Primary Health Care in Mpumalanga:

Primary Health Care in Mpumalanga: Highveld Lowveld Eastern Highveld Guide to district-based action

T 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 Published by the Health Systems Trust S H 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

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 i

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. Maureen Beck Coenie Bekker Kelvin Bellinghurst Leon Bonnet Clara Chiloane Deon Cloete Dave Durrheim Danie Groenewald Bernice Harris Rebecca Hlatshwayo Felicity Gibbs John Gear Nobayeni Dladla David Harrison David Mametja Joan Matji Eddie Mhlanga Eddie McGrath Mandi Mzimba Sam Kazibwe William Okedi Vincent Orinda Steve Tollman Yogan Pillay Rowina Jordaan Gulam Karim Judith Lubisi Elizabeth Malumane Len Mdluli Amos Masango Thalitha Modonsela Janet Maphanga Gladness Mathebula Keith Michael Writers Resource Persons Get Ahead Foundation Wits Rural Foundation Department of Health (National) Health Systems Trust Health Systems Trust UNICEF Department of Health (National) Department of Health (National) Department of Health (National) AMREF AMREF UNICEF Health Systems Development Unit Department of Health (National) Reviewers Sam Mkhabela Irene Mkhabela Pat Mkhwanazi Collin Mupombwa Shirley Ngwenya Sonto Nxumalo Jabulani Mndebele Andrew Pond Christine Phiri Andrina Sambo Alucia Shabangu Kareen Swart Lynn Viljoen Bonnyface Wankya Milani Wolmarans Masingita Zwane Elise Appel Peter Barron Irwin Friedman Lucy Gilson Arthur Haywood Peter Long Lydia Pretorius William Pick Laetitia Rispel Hugh Philpott National Progressive Primary Health Care Network Health Systems Trust National Progressive Primary Health Care Network University of the Witwatersrand University of the Western Cape National Progressive Primary Health Care Network National Disability Desk University of Witwatersrand University of the Witwatersrand Centre for Health and Social Studies - University of Natal ii

Secretariat Graziela DeSouza Theresa Knoetze Irene Mathare Busi Mathabela Rose Mgwenya Anna Nkosi Lucas Nkosi Doreen Nkuna Maritjie Petzer Michael Skhosana Co-ordinators Nomonde Bam Kathy Kahn Wynand Nant ulya Sam O ngayo Primary Health Care (Mpumalanga) Health Systems Development Unit AMREF AMREF Editor David Harrison Health Systems Trust iii

TABLE OF CONTENTS Page 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 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 Community Health Committees 73

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 Evaluation 117

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 Additional References 142

INTRODUCTION

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 Health 2, 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) 2 A Policy for the Development of a District Health System for South Africa, National Department of Health, 1994 3

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. Mpumalanga Province Health Regions Highveld Region Lowveld Region R E G I O N Eastern Highveld Eastern Highveld Region Highveld region Lowveld region N 0 25 50 Kilometers 4

PART 1 Service Organisation and Management

HEALTH CARE IN MPUMALANGA: WHY CHANGE HAD TO COME CHAPTER 1

Chapter 1 HEALTH CARE IN MPUMALANGA: 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 9

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 controls. 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, communitybased rehabilitation of people with chronic disabilities and palliative therapy. The key elements of the new delivery system are briefly discussed below. Quality Service 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 10

Integrated, Comprehensive Services 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. Effectiveness and Efficiency 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. Equity and Accessibility 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. Community Participation and Local Accountability 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. Intersectoral Approach to Health Development 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. Sustainability of Services 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. Where there is a will there is a way! 11

AN OVERVIEW OF THE HEALTH SERVICES IN MPUMALANGA CHAPTER 2

Chapter 2 AN OVERVIEW OF THE HEALTH 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: The MEC for Finance Mr J. Modipane administers polio vaccine 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. 15

Figure 2.1 The Organisational Structure of the Department of Health, Welfare and Gender Affairs Directorate: Primary Health Chief Directorate: Health Directorate: Secondary Services Member of the Executive Council Deputy Director-General Chief Directorate: Welfare Directorate: Policy, Planning & Information Directorate: Administration Directorate: Social Work Directorate: Social Security Sub-Directorate: Population and Development Sub-Directorate: Gender Affairs 16

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 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 * 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. 17

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. Determine norms and 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 and secondary health programmes. 2. Determine norms and standards. 3. Monitor and evaluate 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. 18

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 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 247 264 LOWVELD 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 212 855 EASTERN 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 1 069 567 Total 1 125 641 Total 954 944 * 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 19

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. Referral Hospitals Regional Services and Facilities 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. 20

Tuberculosis Hospitals 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; ensure 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. 21

Table 2.2 Distribution of Public Health Facilities in the Province 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 22

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. This service is already available in the form of: Part-time Medical Officers Part-time Services 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. 1 See Chapter 3 for structure and functions of DHA 23

Part-Time District Surgeon (PTDS) The part-time District Surgeon renders duties for the following services: Personal Health Care: Forensic Medical Duties: Ex-officio Duties: These are mainly curative clinical duties performed for certain categories of patients. 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. 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. 24

THE DISTRICT MANAGER A DISTRICT HEALTH SYSTEM AND ITS MANAGEMENT CHAPTER 3

Tonga Chapter 3 A DISTRICT HEALTH SYSTEM 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. Mpumalanga Health Districts Mmamethlake Philadelphia Bushbuckridge Sabie Groblersdal Kabokweni KwaMhlanga Lydenburg Nelspruit Shongwe Middelburg Barberton Witbank Carolina Delmas R E G I O N Highveld Ridge Bethal Ermelo Eastern Highveld Highveld region Standerton Lowveld region Volksrust Piet Retief N 0 25 50 Kilometers 27

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. Household 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. Visiting Point 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. Clinic 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. 28

Health Centre 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. District Hospital 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. The Health Facility Catchment Area Figure 3.1. depicts the concept of health facility catchment areas. Figure 3.1 The Catchment areas for Various Levels of Health Facilities KEY: Catchment areas for: District hospital Health centre Clinic 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 29

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 OTHER COMMUNITY HOUSEHOLDS HEALTH FACILITIES Collaboration with other providers DISTRICT HEALTH OFFICE Intersectoral Collaboration OTHER SECTORS HOUSEHOLDS HOUSEHOLDS VISITING POINTS HOUSEHOLDS COMMUNITY CLINICS HOUSEHOLDS HEALTH CENTRES HOUSEHOLDS DISTRICT HOSPITAL Key: The arrows indicate the referral network involving health facilities, district health office and other sectors Adapted from Monekosso GL 30

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 for monitoring 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 MANAGER DISTRICT HEALTH INFORMATION MANAGER DISTRICT PHARMACIST FINANCE AND ADMINISTRATION MANAGER HUMAN RESOURCES DEVELOPMENT MANAGER DISTRICT PRIMARY HEALTH CARE CO-ORDINATOR ACADEMIC SUPPORT REPRESENTATIVE 31

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; purchase, via provincial procurement system, pharmaceuticals 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. 32

Standards Standards are the expected levels of work performance and will be central to your work as a District Health Manager, service manager and the PHC team. As a manager you will have to set high standards for yourself and constantly work to improve those standards. If you do this, you will be in a position to require high standards of work from the others. However, those standards should be realistic and should be agreed upon and accepted by those whose duty it is to implement. Promoting Team Work The success of the health activities in the district depends to a large extent on people working well together in small groups and relating to a common goal, which is the co-ordination of efforts to bring about an improvement in the health status of the community as a whole. Definition of tasks will help you to plot out exactly where activities need to be co-ordinated. It will be your responsibility to ensure effective working teams by: defining a clear purpose and common task which everyone in your team understands and is committed to. Each one of your service managers will need to be helped to appreciate what the function of his/her unit is and how it fits into the overall work of the District; ensuring that each member of the team has a clear idea of his/her own job and how it relates to the work of the other team members; ensuring that individual members within each of the teams understand the work and duties of others, particularly where there is an overlap of functions; ensuring flexibility amongst members so that the work of the team does not collapse when one person is absent; ensuring that leadership within the team is clearly identifiable and that the team leader is the person in charge; ensuring stability and continuity - but remember that a group that never changes may become set in its own ways and also become complacent; allocating sufficient resources to carry out tasks and clear working methods and procedures which are well understood; and ensuring linkages amongst teams so that teams are not so cohesive as to become exclusive. Communication Channels Within the District Health System, all efforts should be made to streamline communication channels between you, your service managers and communities. Further, you should establish effective communication links with all the role players in your district including non-governmental organizations, community based organisations and with other sectors. Management of Change Profound changes are going to be needed in the balance between hospital and primary health care. You will have the primary responsibility of bringing about this change in your district. It is going to be important for you to organise and create opportunities for all involved or who will be affected to be informed about the change and what they will now be expected to do. You will have to draw up the tasks and responsibilities for each worker and the skills that will be needed. The tasks should clearly spell out what the health worker is expected to do, when and in what areas of work. It will be your responsibility to consult and work with them on: what they need to learn in order to be effective; how best to help them learn; and how to support them during the transition. You can expect resistance to change. It may not be overt but it could be shown through: being less interested in the work; people sometimes opting out of their responsibilities; refusing to accept that change is going to take place; complaining about their work; becoming antagonistic at times to supervisors or those who are trying to bring about the changes; continuing to do things in the same way as before, particularly if it is a long established practice; and a number of individuals feeling threatened by change, and strengthening themselves as a group to resist the change. 33

How do you handle this? attempt to understand the feelings of the health workers create an atmosphere of confidence and trust, increase understanding and secure co-operation; communicate and explain why transformation and restructuring are taking place and discuss with them the problems; involve them in the planning so as to promote participation; do not make the change long drawn out; set reasonable time frames; reassure personnel that training and support will be available to enable them to cope with the change; and aim to achieve success, even if only in limited areas to build confidence in the process. Managing Conflict Change is threatening, it may also bring about conflict. Try not to be involved in fire fighting as this will take up a lot of your time and energy. Set up a team which will be responsible for problem-solving. Do not avoid or ignore conflict. Unresolved conflicts tend to get worse, so try to be constantly listening to the first signs of major difficulties so that conflicts can be dealt with sooner rather than later. Giving Support to Supervisors You will be responsible for providing support to service managers and supervisors at the facility level as well as at the community level. This is key as it will result in improved quality of health services. Supervisors might need support in the following areas: planning the work of their department/section/health facility; co-ordinating work and services; setting and maintaining standards; communicating with workers, communities and other sectors; motivating, training and support for their teams; problem solving; improving their performance skills; creating and ensuring good physical and social working environment; developing policy making skills and functions at a level which is closest to workers and communities; developing and making budgets; and personal support, advice and praise. Personnel Management and Staff Development Issues dealing with planning, job analysis and description, recruitment, orientation/induction, appraisal, promotion, discipline, benefits, exit, retirement and staff development are discussed in Chapter 10. Finance It is your responsibility to ensure that each specific programme gets the amount of money as budgeted in the district health plan, with a bias towards PHC but without compromising the quality of referral services. Your district health care plans and programmes will need to be translated into financial plans concerned with estimated capital and revenue expenditure for both long-term strategic planning and shorter term operational planning. As capital expenditure is concerned with expensive items of buildings or equipment, the expenditure is often spread over a number of years and can be shown in the form of a capital plan. An example of this is shown below: 34

Table 3.1 Capital Expenditure Name of District: Tiurpslen Year Type of Construction Cost 1997 Outpatient Department R1,000,000 1998 Water Tank R 50,000 1999 Laboratory R 300,000 An expenditure plan relates to the day to day running of services. The financial plan will show the amounts allocated for the current financial year, as well as for future years. Your estimates and forecasts for future years will need to take into account inflation and proposed changes in the levels of services to be provided and income expected from various sources. Operating Budget Operating budgets are concerned with the application of health plan for the current year. Although the DHMT will have overall control of the health budget, the individual service managers will be accountable for funds utilised in their specific service areas. These include health centres, clinics and mobile clinics who will all be responsible for the control of their own budgets. Each one of them will be involved in preparing, controlling and managing that part of the budget that is their responsibility whilst the members of the District Health Management Team retain overall budget responsibility. The method of budgeting which will be used is programme budgeting. Money will be allocated to specific programmes within the District Health Plan e.g. Communicable Disease Control. The weighting of health programmes is to be viewed as part of an overall health plan designed to achieve defined and measurable objectives and outputs of the whole health plan of the district. The allocation of funds to programmes will be done in such a way that the programmes likely to contribute more substantially to the realisation of the aims and objectives of the District Health Plan are given first priority. This enables scarce funds to be distributed more rationally (a weighting formula will be supplied by the provincial office). Programme planning and budgeting will compel you and your District health staff to plan your health activities carefully with well defined and measurable objectives. There must be justification of resources needed in each programme. Therefore every programme must have clearly defined objectives and a detailed budget showing expected revenues and expenditure. In this way your budget will become a management tool which will provide you with feedback for the redefining of your objectives should this be necessary. Financial Management One of your responsibilities is to ensure that the required funds for implementing planned activities at various levels are available. Once in place, you should set up a monitoring system that enables you to obtain information on the current financial situation for each programme. Systems of monitoring are essential means of detecting deviation from the budget early enough so that remedial action can be taken to ensure not only that the budget is not exceeded, but that such action is taken in a measured way, consistent with the objectives of the service plans. Budget management statements such as the one shown in Table 3.2 provide you with the means of monitoring expenditure. 35

Table 3.2 Monthly Financial Management Monitoring Item Budget Expenditure Budget Variance % Projected Variance to date (+ under, Year-end - over Expenditure Expenditure) R000 R000 R000 R000 R000 R000 Personnel 120 10* 30 +20 +66 40 +66 Drugs 80 40 + 20-20 -100 160-100 Transport 40 20 ++ 10-10 -100 80-100 Utilities 12 1** 3 +2 +66 4 +66 252 71 63-8 -13 284-13 Budget Notes: * Personnel: recruitments slow for new posts at beginning of year + Drugs: early stock-taking ++ Transport: Overspent due to petrol price-increase ** Utilities: Water strike - no bill received The above shows a monthly management statement after 3 months of the year. The budget to-date column shows what might be expected to have been spent one quarter of the way through the year. It is assumed here that spending will be equal each month (which is unlikely); more sophisticated estimates could be made. The variance columns show the relative (not actual) over-or underspending. Financial monitoring may detect two variations from the set budget - a likely over- or under-expenditure. Such variations are likely to be the result of: poor initial estimation; initial misallocation between budget items; unplanned change in volume of activity; unexpected change in prices; or change in efficiency levels. It is important, therefore, to be clear as to what is the cause of the deviation, as this may lead to different responses from managers, and planners. A change in activity level may have been unavoidable if it came about, for example, as a result of an epidemic. Inefficient use of resources, however, should be discouraged through budgetary mechanisms. An ideal financial management and budget system should aim to discourage both inefficiency and unplanned activity-level changes. It should also not encourage end-of-year spendingup, a common phenomenon when budget residues cannot be carried forward or budgets are related to the previous year s expenditure. Corrective Financial Actions The options to a manager facing over-or under-expenditure can be summarised as: virement between different items; a request for supplementary funds; improvements in efficiency; a reduction in activity levels; and Each of these is outlined briefly below. Virement Between Different Items Virement is the process of transferring funds from one budget line to another. Where the likely over-expenditure is only in one item, and is compensated for by an underspending in another item, then a transfer of funds from one line item (such as transport) to another (such as drugs) may be possible. Financial control systems usually have restrictions on the ability of a budget-manager to make such virement between certain items. A Request for Supplementary Funds A second option is to seek additional funding. This may under certain circumstances be possible in the form of a supplementary vote of funds from the next level up in the health service (the region or province for 36

