff are committed to providing the necessary technical support to the districts to make the implementation of Primary Health Care a reality.
May I take this opportunity to congratulate all members who contributed to the production of this handbook and the support from the National Department of Health. The enthusiasm demonstrated is a true reflection of the commitment of our staff to transforming the health care delivery system to address the needs of the people.
The usefulness of the handbook, however, will only be realised when we begin seeing positive changes in the health status of our people.
Hon. Candith K. Mashego (Ms)
MEC
Health, Welfare and Gender Affairs, Mpumalanga Province
ACKNOWLEDGEMENTS
The MEC and Management of the Mpumalanga Department of Health, Welfare and Gender Affairs wishes to thank the following persons, as well as those that may have been inadverterly omitted for their vision, insight and commitment in developing this handbook. We also wish to thank David Harrison for editing and planning the layout of this handbook.
This has truly been an example where divergent views have been embroided into synergy.
Writers
Maureen Beck Coenie Bekker Kelvin Bellinghurst Leon Bonnet Clara Chiloane Deon Cloete Dave Durrheim Danie Groenewald Bernice Harris Rebecca HlatshwayoResource Persons
Felicity Gibbs Get Ahead Foundation John Gear Wits Rural Foundation
Nobayeni Dladla Department of Health (National) David Harrison Health Systems Trust
David Mametja Health Systems Trust Joan Matji UNICEF
Eddie Mhlanga Department of Health (National) Eddie McGrath Department of Health (National) Mandi Mzimba Department of Health (National) Sam Kazibwe AMREF
William Okedi AMREF Vincent Orinda UNICEF
Steve Tollman Health Systems Development Unit Yogan Pillay Department of Health (National)
Reviewers
Elise Appel National Progressive Primary Health Care Network Peter Barron Health Systems Trust
Irwin Friedman National Progressive Primary Health Care Network Lucy Gilson University of the Witwatersrand
Arthur Haywood University of the Western Cape
Peter Long National Progressive Primary Health Care Network Lydia Pretorius National Disability Desk
William Pick University of Witwatersrand Laetitia Rispel University of the Witwatersrand
Hugh Philpott Centre for Health and Social Studies - University of Natal
Alucia Shabangu Kareen Swart Lynn Viljoen Bonnyface Wankya Milani Wolmarans Masingita Zwane Sam Mkhabela Irene Mkhabela Pat Mkhwanazi Collin Mupombwa Shirley Ngwenya Sonto Nxumalo Jabulani Mndebele Andrew Pond Christine Phiri Andrina Sambo Rowina Jordaan Gulam Karim Judith Lubisi Elizabeth Malumane Len Mdluli Amos Masango Thalitha Modonsela Janet Maphanga Gladness Mathebula Keith Michael
ii
Secretariat
Graziela DeSouza Theresa Knoetze Irene Mathare Busi Mathabela Rose Mgwenya Anna Nkosi Lucas Nkosi Doreen Nkuna Maritjie Petzer Michael SkhosanaCo-ordinators
Nomonde Bam Primary Health Care (Mpumalanga) Kathy Kahn Health Systems Development Unit Wynand Nant’ulya AMREF
Sam O’ngayo AMREF
Editor
David Harrison Health Systems Trust
FOREWORD
i
ACKNOWLEDGEMENTS
ii
INTRODUCTION
3
CHAPTER 1
HEALTH CARE IN MPUMALANGA:
WHY CHANGE HAD TO COME
9
Background
9
The New Focus
9
CHAPTER 2
AN OVERVIEW OF THE ORGANISATION OF HEALTH SERVICES
IN MPUMALANGA
15
Provincial Health Office
15
Regional Health Office
19
District Health Office
21
Distribution of Public Health Facilities in the Province
21
Other Health Service Providers
23
CHAPTER 3
A DISTRICT HEALTH SYSTEM AND ITS MANAGEMENT
27
The District Health System and Referral Networks
28
The District Health Management Team
31
Functions of other members of the DHMT
39
Health Facility Management Teams
40
Page
TABLE OF CONTENTS
TABLE OF CONTENTS
TABLE OF CONTENTS
Page
CHAPTER 4
THE ROLE OF COMMUNITIES IN HEALTH DEVELOPMENT
45
Getting to Know the Community You Serve
46
Forging Linkages and Partnership
47
Community Involvement in Health Care
47
CHAPTER 5
DELIVERING INTEGRATED PRIMARY HEALTH CARE
IN THE DISTRICT
55
The District Health for All Package
55
The Need for Integration of PHC Services
56
How the District PHC Package will be co-ordinated
58
Delivering Primary Health Care Services to Households
60
Health Facility Based PHC Services
62
CHAPTER 6
GOVERNANCE OF THE DISTRICT HEALTH SYSTEM
IN MPUMALANGA
69
The Governance Option for Mpumalanga
70
Governance of Health Services at Provincial Level
70
Governance of Health Services at District Level
71
Governance of Health Services at Facilities
71
Page
CHAPTER 7
PRIMARY HEALTH CARE SERVICE PROGRAMMES
77
Health Promotion
78
Maternal, Child and Women’s Health
80
Nutrition Programme
83
Primary Oral Health Care
85
Environmental Health
86
Communicable Diseases Control
88
Rehabilitation as a Service Programme
90
Emergency Health Services
92
Curative, Diagnostic and Medico-Legal Services
93
Mental Health and Substance Abuse
95
CHAPTER 8
A DISTRICT HEALTH AND MANAGEMENT INFORMATION SYSTEM
103
Health and Management Information Needs
103
Tools and Methods for Collecting and Processing Information
105
Advocating for the Use of Health Information
107
How to Establish a District Health and Management Information System
108
CHAPTER 9
MONITORING AND EVALUATION OF HEALTH SERVICES
113
Monitoring
113
Page
CHAPTER 10
DEVELOPING AND MANAGING HUMAN RESOURCES
125
Case Study
126
Human Resources Planning
127
Job Analysis and Job Description
127
Recruitment
128
Public Service Commission
128
Probation
128
Orientation and Induction
128
Performance Appraisal
129
Promotion
130
Discipline
130
Benefits
130
When Employees Leave (Exit)
130
Training and Development
131
Annexure of Acronyms
132
District Dictionary
134
3
INTRODUCING THIS GUIDE
Mpumalanga is one of the nine provinces of the Republic of South Africa. The population of the province is about 3 150 000 (1993 estimate).1 There are 10 provincial government departments. One of these is the
Department of Health, Welfare and Gender Affairs which is responsible for the Health portfolio. Within this department, there are two chief directorates: one for health and the other for welfare; and a sub-directorate of Gender Affairs which gives policy support to all the provincial departments.