example), or from central government. The possibilities of this and the appropriateness of such action will depend both on the availability of funds, either through a contingency budget or through underspending elsewhere, and on the cause of the overspending. Unanticipated increases in the levels of activity (for example through an emergency) may be seen as reasonable cause for supplementary funding. Efficiency Improvements The most attractive option for dealing with potential over-expenditure is an increase in efficiency, allowing the same level of service activity to be provided, at the same quality, for less resources. Striving for improved efficiency should, of course, be a concern of all managers at all times, and not just in situations of potential over-expenditure. Possible techniques which may help to identify areas of inefficiency include economic appraisal techniques, or, even more simply, an examination of cost structures. Efficiency may, in general, be improved in three ways. Firstly, by achieving the same ends by a completely different approach. Secondly, by looking for areas where economies of scale can be achieved, perhaps by sharing resources such as transport. And lastly, efficiency improvements may be achieved by negotiating a reduction in the price of inputs, such as drugs. It should be noted though, that often efficiency improvements take some time to filter through into budgets, and thus may not provide an easy solution to short-term over-expenditure problems. There are also efficiency traps which can lure the unsuspecting manager into worse situations. It is worth remarking that undue attention spent on attempting to improve efficiency may be counter-productive, and may divert attention away from more important managerial and planning issues. A Reduction in Activity Levels A fourth option involves reducing the levels of service activity, which, in contrast with the previous option, may lead to budget savings, but possibly also to lower levels of efficiency. Reduction of activity is rarely easy managerially, as there is likely to be understandable resistance to it from health professionals and the community. It may, however, be preferable to other options, or the only option available. Line Item Control The previous options have all dealt with alternative ways of reducing expenditure. In many situations this may be the only realistic option open to a cash-limited budget-manager. An alternative approach, commonly followed, starts with the existing line item budgets (such as transport or drugs) and looks for savings in these. Such an approach is a useful way of involving other functional managers. However, it is important to recognise that this and the previous approaches are closely linked. Any change in such line items will always result in a change in either the efficiency, the quality, or the levels of activity of services. Similarly, any change in efficiency, quality, or quantity can only be realised through changes in the actual budget lines. Buildings These are in the form of clinics, health centres, hospitals and are a normal part of the health care set-up. As a district health manager, you will have to think carefully before deciding to spend money on new buildings and extensions of existing ones. The first question that you should always ask yourself is How can I develop a health plan that makes maximum use of existing buildings? Supplies and Stores You will need an effective supplies systems for the smooth running of your district. Your district supplies system will essentially deal with requisitioning, ordering, purchasing receipts, storage and issue of supplies to users. You will need a centralised store at the district level which will be managed by a stores manager with expertise in the various stages of supplies management. All members of the District Health Team should be familiar with the way the system operates, so as to ensure that the essential requirements for the district are in regular supply. Factors to be taken into consideration when determining how much stock to keep will be: monthly, quarterly or annual requirement for each item; price of items; and time taken between placing an order and receiving goods. Stores records are important. The following records will be used: an inventory register; a standard requisition form; a store ledger and a tally card; 37

a stores issue voucher; and a stores issue book. Your team must clearly understand the supplies procedures in order to ensure that goods are ordered and obtained before stocks run down. You need to put in place a system of periodic stock taking and auditing to ensure that goods are not stolen, lost, misappropriated and/or deteriorate through poor storage. Where certain goods are used frequently you will have to develop a topping up system whereby a top limit e.g. of not less than 50% of stock are held at any one time and once stocks reach this limit they are replenished. To avoid abuses however, you will have to set an upper limit. You will also have to become skilled in using locally available resources and technology and not depend on imported expensive supplies and equipment. Transport and Communication Transport will be an essential part of your communication system in your district. It will be necessary for: supervision and support; distribution of drugs and supplies; mobile teams; health promotion workers; programme co-ordinators; referral of patients to clinics, health centres and hospitals; and administration. Transport, if not properly organised and co-ordinated will consume a large part of your district health budget, because of the high costs of vehicles, maintenance and fuel. You will need to properly co-ordinate your transport and communication needs. (The provincial transport policy document will provide you with guidelines). Whenever possible you will have to use multi-purpose vehicles which can be used by teams rather than individuals. Apart from transport you are expected to ensure control and economic use of other communication systems including telephone, fax, radio communication and mail. Delegating and Motivating Others Whilst it is important for you to understand your district function holistically, you cannot carry out all the activities alone. You are dependent on others to do some of the work. As a district health manager you must be able to delegate work to others, motivate them and win over their commitment. You and your team will be provided with training and professional support by the provincial and regional offices to enable you to perform your duties more effectively. It will be important for those that you delegate to, to know that they will get your support whenever they make decisions within their own area of delegated responsibility. Even where bad decisions are made, it is important that they are supported, whilst being given help to address the situation and guidance on how to make better decisions in the future. It is better for the occasional mistake to be made than for supervisors to be afraid of making any decisions. Some of your duties and responsibilities will be delegated to other managers and supervisors in the following offices: Administration and Finance Human Resources Development Unit PHC Co-ordination District Pharmacist s Office District Health Information Unit Management Teams at various facilities It will be however important for you to ensure that the different parts of the health systems are well coordinated, so that they do not work in isolation but work together towards a common goal. In delegating you have to make it clear where authority and responsibility lie. Accountability however cannot be delegated and you as the manager holds the utmost responsibility and accountability. 38

FUNCTIONS OF OTHER MEMBERS OF THE DHMT District Primary Health Care Co-ordinator As a District Primary Health Care (PHC) Co-ordinator, you will be responsible for developing, integrating and ensuring delivery of PHC services at all the service levels in the district. Your responsibility is to: develop plans for implementation of primary health care service programmes in the district ensure integration of the PHC service programme components into appropriate packages for the various service levels; provide technical and logistical support to the PHC service providers; identify inputs for the PHC service programmes; monitor implementation, coverage, effectiveness, efficiency and impact of PHC service programmes; and set up community structures for promoting participation of communities in PHC service delivery. In this role you will be assisted by programme co-ordinators who will be responsible for: assisting service implementors in planning, implementation, supervision, monitoring and evaluation of services; advising the DHMT on health matters affecting the district; and advising policy makers at regional and provincial levels in matters relating to their areas of expertise. Administration and Finance Manager The support from Administration and Finance is meant to be a non-prescriptive support service which sets free the health managers and their technical personnel to function in a cost effective and targeted manner. In each district the hospital secretary will become the administration officer. As Administration and Finance Manager you will play the following supportive role: Personnel: You will deal with all staff matters in the health district. This includes matters pertaining to leave forms, merit reports, salary and pension queries and housing subsidies. Transport and auxiliary services: Transport officers deal with the transport needs of the DHMT, their staff as well as clinic, health centre and hospital requirements in the district. This includes supplying Government and subsidised vehicles. This section is responsible for processing all transport claims and forwarding them to Finance. Finance: Budgets and expenditure at the District Health Office are controlled by the District Health Manager concerned. However, the District Administration and Finance Manager processes payments and distributes cheques. Provisioning and stores: Purchases of stationery and equipment, the acquisition of premises, and rental of labour saving devices is done on behalf of the District Health Manager and is controlled and distributed from the District Administration and Finance Manager s Office. Provision of administrative support personnel: The administrative office supplies the required support to the District Health Office on request. This includes advertisement and acquisition of new personnel. District Health Information Manager Working in the districts, you may find yourself isolated by geographic and communication circumstances. To manage the services and health resources available to you, it is necessary that you gather, analyse and put to use the health and management data available to you. As District Health Information Manager, you will assist the DHMT and other stakeholders in the following way: develop and maintain a register of information on the health status of the communities in the district; analyse and provide feedback to the service managers and relevant communities about the conclusions and lessons from the data gathered; facilitate communities and service managers in applying the data in planning of resources and services; 39

develop and maintain a register of information on health service management itself i.e. how the services are rendered and by who, how effective are the services at all levels, what are the constraints in the service etc; develop tools for monitoring progress and achievements of services; provide tools for mobilisation of communities to take actions that promote their own health; and maintain a continuous and up to date audit of all district resources. Human Resources Development Manager It is often forgotten that health workers and health service managers in the district constitute a resource that needs support and training, continuing education, continuous appraisal and recognition (read chapter 10). In a departure from the past the District Health Management Team is to ensure that this is done, through the Human Resources Development Unit in the following way: advise on deployment of appropriately trained personnel in health facilities; develop tools for support supervision of personnel in all health facilities; develop tools for personnel appraisal; provide continuing education and training to health personnel in the district; and develop career guidelines for health personnel in the district. Academic Support Representative The academic support unit supports and advises the District Health Management Team on issues pertaining to service delivery, training monitoring and research. The academic support representative has a functional e.g. clinical role in the district and also participates in activities implemented by the District Health Management Team (DHMT). He/she also co-ordinates academic activities within the district and liaises with the relevant academic institution. The unit will be established in a phased approach as districts employ personnel on the joint establishments mentioned in chapter 2. The functions of a district pharmacist are: District Pharmacist to purchase, via the provincial procurement system, pharmaceuticals and surgical sundries for the district; to provide pharmaceuticals and surgical sundries to all the public sector health facilities in the district; and to monitor and ensure compliance of usage of pharmaceuticals in the district in accordance with policy guidelines. The DHMT will need to monitor how the services are being implemented in the district. Therefore, the DHMT would be interested in knowing how effective the management support has been in areas such as: planning of services; management of personnel; training of staff; supervision of health personnel; management of finance; management of logistics; health information and community organisation. For more information on monitoring and evaluation you should read chapter 9. HEALTH FACILITY MANAGEMENT TEAMS All facilities will be managed by management teams The Hospital Management Team (HMT) A hospital has its own management team for running the day-to-day business. This management team is known as the Hospital Management Team. Composition The Hospital Management Team consists of: Hospital Manager/Medical Superintendent; 40

Heads of Departments (Unit Heads); and Elected representatives from each unit. Functions If you are a member of the Hospital Management Team, you are expected to support the Hospital Manager to carry out the following: provide technical support to health centres and clinics; manage and maintain all the non-human resources of the hospital; identify resource requirements for supporting the hospital; render curative and diagnostic services to the health district; provide referral services for the lower level health facilities and as a referral source for higher level facilities in the district; and participate in human resources development, including technical support to the clinics and health centres in the district. District Managers are expected to meet regularly (at least quarterly) with health centre, clinic and hospital managers to review and plan strategies for health service delivery in the district. The Health Centre Management Team (HCMT) In a District Health system, a health centre has its own management team: The Health Centre Management Team (HCMT). Composition The Health Centre Management Team is made up of the following: The Health Centre Manager Unit Heads at the Health Centre District Primary Health Care Co-ordinator Functions The health centre is a kingpin in the health care system. It is a unit for steering development of health in its catchment area. As a member of the Health Centre Management Team, you are expected to support the Health Centre Manager in: providing both primary and secondary health care services to communities in its catchment area; providing referral service to the clinics and serving as a referral source for the district; establishing linkages with other sectors in matters pertaining to health promotion and development; promoting linkages with community based health development initiatives by CBOs, NGOs, local authorities and private sector; supervising and maintaining the health centre based health information system; identifying resource requirements for support to the health centre; and providing technical support to satellite clinics within its catchment area. The Health Centre Manager is expected to meet regularly (at least once a month) with managers of the clinics in the health centre catchment area together with the PHC Co-ordinator, to share information and to plan and evaluate the services for the catchment area. The Clinic Management Team (CMT) A community health clinic also has its own management team, the Clinic Management Team (CMT) Composition The Clinic Management Team comprises: The Clinic Manager Representatives of Units based at the clinic 41

Functions The clinic represents the first formal structure of the health service in the community. It thus has an important role to play in promoting the health of the community. The Clinic Management Team is expected to uphold and promote this role. Specifically the team is to support the Clinic Manager to render the following services to the community in the catchment area: provide quality primary health care services to the communities; facilitate and encourage community based health development initiatives; promote intersectoral collaboration in community based health development initiatives; participate in establishment, implementation and maintenance of a community based Health and Management Information System; provide a source for referral to the health centre; and promote linkage with community health development initiatives by CBOs, NGOs, local authorities and private sector. You have read, in this chapter, about the District Health System for Mpumalanga and how it will be used as a vehicle for facilitating the delivery of Primary Health Care. The chapter has also discussed the referral system that provides linkage from one service level to another. In addition the management system for the District Health System has been discussed in detail, highlighting the responsibilities of various management teams. An important link in the District Health System is the people. The role of communities in ensuring ownership and sustainability of community based health development initiative is discussed in the next chapter. 42

THE ROLE OF COMMUNITIES IN HEALTH DEVELOPMENT CHAPTER 4

Chapter 4 THE ROLE OF COMMUNITIES IN HEALTH DEVELOPMENT The purpose of this chapter is to discuss the importance of involving local communities in planning, implementation, monitoring and evaluation of health development activities. After reading this chapter, you will be able to understand: the need for community participation in health planning and service delivery; the requirements/prerequisites for successful community participation; common obstacles to community participation; strategies to promote/enhance community participation; and the importance of monitoring and evaluating participation by communities in health development. Through decentralisation the health services in the province have been brought closer to the people to facilitate meaningful participation by communities in planning and delivery of health services (refer to chapters 1-3). This promotes responsiveness of the services to the local health needs, ownership by accountability of the services to the communities. However, community participation in health services should be orderly and well co-ordinated. How would you achieve this? Community participation means a lot of different things to different people. For us in Mpumalanga, community participation is taken as the process of involving communities in setting the health priorities, planning, implementation and evaluation of activities relating to improvements in their own health status. The process itself is empowering, and it builds skills and confidence in the people involved. It is also a mechanism of mobilising human and material resources at local level for health and development efforts. Community participation is not the sporadic and superficial consultations with not-so-representative community forums, nor does it imply abdication by the Department on its responsibilities in providing health services. The community is the core of the District Health Strategy as all health functions and tasks have a community component. Local people are the greatest resource and by working closely with them it can be ensured that the health care system is part of their responsibility. It is important for you to remember that there is more than one degree of community participation, namely: nominating representatives to sit on committees; a truly democratic dialogue with the community or its elected leaders; and active participation in service delivery activities. The Department supports the option of democratic dialogue with communities because not only is community involvement a democratic right, it should be seen also as part of the broader social development and utilisation of human potential envisioned and propagated in the Reconstruction and Development Plan (RDP) as well as in the National Health Plan for South Africa. 45

It is clearly stated in the RDP document that development is not about the delivery of goods to a passive society, it is about active involvement and growing empowerment For many health workers, working together with a community is a new experience. Remember, this is true for communities as well. You will be learning together. The degree to which the community is involved will depend initially on the extent of community organisations already in existence, as well as the relationship with the health service. Involvement will be built up from there, increasing as the community develops capacity to participate in health development. GETTING TO KNOW THE COMMUNITY YOU SERVE The process of getting to know the community is not easy. It will vary with different communities and the health worker should guard against concentrating on the elite and the vocal and forgetting the silent majority (see Figure 4.1). Figure 4.1: Characteristics of Community Representation 1 2 3 Key: 1. The elite (big leaders) who presume they represent the community; 2. The better off members of the community; 3. The silent majority (community): marginalised and dominated; usually the last to be consulted or contacted. As one gets to know the communities in the catchment area served by the clinic, health centre or hospital, one will come to realise that the status of their health is intimately influenced by many social determinants. Important determinants include socio-economic status, life style choices, health seeking behaviour, cultural beliefs and practices, religious beliefs, education and general awareness. Without addressing these needs, health interventions can be a very frustrating experience. Health professionals have the technical knowledge and skills but the communities have the knowledge about their culture and social organisation. That knowledge needs to be tapped in designing and implementing health programmes which will be acceptable to the community. Acceptance of health interventions by the community will ensure not only the success of the intervention but also sustainability of the effects and impact of the intervention. Community participation will also allow health programmes to access other resources in the community such as the human resources which would not otherwise be available. 46

FORGING LINKAGES AND PARTNERSHIPS Intersectoral collaboration is simply the connection between statutory and non-statutory sectors sharing common interests in the promotion of health, prevention of diseases and conditions, curing of health ailments and rehabilitation. Partnerships between the community, health service, and other sectors need to be established. It is advisable to begin by: identifying staff who are going to drive this process (The Provincial Health Office will assist you in establishing governance and management structures, whilst the PHC team will support community involvement in service programmes); identifying existing community structures, eg. church, women s, and youth groups, NGOs, CBOs, Reconstruction and Development Councils (RDCs), traditional groupings, political organisations, labour movements; identifying additional structures which need to be formed, including representative community structures; identifying intersectoral linkages, particularly with the departments of works, water affairs, safety and security, education and agriculture; collaborating with statutory bodies such as local government; bringing different groups together to promote linkages and formalise networks; raising awareness of health issues, in community and other sector forums ; sharing information with other agencies; and facilitating formation of representative community structures, eg. community health committees. A database (descriptive inventory) of all potentially health-related structures within the district, including RDCs, local government councils, NGOs, and community groups of various kinds, should be built up through the district health information unit. The Regional National Progressive Primary Health Care Network (NPPHCN) already has this information. The importance of intersectoral collaboration Many health problems have multiple underlying causes. Their solutions may, therefore, require interventions from a number of different sectors. Depending on the problems you have prioritised, you may need to develop links not only with the community but also with other development sectors e.g. education, water supply, agriculture, social welfare and gender affairs, safety and security, and correctional services operating in that community. It is most useful if your health team, representatives of the community health committee, and the other sector structures sit together, agree on a common goal, and plan the intervention jointly. Each player would then contribute to the implementation according to his or her particular role. The principles to be borne in mind include: identification of common ground/interests; official, meaningful consultation; commitment from each sector towards a shared goal; and effective, efficient feedback mechanisms for all sectors. COMMUNITY INVOLVEMENT IN HEALTH CARE Communities need to be involved at all stages of the development and implementation of health initiatives. These include: identification of health needs; setting of priorities; designing of interventions; implementation of the interventions; and monitoring and evaluation of the interventions and their impacts. 47

The health worker, in cultivating the involvement of communities should ensure that: all stakeholders in the community and health service are well informed; all stakeholders are consulted from the very beginning (needs assessment); a participatory approach is employed in gathering detailed information about the problems; feedback information is supplied to all stakeholders, using this as an opportunity for networking within and between communities; the collected information is used to advocate for new service; a community support group is established; available resources are brought as close to the community as possible and that existing resources are utilised for the benefit of community members; the community is involved in supporting/maintaining these resources; awareness is raised in the community through occasions such as health days, competitions etc; and an appropriate communication system is used to convey health messages. Communities should also be encouraged to take responsibility for their own health through healthy lifestyle and healthy behaviour. The following case study illustrates several principles in community participation. Case Study The Speaking Gardens of Makoko Somewhere in the year 1984, Agnes, a midwife was transferred from a hospital to a very remote clinic. The people of the area were referred to as Bonjobe Njobeni meaning the illiterate. They were plagued with a host of different but preventable diseases - including malnutrition and other diseases that came as result of not taking a balanced diet. People depended on the traditional food crops grown in their gardens: maize and ground nuts. Although she was born in the area, she had lived away for a long time and was practically a stranger to the area. She was unfamiliar to the people and was treated as a different species because of her education. She realised that to succeed in her work, she had to work her way into the hearts of the people. She had to show that she belonged to and was a person of the people. She spoke the language well, attended the traditional meetings and gatherings, Amongst the other things she did to win the community was working in her garden like every body else; keeping chickens in her fowlrun and participating in traditional craft making. Her identification with the community paid off, for she gradually became accepted. She understood the local jargon for describing childhood diseases. She knew, for instance, that Isifo Sabe Sotho was nothing but kwashiorkor. In her own exemplary way of fighting malnutrition, Agnes began educating the community on what to do about kwashiorkor. Women admired her garden which she explained as the tool for fighting kwashiorkor. They decided to give it a try and see if it was the answer to their sick children. They gathered themselves and requested Agnes to teach them how to do gardening. This she turned into an enjoyable experience for women. They planted their own little plots with nutritious vegetables. Getting water to irrigate their gardens was not an easy task, but they made it enjoyable by singing traditional songs as they went down to the river. They also had to fight off goats and other livestock that grazed in their crops. They further promoted togetherness by engaging in group activities after working in the garden. After many seasons of battling crop failures, the group became progressively successful and became an example of success through hard work and perseverance. More women joined the group and more land was cultivated. They won public recognition and assistance. Maheshe from Spring Ministry donated water tanks for the group. The Department of Agriculture provided fencing material to protect the gardens. The group grew from strength to strength. They entered a local agricultural competition and won. This was an incentive for even harder work. However, the most important reward was a reduction in malnutrition. This was the success story of The Speaking Gardens of Makoko. 48

Lessons Learnt from the Case Study: Agnes was quick to appreciate the need to be identified with the community and be accepted by them. Agnes realised the need to have certain skills in order to further develop the community. She learnt how to write project proposals in order to get assistance from other organisations and she was able to sell her ideas to other sectors. Working with the community requires certain skills. You, like Agnes, will need to empower yourself with the ability to recognise : the characteristics and values of the community you work in; the needs and root causes of the problems in the community; solutions to the problems; and the opportunities within the community for participatory action to solving the problem. Requirements for effective community participation There are four basic conditions which must be met if community participation is to be more than just lip service. These are: 1. Political commitment to support community involvement in health service programmes and community based health development programmes. 2. Reorientation and retraining of health care providers, in terms of attitudes and skills in interactions with communities. 3. Support for community-based activities in the form of effective decentralisation of services, logistical support, and intersectoral co-ordination ( in other words, a well established and functioning district health system as already explained in chapter 3). 4. Empowering communities to enhance their participation in health planning and development. This includes supplying information on: health issues, their causes, appropriate preventive and promotive measures; how to plan, implement, monitor and evaluate programmes; management skills, including fundraising, bookkeeping; available resources within the community, government, and non-governmental sectors; methods of accessing these resources; advocacy; and related health and development groups within the community. At provincial and district level, there is commitment and support for community participation. Empowering communities to participate meaningfully needs to occur at the local level, and this should be made possible through affirmative action by the DHMT. Common obstacles to community participation in health development Significant obstacles may be met when attempting to involve communities in health development. These are some of the obstacles that may be encountered: inadequate empowerment to facilitate meaningful community participation in their health care; lack of a mechanism for joint decision making. This may frustrate efforts of the communities; inadequate funds allocated for community development; lack of representation in community structures; inadequate skills among health professionals in working with communities; lack of appropriate tools such as an operational manual or guideline on community-based health development; reluctance to co-operate intersectorally; resistance to change from a curative and facility based health system to one that is health development-oriented and community based; community members pursuing individual interests; and negative political influence. 49

Monitoring and Evaluating Community Participation It is necessary to monitor and evaluate community involvement in order to assess whether you are succeeding in enlisting their support in health development. You will know if you are succeeding by the: number or percentage of community members who state that PHC services are accessible, and convenient; number or percentage of community members who state that the PHC services are acceptable and relevant to their needs; number or percentage of community committees that meet regularly; number or percentage of communities participating in health activities; and number or percentage of health units with an affiliated health committee or community organisation. This chapter has stressed the importance of involving the communities in planning and delivery of primary health care services. In addition, it has explained the ways by which this could be achieved and has identified some of the common obstacles that you could encounter in enlisting the participation of communities in service delivery. The chapter that follows describes the services to be rendered to the communities and the manner in which they will be delivered. 50

PART 1i Service Delivery and Governance

Ag nee Willem! Primary Health Care means more than being a barefoot doctor! DELIVERING INTEGRATED PRIMARY HEALTH CARE CHAPTER 5

Chapter 5 DELIVERING INTEGRATED PRIMARY HEALTH CARE This chapter describes the comprehensive PHC services to be rendered at various levels of health care and the mechanisms for delivering the services to households and communities in the district. After reading this chapter, you will be able to: appreciate the need for integrated primary health care (PHC) services; define the minimum integrated PHC service packages for various health service levels; recognise the important role of the community-based health worker in PHC services; appreciate the need for co-ordination of PHC services in the district; understand the role of programme co-ordinators. define the support needed at various health facility levels; and define the staffing requirements for each service level. THE DISTRICT HEALTH FOR ALL PACKAGE Achieving the goal of health for all in the province calls for strategies that will address the health problems of individuals of all age groups as households and community members. This will be done through implementation of an integrated health for all package based on Primary Health Care. The district health for all package includes: basic health care interventions; and health related interventions 55

Such interventions will include: Basic Health Care Interventions control and prevention of communicable diseases, including STD/HIV; immunisation against major infectious diseases, especially those included in the expanded programme of immunisation; promotion of maternal, child and women s health, including family planning; provision of education on prevailing health problems as well as basic public health activities for disease prevention and control; provision of appropriate treatment of common diseases and injuries viz; curative care, including early diagnosis, treatment and prevention of medical, surgical, mental, dental and other common problems; early rehabilitation to prevent complications and disabilities; provision of essential drugs; and provision of district health emergency and first aid. These basic health care interventions are in line with the PHC priority service programmes which are to be implemented in the province. The priority programmes are: Health Promotion Maternal, Child and Women s Health Nutrition Oral Health Environmental Health Communicable Diseases Control Rehabilitation Emergency Medical Service Curative, Diagnostic and Medico-Legal Services Mental Health and Substance Abuse Each of these programmes is discussed in chapter 7. Health Related Interventions Health related interventions include adult health literacy, household food security, water supply and sanitation. These will be organised in health facilities and other locations in collaboration with the departments responsible for Education, Agriculture, Housing, Works, Water Affairs and Forestry. Health workers will co-operate with their counterparts in these departments to facilitate community access to health related needs. These elements will accelerate attainment of health for all and contribute significantly to promoting health as a determinant factor for achieving socio-economic development at district level. Utilising these elements, district health authorities will define objectives and targets for district health plans, organise activities for implementation by health management teams, and collect data locally for monitoring progress. THE NEED FOR INTEGRATION OF PHC SERVICES Case Study A young couple from the Mhluzi district, in Mpumalanga, has four children aged 5, 4, 3, and 2 years. They are also expecting another child in 5 months. The first child appears mentally handicapped; the second child has dental caries; the third and fourth look small for their age. The husband, a casual labourer in a neighbouring urban centre, has not been to work for one week due to fever. The neighbour thinks that he might have typhoid because three people in the neighbourhood have been treated for it. How would you deliver primary health care to this family and to the community they live in? 56

Table 5.1 Analysis of Primary Health Care (PHC) required by the family in the case study. Services required by the family Antenatal; maternity; postnatal; family planning Immunisation Growth monitoring; nutritional therapy Health education in oral hygiene; management of dental caries Evaluation, management and rehabilitation of mentally handicapped child PHC Service Programme Involved Maternal Health; Health Promotion Child Health; Health Promotion; Nutrition Communicable Diseases Control Nutrition; Child Health; Health Promotion Oral health; Health promotion; Curative and Diagnostic Services; Mental Health; Rehabilitation; Curative and Diagnostic Services; Health Promotion Investigation of typhoid epidemic; Investigation of water safety and sanitation Ambulance service for possible complications at 5th delivery Communicable Diseases Control; Environmental Health; Curative and Diagnostic Services; Health Promotion Environmental Health; Health Promotion facilities; Health education; Communicable Disease Control Emergency Services; Maternal Health; Health Promotion This case study illustrates many interesting and practical questions which are relevant to the manner in which PHC services should be organised at the operational level such as: What PHC services would be needed by this family? What co-ordination mechanism will ensure that the necessary services are rendered to the family and community? At what level would integration of the PHC service programmes occur, and who would be responsible for this? What support would be made available at various health service levels? What referral system would ensure accessibility of appropriate PHC services to the family at various service levels? What category of health worker should be at the front-line (i.e. interface with the community?) How many staff should be at the front-line: a multidisciplinary team of health workers or one multi-skilled health worker? How will other sectors be engaged in joint promotion of health in this community? The case study illustrates the point that primary health care is about real health problems of individuals and families in a community. Their health problems usually will require the services of more than one primary health care programme. The choice you have to make is that you either integrate all the PHC programmes into one specific service package or you deliver the services as individual vertical programmes. In the case study cited it is not cost effective to mobilise a team of different health workers, each representing a different vertical programme, to descend on this household! The programmes are better integrated into one package that can be delivered at different service levels (household, clinic, health centre, hospital) using different categories of health workers with different skills. The Mpumalanga choice is for: integrated services with specific service packages for each service level: community, clinic, health centre and hospital; delivery of primary health care services to the household within the community where the family lives, using health promotion as the strategy; and use of community based health worker (CBHW) as the first contact with the health service. This worker will provide health promotion and link the community with the formal health service. 57

HOW THE DISTRICT PHC SERVICE PACKAGE WILL BE CO-ORDINATED The province has taken a decision to do away with provincially-based and vertically run programmes which normally take little account of local health needs. This decision, therefore, involves strengthening district level programme planning and co-ordination through a team of co-ordinators based at the health centres and supported and supervised by the District PHC Co-ordinator. Posts will be identified for full time programme co-ordinators, according to the identified health needs in a district. In the meantime, capacity is already being built in the districts by utilising professionals from existing services to perform programme co-ordination work in identified key programme areas e.g. Communicable Diseases Control, Nutrition, Maternal Child and Women s Health and Environmental Health To ensure that they do not develop into vertical programmes, all new health care initiatives (projects) should be developed within the framework of the District PHC Package. For example the Provincial Community Sanitation Initiative which focuses on health and hygiene education promotion will integrate with the following programmes: child health component of the maternal, child and women s health programme; diarrhoeal diseases control component of the communicable diseases control programme diagnostic and curative services programme; and health promotion programme. The involvement of other sectors is also important. These will include: Water Affairs and Forestry; Education; Environment Affairs and Tourism; Provincial Affairs; and Housing. Together with the District PHC Co-ordinator, the Programme Co-ordinators will constitute the district PHC team. The PHC team will form the technical nucleus for planning and co-ordinating primary health care service programmes in the district. The PHC team will provide support to the service providers at all levels of health care and to the District Health Management Team. While having a joint responsibility for the district as a whole, however, each team member will retain responsibility as a resource for his/her own area of specialisation. The responsibilities of the District PHC team will be: to assist service implementors in the community and in health facilities to plan, implement, monitor and evaluate primary health care services by: - identifying the priority problems and their root causes; - identifying a range of solutions to each prioritised problem; - planning implementation activities based on the prioritised solutions; - designing an integrated PHC service package for the district; - monitoring and evaluating service implementation; and - repeating the whole cycle for the same problems (depending on success or failure) or starting afresh with other problems using the above steps (see figure 5.1). 58

Figure 5.1 Programme Planning and Co-ordination Cycle Identifying and selecting problems Outcome: a list of problems in order of priority Evaluating the impact of the solutions Outcome: Assessment of whether the intervention strategy is working or not and feeding this into the planning process Analysing the problems Outcome: A precise description of the problem and its root causes Implementing the solutions to the problems Outcome: Implementation of the activity's various components e.g. health promotion, prevention, cure, rehabilitation at a particular level of service delivery Suggesting Solutions Outcome: A description of the activities which would solve the problem Adapted from Amondo-Lartson R etal Other responsibilities will be: advising the DHMT as individuals in their areas of expertise; serving as a resource for advice to policy makers at regional and provincial levels; identifying training needs and organising appropriate training for PHC service implementors; assisting the PHC co-ordinator in identifying resource inputs for PHC services; ensuring integration of PHC service components into community based health development initiatives; and carrying out such other duties as may from time to time be assigned by the PHC Co-ordinator. In order to enable them to carry out the above responsibilities, the programme co-ordinators will receive inservice training in programme planning. Implementation of Programme Co-ordination Three districts in each region have been selected as model sites for integration and co-ordination of the following initiatives: well child initiative including components of maternal and reproductive health; sanitation project; communicable diseases control; community based nutrition; and initiative for sub-district support. Experiences learnt from the model districts will be transferred to other districts. 59

DELIVERING PRIMARY HEALTH CARE SERVICES TO HOUSEHOLDS Who is the first contact person in a case of illness? Different types of people provide health advice and health care. Depending on where you are, the first person who is consulted when illness strikes is not usually a health worker. It is either a gogo, mkhulu, mama, baba, a neighbour or a friend, etc. After consulting any one of the above mentioned, the next type of person consulted will depend on what the family, relatives etc think are the causes of illness and which service they think may be able to help. The next level, therefore, could be the spaza shop, traditional or spiritual healer, private health worker or pharmacy or the health services. From the above, it becomes clear that the first level of advice and care takes place in the community and it is by the community. It also follows that when equipped with the right information, this first line consultation will have a far-reaching effect on the health of individuals and families in the community. Household Health Promotion Service The aim of the Department is to empower households to take correct decisions concerning the health of their members through a household health promotion service, using a community based health worker (CBHW). This service already exists in the districts but at present it is highly fragmented, non-homogeneously distributed and too limited to function optimally. In the various areas where it is provided, the providers include: the public sector services, non-governmental organisations, the private sector, local authorities, community based organisations, etc. The aim of this service is to link the health service with households in the province, thus facilitating the linkage between health and socio-economic development. The main advantages of this service are two fold: information and health education is provided to the household which will empower families to take charge of their own health; the household health promotion worker will provide valuable information to the facility based services. This information will enable the DHMT to plan and prioritise services which are responsive to the people s needs. Implementation Implementation of the household health promotion service will be in phases, starting with the most disadvantaged areas within a district. The DHMTs are encouraged to give priority to existing voluntary workers when recruiting community based health workers. Initially each worker will look after a specified number of households. The department will develop a standard training curriculum and establish the capacity for training which will take place in the community. Two specialised auxiliary services assistants (SASAs) from each sub-region have already been identified to undergo training as trainers of trainers for the CBHWs. The department will also provide technical support to the household health promotion service. However, supervision and control of the service will be the responsibility of the communities through identified community structures. This will ensure that the workers are accountable to the community. Before establishing this service in the district, the district manager will be required to submit a specific proposal to the Chief Director for approval. The community based health worker will act as a catalyst for development by mobilising resources and community capabilities to carry out those activities which will improve the status of the community. In this area he/she will be working with other development agents in the community. PHC Service Package for Community/Household Level Health Promotion The PHC package for household level health care focuses on empowerment of communities to promote and protect their health; prevent common illnesses which afflict the community; identify common illnesses for referral to health facilities for treatment; and rehabilitate their members who may have suffered chronic disabilities. The full package is given below: 60