Tremendous change is taking place in the character and organisation of health services in Mpumalanga. These changes are in accordance with policy guidelines from the National Department of Health2, and they
involve:
• decentralisation of services to the regions and districts to bring the services close to the people;
• adoption of the district health system as the vehicle for health care delivery in the province;
• the choice of primary health care as the strategy for delivery of universal health care to individuals, families and communities in the province;
• the need to involve stakeholders in planning and delivery of health services to the communities through meaningful community participation; and
• the need and desire to create a health service that cares for, and is responsive to client needs.
This guide is intended for you (health service managers, providers and consumers) in the province. The purpose of the guide is to:
• help all people involved in health care to understand the philosophy underlying the new developments in health care provision in the province;
• help those involved in health care to define their own roles and responsibilities; stimulate and guide all involved in health care to translate plans into action and concepts into practice; and
• enable health providers to explain to communities the changes and what the District Health System is all about.
The guide will help to accelerate the implementation of integrated health care services within the district health system, based on primary health care principles. As the key actions highlighted in the guide are put into practice, the province will be able to achieve its health goals and objectives - in line with the goals of the Reconstruction and Development Programme and the National Programme of Action for Children in South Africa. The guide provides a detailed description of the health services and should not be seen as prescriptive, but as providing guidelines. In applying the guidelines, you are encouraged to use your initiative and judgement.
The guide is divided into four parts. The first part, on service organisation and management, contains four chapters. The first chapter describes the philosophy behind the new changes. Chapter 2 sketches the services presently available in the province. The third chapter introduces the district health system, while chapter 4 describes the role of the communities in health development.
Part two of the handbook deals with PHC service delivery and governance and the section contains three chapters. Chapter 5 provides the framework for implementation of the PHC services, while chapter 6 focuses on governance systems for the health services. Chapter 7 describes the 10 (PHC) service programmes. The third part of the handbook discusses information, monitoring and evaluation. Chapter 8 discusses the district health and management information system (DHMIS) and chapter 9 focuses on monitoring and evaluation.
Part four of the handbook contains one chapter which describes the provincial plans for human resources development and management.
The process of writing the handbook took 6 months and it involved:
• rapid assessment of health needs in the province • literature review
• four workshops, a field visit to Agincourt, a health centre network in Bushbuckridge district, Northern Province; and
• extensive consultations with National officials, Regional Health Directors and District Health Managers, NGOs, and private providers.
1 Source: Regional Health Management Information System (ReHMIS)
4
The workshops and consultations provided the department with an opportunity to examine certain policies, and to think through the proposed structural and operational frameworks for service delivery. Some old policies and practices have been revised; new ideas have been introduced; and issues which require further debate, deliberation and provincial legislation have been identified.
The ideas presented in the text are not fixed; they are in evolution and will be redefined as necessary. Unresolved issues still remain. The department faces certain constraints and obstacles. Certain national and provincial policies are still to be finalised. Some changes in the service structure have already been put in place, but others are yet to come. A lot stands to be learnt during the first few years of implementing this new system. The lessons learnt will be put to use in improving the quality of health care for all individuals, families and communities in the province and in making future revisions to the handbook. The handbook does not provide all the answers - but we had to start somewhere. We are sure that this handbook will be of interest to the other provinces, too.
0 25 50 N Kilometers
Mpumalanga Province
Health Regions
Eastern Highveld Highveld region Lowveld regionR
E
G
I
O
N
Eastern Highveld Region Highveld Region
PART 1
HEALTH CARE IN MPUMALANGA:
WHY CHANGE HAD TO COME
CHA
9
Chapter 1
HEALTH CARE IN MPUMALANGA:
HEALTH CARE IN MPUMALANGA:
HEALTH CARE IN MPUMALANGA:
HEALTH CARE IN MPUMALANGA:
HEALTH CARE IN MPUMALANGA:
WHY CHANGE HAD TO COME
WHY CHANGE HAD TO COME
WHY CHANGE HAD TO COME
WHY CHANGE HAD TO COME
WHY CHANGE HAD TO COME
The objective of this chapter is to provide background information that will help you to understand why the change in health service delivery became necessary.
After reading this chapter, you will be able to:
• visualise the background to health services in the province;
• understand factors leading to changes in the health delivery system; • appreciate the need for change;
• identify key elements in the new focus for health care in the province; and • understand the rationale for decentralisation of health services to the districts.
BACKGROUND
The Department of Health, Welfare and Gender Affairs in Mpumalanga inherited a health system which was fragmented; inaccessible to the majority of the citizens of the province; and was also curative oriented and hospital based.
The hospital based, curative health services consumed the bulk of health resources of the province at the expense of preventive and promotive health services. As a result, patients with preventable conditions overloaded the hospital services. Prominent amongst these conditions were communicable diseases, diseases of childhood, nutritional deficiencies and manageable complications of pregnancy. For most of these conditions, prevention, easy treatment and control measures exist.
The overloading of hospitals by patients with preventable conditions created a vicious cycle which led to a greater demand for more hospitals. Huge investments were put into the construction and equipping of hospitals and the training of sophisticated health workers, with little or no allocation of resources for the development of a Primary Health Care system. Moreover, health care was available to only small numbers of the population, mainly those with the ability to pay and with easy access to hospitals and other facilities situated mainly in the cities and urban areas.
The other feature of the system inherited was the unequal distribution of resources along geographic and other lines. Health care facilities were concentrated in urban areas. This unequal distribution of health facilities led to disparities in health care coverage. The old strategy was thus inappropriate for the health care needs of the majority of people.
THE NEW FOCUS
The goal of the Department is to change, in four major ways, the manner in which health services are delivered in the province by:
• designing a health service delivery system which can reach the majority of people; • employing measures to prevent and treat preventable diseases and conditions • redirecting the thrust of health care in the broader context of development; and • providing a caring, compassionate service.
Primary Health Care Strategy
The Department is in the process of implementing a new strategy which will change the fragmented health system into a comprehensive and integrated health system based on Primary Health Care (PHC). This
10
strategy is derived from the National Health Bill, the Reconstruction and Development Programme (RDP), the official policy of the National Department of Health and the National Programme of Action for Children (NPA). Central to this strategy is commitment to a system of health care that is accessible and affordable and addresses the socio-economic issues which impact on health, through community participation and intersectoral collaboration
Defined simply, primary health care is affordable, sustainable, and universal essential health care for all
individuals, families and communities in the district, rendered in accordance with the people’s health needs,
acceptance and their full participation.1
Enshrined in the primary health care strategy are the concepts of keeping people healthy in their homes and caring for them in health facilities when they become unwell. This strategy uses the district as the centre for planning, implementing and evaluating PHC services. The comprehensive primary health care approach incorporates a broad definition of health; the nature and role of health services; and the relationship between health services and other interventions which improve the health status of the people.
Decentralisation of Health Services
Health services in the province are decentralised to the districts, giving the District Health Managers appropriate powers in respect of personnel and financial contr ols. This will increase responsibility, accountability and efficiency of the service. It will also boost staff morale and encourage local initiative and flexibility in dealing with changing local circumstances
The purpose for decentralising health services to the district level is to:
• allow primary health care services to be brought nearer to all communities in the district so as to allow decisions to be taken at the operational level;
• promote participation by communities in planning and delivery of health services; • ensure responsiveness of health services to the health needs of the communities;
• create an environment for transparency and accountability of the services to the communities; and
• facilitate collaboration with other government sectors that have a bearing on health.
Characteristics of the New Service
The Department aims to transform health care in Mpumalanga into a caring, compassionate service that is responsive to local health needs and is accountable to its community. The service will put emphasis on health promotion, disease prevention, early diagnosis and treatment to prevent complications, community-based r ehabilitation of people with chronic disabilities and palliative therapy. The key elements of the new delivery system are briefly discussed below.
Q u a l i t y S e r v i c e
The following factors are regarded as important and will be assured in all health facilities:
• care should be technically sound and in accordance with national standards of practice; • the general environment of the health facility, including cleanliness, attitude and approach of
staff should be caring;
• client satisfaction and happiness should be a prime consideration; and
• health services should be responsive to the broader problems of the community e.g. lack of food, water and sanitation; and illiteracy.
Good quality health care includes:
• ensuring that the patient’s and health provider’s rights are protected in accordance with the provisions of Chapter 2 of the National Health Act;
• minimising waiting time for the patient/client;
• having a pleasant staff and a hospitable environment; • respecting the client’s/patient’s dignity, culture and values;
• giving full explanation to the patient/client as well as to relatives about his/her condition; • ensuring availability of drugs; and
• organising opening and closing time to meet the needs of the community. 1 Adapted from Alma Ata Declaration
11
I n t e g r a t e d , C o m p r e h e n s i v e S e r v i c e s
The District Health Management Teams (DHMTs) will have an effective service delivery strategy that minimises wastage and maximises benefits to the people. All activities will be integrated and the health care system organised to focus on PHC. The DHMTs will plan, deliver and manage an integrated and comprehensive service both at household and facility levels.
E f f e c t i v e n e s s a n d E f f i c i e n c y
The DHMTs should target resources appropriately in order to obtain demonstrable health benefits and maximise health gains at the lowest possible cost. This will need careful planning, implementation and monitoring of health activities. Use of services will be rationalised such that only services that cannot be provided at lower levels of health care are rendered at the higher levels, with a clearly established referral system.
E q u i t y a n d A c c e s s i b i l i t y
Service planning will ensure that underserved communities benefit from a system that promotes equity in the provision of services. This system will be developed and put in place by directing resources according to need, with emphasis on disadvantaged communities. Any person who needs access to primary health care services will obtain them without restrictions from the health authorities.
C o m m u n i t y P a r t i c i p a t i o n a n d L o c a l A c c o u n t a b i l i t y
In order to promote ownership of health development, the communities, through their representatives and interest groups, will be encouraged to participate in the planning, provision, control and monitoring of health services. Communities will be represented in governance structures at community and district levels. Mechanisms are being developed for ensuring that staff and service in a district or local area within the district are accountable to the local communities they serve. Continuing dialogue between the communities, health service providers and relevant sectors will be essential in establishing the mechanisms.
I n t e r s e c t o r a l A p p r o a c h t o H e a l t h D e v e l o p m e n t
Intersectoral collaboration, information sharing and joint efforts are essential for health promotion and prevention of ill health. Partnership is the key to empowering communities and individuals to take responsibility for the promotion and maintenance of their health. While carrying out their tasks, health workers will give due recognition to the role and place of other players and facilitate their participation.
S u s t a i n a b i l i t y o f S e r v i c e s
As DHMTs attempt to put new systems in place, they should develop ways and means of ensuring that services are sustainable. In this regard the districts will need to establish a secure financial base to allow for long-term planning.
In this chapter you have read about the background leading to changes in the way health services are delivered in the province. These changes affect you - the consumer, health provider or service manager. Implementation and management of change is difficult. In order for the changes to be successfully implemented, all stakeholders have a role to play. This calls for conviction, commitment, dedication and understanding.