The PHC Package for Community/household Level Health Care Individuals and families in the community will be enabled through provision of the necessary information (awareness) of the problems which affect their health and the tools (knowledge) and means (resources) required to: promote and protect their own health against health problems in their community; e.g. through health education; prevent common diseases that affect them and their community; e.g. through immunisation, change of behaviour; identify common ailments in the community and refer them to the nearest clinic for early management so as to prevent complications and disabilities; give support to, and rehabilitate, their members who may have mental, physical or other disabilities; and mobilise communities to take responsibility of their own health, emphasising in particular improvement of individual life styles, reproductive practices of families and environmental management of communities. Community based health care will be given maximum emphasis. The support from the clinics, health centre and the district hospital will: ensure that community based interventions are rendered efficiently and effectively in a co-ordinated, controlled way; and provide a referral service for the level of health care that is not available at the lower facilities. In carrying out their duties in the community, the community based health workers will need support from staff from the nearest health facility (clinic or health centre) in the form of: technical support; supplies referral support; and supervision. The Clinic Manager who will be a member of the Community Health Committee (see chapter 6) is well placed to provide support to and co-ordinate all community based health care and development activities within the clinic catchment area, including support supervision of the community based health workers in that area. Outreach Health Promotion Services to Communities In its broader catchment area, the health centre, plays an important role in supporting community health care services in its catchment areas, apart from serving as a referral centre for the clinics. Effective coverage of clinic and health centre catchment areas will call for the organisation of outreach sessions (campaigns), e.g. for vaccination and maternal and child health, surveillance for populations living far away from health facilities. This makes the promotive health services accessible to the population. This method of primary health care delivery reaches out to people in the catchment area who live far from the facility. This will assume increasing importance as service delivery shifts emphasis from curative to preventive and promotive care. Implementation A special category of outreach health workers in the form of Specialised Auxiliary Services Assistants (SASAs), Specialised Auxiliary Services Officers (SASOs), health educators and health promoters will play a key role in this service. The DHMT will restructure and harmonise this service as it has an important role to play in the promotion of the health of households and prevention of illnesses. Some of these workers are already skilled in health promotion work and are a resource that, with proper planning and co-ordination, can immediately render an effective support and supervision to health promotion and rehabilitation services. Initially this category of health workers will operate from a community health centre under the supervision of a liaison officer. The liaison officer will be accountable to the Health Centre Manager, and will work closely with other development agencies. The ideal situation is that this category of workers should be based at the clinic level. Though these workers are government employees, in future, the community will have a role in their recruitment 61

and selection. Care will, however, be taken that the partnership between communities and government are clearly defined, so that these workers do not serve two masters. The implementation of the statutory district health authority will solve this problem. The facility based community health promotion workers, clinic and health centre managers and health committees will be involved in mobilising local populations for outreach and other community-based activities. Co-ordination of PHC services in the broader catchment area of the health centre and its satellite clinics will be undertaken by the outreach services team comprising: Programme Co-ordinators Health Centre Manager Clinic Managers This team will ensure enlisting necessary support from the district hospital and the participation of other development sectors in community development initiatives. The Outreach Services Team will: provide support to preventive services e.g. immunisation, oral rehydration therapy for diarrhoea, health promotion, STDs and HIV/AIDS, nutrition, hygiene and environmental sanitation etc; provide support to the community based health workers and community health activities. provide training to the community based health workers; and serve as a link with other government departments, NGOs and the private sector. The reason for linkage of the outreach services to the public health sector is that Primary Health Care is part and parcel of the health service. This linkage will ensure integration of PHC programme activities into one health service. PHC services are intimately linked with other levels of the health care system i.e. the community, clinic, health centre, and hospital levels. HEALTH FACILITY BASED PHC SERVICES Primary health care services are delivered at all health facilities. This means that people come to the visiting post, clinic, health centre or hospital for the services. Some of them may have been referred to the facility (health centre, hospital) from the facilities at lower level. The types of service packages rendered at each level of facility are described below. PHC Service Package at Visiting Posts The visiting post is the most peripheral unit which serves as a regular (at least every fortnight) outreach service. It is organised from various health facility levels involving various health providers. The main PHC package for this level is: health education, health campaigns and immunisation; treatment of simple injuries and common diseases; and referral of those who need further care. Staffing Pattern The staff mix in visiting mobile units is quite variable because it depends on the health provider that is servicing the post. However, it usually involves a nurse and community health workers. The staff number is determined by the number of activities and service demand. The PHC Service Package at Clinic Level The clinic is a one-stop station for primary health care services. It is a facility provided according to the needs of the community; a joint venture between the communities and the providers to ensure maximum acceptability and accessibility to the community. 62

The main role of a clinic is to re-enforce the PHC services rendered in the community and to support and supervise activities of the community health workers. It is necessary to emphasise that the PHC service package at the clinic level is not independent of the services rendered in the community. It supports and supplements the community level service package as an integrated service for, and with the community. Personnel Promotive and Protective: PHC service package for the clinic level child care (including immunisation and growth monitoring); maternal care (including antenatal care, post natal and family planning); women s health (screening for cervical and breast cancer, health education); promotion of breastfeeding and nutrition education; recognition, treatment and control of communicable diseases; training and supervision of community health workers; provision of outreach/mobile services including school health services; and provision of health education on oral health. Curative and Diagnostic: treatment of common diseases and basic emergencies; handling normal deliveries; follow-up of patients who are on maintenance therapy for chronic diseases; and referral of patients to community health workers for follow-up or to health centres and hospital for more appropriate care. Rehabilitative rehabilitation of people with disabilities and rendering of counselling services to individuals and families in need in the community; Palliative therapy for the terminally ill. A clinic is staffed by at least one registered nurse, enrolled nurse and nursing assistant. The clinic should provide a 12 hour service each day. The support staff include watchmen, gardeners and cleaners. The actual staffing level is determined by service demand. At present, our clinics are under staffed, and the Province has proposed a new staff establishment based on the district health system. PHC Service Package for Health Centre Level A health centre is a vital facility in health care development in the districts. It is the level in the service where the technical and staff mix has the necessary multi-disciplinary integration and co-ordination of primary health care service programmes occurs. It is also the level at which intersectoral collaboration is co-ordinated. The staff mix at the health centre is a reflection of functions at the facility and its supportive role to the satellite clinics and communities. The health centre offers all the PHC services which are offered at the community and clinic levels. It is important to emphasise that the health centre PHC service package is meant to enhance the health initiatives of the communities themselves and the support provided to them by community health workers and staff at satellite clinics. 63

PHC Service Package for Health Centre Level The full PHC package for health centre level offers the same services as those rendered by the clinic, but in addition it offers the following:- manages rehabilitation services; provides ambulance services; serves as a referral centre for all the satellite clinics; and referral source for the district hospital; monitors and provides technical guidance to the satellite clinics; monitors community health services in all the catchment areas of its satellite clinics; promotes self help groups/care groups; promotes intersectoral collaboration; provides basic curative services, with laboratory 1 and x-ray facilities and may also have facilities for doing minor surgery and management of uncomplicated fractures; provides inpatient care for normal deliveries, short illnesses requiring observation (to a maximum of 48 hours) and care, before and after hospital admission, as and when necessary; and serves as a focus for co-ordination of PHC services in the catchment area of the health centre and its satellite clinics. Staff mix at a health centre Nursing Profession: Pharmacy Assistant - Nurse Clinician Environmental Health Officer - Nurse/Midwife - Psychiatric Nurse Therapists: - Enrolled Nurse Programme Co-ordinators Social Worker - Occupational Therapist Laboratory Technician/Technologist - Physiotherapist Support Staff - Dental Therapist/oral hygienist - Gardener - Nutritionist/Dietician - Watchman - Cleaner The draft Report of the Committee on Human Resources for Health which was published in December 1994 recommends that there should be one staff for each of the categories identified for every population of 30,000 people. Therefore, the number of staff of each category in your health centre will be determined by the population the health centre is serving (catchment population). District Hospital Referral Services A district hospital is the ultimate referral point for the District Health System. It will provide essential back-up services and will act as a support to the community based activities, health centres and clinics which are in more direct contact with individuals, families and communities. Hospital support to PHC entails its integration into the district health system as a referral unit. A district hospital provides comprehensive care (promotive, protective, preventive, curative and rehabilitative) on a 24 hour basis. Its bed capacity is approximately 200 and may have a few specialised health service beds (e.g. psychiatric unit). 1 The directorate of Primary Health Care has been given the responsibility of setting up PHC laboratories in health centres (1 health centre per district) in conjunction with the South African Institute for Medical Research (SAIMR). 64

PHC package at district hospital level diagnosis and treatment of common diseases and injuries, with a resident doctor service; casualty service for the immediate treatment of injuries, medical and surgical emergencies, with a resident medical officer; basic diagnostic theatre and Central Sterile Supplies services to enable the performance of common surgical procedures; social work services, oral health, mental health, basic rehabilitation services, including physiotherapy, counselling, eye care etc which may be provided on a permanent or intermittent basis depending on the size of the community served; and in-service training of health workers in the service to upgrade their skills and knowledge. Staff at district hospital Medical Practitioners Social Worker Nursing Profession - Advanced Midwives Therapists: - Nurse Clinicians - occupational - Psychiatric Nurse - physiotherapist - Enrolled Nurses - speech and hearing - Nursing Auxiliaries - Nutritionist/Dietician - Hospital Infection Control - Oral Hygienist/dental therapists Nurse Pharmacy Laboratory - Pharmacist Technician/Technologist - Pharmacy Assistants Support Staff - Driver - Watchman - Cleaner - Gardener - Handyman The Report of the Committee on Human Resources for Health recommends that there should be one referral health team for every ten frontline teams (health centre teams). In this chapter you have read about the district health for all PHC package and how it will be delivered in the district in an integrated and co-ordinated manner. The chapter has also discussed the importance of community based health promotion and the ways in which health facilities will support the community based health initiatives. The governance system that will facilitate and also ensure that PHC services are delivered in the district is the subject for discussion in the chapter that follows. 65

GOVERNANCE OF THE DISTRICT HEALTH SYSTEM CHAPTER 6

Chapter 6 GOVERNANCE OF THE DISTRICT HEALTH SYSTEM The previous chapters have described how health services in the province are organised (chapter 2); the District Health System as a mechanism for facilitating PHC service delivery in the district (chapter 3); the role of communities in planning and delivery of health services (chapter 4); and the integration and co-ordination of the district health for all PHC package (chapter 5). The purpose of this chapter is to describe the manner in which the various service levels of the District Health System will be governed. After reading the chapter, you will be able to: clearly understand the option for governance of health services in this province; appreciate the reasons for this choice; identify the composition and functions of governance structures for each service level; and appreciate the degree and role of community representation in governance of their health services. Governance describes the structure, functions, powers and inter-relationships between the various levels of authority and control of an establishment. The National Department of Health has set out in its policy guidelines to the provinces three options for governance of the District Health System, giving each province the full authority to choose its initial option 1. Briefly described, the three options are: 1. A province can choose to run the health services in all its districts, delegating limited powers to the District Health Managers. The role of the District Health Authority, as a governance structure, in this option is only advisory. Executive powers are retained by the Provincial Health Office. This is known as Option 1. 2. The second option is that of full powers being delegated to the District Health Authority. In this option (Option 2 or the Statutory District Health Authority), the District Health Authority takes over all the public health services in the district; becomes the employer of all public health personnel; and is responsible for management of all public health resources. The role of the Provincial Health Office would then be to set policy, norms and standards, and to monitor and evaluate the services. 3. In the third option (the Local Authority option or Option 3), responsibility for provision and management of health services is vested in the local authorities. This means that in a health district there would be one local authority. Here too the role of the Provincial Health Office would be to set policy, norms and standards, and to monitor and evaluate the services. Regardless of the initial option chosen by a province, the long-term aim will be Option 3. Each province will determine its own pace in the move towards the final option. This will be influenced by the evolutionary process currently taking place in local government. THE GOVERNANCE OPTION FOR MPUMALANGA The province has chosen to start with the provincial option or Option one. This decision is based on the fact that the province does not yet have the necessary infrastructure and capacity in the districts for any of the alternative options to work well. 1 A policy for the Development of a District Health System for South Africa. 69

In this option, the Provincial Health Office is responsible for the administration and provision of health services in the province. Each district will have an Interim District Health Authority, which is to be established by provincial legislation. Its role will be advisory to the District Health Manager who is an employee of the Provincial Health Office. The Governance Structures There will be an interim health authority at each level of the health service. Although initially advisory, the interim health authorities are intended, in time, to take full responsibility for health services. The purpose of these structures is to: ensure that health services are responsive to the needs of communities; link health services more closely to improvements in the health of communities; find ways of making partnerships between health services and communities so that joint planning can be undertaken to address genuinely shared concerns. The composition, powers and functions for the governance structures at various levels of the health service are described below: GOVERNANCE OF HEALTH SERVICES AT PROVINCIAL LEVEL The provincial-level governance structure is the Interim Provincial Health Authority (IPHA) which will be chaired by the Member of the Executive Council (MEC). The IPHA will comprise: Composition Chairpersons of the interim District Health Authorities; Deputy Director-General; and Chief Director, Health Services (ex-officio). Powers and Functions The Interim Provincial Health Authority will be an advisory body to ensure community participation in the governance of health services at various levels in the province. It will provide advice that will enable the MEC to carry out the following functions: define guidelines for resource allocation to districts based on allocation to all the districts in the province; approve health plans and budget; approve capital expenditure via the provincial capital works programme and tender system; re-allocate revenue from Revenue Equalisation Fund according to district needs; set limits for expenditure requiring provincial approval; approve creation and abolition of posts in the provincial health service. GOVERNANCE OF THE HEALTH SERVICES AT DISTRICT LEVEL The Interim District Health Authority (IDHA) will be an advisory body meant to enlist community participation at the various health service levels in the district. However, with time, this body will evolve towards a formal statutory one namely, the District Health Authority once the necessary infrastructure and capacity have been developed in the districts. In other words, the objective is that, in time, the district health service will be accountable to the District Health Authority or Local Authority. The District Health Authority or Local Authority will hold responsibility for local health service governance, local policy issues and also be accountable for the use of financial resources. 70

Composition The composition of the Interim District Health Authority will be: Equal numbers of: - members appointed by the local or other authority or authorities within the health district; - members representing organisations with an interest in the health of the communities resident within the health district and appointed by the relevant MEC; District Health Manager (as ex-officio representative of Provincial Health Office); Financial management expert appointed by the IDHA; and Representation of personnel employed by the IDHA. Powers and Functions of the Interim District Health Authority The Interim District Health Authority will meet regularly at intervals determined by the MEC. Its role will be advisory to the District Health Management Team. The specific functions are given below: define requirements for capital and recurrent expenditure based on national and provincial guidelines and local needs; develop, together with the District Health Manager, annual plans and budget within allocation awarded generate additional revenue for the district health services; monitor and evaluate the provision of health services in the light of community needs and advise accordingly. GOVERNANCE OF HEALTH SERVICES AT FACILITIES Each health facility level within the district will have its own governance structure, with its particular composition and functions. Governance of a District Hospital The governance structure for a district hospital will be the District Hospital Board. Composition The composition of the District Hospital Board will be: Two representatives from the Interim District Health Authority (IDHA); nominated by the IDHA itself (one from NGO/CBO; one from private sector); Hospital Manager/Hospital Superintendent (ex-officio); One member from each clinic and health centre governance structure; District Health Manager (ex-officio) Health Centre Managers. Powers and Functions of a District Hospital Board The functions and powers of the District Hospital Board are given below: advocate on behalf of community and provide input into management of the hospital; raise additional funds for the hospital and its activities; and ensure co-ordination between the hospital and other health facilities in the district. Referral Hospital Governance There are hospitals in the province which have been designated a referral status (see Chapter 2). Governance of a referral hospital will be by the Referral Hospital Board. 71