AN OVERVIEW OF THE HEALTH SERVICES IN
MPUMALANGA
CHA
15
Chapter 2
AN OVERVIEW OF THE HEALTH
AN OVERVIEW OF THE HEALTH
AN OVERVIEW OF THE HEALTH
AN OVERVIEW OF THE HEALTH
AN OVERVIEW OF THE HEALTH
SERVICES IN MPUMALANGA
SERVICES IN MPUMALANGA
SERVICES IN MPUMALANGA
SERVICES IN MPUMALANGA
SERVICES IN MPUMALANGA
In chapter one, you read about the circumstances leading to changes in the delivery of health care in the province. This chapter describes the organisational structure of health services in Mpumalanga Province and the functional relationships between various service levels in the province.
After reading the chapter, you will be able to:
• understand how health services are organised in the province; • know how the province is divided into regions and districts;
• understand the roles of the provincial, regional and district health offices; and • appreciate the functional linkages between different service levels.
National and provincial levels of health care in many countries (particularly those which are geographically large or have large populations) are too far removed from the community to be responsive to local health needs. In Mpumalanga, the system of delivery and management of health services has been decentralised in accordance with Government guidelines, in an attempt to bring both the services and service management closer to the people, thereby enabling them to respond more effectively to local needs. The health services in the province are therefore structured in three levels: provincial, regional and district. Each level will be discussed below:
PROVINCIAL HEALTH OFFICE
The political head of the provincial Department of Health, Welfare and Gender Affairs is the Member of the Executive Council (MEC) with the Deputy Director-General (DDG) as the chief executive of the department.
There are two Chief Directorates in the department: Health and Welfare. Gender Affairs is an independent sub-directorate that gives gender policy support to the two Chief Directorates and all the departments in the province (see Figure 2.1). The Chief Directorate receives administrative support from the Directorate of Administration which also serves the Chief Directorate for Welfare and the Gender Affairs Sub-Directorate (see Figures 2.1 & 2.2). The specific functions of the Directorate of Administration are:
• formulation of policies in respect of general administration and financial matters; • determination of norms and standards; and
• handling of matters pertaining to personnel administration, transport and auxiliary services, finance, provisioning and procurement.
16
Figure 2.1 The Organisational Structure of the Department of Health, Welfare and Gender Affairs
Member of the Ex
ecutive Council
Chief
Dir
ectorate:
Health
Dir
ectorate:
Primary
Health
Dir
ectorate:
Secondary
Services
Dir
ectorate:
Policy
, Planning
& Information
Chief
Dir
ectorate:
W
elfar
e
Dir
ectorate:
Social
W
ork
Sub-Dir
ectorate:
Population and
Development
Dir
ectorate:
Social
Security
Dir
ectorate:
Administration
Sub-Dir
ectorate:
Gender
Affairs
Deputy Dir
ector
-General
17
The Provincial Health Office derives its authority from the Health Act, the National Constitution and other relevant health related legislation. The purpose of the Provincial Health Office is to ensure that national and provincial health policies are translated into action.
How is the Provincial Health Office Structured?
The Provincial Health Office (see Figure 2.2) consists of:
• The Chief Directorate; • 3 Support Directorates:
- Primary Health Care Services - Secondary Health Care Services
- Policy, Planning and Information Services; • 3 Regional Directorates:
- Lowveld Region - Highveld Region
- Eastern Highveld Region; • The Nursing College; and
• Provincial Pharmaceutical Services and Medicines Control Unit. Figure 2.2 The Organisational Structure of the Provincial Health Office
* The Nursing College will remain a line function of the Chief Directorate until a national decision is made as to whether the training of nurses will be the responsibility of General Education or Health. If this does not happen, the possibility of setting up satellite colleges in each region will be looked into.
Chief Directorate:
Health
Directorate:
Primary Health
Care Services
Directorate:
Secondary
Health Services
Directorate:
Policy, Planning
and Information
Services
Directorate:
Administration
*Nursing
College
Pharmaceutical
Services &
Medicines
Control Unit
Regional
Directorate:
Lowveld
Regional
Directorate:
Highveld
Regional
Directorate:
Eastern
Highveld
18
The Functions of the Chief Directorate
The specific responsibilities of the Chief Directorate are:
• development of policy guidelines, norms and standards, in accordance with national policy framework;
• provision of professional support to planning, development and implementation of primary and secondary health care programmes and services as well as an information service;
• provision of support to planning, development and implementation of the district health system; • monitoring and evaluation of the health services;
• national and inter-provincial liaison; and
• procurement, distribution and control of pharmaceuticals and medicines.
Functions of the Support Directorates
The 3 Directorates (Primary Health Care; Secondary Health Services; and Policy, Planning and Information Services) have no line functions. They provide support to the Chief Directorate. Their specific functions are given in Table 2.1
Table 2.1 Functions of the Support Directorates
Directorate:
Primary Health Care Services
Purpose:
To provide service development
support function to the Chief
Directorate of Health in respect of
Primary Health Care Services (PHC
Programmes and Community
Services)
Functions:
1. Formulate policy for Primary
Health Care Services.
2. D e t e r m i n e n o r m s a n d
standards.
3. Plan and develop Primary
Health Care Services and
Programmes and provide
service support to regional
directors.
4. Provide support in planning
and development of a District
Health System.
5. Monitor and evaluate Primary
Health Care Services.
6. Provide support to human
resources development in
respect of primary health
care
Directorate:
Secondary Health Services
Purpose:
To provide service development
support function to the Chief
Directorate of Health in respect of
Secondary Health Care Services
(curative and related programmes,
emergency health, laboratory and
associated health services).
Functions:
1. Formulate policy for curative
a n d s e c o n d a r y h e a l t h
programmes.
2. D e t e r m i n e n o r m s a n d
standards.
3. M o n i t o r a n d e v a l u a t e
curative and secondary health
programmes.
4. Provide support to Secondary
Health Services.
5. Provide support to human
resources development in
respect of Secondary Health
Sevices.
Directorate:
Policy, Planning and Information
Purpose:
To provide service development
support function to the Chief
Directorate of Health in respect of
General Health Policy, Planning
and Information Services (including
Health Information).
Functions:
1. Co-ordinate policy formulation
in support of the directorates
for primary and secondary
health services.
2. Determine norms and standards
for policy, planning and
information.
3. Plan, develop and integrate
policy, planning and information
services.
4. Provide support to regional
directors in respect of policy,
planning and information.
5. Monitor and evaluate policy,
planning and information
services.
6. Provide support in planning
and information development
for the District Health System.
19
The policies of the Provincial Health Office are implemented through 3 regional health directorates (Highveld, Eastern Highveld and Lowveld), a Nursing College and a provincial Pharmaceutical and Medicines Control Unit (see Figure 2.2).
The Nursing College
The Nursing College has line responsibility to the Provincial Health Office with regard to human resources development in the nursing profession.
Provincial Pharmaceutical & Medicines Control Unit
The Provincial Pharmaceutical and Medicines Control Unit will be responsible for:
• procuring and supplying pharmaceuticals and surgical sundries to service points; • implementing and monitoring drug policies, with emphasis on rational use of drugs; • control and inspection of medicines;
• providing information and advice on pharmaceuticals to prescribers and users with emphasis on essential drugs; and
• developing computer systems for pharmacies with the assistance of the computer division in the administration.
THE REGIONAL HEALTH OFFICE
The province has been divided into 3 health regions: the Lowveld, Highveld and Eastern Highveld. The three regions and their districts are given in Figure 2.3. The population of each district is also included.
Figure 2.3 The Health Regions and Districts in Mpumalanga
* Source: ReHMIS (1993 figures)
** It is envisaged that Bushbuckridge (presently part of Northern Province) will be incorporated into Mpumalanga Province. If that happens it will then be part of the Lowveld Region. It has an estimated population of 500,000
Mpumalanga Province
HIGHVELD REGION
District Population* 1. Lydenburg 83 961 2. Middelburg 148 837 3. Witbank 184 675 4. Groblersdal 62 005 5. Kwamhlanga 231 076 6. Mmamethlake 111 749 7. Philadelphia 247 264LOWVELD REGION**
District Population* 1. Barberton 37 599 2. Tonga 314 732 3. Shongwe 307 948 4. Kabokweni 221 346 5. Sabie 31 110 6. Nelspruit 212 855EASTERN HIGHVELD
District Population* 1. Eerste Hoek 241 396 2. Volkrust 81 967 3. Ermelo 116 632 4. Piet Retief 92 740 5. Delmas 52 105 6. Standerton 133 327 7. Bethal 70 628 8. Highveld Ridge 166 149 Total 954 944 Total 1 125 641 Total 1 069 56720
The Health Regions will be managed through the Regional Health Offices (RHOs). The RHOs are responsible for facilitating establishment of the district health system and for providing support to the District Health Management Teams in rendering health care to the communities. The RHO consists of:
• Regional Directorate;
• Sub-Directorate for Health Information;
• Sub-Directorate for Administration and Finance; and • Academic Support Unit
Functions of the Regional Directorate
Reporting directly to the Chief Directorate, the Regional Directorates are to:
• translate provincial health policies and strategies into operational plans; • co-ordinate regional health programmes and activities;
• provide support to districts in development of health plans and service delivery.
• promote and co-ordinate inter-sectoral collaboration in health promotion and development activities;
• promote and co-ordinate liaison between the health services in the region and relevant academic institutions;
• ensure provision of referral health services to all districts by their designated referral hospitals; • co-ordinate emergency services in the region; and
• oversee the functions of regional referral hospitals.
The Sub-Directorate for Health Information
This Sub-Directorate provides support to districts in development of health and management information systems.
The Sub-Directorate for Administration and Finance is to:
• ensure the provision of support services including laundry and catering to the districts; • provide support to the districts in development of budgets and finance management; and • provide support to the districts in staff development and management.
The Academic Support Unit
The province has entered into agreements with the Medical University of Southern Africa (MEDUNSA), the University of Pretoria and the University of the Witwatersrand through which it is envisaged that the following will take place:
• appointment of personnel to support the clinical, research, human resource development, and management needs of the province through joint contracts;
• provision of access to all health facilities in the province to under-and post-graduate students for service attachment;
• provision of advice to the regional manager on norms, standards, protocols and managerial inputs by the academic support representative; and
• provision of opportunities for joint development of community-based and problem-oriented learning.
Regional Services and Facilities
R e f e r r a l H o s p i t a l s
It is envisaged that there will be a referral hospital complex in each Region. A referral hospital should have the following specialities:
Full time: Surgery, Obstetrics & Gynaecology, Paediatrics; Internal Medicine; Family Medicine; Orthopaedics; Radiology; Anaesthesiology; Community Health. Part-time: Ophthalmology; Ear, Nose and Throat Surgery; Dermatology; Psychiatry; Urology The specialists will also provide support to the lower levels of health facilities.
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Tu b e r c u l o s i s H o s p i t a l s
There are also 3 hospitals run by the South African National Tuberculosis Association (SANTA) and subsidised by the state. They are:
• Barberton (SANTA) - Lowveld;
• Standerton (SANTA)- Eastern Highveld; and • Witbank (SANTA)- Highveld.
They are regionally controlled and supervised. There is also a chronic care facility in the Lowveld Region (Bongani Hospital) and a small local authority tuberculosis (TB) hospital (Sesifuba) in the Eastern Highveld Region. With the increase in TB and the HIV epidemic, the Department intends to maintain one TB hospital per region.
A Multiple Drug Resistance Unit (MDRU) will be established in one TB hospital in the province for standardised therapy and monitoring of all multiple drug resistance tuberculosis (MDR TB) patients under supervision of the provincial TB specialist.
THE DISTRICT HEALTH OFFICE
At present the province is divided into 21 health districts: 7 in the Highveld; 8 in the Eastern Highveld; and 6 in the Lowveld. The boundaries between districts are not fixed, they are “soft.” This means that the existing boundaries could still be re-defined, by creating new health districts or abolishing existing ones. The National Health Bill provides powers to the MEC to create new health districts or abolish existing ones.
The criteria for establishment of a health district include the following:
• health needs;
• population size and distribution;
• communication network (roads, telephones); • social and economic factors;
• political factors (coterminous with local government/magisterial boundaries); • physical barriers; and
• sustainability.