Composition The Referral Hospital Board will consist of: Regional Health Director from the relevant region (ex-officio); Hospital Manager/Hospital Superintendent; Hospital Administrator Representation from IDHAs of communities served by the referral hospital; 2 members nominated by MEC from CBO/NGO/private sector. Powers and Functions of a Referral Hospital Board The powers and functions of the Referral Hospital Board will be to: advocate on behalf of the communities served and provide input in management of the hospital; raise additional funds for the referral hospital and its activities; and ensure co-ordination of referral services in the region. Governance of Services at Health Centre The Health Centre will have a governance structure which represents the local interests of the communities served by the Health Centre. This governance structure is the Health Centre Committee. Composition The composition of the Health Centre Committee will be as follows: Health Centre Manager; and Representatives from clinic committees served by the Health Centre. Powers and Functions of the Health Centre Committee The powers and functions of the Health Centre Committee will be to: advocate on behalf of the community and provide input in management of services at the Health Centre and in its catchment area; ensure co-ordination between the health centre and clinics; participate in needs assessment, planning and implementation of PHC; elect 2 members to serve on the local Reconstruction and Development Committee (RDC). Governance of a Community Clinic Governance of a community clinic will be by the Clinic Committee. Composition The composition of a Clinic Committee is given below: Clinic Manager (ex-officio); and Representation from the communities served by the clinic. Powers and Functions The powers and functions of the Clinic Committee are given below: advocate on behalf of community and provide input in management of services at the clinic and in its catchment area; ensure co-ordination between the clinic and health centre; participate in needs assessment, planning and implementation of PHC; and elect 2 members to serve on the local RDC. The Chairperson of the Clinic Committee will come from the community and will be elected by the committee. 72

COMMUNITY HEALTH COMMITTEES There will be a Community Health Committee for each community. The Manager of the clinic serving the community will be an ex-officio member. The role of community health committees will be to: Powers and Functions participate in the needs analysis, planning and implementation of primary health care services in the community; participate in community mobilisation for health development; elect/nominate representatives to the Clinic Health Committee; create awareness in the community of its responsibility for its own health. This chapter has described the system for governance of health services which is to be established during 1997 in Mpumalanga. The composition and functions of the authorities at various levels have been explained. Also covered in the same chapter is a discussion on the importance of community representation as well as the mechanisms for that representation. It has further explained that people s participation promotes ownership and ensures acceptance and sustainability of health care interventions. The PHC service programmes are described in the next chapter. 73

PRIMARY HEALTH CARE SERVICE PROGRAMMES CHAPTER 7

Chapter 7 PRIMARY HEALTH CARE SERVICE PROGRAMMES The purpose of this chapter is to outline the Primary Health Care service programmes that make up the minimum package to be delivered in all districts in the province. After reading this chapter, you will be able to: describe the PHC service programmes to be implemented in the districts understand the goal and objectives of each service programme plan and implement activities in each programme area identify some of the indicators for assessing programme performance. As you have read in chapter 1, 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 - and with their full acceptance and participation. In Mpumalanga, PHC services will be provided through service programmes, each of which will address identified community health problems and their causes. The development and implementation of service programmes signifies a major shift in health service delivery, in that the focus will now be on the health of each individual and family. Each health programme will have several components, namely: health promotion prevention of health problems cure rehabilitation palliation, where necessary Depending on the skill needed, the activity could be implemented in the homes, at community locations (schools, factories, offices, etc), clinics, health centres or hospitals. 77

Ten priority PHC programmes have been selected for implementation in the province. The choice was based on the results from a situation analysis carried out throughout the districts. The order of priority for the programmes in each district will vary and will be influenced by differences in the prevalence of health problems. The programme goals, objectives and strategies are in accordance with national policies outlined in documents such as the National Programme of Action for Children (NPA); Year 2000 Health Goals, Objectives, Strategies and Indicators for South Africa; and the National Health Plan for South Africa. The essence of each programme is discussed below. HEALTH PROMOTION Goal Health promotive activities should enable individuals, households and communities to gain and maintain good health through improved knowledge and skills. Although it is presented here as a programme, health promotion will form an important strategy in all PHC provision. The Health Promotion programme will ensure communication, information exchange and health promotional support to all the service programmes in the districts. The objectives of this programme are to: Objectives provide people with the knowledge to live healthy lives encourage and support people in keep up healthy lifestyles encourage national, provincial, district and community leaders to promote health in all development policies and activities encourage government to enact legislation that promotes, rather than constrains good health. Opportunities for Health Promotion Opportunities for health promotion exist at various service levels: the community, health facility and the district health office. The community level offers a tremendous opportunity for empowering individuals, households and communities to be pro-active role in promoting their own health, because health promotional messages are delivered right where the problems exist. At the health facility level, opportunities present in the form of contact between the health worker and the client/patient. At that time of first contact, the patient/client is most receptive to health promotional messages. You can take maximum advantage by involving all health workers in health promotion at a time when individuals are particularly receptive. The district health office also offers unique opportunities for health promotion because decisions in health service design made here have district-wide application. In addition, the District Health Office is the most effective level for intersectoral collaboration and mobilisation of resources and technologies for health interventions. Strategies You should take advantage of these opportunities by developing effective health promotion and communication strategies which target different groups. Your strategies should: upgrade the communication and counselling skills of health workers, who have an important role in sharing health information with mothers, fathers, grandparents, youth, teachers, leaders, church leaders etc train community members, including community-based health workers, who will contribute towards health education and mobilisation of communities adopt a research-based approach to identify information needs in the communities, develop effective messages which are well targeted, and assess impact of health promotion activities. establish information resource centres at the district level, to facilitate dissemination of information through the district health information unit. 78

Table 7.1. Health Promotion - Major Activities at Various Service Levels Household/Community Clinic Health Centre District Hospital Mobilise communities to take an active Provide information Plan health Provide support to interest in health-related development feedback to promotion service health centres Assist communities identify health and communities within in its catchment and clinics in development problems and health needs the respective area designing health Assist communities improve their knowledge catchment areas Establish linkages promotion of the causes of ill health and how good Organise and with mass and materials and health can be maintained conduct training for traditional media messages Mobilise community resources to enhance community based for supporting self help for health improvements with a health workers health promotion special focus on community groups Provide technical activities in the Strengthen public participation in support to community in the catchment development-related activities based health workers area Train health workers in community Provide support to organisation,communication and clinics in health counselling skills promotion activities Provide support to community based including training services e.g. immunisation, oral rehydration therapy for diarrhoea, health education and counselling in priority areas such as maternal and child health, STDs and HIV/AIDS, nutrition, hygiene and environmental sanitation, etc. Provide training and educational opportunities to the community based health worker Empower communities to realise their own role in promoting their own health 79

Activities The district health office will do the following: identify district and community training needs in health education and community health skills and co-ordinate necessary training advocate for cross-sectoral policies which will support improved community health oversee the development of appropriate health education materials and community based health education in support of all PHC programmes commission and oversee the research required to ensure that health education materials and activities are culturally appropriate co-ordinate and organise district health promotion activities establish structures for inter-district exchange of information and knowledge; establish structures for intersectoral collaboration establish linkages with mass and traditional media for supporting health promotion activities help establish health promotion/communication resource centres. Some of the major health promotion activities at various service levels are given in Table 7.1. How to judge the success of your programme You will know your programme is working well when: the number of health workers trained in health promotion and communication skills increases more health workers use health promotion techniques such as role-playing and demonstration your target groups show greater knowledge of your key health education messages more survey respondents state that they practise healthy lifestyles defined by your health education objectives your district has an active, effective health promotion resource centre. MATERNAL, CHILD AND WOMEN S HEALTH Goal The goal of the Maternal, Child and Women s Health programme in your district is to reduce sickness and death in mothers, children, adolescents and women. Objectives The programme focuses on health protection, promotion and development of children and women. The programme aims to: provide accessible, comprehensive services in antenatal, delivery, postnatal and reproductive health for mothers provide accessible, quality, preventive health care services to children reduce illness and death in children arising from preventable conditions provide accessible, health care services to adolescents to address problems of substance abuse, depression, teenage pregnancies and sexually transmitted diseases maintain the health status of the elderly and their access to health services. Strategies Some of the strategies your team will use to attain the goal of less morbidity and mortality for each group are to: Maternal Health ensure access to quality antenatal care, quality care during and after delivery to mothers and their babies - and encourage the use of these services implement a system of service delivery for mothers and their babies which strives to achieve agreed objectives 80

ensure that all maternity facilities are mother and baby friendly provide comprehensive family planning services to families and individuals requiring them. Child Health establish capacity for management of common illnesses that affect children establish services for low birth weight babies reduce mortality due to diarrhoea, measles and acute respiratory infections in children, through appropriate disease management activities increase immunisation coverage among children of one year of age against diphtheria, pertussis, tetanus, measles, poliomyelitis, hepatitis and tuberculosis provide oral rehydration therapy (ORT) and continued feeding for children suffering from diarrhoeal disorders ensure regular growth monitoring for all pre-school children encourage breastfeeding introduce nutrition-supportive strategies within health facilities and the community ensure adequate management of malnourished children ensure appropriate weaning practices and nutritional rehabilitation of vulnerable children. Adolescent Health provide teenager support programmes aimed at reducing substance abuse, teen pregnancies and intentional and unintentional injuries among adolescents provide peer group education for sexuality and life skills. Women s Health support education and literacy programmes for girls and women provide information on sexuality and reproduction provide confidential services for the diagnosis, management and counselling of HIV/AIDS/STD for girls and women implement a plan for health education, screening and treatment of cervical and breast cancer. Activities Some of the major activities to be implemented at various service levels are given in Table 7.2. How to judge the success of your programme You will know this programme is working well when: Child health fewer babies are born with low weights immunisation coverage increases there are fewer deaths from preventable diseases fewer children are stunted or wasted fewer children have severe malnutrition Adolescent health there are fewer cases of adolescent injury and suicide less adolescents abuse drugs and alcohol there are fewer teenage pregnancies Women s health there is a decrease in the fertility rate more women have access to antenatal care more health facilities have health workers trained to recognise high risk pregnancies more women receive postnatal care from health care workers more facilities provide screening services for women s cancer more health care initiatives target women s health. more women taking informed decisions about their sexuality and fertility 81

Table 7.2. Maternal, Child and Women s Health Programme - Major Activities at Various Service Levels Community Level Clinic Level Health Centre District Hospital Empower households through health Provide antenatal, Provide services for Provide referral promotion to make the right decisions maternal and antenatal, maternal services for the to ensure safe motherhood postnatal care and postnatal care lower levels eg. Provide training for TBAs (Traditional Birth Provide family Provide family - delivery of high Attendants) planning services planning services risk cases incl. Provide information on ORT (oral-rehydration Provide training for Provide screening Caesarean section; therapy) TBAs (Traditional service for high-risk - managing congenital Empower households through health Birth Attendants) cases for referral to abnormalities promotion to prevent home injuries Provide screening hospital and premature Provide counselling against child abuse of high risk antenatal Manage simple post mature babies; Promote breast feeding cases for referral to partum complications - screening for Empower households through health health centre/ and abortions cervical and promotion to seek immunisation and hospital Provide care for breast cancer; growth monitoring services at health Undertake post-natal normal and sick new- - rendering infertility facilities follow-ups borns services. Provide education and counselling to Provide growth Provide counselling youth groups and schools regarding monitoring services against child abuse sexuality, unwanted pregnancies, Provide diagnosis and Provide service for substance abuse, abortions, sexual treatment of minor monitoring develophealth (HIV/STDs) ailments ment milestones Empower women through health Provide ORT Provide health promotion to seek screening service Provide counselling promotion services for cervical and breast cancer against child abuse in support of school Empower households through health Provide health health promotion to be gender conscious promotion services Provide screening Provide services for infertility in support of school service for cervical health (pap smear) and Provide screening breast cancer service for cervical Provide good (pap smear) and quality immunisation breast cancer services and increase Provide good quality public awareness immunisation services about its benefits and increase public awareness about its benefits 82

NUTRITION PROGRAMME Goal This programme seeks to ensure good nutrition for everyone in Mpumalanga Objectives The nutrition programme aims to: reduce the prevalence of underweight, stunting and severe malnutrition among children under the age of six prevent severe malnutrition of pregnant and lactating women reduce the prevalence of micro-nutrient deficiency i.e. vitamin A, iodine and iron promote exclusive breast feeding for 4-6 months and establish breast feeding support groups promote baby friendly hospital initiatives prevent diseases of lifestyle provide specialised therapy to nutrition related diseases give support to community-based nutrition surveillance and rehabilitation programmes. Strategies The strategies for achieving the objectives of the nutrition programme include: Provision of preventive, curative, rehabilitative and promotive services; Promotion of intersectoral collaboration and community participation Development of an effective referral system. Components The main components of the nutrition programme are: nutrition promotion and education nutrition surveillance nutrition therapy and rehabilitation. Activities Some of the major activities of this programme are given in Table 7.3. How to judge the success of your programme You will know your programme is doing well when: more children up to 23 months of age are still breastfeeding; fewer children are wasted or stunted people in more households consume adequately iodised salt more mothers know how to interpret growth charts. 83

Table 7.3. Nutrition Programme - Major Activities at Various Service Levels Community Level Clinic Level Health Centre District Hospital Promote household food security, correct eating habits and hygiene Promote, support and participate in breastfeeding initiative Form support groups for lactation management at baby friendly institutions/facilities Monitor, evaluate and upgrade nutrition education programme Provide health workers with skills on promotion of health/nutrition Train communities to assess/analyse and take action on specific or identified needs Implement primary school nutrition programme Empower households through health promotion to recognise and refer nutrition related cases/ diseases to the health facility for treatment or specialised care Empower households to manage and rehabilitate members with nutrition related conditions Provide nutrition education, guidance and demonstrations to target groups Provide support to breastfeeding initiative Provide support to communities to plan nutrition projects Monitor nutritional status especially children under 6 years Implement micronutrient supplementation Give support to monitoring and evaluation of nutrition interventions such as breastfeeding and iodine deficiency disorders control Participate in routine data collection through Health Information System Provide supervisory support to clinics Plan and support nutrition campaigns Give support to training activities Give support to communities to plan projects Provide support in compiling of community profile Provide support and maintain referral and support system for follow-up Provide specialised treatment of diseases of lifestyle Provide diet therapy Develop special nutrition interventions Implement Baby Friendly Hospital Initiative Collect and collate data from referring clinics and communities Monitor nutritional status of children under 6 years Provide specialised prevention, cure and rehabilitation of malnutrition Implement Baby Friendly Hospital Initiative Formulate special therapeutic diets Conduct nutrition related research 84

PRIMARY ORAL HEALTH CARE Goal This programme aims to promote oral health in children and adults. Primary Oral Health Care (POHC) means the control and prevention of oral diseases without expensive restorative procedures for teeth. The programme focuses on diagnosis and prevention of oral diseases using local technology wherever possible, with the full co-operation and participation of the community. The objectives of primary oral health care are to: Objectives reduce the incidence of oral diseases in children and adults; and promote proper oral health practices. Strategies include: Strategies advocating for the fluoridation of public drinking water where necessary using alternatives to water fluoridation prophylactic fissure sealing of occlusal pit and fissures of posterior teeth of high-risk patients provision of oral health education provision of oral hygiene information, with emphasis on the role of plaque in causing oral disease. Components personal primary health care services (basic oral health services, including treatment of pain and sepsis); and non personal primary health care services (health education and promotion activities aimed at groups and communities. For the oral health programme to be successful in your district, it needs to be integrated into general health promotion strategies, as it will require full co-operation and active participation by the community. How to judge the success of your programme You will know this programme is effective when: more children under six are free of caries fewer twelve year olds have decayed, missing or filled teeth more health units have dental facilities. 85

ENVIRONMENTAL HEALTH Goal This programme should ensure a healthy environment for all communities in the province. This programme should: Objectives and strategies ensure that safe, clean water and basic sanitation is available: - monitor and advocate the use of safe drinking water - promote personal hygiene - prevent water and environmental pollution - promote good and safe housing reduce health risks related to food, water and sanitation, labelling and importing of consumer goods, hazardous substances, industrial and occupational hygiene, and port health: - implement environmental health education - promulgation of related legislation and regulations - control smoking - promote industrial and occupational safety improve accessibility for all in the district to a comprehensive environmental health service: - investigate communicable and environment related diseases - control disease vectors promote quality assurance of environmental health programmes through operations research establish an effective environmental health information system. Activities The major activities carried out in this programme are listed in Table 7.4. How to judge the success of your programme You will know your programme is working well when: people live within 15 minutes walk of a safe source of water households use a safe form of waste disposal people know the importance of washing hands after using the toilet food outlets meet hygiene standards safe dumping sites are proclaimed the frequency of epidemics caused by contaminated water, food and other substances decreases households in malaria areas are adequately sprayed. 86