Functions of a District Health Office
The health district is managed through the District Health Office. The generic functions of a district health office are to:
• ensure health service delivery to the communities in the district;
• ensur e proper management and utilisation of resources allocated to the health district; • manage and develop health personnel serving in the district; and
• develop, maintain and manage the district health information system.
These functions are described in detail in chapter 3.
Distribution of Public Health Facilities in the Province
There are 27 hospitals, 22 community health centres, 199 clinics, 97 mobile clinics and 3570 visiting points in the province. The distribution of these facilities in the districts is given in Table 2.2. The task facing the DHMT is to organise the health facilities into a district health system by:
• identifying primary and secondary catchment areas;
• rationalising facility distribution according to the health needs which might mean that some facilities are down graded or upgraded;
• ensuring that patients do not walk more than 5 kilometres to a clinic;
• maintaining a balance between primary care and secondary care (this may mean a conscious and determined action to shift resources from secondary to primary care level);
• restructuring the district staff establishments to reflect needs at all levels of care; and • rationalising the distribution of personnel according to PHC needs at various levels.
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1. Eastern Highveld Region
Type of Facility
District Clinics Health Centres Hospitals Mobile Clinics Visiting Points
1 Bethal 6 0 1 4 205 2 Delmas 2 2 1 4 144 3 Eerstehoek 16 1 2 3 144 4 Ermelo 9 0 2(1TB) 4 193 5 Highveld Ridge 6 1 1 2 71 6 Piet Retief 5 0 1 4 210 7 Standerton 10 0 1(TB) 5 229 8 Volksrust 7 0 1 6 230 Sub-Total Eastern Highveld 61 4 10 32 1426 2. Highveld Region Type of Facility
District Clinics Health Centres Hospitals Mobile Clinics Visiting Points
1 Groblersdal 1 0 1 6 727 2 Kwa-Mhlanga 17 3 1 1 4 3 Lydenburg 13 0 3 7 246 4 Middelburg 9 0 1 3 145 5 Mmamethlake 13 4 1 2 12 6 Philadelphia 10 3 1 5 21 7 Witbank 10 1 2(1TB) 7 236 Sub-Total Highveld 73 11 10 31 1391 3. Lowveld Region Type of Facility
District Clinics Health Centres Hospitals Mobile Clinics Visiting Points
1 Barberton 4 2 2(1TB) 4 231 2 Kabokweni 18 0 2(1TB) 5 26 3 Nelspruit 8 3 1 4 168 4 Tonga 11 2 0 12 118 5 Shongwe 16 0 1 8 117 6 Sabie-Mathibidi 8 0 1 1 93 Sub-Total Lowveld 65 7 7 34 753 Provincial Total 199 22 27 97 3570
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OTHER HEALTH SERVICE PROVIDERS
Local Authorities
Apart from the Provincial Health Department, various authorities are responsible for the provision of health services e.g. Transitional Local Councils (TLCs), Transitional Rural Councils (TRCs) and District Councils (DCs). In the past, local authorities provided mainly preventive health services. This will, however, change so that all local authorities are involved in delivering comprehensive primary health care to their residents. The Department of Health, Gender and Welfare Affairs together with the respective local authorities will bring change by:
• eliminating the duplication of services e.g. where a provincial and a local authority clinic are operating next to each other, the district will negotiate with stakeholders and rationalise the services by closing down one of them; and
• providing all local authorities with medicines on the essential drug list free of cost.
Successful implementation of this will require:
• working towards harmonised conditions of service; and
• delivering a comprehensive PHC package at the local authority clinics based on needs of the community.
Private Sector
It is envisaged that the District Health Authority (DHA)1 will be directly responsible for the provision of
all public sector primary health care services in the district. The DHA will also be the mechanism through which links are established with other health care providers in the district, including the private health care providers and non-governmental organisations.
The National Health Plan for Universal Access to Primary Health Care envisages a district health system based primarily on the public health sector, but providing for contractual relationships between the district health authority and accredited private providers within the district. These private providers will complement the public sector service provided by the DHA.
Non-government Organisations
A variety of non-governmental initiatives including community based organisations (CBOs), religious organisations and other non-governmental organisations are active in a variety of health-related development and service activities. These activities are important in mobilising effective community participation and promoting intersectoral action for health development.
Part-time Services
This service is already available in the form of:
Part-time Medical Officers
The part-time Medical Officer (or specialist) performs duties on a session basis as described in the Public Administration Standards manual. The sessions referred to are a period of duty performed on a continuous basis. One session equals one hour per week duty over a year, i.e. 52 hours per year.
The part-time Medical Officer is appointed on a temporary basis against a vacant post or sessions provided for on the establishment of the institution where duty is rendered. The duties assigned to the part-time Medical Officer may consist of regular duties performed during normal working hours or duties performed after hours on a more irregular basis. The temporary and part-time appointment means that he/she is not entitled to the benefits accorded to full-time employees such as paid annual leave, membership of pension fund and medical aid.
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Part-Time District Surgeon (PTDS)
The part-time District Surgeon renders duties for the following services:
Personal Health Care: These are mainly curative clinical duties performed for certain categories of patients.
Forensic Medical Duties: These are duties performed at the request of government officers charged with the responsibility of investigating activities of a criminal nature and other fact finding processes of the law. This includes the performance of post-mortems, examination of persons involved in cases of assault, rape or other criminal activities.
Ex-officio Duties: These are duties that are mainly performed on behalf of other state departments and includes the examination of persons for disability, determination of age, admitted and discharged prisoners or persons in custody, and the certification of persons under the Mental Health Act.
The part-time District Surgeon is currently appointed on a contractual basis, with the contract detailing the duties and obligations of the District Surgeon as well as the employer (the Province). Legal opinion is currently being sought on the exact position the part-time District Surgeon has and whether he/she should be regarded as a contract worker or as an official.