Table 7.4 Environmental Health Programme - Major Activities at Various Service Levels Community Clinic Health Centre District Hospital Empower communities to recognise and take protective action against environmental health hazards Train households in personal hygiene Advocate environmental health development eg. the provision of safe housing, water, sanitation Mobilise communities for environmental health action Promote intersectoral collaboration Collect information on environmental health in the communities Carry out environmental sampling of milk, soil, water and food Provide education on environmental health Advocate personal hygiene Support community environmental health initiatives Collect relevant data Monitor and evaluate environmental health programme at community and clinic levels Support and provide training to community health workers in environmental health Carry out surveillance of environmental health programme eg. food outlets Monitor the implementation of relevant legislation Inspect government and nongovernment facilities Promote safe working environment Inspect/monitor food hygiene and food handling in public facilities Give support to and monitor vector control programme Collect relevant data Provide referral services e.g. monitoring of safety of food outlets Conduct operational research in environmental health Key Notes * Functions of the Environmental Health Programme are governed by acts of Parliament, many of which are presently under revision: Health Act of 1977 (Under revision) National Building Regulations (Act 103 of 1977) Food Cosmetics and disinfectants act (Act 54 of 1972) Water Act (Act 54 of 1956) (Under revision) Act on Hazardous Substances (Act 28 of 1975) The Occupational Health and Safety Act (Act of 1993) * Revisions of standing legislation may impact on the legal responsibility of environmental health services at the various levels 87

The MEC for Health, Welfare & Gender Affairs, Ms Candith Mashego, promotes an immunisation campaign COMMUNICABLE DISEASES CONTROL Goal This programme aims to prevent exposure to and risk from endemic and epidemic communicable diseases which currently account for 70% of the morbidity and mortality burden in Mpumalanga. The programme aims to achieve: Objectives 90% coverage of 7 major vaccines (diphtheria, pertussis, tetanus, hepatitis B, polio, tuberculosis, measles) before 2 years of age 85% cure of sputum smear positive tuberculosis patients 90% completion of multiple drug therapy by leprosy patients 95% correct syndromic treatment for sexually transmitted diseases increased knowledge in at least 90% of households on how to treat acute respiratory infections (ARI) and diarrhoeal diseases (DD) and when to refer reduction in the malaria mortality rate to less than 0.5%. Strategy This programme should achieve effective and efficient control of priority communicable diseases using appropriate and proven interventions (Table 7.5). Components The components of the Communicable Diseases Control programme are: expanded programme on immunisation control of tuberculosis/leprosy control of HIV/AIDS and sexually transmitted diseases control of diarrhoeal diseases control of acute respiratory infections control of vector borne and parasitic diseases and zoonoses outbreaks. 88

Table 7.5 Communicable Diseases Control Programme - Major Activities at Various Service Levels Community Level Clinic Health Centre District Hospital Provide education on value of health interventions Mobilise communities for special activities Train communities on lay definitions of diseases Encourage communities to bring animals for vaccinations Recruit treatment supporters Develop life skills and mobilise interest and youth groups Communicate simple, accurate messages Supply condoms Support home based care Train on prevention, especially environmental health measures Provide health education Co-ordinate special local outreach efforts Provide day-to-day services to suit community needs Order, supply and manage vaccines, drugs and consumables Set local coverage targets Liaise with local community-based health workers on ways to make service more relevant to community needs Record and interpret practice in line with targets Counselling on contacts and importance of completing therapy Treat with appropriate medication on syndromic basis Refer complicated/non-responsive cases to next level Notify Communicable Diseases Control Co-ordinators of suspected cases of contagious diseases (outbreaks) Initiate prompt response for control of contagious conditions Develop mechanisms for contacting local state veterinarians Maintain close contact with local Environmental Health Staff for dual community based interventions Provide Health Education Co-ordinate special local outreach efforts Provide day-to-day services to suit community needs Order, supply and manage vaccines drugs and consumables Set local coverage targets Liaise with local community-based health workers on ways to make services more relevant to community needs Record and interpret practice in line with targets Conduct training of all staff in the catchment area Counselling on contacts and importance of completing therapy Treat with appropriate medication on syndromic basis Refers complicated/non-responsive cases Provide service to referred cases (eg. STDs) or complicated cases (eg. abscess following vaccination) Notify Communicable Diseases Control Co-ordinators of suspected cases of contagious diseases (outbreaks) Initiate prompt response for control of contagious conditions Develop mechanisms for contacting local state veterinarians Maintain close contact with local Environmental Health for dual community based interventions Treatment of the referral cases Treatment of infectious diseases meriting hospital level management 89

Activities Some of the major activities of the programme are given in Table 7.5 How to judge the success of your programme You will know the programme is working well when: fewer children under five are hospitalised with acute respiratory infection fewer health units experience stock shortages of antibiotics more mothers know how to prepare and administer oral rehydration salt (ORS) solution more children aged 12-23 months are fully immunised with BCG, DPT, measles, and polio vaccines more people know how TB is spread and how to prevent infection more people have the correct knowledge about ways to prevent HIV/STD transmission. REHABILITATION AS A SERVICE PROGRAMME Goal The goal of this programme is to prevent disabilities, detect disabilities early and provide rehabilitation services. Strategy The strategy of community-based rehabilitation (CBR) places rehabilitation within a community development context, in which rehabilitation services are delivered by community based rehabilitation workers supervised by professional staff. It includes equalisation of opportunities and social integration of people with disabilities. For the strategy of CBR to succeed, referral to and support from specialized rehabilitation centres at secondary level is essential. All people with physical and mental disabilities should be enabled to make decisions about appropriate health care, education, vocational training and re-integration into society. This highlights the need for intersectoral collaboration involving education, welfare, labour, transport, sport and recreation and housing. Rehabilitation focuses on the following: visual difficulties; hearing and speaking difficulties; movement difficulties; mood and behaviour disorders; learning difficulties; and epilepsy. Components Activities Some of the major activities of the programme are listed in Table 7.6 How to judge the success of your programme You will know the programme is effective when: more disabled children enrol in special schools fewer adults are disabled more disabled children have access to appropriate health services more health workers can identify signs and symptoms associated with disabilities more mothers with disabled children know how to prevent a similar disability. 90

Table 7.6 Rehabilitation Programme - Major Activities at Various Service Levels Community Level Clinic Health Centre District Hospital Identify people with disabilities Carry out basic assessment of people with disabilities to the relevant resources Select appropriate rehabilitation procedure, including health promotion and prevention Promote social rehabilitation Work towards community development and empowerment of disabled people Support and strengthen community initiatives such as self help groups and care groups for disabled children Provide emotional and informational support Encourage normal development in disabled Encourage normal activities in disabled adults Assist with the acquisition of assistive devices Link the disabled with appropriate resources Refer people with disabilities to appropriate rehabilitation services Provide intensive rehabilitation with emphasis on disability Support community-based rehabilitation workers Act as resource for communities Provide community outreach visits especially to the areas where no community based rehabilitation programme exists Provide referral rehabilitation services with emphasis on the provision of early phases of rehabilitation including a spectrum of therapeutic services, early detection and prevention disabilities following illness or trauma 91

EMERGENCY HEALTH SERVICES Goal The goal of this programme is to provide a quick response to emergencies, and train communities to deal with emergencies and disasters. This programme aims to: Objectives facilitate speedy and safe transport of the seriously ill or injured patient from the site of injury or illness to the appropriate health facility, or between facilities. develop capacity of the health facilities to attend to medical, surgical, paediatric, obstetric and all other emergencies in the district; sensitise the communities to risk-taking behaviour and the potential for disasters put in place an early warning system at community level reinforce preventive and disease control measures to minimise risks to people co-ordinate emergency preparedness activities within the community prepare a health emergency plan which mobilises available local resources ensure that the training for community health workers includes health emergencies improve first aid and improve existing district emergency plans and the state of readiness of emergency teams empower households to manage domestic injuries promote safe use of roads in order to reduce traffic accidents prevent domestic injuries. Strategies In order to accomplish the programme objectives, the provincial health office will: ensure sufficient programme coverage in the province make available vehicles equipped with all relevant resuscitation equipment ensure that all emergency vehicles and stations are staffed with adequately skilled personnel inform all communities and health facilities of the service points for ambulance services in the province market the service through media. develop and implement first aid training programmes. Components The components of this programme are to: manage medical emergencies evacuate emergencies and referral train at risk groups in disaster preparedness educate people about First Aid management of emergencies. The Provincial Health Office has contracted out the emergency services to the District Council (old regional services board) at the Lowveld, the Highveld and Eastern Highveld. The Lowveld has a control room in Nelspruit and information about the service points to cover the whole of the Lowveld Region can be obtained from the Nelspruit office. The Highveld Control room is in Middelburg and information about service points to cover the whole of the Highveld region, can be obtained from there. Eastern Highveld Region has a control room at Secunda from where information about service points and location of ambulances may be obtained. Disasters/Epidemics A body known as the Medical Joint Operations Command (MJOC) exists which co-ordinates interventions intersectorally in cases of epidemics and disasters. 92

The MJOC comprises representatives from the departments of Health, South African Medical Services, Welfare and NGOs. The MJOC liaises with the Provincial Joint Operations Command (PJOC) which has broader representation including the police services, armed forces and local government. The services of these bodies are initiated through the regional and provincial health offices. Personnel Skills-Mix Each region has set up training colleges for purposes of training and retraining all ambulance personnel in transporting and First Aid management of the acutely ill/injured while in transit to hospitals. Suitably qualified and/or trained staff have been absorbed from former Homelands Governments and Transvaal Provincial Administration to constitute the New Mpumalanga Medical Emergency Staff. Telephone numbers of the ambulance stations and/or control room contact telephone numbers are available in the appropriate phone books in each region or can be obtained on request from Post Office telephone operators or from the Police Stations nearest to the client. National emergency numbers in the province are being introduced. How to judge the success of your programme You will know the programme is working well when: less time passes between occurrence of injury and emergency response safety regulations are implemented and enforced in a work place or other high-risk environment more community-based workers, factory or plant cadres, and traditional practitioners are trained in injury care more health care facilities offer 24 hour emergency care services people in more households are trained in the management of injuries CURATIVE, DIAGNOSTIC AND MEDICO-LEGAL SERVICES Goal The goal of this programme is early diagnosis, treatment and management of diseases to prevent diseases progressing to a chronic state, disability or death. Objectives The long-term objectives of the programme include ensuring that: communities have access to health facilities and health workers service programme coverage such as curative diagnostic and medico-legal are adequate sufficient capacity for clinical skills exists at each service level a well functioning referral system is built within the district health system accurate and reliable medical records of individual patients, disease profile, including incidents of patient-health worker contacts, for patient follow-ups, planning, monitoring and evaluation and operational research, are kept treatment, management and control of disease is carried out using given therapeutic protocols appropriate for different service levels and by prescribing strictly essential drugs sufficient supply of essential drugs and treatment protocols are in stock in all primary health care facilities. The strategies for this programme include: Strategies development of protocols and provision of in-service training for the early diagnosis and treatment of simple ailments in homes, public institutions and community based facilities (first aid and primary curative interventions), through the community based health workers, outreach services, community clinics 93

Table 7.7 Curative, Diagnostic and Medico-Legal Services Programme - Major Activities at Various Service Levels Community Level Clinic Health Centre District Hospital Provide support to people with chronic illnesses e.g. AIDS (Home Care); Diabetes (insulin administration) and cancer Distribution drugs to individuals who cannot access them at health facility eg. disabled, old people Provide care for terminally ill Provide information and health education on 5 priority cancers - cancer of the uterine cervix - cancer of oesophagus - liver cancer - lung cancer - breast cancer Empower communities to recognise and manage common illnesses eg. malaria, vomiting and diarrhoea in children, minor domestic injuries Empower households to seek health services in cases of assault, sexual abuse, rape, dog bites, etc. Provide counselling services for: rapes, assault, sexual abuse, HIV Provide treatment and management of minor and chronic illnesses and injuries Provide counselling services eg. (HIV/AIDS) Examine and treat some assault cases Provide referral services for: sexual abuse, rape, dog bites Provide medico-legal services to clients for old age pensions and disability grants Diagnose and manage minor illnesses including minor surgery, manage emergencies and refer to hospital those requiring higher level care Provide two-way referral point from clinic/community to hospital; and referral to clinic/community Provide diagnostic examination of specimens both from the community and clinics Examine and treat some assault cases and refer those requiring higher level care Examine and treat rape cases, sexual abuse, dog bites Provide medico-legal services to clients requiring, disability grants, boarding, completing medico-legal forms; issuing of death certificates Provide treatment for major ailments (referral level component), medical and surgical emergencies Initiate treatment and supervised management of chronic diseases (diabetes, hypertension) Provide diagnostic services; - x-ray - laboratory - histology - endoscopy - ultra-sound - laparoscopy Examine, treat and issue reports for rape, sexually abused and serious dog bites Provide medico-legal services to clients such as examination for old age, pensions/disability grants, issuing of death certificates, post mortem examinations 94

auxiliary management of chronic diseases like tuberculosis, heart, hypertension, diabetes, mental health and cancer provision of laboratory and radiographic services in support of clinical services, patient management and surveillance of diseases timely supply and management of medicines, re agents and other chemicals to support early diagnosis and effective treatment provision of timely and accessible services for post mortem, medico-legal examinations and injury assessment, medical boarding and medical testimony, visiting justice for the prisons (forensic and medico-legal) establishment of an effective referral system in support of the PHC services that ensures equity and accessibility to quality service at secondary and tertiary levels. Activities Your team should ensure that adequate services are provided at various levels. Some of the activities the staff will be implementing at various levels are mentioned in Table 7.7 How to judge the success of your programme You will know your programme is doing well when: illnesses are diagnosed earlier health facilities have adequate diagnostic capabilities; households have the ability to recognise and take appropriate action for the common illnesses in the community; primary health workers have the knowledge and management skills for local common conditions and illnesses; health workers know the criteria for referring patients to a higher level of health care health facilities have in stock the essential drugs at any given time. MENTAL HEALTH AND SUBSTANCE ABUSE PROGRAMME Goal The goal of the programme is quality mental health services for all the province s people. The objectives of this programme are to: Objectives reduce and prevent mental illness and substance abuse promote social re-integration of people with mental disabilities. The following are the strategies of the programme: Strategies identify mental ill health at an early stage and treat appropriately to avoid complications identify those who need rehabilitation and refer them establish rehabilitation services at all levels promote mental health within the communities e.g. through campaigns encourage community and family participation in mental health programmes establish community networking establish a child mental health programme; establish effective management of mental illness at all levels of care establish an effective referral system through all the levels of care. 95

Components The components of this programme are: adult mental health; adolescent mental health; child mental health; and geriatric mental health. Activities Some of the major activities of this programme are given in Table 7.8 How to judge the success of your programme You will know the programme is running well when: fewer people with a psychiatric diagnosis are detained in police cells fewer people with a psychiatric diagnosis are admitted to hospital fewer children and adults have mental disorders cases of child abuse/family violence are reported and managed effectively people who are abused seek help and are helped fewer people commit suicide more victims of rape, child abuse, women abuse receive psychological/social counselling A lot of effort will be required from your team to put mental health services in place. In the past mental health was limited to treating the mentally ill in a few facilities. It is of utmost importance that mental health services form an integral part of PHC services. Rehabilitation of people with mental conditions need to be developed extensively. The strategy of community-based rehabilitation should be employed in addressing this issue. This chapter has described the goals, objectives, strategies and activities of the 10 PHC service programmes which are to be implemented in the district, together with ways in which you can judge the success of each of the service programmes. The chapter that follows describes the management and health information system which will enable the health workers and service managers to plan, implement, monitor and evaluate the service programmes. 96

Table 7.8 Mental Health Programme -Activities at Various Service Levels Community Level Clinic Health Centre District Hospital Empower households to recognise health risks of substance abuse and violence and to take the necessary action Provide counselling services eg. marriage guidance, etc. Provide life skills training eg. how to cope with death in the family or chronic disease within a family Build capacity of households to identify early mental ill health for referral to health facilities Provide maintenance therapy Resocialise prisoners and chronic mentally ill patients following long institutional admission Establish support groups eg. youth groups Establish counselling centres Provide counselling services Empower households to recognise health causes of mental illness and how to prevent it Provide maintenance therapy Provide support for community based mental health programmes Initiate individual, group and family therapy Provide pyschotherapy Provide advanced counselling services Provide training to counsellors, basic life skills educators Conduct specialised screening eg. screening for slow learner children Assist in screening for disability grant Supervise services at clinics Provide diagnostic and treatment services for patients suffering from mental illness Establish mental health forum Assist in the rehabilitation of the mentally sick Provide advanced psychotherapy Manage acutely ill patients Provide specialised therapy eg. drug, alcohol withdrawal and advanced counselling services Provide advanced diagnostic services Conduct research with assistance from regional office 97