The remuneration of the part-time District Surgeon is largely determined by the activities resulting from his duties. The activities are converted into hours per week equalling sessions as paid to the part-time Medical Officer. The sessions are adjusted on a regular basis according to statistics of activities.
This service will be restructured and integrated into the Primary Health Care System to achieve an integrated community health service. All clinical aspects of their service will be provided at clinics or health centres. Medico-legal services for assaults, rape, drunkenness, etc will be referred to the health centre or district hospital. Prison medical services and Forensic Pathology (i.e. post mortems, exhumations) will for the time being remain with the PTDS.
The Traditional Healers
In some districts there is already a close working relationship with the traditional healers. The department supports this relationship and District Health Managers are encouraged to strengthen this relationship so that they can involve Traditional Healers in the delivery of PHC services.
This chapter has described the decentralisation of services to the district level and the structure, composition and functions at the various levels. You have also read about the distribution of health facilities in the province and the service providers. The management of the services at various levels is discussed in the next chapter.
A DISTRICT HEALTH SYSTEM AND ITS
MANAGEMENT
CHA
PTER 3
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Chapter 3
A DISTRICT HEALTH SYSTEM
A DISTRICT HEALTH SYSTEM
A DISTRICT HEALTH SYSTEM
A DISTRICT HEALTH SYSTEM
A DISTRICT HEALTH SYSTEM
AND ITS MANAGEMENT
AND ITS MANAGEMENT
AND ITS MANAGEMENT
AND ITS MANAGEMENT
AND ITS MANAGEMENT
The previous chapter discussed the organisation of health services in the province and the rationale for their decentralisation. This chapter aims at presenting to you the concept of a District Health System, its various components, functional inter-relationships and management.
After reading the chapter, you will be able to:
• understand the concept of a District Health System;
• appreciate a District Health System as a vehicle for delivery of primary health care; • identify the elements that constitute a District Health System;
• understand the importance of the facility and service referral network in a District Health System;
• understand the methods for delivery of health services in facility catchment areas; and • understand the management system for District Health Office and its component health
facilities. Eastern Highveld Highveld region Lowveld region R E G I O N 0 25 50 N Kilometers Standerton Highveld Ridge Delmas Bethal Volksrust Ermelo Piet Retief Carolina Lydenburg Middelburg Witbank Groblersdal KwaMhlanga Mmamethlake Philadelphia Sabie Nelspruit Barberton Kabokweni Shongwe Tonga Bushbuckridge
Mpumalanga
Health Districts
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If you are a health service manager, health worker or a service beneficiary, you need to know the range of health facilities in your district; what health services are rendered at each health facility, and by who. You need to know also the referral system that links the various health service levels. Ultimately you need to know how these services and facilities relate to you.
THE DISTRICT HEALTH SYSTEM AND REFERRAL NETWORKS
What is a District Health System?
The World Health Organization defines a District Health System as follows:
A District Health System based on Primary Health Care is a more or less contained segment of the National Health System. It comprises, first and foremost, a well-defined population, living within a clearly delineated administrative and geographical area, whether urban or rural. It includes all institutions and individuals providing health care in the district, whether governmental, social security, non-governmental, private, or traditional. A District Health System, therefore, consists of a large variety of inter-related elements that contribute to health in homes, schools, work places, and communities, through the health and other related sectors. It includes self care and all health care workers and facilities, up to and including the hospital at the first referral levels, and the appropriate laboratory, other diagnostic, and logistic support services.
A district health system is thus a network of health facilities, services and providers, all catering for the same ultimate goal of promoting the health of a defined population in the district.
In Mpumalanga, the district health system comprises the district health office, district hospital, community health centres, clinics and smaller facilities such as mobile units and visiting points, operated by both the provincial department, local authorities, the private sector, non-governmental organisations (NGOs) and community based organisations (CBOs).
Health Service Levels in the District Health System
In Mpumalanga the District Health System is based on a five-level network of functional units which includes:
• households; • visiting points; • clinics;
• health centres; and • the district hospital.
Each of these services is described below.
H o u s e h o l d
The household level is the focus for health development in Mpumalanga and the starting point for health care. Household members require adequate information based upon which they can make decisions and adopt appropriate health seeking behaviour. Community based health workers/promoters are essential in the empowerment of households with the necessary information and skills.
V i s i t i n g P o i n t
This is a service delivery point where the health providers render primary health care services to the community as an outreach activity. The providers visit the facility at intermittent but regular intervals.
C l i n i c
This is a fixed structure in which basic health services are provided, usually by nurses. It should open 12 hours a day for five days in a week. It is the facility in the referral system which links the community to the formal health facility referral network. It renders primary health care services to the communities around it. This area of jurisdiction is known as the catchment area.
H e a l t h C e n t r e
The health centre is a fixed structure which provides comprehensive primary health care to the immediate community around it. It is also a referral centre for the clinics. However, the primary health care services rendered to the immediate community around should, wherever possible, be provided at a point different from the outpatient department which should receive the referrals from the clinics.
D i s t r i c t H o s p i t a l
The district hospital is the non-specialist facility to which patients from clinics or health centres may be referred. The district hospital provides comprehensive PHC services to the community around it. However, this service should be rendered at a service point different from the outpatient department which should be reserved for receiving referrals from health centres and clinics in the district.
T h e H e a l t h F a c i l i t y C a t c h m e n t A r e a
Figure 3.1. depicts the concept of health facility catchment areas.
Figure 3.1 The Catchment areas for Various Levels of Health Facilities
Each health facility in the network is expected to render comprehensive primary health care services to the communities in a defined geographic area around the facility, referred to as the catchment area. The health facility is responsible for the health of all people in the catchment area and not only those who attend the facility for care. Whereas every health clinic will serve the population within a defined geographic area
District hospital Health centre Clinic
KEY: Catchment areas for:
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around it, a health centre will cover both the community around it as well as several catchment areas catered for by the clinics for which the health centre serves as a referral facility.
A district hospital will serve as a referral facility for all the health centres and clinics within the district. Hence its catchment area is the district.
How The Referral System Will Work
In the past the various health facilities and services in the province were independent of one another. In the transformed health organisation, a simple common integrated system is envisaged and will be emphasised in order to bring together a number of separate systems and administrations.
In the District Health System model, all the facilities in the district form a clear referral network of health services from household➮community➮clinic➮ health centre➮ hospital with increasing service capacity from one level to the next, in terms of the range and complexity of services rendered. The referral hierarchy however does not mean that the higher health care levels are superior in terms of benefits and resource allocation (see Figure 3.2).
Figure 3.2 The District Health Facility Network
HOUSEHOLDS
HOUSEHOLDS
VISITING
POINTS
HOUSEHOLDS
COMMUNITY
CLINICS
HOUSEHOLDS
HEALTH
CENTRES
HOUSEHOLDS
DISTRICT
HOSPITAL
HOUSEHOLDS
OTHER
COMMUNITY
HEALTH
FACILITIES
OTHER
SECTORS
DISTRICT HEALTH OFFICE
Collaboration with other
providers
Intersectoral Collaboration
Key: The arrows indicate the referral network involving health facilities, district health office and other sectors Adapted from Monekosso GL
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The referral system in the District Health System will entail:
• knowing what condition needs to be referred; • knowing where to refer to;
• knowing when to refer;
• establishing the procedures for referral; and • training the staff on managing the referral system.
Ideally the entry point for the referral system is the lower level facility, namely the clinic.
At the community level, the community based health workers (CBHWs/promoters) advise clients/patients to seek health care at the clinic. At the clinic, the manager may refer a patient/client to a health centre or hospital clearly indicating the reason for referral. At the health centre, the manager or any appropriate staff may refer a patient/client to the district hospital for emergency or regular clinics. Patients/clients requiring specialised treatment will be screened at the district hospital and referred to regional referral hospitals. Higher levels of care may also refer patients/clients to the lower levels for maintenance therapy or follow-up. Only in emergencies can patients enter at any level (see Figure 3.1). It is envisaged that patients/clients who do not follow the referral system will be liable to a by-pass fee.
A critical element in the referral system is communication. An appropriate referral tool (form) and protocol will be developed by the provincial health office.
Within the multi-level health service structure in your district there are a number of systems that need to work effectively. Such systems include:
• systems for diagnosis, referral, treatment and care of patients;
• systems for identifying and tackling the community’s major health problems; • transport and communication systems;
• management systems related to staff recruitment, selection, training, supervision, support and performance appraisal;
• systems for the procurement and distribution of drugs, pharmaceuticals, equipment and other supplies;
• systems for management of finance;
• systems for health information management; and
• systems formonitoring and evaluation of the health services.
Good management of these systems is critical for effective service delivery in the district.
Each Service Level i.e. the clinic, community health centre, district or referral hospital and district health office will be managed by a specific management team, namely, the:
• District Health Management Team for the district health office; • Hospital Management Team for the district hospital;
• Health Centre Management Team for the health centre; and • Clinic Management Team for the clinic.
The composition and functions of each management team are discussed separately below:
THE DISTRICT HEALTH MANAGEMENT TEAM (DHMT)
Each health district will be managed by a District Health Management (DHMT) which will have overall responsibility for provision and management of the district health services. The organogram illustrating the relationships between the various staff positions of the DHMT is given in Figure 3.3.
Figure 3.3 Composition of a District Health Management Team
DISTRICT HEALTH INFORMATION MANAGER DISTRICT PHARMACIST FINANCE AND ADMINISTRATION MANAGER HUMAN RESOURCES DEVELOPMENT MANAGER DISTRICT PRIMARY HEALTH CARE CO-ORDINATOR ACADEMIC SUPPORT REPRESENTATIVE DISTRICT HEALTH MANAGER
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Members of the District Health Management Team (DHMT) (see Figure 3.3) are:
• District Health Manager
• District Primary Health Care Co-ordinator • Administration & Finance Manager • Health Information Manager
• Human Resources Development Manager • District Pharmacist
• Academic Support Representative
The District Health Manager
As District Health Manager, you are responsible for the development, provision and supervision of health services in the district, including monitoring and evaluation of coverage, efficiency and effectiveness. In particular you are expected to:
• co-ordinate the development and implementation of the district health plan;
• ensure delivery of comprehensive primary health care to the communities in the district; • ensure access to referral health services;
• pur chase, via provincial procurement system, phar maceuticals and surgical sundries; • ensure registration and maintenance of district health assets;
• appoint, evaluate, discipline and promote staff in the district, subject to powers delegated by the Provincial Health Office;
• control the district capital and recurrent health budget;
• purchase services from independent providers in the district where appropriate e.g. accredited private practitioners, environmental services, local authorities, NGOs, etc;
• take responsibility for ensuring that decisions made by the DHMT are implemented; and • ensure a caring, quality service.
The District Health Manager carries a very important responsibility especially at this critical phase in the development and establishment of a district health system. The task will require establishing a management culture based on the principles of management by objectives which are described below:
Management by Objectives
Management by objectives is a continuous process that requires you to:
• critically review and even re-state the long-term and short-term health plans of the district;
• clarify with each manager and the PHC team their roles, responsibilities and key outcome areas; • agree with each manager, PHC team on “targets” and “action plans” based on identified health
problems and resources available; and
• provide the right working atmosphere in which other team members can achieve their objectives, for example through training and support where necessary.
This approach seeks to integrate three things:
• the achievement of the aim and purposes of the district plan (as expressed in the Policy Guidelines on District Health Systems, the National Health Act and your own district health plan); • incorporation of individual plans of all health service managers within the district to the overall district
health plan; and
• development of skills in your own sphere of work and those who work with you.
For you and your service managers to be successful, you need to agree on broad objectives and targets with other people, thereby benefitting from their ideas. Such an exercise also helps to strengthen the commitment of all concerned. You should as much as possible attempt to link new programme objectives to ongoing and planned health and health related interventions and support systems in the district.
Used sensibly, management by objectives is a technique which helps the District Manager, service managers and the PHC team to tackle the day to day work and the future development of the district in a systematic way.