PART 1iI Information, Programme Monitoring and Evaluation

A DISTRICT HEALTH AND MANAGEMENT INFORMATION SYSTEM CHAPTER 8

Chapter 8 A DISTRICT HEALTH AND MANAGEMENT INFORMATION SYSTEM The previous chapter described the PHC service programmes which are to be implemented in the district. Chapter 8 aims at equipping the health worker with knowledge on the importance of health and management information in facilitating planning and implementation of health services. After reading this chapter, you will be able to: identify what makes up the District Health and Management Information Systems; state health and management information needs at district level; identify tools and methods for collecting and processing data; describe what is involved in data analysis, interpretation, presentation and reporting; advocate for the use of information; and identify the resources and management support needed to develop a District Health and Management Information System. The District Health and Management Information System (DHMIS) is made up of human resources, financial resources and equipment that result in collecting, processing, analysing, storing, retrieving, disseminating and using data for the purpose of efficient and effective management of health services in the district. There are two components of the DHMIS; one is information on management and the other is health information. The management component deals with information that helps your team handle management issues, and the health information component focuses on information dealing with the health status of the community and health programmes. The DHMIS must not be seen as the end in itself. It is a tool you will use to improve health. At whatever level you work, the DHMIS will make it possible for your team to: assist in the carrying out of day-to-day PHC operations and provide quality services to clients; and make health services more effective through improved planning, more efficient use of resources, and systematic monitoring and evaluation. The purpose of a district health information system is to provide information that can help improve the planning, implementation and evaluation of all activities, including those in sectors other than health, that will directly lead to an improvement in the health status of the district population. HEALTH AND MANAGEMENT INFORMATION NEEDS In order to enable you and your team to better plan and manage the district health services, you will require information covering a wide range of areas. Therefore, your team will be required to have some information in each of the following six categories: Socio-economic and Environmental Information The information needed in this category includes: communication network (roads, transportation etc); physical features (the terrain, mountains, rivers etc); climate (rainfall, temperature, seasonal pattern); and organisation of local government and administration. 103

Your knowledge of the general socio-economic conditions and the environment under which you are operating, helps you better understand your district. You should consult local authorities, rural councils and local leaders. In this category you obtain information on: Demographic Information population size, age and sex structure; population distribution between rural and urban areas; population distribution in various geographical areas in the district; births, deaths, migration patterns and population growth rate; and family size and composition The DHMT must know the population within the district catchment area so that the team can determine target populations for programme coverage and accessibility of services to the people. The same information guides your team in resource allocation and serves as a denominator when calculating rates, such as birth and death rates, population growth rates and disease prevalence. Your team should obtain information on: Health Status Patterns and Trends common causes of illness, disability, mortality; frequency of common lifestyle risk factors for communicable and other diseases e.g. promiscuity and HIV/AIDS; smoking and lung cancer; mining and lung disease; frequency of use of harmful substances including cigarette smoking, alcohol, drugs; problems associated with food availability, housing, water supply and excreta disposal; and health care seeking behaviour through knowledge, attitudes, practice and behaviour (KAPB). Your knowledge of health status helps your team to: determine health priorities, evaluate effectiveness of PHC programmes, control measures for epidemics, determine met and unmet needs and describe the level of community well being. Access, Utilisation, Coverage and Quality of Health Care Under this category the information required includes: safe motherhood (family planning, antenatal, delivery, and postnatal care); nutrition (breastfeeding, growth monitoring, malnutrition); immunisation; environmental health (water supplies, housing), household hygiene, excreta disposal); control of communicable and non communicable diseases (risk factors, cases diagnosed, control activities implemented); utilisation of outpatient and inpatient health care facilities for acute and chronic diseases; and utilisation of diagnostic services (laboratory, x-ray). This information enables the DHMT to determine case work load(volume), coverage and quality of care provided in the facilities. It also allows your team to assess the effectiveness and efficiency of the service programmes. 104

Resource Mobilisation, Allocation and Utilisation The information required here includes: number, capacity and distribution of facilities (Government, NGO, private); number and distribution of personnel by qualification (Government, NGO, private); distribution of programmes (Government, NGO, private); sources of funding, budget allocation; expenditure on various programmes; and availability and performance of management support (supervision, transport, logistics and supplies). With this information, your DHMT is in a position to: determine resources available for health programmes; estimate future resource requirements; account for use of resources; and calculate programme efficiency. District Health System Management Process In this category, we need information to assist the manager in: decision making; planning (implementation of national and provincial policies, strategies, plans); co-ordination (collaboration within programme implementors and co-ordinators, intersectoral health and development activities, the role of communities and the private sector); and monitoring and evaluation (extent to which indicators decided by the district health system are used). Successful planning and implementation of PHC programmes in your district requires support from provincial level. Your team must identify areas where they need support and then ask for guidance. Equally important is the involvement of communities and other health development agencies in health development. The role of monitoring and evaluation is to improve the management of PHC at all levels as you will find out in chapter 9. TOOLS AND METHODS FOR COLLECTING AND PROCESSING INFORMATION What are the sources of data at district level? The Health Information System (HIS) will collect its data from different sources. Some of these are: routine records of patients, clients and activities in health facilities; public health programmes e.g. malaria control; population based records such as the national censuses; ad hoc surveys that are carried out by programmes/projects for monitoring and evaluation purposes; vital events such as registration of births and deaths; community based health worker with community register; and tribal authorities. In collecting routine records, the HIS utilises specially designed forms. Once filled by the relevant service providers, these forms are analysed locally, and the processed information sent to the District Health Information Office for preparation of district summaries. These are then forwarded to provincial level and fed back to the service providers. The DHIS draws its quantitative data (numbers) from the mainstream of routine facility-based information. This provides a reasonable estimate of the number of activities carried out by the programmes. This is the information your team uses in estimating coverage indicators such as percentage of children immunised. Assessment of direct and indirect costs of services and facilities, requires the use of techniques in economics. These skills may also not be readily available in your district. Therefore seek guidance from the provincial Directorate of Policy, Planning and Information Services.. 105

How will you process the data? The handling and processing of large volumes of data collected through the routine health information system is made more manageable by using computers and associated technologies. The provincial team should plan to introduce computers in all the districts and promote their use. While the provincial team organises to have this in place, your team has to contend with handling data manually. This means that you should design the information system around carbon papers, calculators, pens and filing cabinets. Use of telephone/ radiophones will facilitate the ability of your team to share information with other people. Data Analysis, Presentation and Reporting The real purpose of collecting data is to transform it into information that can be used to make rational and informed decisions. A good information system enables local level health workers to know whether the health service is achieving its objectives. They use information to set local objectives and targets and this enables them to see how well they are progressing towards achieving these targets. Data becomes information when it is placed in context, and demonstrates that objectives have been met. For example, the number of children under one year immunised by clinic A against measles only becomes information when it is compared to the number of infants in the catchment area of clinic A. The team should develop reliable and regular information on major key indicators for various PHC programmes. How do you present the information? Your team should present the information in a manner that promotes wide use. Some of the ways you can present the information are outlined here below: Tables and Figures Tables are an essential means of presenting organised sets of analysed data, particularly numerical data. Figures and graphs are also frequently used because they can present visual information much more clearly than tables. Note these important points about using tables and figures: titles should always be concise and self-explanatory, expressing clearly all the information that is being presented. The meaning of the title should be immediately obvious to the reader; rows and columns must be clearly labelled and, where appropriate, all the categories should be clearly shown; Axes of graphs and diagrams should be properly defined and clearly labelled with their scales; Keys or labels are necessary in graphs with more than one line or group. The labels identify the different groups being presented for comparison; and Footnotes are used to indicate the source of the original information. Tables Tables are a common feature in most of our reports. If done properly, they are quite easy to construct and they deliver the message more effectively than the written text. However, there are different types of tables with varying levels of complexity. In its simplest form a table can present only one variable, for example, diseases and their corresponding cases. The complexity of a table rises with the number of variables/items depicted. Table 8.1 illustrates an example of a table with one variable and Table 8.2 illustrates one with three variables. A One Variable Table Table 8.1 The Top Five Causes of Morbidity in Tiursplen District, Mpumalanga (Population 412 755) Disease Number of cases Incidence (%) Malaria 4786 1.15 Skin disease 18735 4.53 Coughs 35998 8.72 Accidents 6234 1.51 Pneumonia 13735 3.32 TOTAL 79488-106

A Three Variable Table Table 8.2: Population Distribution by Age and Sex in Four Wards in Tiursplen District, Mpumalanga SEX WARD Males Females Age <15 yrs 15+ yrs <15 yrs 15+ yrs A 24337 28904 25778 27887 B 27652 25689 28199 29564 C 24953 23400 26643 28774 D 19875 18579 24557 27964 Graphs and Figures A graph is the most commonly used type of figure. Graphs and figures are useful for showing two or more distributions, provided the difference between the lines is clearly shown. There are many types of graphs for example, the line graph, bar chart and pie chart. Only when your team is comfortable with the simpler forms of presentation, will you begin using the more difficult ones. So the DHMT is encouraged to start presentation of information by using whole numbers, totals and percentages before doing so by using rates and ratios. Remember that the information you generate should serve your team first before it is taken elsewhere. The drawing of a map is a basic step for every District Health Management Team. A map is an essential epidemiological tool, as it allows health staff and others to see the important features of the catchment area. The most important attribute of a map is its usefulness. By far the most useful maps are those which have been drawn by health workers themselves based on existing maps. Anyone can draw a map with ordinary paper, pens and crayons. What do you do with the information generated? As mentioned above, you are the first user of the information you collect. The information is to help you better manage PHC implementation in the District. Common uses of the information are: writing and drawing a district profile, including mapping assessment of health situation and prioritisation of health needs of the catchment population; planning of services and resources; management of services and resources; monitoring and evaluation of progress and impact of health programmes; and mobilisation for action at the community and household levels. The information flow to provincial and national levels should be timely to facilitate the process of prompt decision making. Given that the provincial level policy makers are pressed with time, they should receive information that is absolutely necessary. However, the provincial level needs to provide guidance to the DHMT on appropriate channels of communication and also provide a clear definition of what should be reported, when and in which form. A major role for the province will be to provide relevant feedback to the DHMT. Information that can be shared by the general public can be effectively disseminated through public media (radio, newspapers, television). ADVOCATING FOR THE USE OF HEALTH INFORMATION Your DHMT should encourage information use. You should start district planning with an analysis of the present situation, set priorities, goals, objectives and targets; develop and implement an action plan, with clear indicators for monitoring and evaluating your activities (Figure 8.1) The decision on the data to be collected should be based on the objectives and targets of your district health plan. 107

Figure 8.1 District Health Planning Process 1. Where are we now? (assessing the present situation, setting priorities) 4. How will we know that we have arrived? (monitoring and evaluation) 2. Where do we want to go? (setting targets) 3. How will we get there? (making and implementing an action plan) These principles have been used in the formulation of the district health plans for the period 1997/98 to 1999/2000. The identification of needs, setting of objectives and targets was possible because DHMTs used existing information. During the implementation period, the DHMTs will use the indicators to monitor progress and evaluate programme achievements. As your team completes the planning cycle, this stimulates the need for further information and reassessment of the situation. Therefore, all district managers are encouraged to appreciate the value of information so that they can give support to collection of quality data that can improve the whole district information system. HOW TO ESTABLISH A DISTRICT HEALTH AND MANAGEMENT INFORMATION SYSTEM As your team puts in place a health information system, this should be seen in the overall effort to strengthen the district health system. Therefore, the collection of information must be viewed in terms of its usefulness in decision making both for your team, provincial and national decision makers and other interested parties. General Principles For collecting information, you should apply the following principles: data that is used at the level of collection should be the main one collected; relevant information that supports decision-making should be collected; keep the system simple, understandable and within the capability of the resources; all data collected must be accessible to all users, managers and decision makers; data collected should be accurate, complete and timely; data collection instruments (forms) must be standardised in line with national and provincial guidelines; improvements in data collection and use should be viewed as improvements in service/programme activities; changes in data being collected should be made only if they lead to improvements in provision of care to the communities served; and ensure that the data collected is reliable and valid. 108

Based on the guidelines from the Provincial level, the DHMT should implement the District Health and Management Information System following the steps suggested below: Phase I: Preparatory review the proposed National Health Information System (NHIS) data collection tools and reconcile with information needs for Mpumalanga Province; develop/modify the tools in line with provincial guidelines; pre-test the data collection and reporting forms; obtain approval to use the modified data collection and reporting forms; develop training guidelines for data collection and reporting forms; print the forms and guidelines at provincial level; create awareness of the new system in the district (identification of trainees and trainers, ordering forms, hardware and software, deciding on launching date); and take inventory of who is collecting what information at district level (include community health level); identify individuals in communities who will be responsible for the community based health register and train them; and create awareness within the communities on the information system. Phase II: Implementation organise and conduct training of district staff who will be responsible for training health facility staff (hospital units, health centres and clinics) in health information management; set the date for starting the implementation of the new information system throughout the district; and promote the use of the new information system. Phase III: Review of System and Consolidation review the system with a view to making corrections where necessary; and consolidate the system. Technical support will be provided by the Policy, Planning and Information Directorate. It is however, important that each DHMT outlines the kind of support it requires from this office. This includes requests for assistance in determining the district s needs in this area. Monitoring and Evaluation of the DHMIS Indicators of how well the system is working will include assessment of inputs, processes, outputs and impact of the system (see Table 8.3). Table 8.3: Examples of Indicators for Monitoring the Information System Type of Indicator Assessment Inputs - number of trained (skillful) personnel in the district health facilities - availability of hardware - availability of software - availability of data collection tools/forms - establishment of district health information office Processes - use of information at various levels - number of people using information at various levels - information flow from various levels Outputs - number of communities trained on data collection and use - number of health workers trained in data collection, analysis and use Impact (based on situation prior to implementation of the system) - number of staff using information for decision making - number of quality plans developed - community perceptions and Knowledge, Attitude, Practice and Behaviour (KAPB) on the system - number of facilities using health information system 109

Resources and Management Support for Developing DHMIS Decentralisation of health service delivery to district level has given DHMTs the mandate to make decisions concerning health priorities and the resources needed to implement health programmes. Information will be a key element in this endeavour. To facilitate the development of this system, the districts will require resources such as trained staff, computers and supplies. They will need funding for systems and staff development as well. This kind of support will be provided by the Provincial and Regional Health Offices which will also train DHMTs in planning and management of health services. The training will also cover development and management of health information systems with emphasis on use of data. Some DHMT members have to undertake training that equips them with basic skills in epidemiology, statistics and computing; all of which are essential for population based planning and management. Again the District Health Manager has to take the initiative to ensure that health workers are trained to use statistical data and health indicators in their work. The DHMT should consult the relevant provincial level unit to work out how the training can be organised and conducted. The staff at provincial level will identify the relevant materials both within and outside the country that may be used for this type of training. Further information on training is discussed in chapter 10. In this chapter you have read about District Health and Management Information System (DHMIS) and how it will be established and operated. The importance of DHMIS in service planning, has been highlighted. The chapter that follows discusses the application of DHMIS in service monitoring and evaluation. 110

MONITORING AND EVALUATION OF HEALTH DISTRICTS CHAPTER 9

Chapter 9 MONITORING AND EVALUATION OF HEALTH SERVICES The last chapter described what a District Health and Management Information System is and how to establish it in a district. This chapter will introduce you to one of the most important uses of DHMIS. After reading this chapter, you will be able to: understand what monitoring and evaluation are; identify the types of monitoring; explain and evaluate programme activities; explain the procedures you will follow in monitoring and evaluating; explain the process you will follow to develop a monitoring and evaluation system for your programmes; and identify indicators to be used in monitoring and evaluating your programme. The District Health Management Team (DHMT) will need to monitor and evaluate PHC policies, systems and programme in order to establish whether the intended results are being accomplished. The findings of the monitoring and evaluation process will assist the DHMT in ensuring that Primary Health Care Programme activity implementation is addressing the set targets and objectives. Monitoring and evaluation are thus essential functions of programme management (See Figure 8.1. in the previous chapter). MONITORING One of the functions of the DHMT is monitoring of the implementation of PHC programme activities. Monitoring is a continuous process of assessing whether an activity or service is proceeding as planned. Monitoring is not an activity by itself. It must serve to improve project implementation and achieving of expected results. There are two types of monitoring: Routine Types of Monitoring This type of monitoring focuses on collecting information on a regular, ongoing basis for a core set of indicators which provide the manager with enough information to track progress in programme implementation. Short-term This is done for a limited period of time and usually tracks new initiatives or processes. The objective is to collect information to help solve a problem after which short term monitoring is incorporated into routine monitoring. What You Need to Monitor There are various aspects or components of a programme that have to be monitored. These are the programme inputs, processes and outputs. Inputs Inputs are the resources necessary in order to implement the programme. These include personnel, finances, drugs, buildings and equipments. During the planning stage estimates of the cost of inputs to complete each 113

of the activities in support of Primary Health Care is done and a budget is drawn. The procurement and use of these resources should be monitored to ensure that you are within the budget and are being used as intended. Processes Processes involve setting in motion a sequence of events or tasks expected to achieve the desired outputs. These events should be monitored to ensure they are of the expected quality, are happening smoothly and in a logical manner. Examples include; weighing a child, dispensing drugs, giving an injection and distributing oral rehydration salts. Outputs Outputs are products or achievements as a result of the successful completion of a programme. Examples are: numbers of out-patient attendances, in-patient cases or health promotion sessions held. Ask yourself, what are the results, and why are they different from what was expected or promised? This monitoring of the performance gap is very essential as it can lead to withdrawal from the programme by the target population if they are not seeing the benefits. The project staff may also become disappointed and neglect their roles if they find their efforts to be futile. At whatever level you work, you need to monitor your programme activities to ensure that you are within the time and budget you stipulated. If there are variations, document the reasons as this will assist you to justify your request for additional resources and time extension. Figure 9.1. shows the relationship between input, process and outputs. Figure 9.1 Relationship between input, process, output and impact Programme Inputs set in motion which which lead to lead to Processes Outputs Impact 114

Designing a Monitoring System At whatever level you work, you need to develop a simple routine or short-term monitoring system to keep track of the events happening. When designing such a system you should consider the following: select only the key indicators (these are variables that indicate or show a given situation such as 80% immunisation coverage) that will be used by managers and other key users; Do not try to monitor everything as this can be very expensive and time consuming; do not overburden yourself by collecting too much data. The information required is for only assisting to monitor the key indicators you selected above; provide feedback to the interested parties in good time; and report the findings in a way that is easy to understand and facilitates data interpretation and action. The DHMT must prepare monitoring reports which should be shared with all interested parties. These reports must highlight both the success and weakness of the implementation process. The DHMT need not feel shy to say that they have failed in implementing a particular programme as long as the reasons are well documented. However, learn from factors that resulted in failure previously so that when you undertake the implementation of another project in future you do not repeat the same mistakes. Always document the successes and lessons learnt. Monitoring Procedures There are nine steps to activity monitoring. The first four cover the planning stage of monitoring and seek to ensure that the information collected is relevant, specific, feasible to collect, and can be analysed. The next five steps cover the implementation of monitoring: collecting data, compiling and analysing it, reporting and using the results for management action. The tenth step suggests taking a look at the system periodically to decide whether to continue monitoring activities at the current level. Ten steps in activity monitoring: Step 1: Step 2: Step 3: Specify the monitoring objectives. Indicate what services are going to be monitored; for what purpose and who will use the monitoring results. For example your team, at whatever service level, may be interested in monitoring environmental sanitation activities for the purpose of knowing whether the programme is being implemented as planned. This information will be used by the Environmental Health Officer and the DHMT in finding out the effectiveness of the programme. The DHMT may wish to focus on information that will enable them determine the percentage of households using latrines (effect indicator); number of latrines constructed in the past two years (output indicator) and number of communities/households with access to environmental health officers (input indicator). Decide on the scope of the monitoring. The DHMT may be interested in monitoring activities either within a smaller area in the district or the whole district. Before introducing routine monitoring procedures the team may wish to pilot test them in a few places before implementing them in all areas. In this connection the duration that monitoring will take should be specified. Select indicators and set performance standards. Indicators can be formulated by using either of the following methods: a count (just counting the number of events or objects), for example 1,000 children immunised a rate (measure of the frequency with which an event occurs in a given period (e.g. children immunised) a ratio (two numbers related to each other in a fraction e.g. number of environmental health officers per population) a percentage (a proportion multiplied by 100, e.g. if only 40 out of 200 nurses received training in family planning then twenty per cent of the nurses were trained in family planning last year) Performance standards, also called targets, are set for each indicator in order to assist the team determine whether the activity has been implemented as planned or has been effective. The targets are usually quantified and this is what enables you to judge actual performance with planned (target) performance. The target becomes the denominator in computing performance while the actual performance is 115

the numerator. In the example indicated in step one, the DHMT may find that at the end of the year, the number of households with access to environmental health officers is 300 while the target may have been set at 500 households. The result shows that the programme met only 60 percent of its target. This result is obtained by dividing the actual performance (numerator) by the target (denominator) expressed as a percentage. Step 4: Choose information sources and develop data collection procedures. Your team has to identify the source and procedures for collecting monitoring data. The routine records from your District Health Information System is one of the sources from which you can obtain data. Most of the input indicators can be obtained from the routine records. For the process and output indicators it may be necessary to develop new tools to collect the data if this is not possible from existing sources. Also your team may consider talking to community leaders, health workers and other relevant people to obtain a general feeling of how the PHC programme is doing. Step 5: Collect the Data The team to collect data must be told the procedures for doing so. If data is not available from existing sources, some training of those involved will be necessary. Step 6: Tabulate and Analyse Data Data can be displayed in various ways. You may use lists, tables and graphs because these are not complicated to make. Step 7: Interpret the data Interpret the data i.e. what the findings from the analysis mean. Step 8: Present the Findings Decide who should receive information regularly e.g. all DHMT members plus any other individuals or agencies involved in PHC implementation in your district. The provincial level should because they need to know some of the problems identified and together with the DHMT work out the solution. Establish a mechanism for disseminating information. Step 9: Take Appropriate Action A very important reason for monitoring is to enable a programme manager or implementor to identify shortfalls and take corrective action in time. This enables a health service provider/manager to be in control and to ensure quality services. When evaluation results have been presented and discussed among the interested parties, you should organise to use the results. Decide whether action needs to be taken, and if so which action. Explore the causes and then develop solutions based on what will be easy to implement. Step 10: Decide whether to continue monitoring. Your team designs monitoring in order to meet its needs. Therefore as the needs change, the team must adjust the frequency, especially if there is improvement in programme implementation. Experience has shown that there is less need for frequent detailed information on some inputs and outputs, as programmes improve over time. Therefore, the focus shifts to effect indicators as your PHC programmes show good progress in implementation. As the implementation of recommendation takes place for some programmes, the monitoring cycle starts for others. Limitations to Monitoring You and your team should realise that collecting information on most impact indicators (that is changes in health status of the community) that may have taken place as a result of the introduction of a programme, for example, changes in infant mortality is not feasible over a short period of time. Therefore, your team is encouraged to focus monitoring on input, process, output and effect indicators to establish whether the PHC services are being carried out as planned. 116

EVALUATION Evaluation can simply be defined as assessing or finding out the value of something. Evaluation is carried out after completion of the activity or project. An evaluation assists in determining whether the activity or project accomplished the objectives it set out to achieve. Purpose of Evaluation Evaluation is the process by which programme achievements are examined from time to time. It compares outputs to the set objectives, programme implementation with programme design. It looks at the organisational set up and the use of resources to determine the effectiveness and efficiency of the programme. The Use of Evaluation The DHMT will be called upon to evaluate health programmes in the district with the aim of seeking answers to pressing questions about the programme s future such as, should the programme be continued, expanded, or should changes be made in its operation? To fully respond to these challenging questions relating to the programme s future, the DHMT will: have to clearly understand the various components of the programme (scope, objectives, organisation and expected outputs); and collect the necessary information which may assist in the evaluation. The information sought may concern health and related socio-economic policies, plans, programmes as well as the extent, scope and use of health systems and institutions. The monitoring reports, District Health Management Information System (DHMIS), district profile and the project document are good sources of information for an evaluator. Remember that evaluation has to be based on valid and relevant data (read chapter 8). Evaluators use a whole range of research methods and tools to collect information such as interviews, sampling questionnaires, test of knowledge skills and attitude, observations, content analysis of documents, records and examinations of physical evidence. What You Need to Evaluate There are three key parameters that are of interest to the DHMT in the process of evaluation. Inputs One reason for the failure of a project is that for a variety of reasons, resources did not arrive as planned or they were not available. Another reason may be that the resources were insufficient to provide the services planned. The evaluator has to find out whether the resources were transformed into service or misused. Outputs The evaluator needs to took at whether the services provided were appropriate, relevant and adequate. In particular, the evaluator needs to look at the quality and quantity of services provided, efficiency of services, whether the community accepted the programme and its outcomes, and whether the effects were felt by the targeted population. Outcome (effects and impact) The evaluator should know the objectives of the programme being evaluated. Perhaps the most fundamental question to determine is what the activity being evaluated was intended to achieve. It is against these benchmarks that the activity s success or failure will be largely measured. The evaluator must also look into any other possible effects of the project. Besides the planned effects of the project, there may have been other effects which were not intended. Assess these impacts. For example, a family planning project may have other effects such as a decline in female student dropouts in educational institutions. 117

Another question the evaluator must answer is whether any health improvements were the direct result of the programme. It is important that any health improvements detected are identified as being the direct result of the programme. Otherwise, you may end up glorifying a programme that did not impact any change at all. How to Carry Out an Evaluation Designing an evaluation may be done in six steps: 1. Setting out clearly the questions to be answered. These have been outlined in general terms above. To answer each of the questions raised under the section on what you need to evaluate, you must identify indicators which will allow you to compare what actually took place with what was expected. Four types of information are likely to be required. Baseline Information Baseline information will assist you to describe the situation prior to the implementation of the programme. For example, in an oral rehydration programme, you would want to know the number or percentage of mothers who were using oral rehydration salts (ORS) or knew how to prepare ORS solutions prior to the start of the programme. Input Information Input information will describe the resources used in the programme. For example, in an immunisation programme, you may want to know how many fridges or staff were utilised to provide the service. Process Information Process information will help you to describe the implementation process of the programme. For example, in an immunisation programme, you will want to know how the immunisation was organised and conducted. Output Information Output information will help you describe the situation after implementation of the project. For example, in an immunisation programme, you would like to know the number of children fully immunised against your set objective. 2. Identifying the Sources of Information for Evaluation: Existing records, for example, hospital statistics, may be good sources of some information. Other information may not be available and surveys or other methods may have to be conducted to obtain it. If the latter is the case you should then design a questionnaire that will capture all the information required. Pre-test your questionnaire before embarking on actual evaluation. 3. Collecting the Information When questionnaires have been developed, pre-tested and the people to administer the questionnaire trained, organise how the information is to be collected from the field. 4. Analysing the Information Before the information is collected, you should start making arrangements on how the data is to be analysed and tabulated. Prepare possible tables that you will expect to generate from the data such as Table 9.2. Table 9.2 Number of Children Immunised by Facility Type Before Programme After Programme Hospital Health Centre Clinic Others 118

5. Preparing the evaluation report and presenting findings The evaluator has to write an evaluation report and present it to other interested parties. The report should be simple and point out major recommendations. The programme implementors should be allowed to contribute on potential causes of and solutions to the problems identified. 6. Taking appropriate actions. When evaluation results have been presented and discussed among the various programme implementors, then you should make arrangements to use these results to decide whether action needs to be taken, and if so which action. This means that you first explore the causes and then develop the solutions. Points to note about evaluations There are instances where observed changes are caused by something other than the programme intervention. In such cases the evaluator has to determine what factors brought about these changes, and not attribute them to the programme. Occasionally, there is resistance to accept the evaluation and its results especially if it shows negative findings. Participatory evaluation reduces conflict between evaluators and programme implementors. The Provincial Policy and Planning Information Directorate will set up specific training programmes in monitoring and evaluation for service providers, programme coordinators and the DHMT. This chapter has described the principles and elements of monitoring and evaluation and their application in programme management. The need to have clear indicators has been stressed and examples given. Availability of trained staff is one of the key elements that will make it possible not only to monitor and evaluate but also implement and manage the service programmes. Development and management of staff is the subject of the chapter that follows. 119

PART 1V Human Resources Development

DEVELOPING AND MANAGING HUMAN RESOURCES CHAPTER 10

Chapter 10 DEVELOPING AND MANAGING HUMAN RESOURCES The previous chapters have described the processes for decentralisation of health services to the districts and the primary health care packages that are to be implemented at various service levels. Accomplishment of this process is not possible without trained, dedicated personnel. This chapter describes the development and management of the health worker as a valuable resource for providing a caring, compassionate health service. After reading the chapter, you will be able to: understand the principles of human resources development and management; identify factors that can affect your performance in your work place; identify the steps in human resources planning; understand the importance of preparing a job description for each member of staff; understand the procedures for recruiting, promoting and disciplining staff; understand the importance of staff performance appraisal; and understand the importance of training and developing staff. Human resources development and management is the attraction, selection, retention, development and deployment of staff in order to achieve the individual and organisational objectives. The health sector is labour-intensive and people are its most important resource. There may be money, equipment, materials and techniques but without people none of these things can perform any task. It is people who make things happen. However, resources are very expensive and staff salaries/wages in many developing countries account for more than two thirds of the recurrent expenditure. It is, therefore, important that the right people are recruited, trained, retained and properly deployed. Effective human resources development and management contributes in a major way to the morale, motivation, job satisfaction, knowledge and skills of personnel in the health service, all of which have a bearing on the quality of care provided. Human resources development entails upgrading and updating the skills and knowledge of personnel through education and training. Human resources development at the provincial level is the responsibility of the Directorate of Policy, Planning and Information in liaison with the Public Service Commission and the National Department of Health. At district level the responsibility falls under the Human Resources Development Unit. The aim of human resources development is to make you a more caring and effective health worker or service manager through positive change of attitude, upgrading of knowledge and improvement of skills through continuing education and support supervision. Human resources management encompasses human resources planning, job analysis and job descriptions, staff recruitment, orientation and placement, performance appraisal, discipline, benefits and retirement. Human resources management at provincial level is the responsibility of the Directorate of Administration, while at the district level it is under the Finance and Administration Unit. 125

The aim of human resources management is to support and care for you so that you can: feel appreciated; improve your output; get job satisfaction; and work in a conducive environment. There are obstacles that are faced by health workers. Some of these are illustrated in the following case study. CASE STUDY Nonjabulo and Lahliwe both entered the health service as professional nurses, in 1990. Nonjabulo rose rapidly through the ranks and by 1996 she was already destined to make it to the top of her career. Lahliwe, on the other hand, did not do well at all. Six years after entering the service, she was still languishing at the bottom of the career path. What Happened To Lahliwe? A detailed analysis of her experiences revealed that Lahliwe completed general nursing and midwifery in a dilapidated, under-equipped and under-staffed hospital, and was sent to work in a hospital ward. She enjoyed talking to patients in order to understand the underlying causes of their problems. Because she spent much time in discussion with patients in the ward, she was labelled lazy by her supervisors and colleagues. She tried to explain her intentions, but the result was that she was now labelled trouble maker. She was abruptly posted to the intensive care unit (ICU) to stop her so called laziness. There she made no progress, so she got bad reports. She got no job satisfaction in the (ICU). Moreover she received no orientation. Furthermore the ICU was poorly equipped. This environment stifled her interest and initiative. By the third year in the ICU Lahliwe was aggressive, defensive, ineffective and depressed. What factors contributed to Lahliwe s slump to the bottom of the career path? The following are some of the identifiable factors that may have contributed to Lahliwe s lack of career progress: being pushed into a job in which she had little interest; inadequate and inappropriate skills for her job; lack of support and encouragement from establishment; lack of recognition by establishment; isolation; poor equipment; neglect of staff development by establishment; and poor infrastructure. What do you learn from Lahliwe s case study? Many health workers are in Lahliwe s position. As a health worker: you may become demotivated if neglected and misplaced; you need to participate actively in decisions regarding your professional training and job placement; your personal needs should be balanced with organisational needs; you should be deployed according to your skills; your ideas should be heard and respected, not punished, irrespective of your position in the hierarchy; and you require professional development at all stages. What factors will help Lahliwe to move up the career path? The following are some of the factors that would help Lahliwe to rise up the career path: support and encouragement from her supervisors; clear and appropriate description of roles; delegation of responsibilities that encourage use of broad skills and knowledge; career planning and development; 126

incentives e.g. salary, promotion, study opportunities; time to reflect, to mend and to discuss; job satisfaction; and improved working conditions. The provincial Department of Health, Welfare and Gender Affairs believes that one of the ways to achieve a caring health service is to be a caring and supportive employer. The development of human resources begins with planning. The purpose of human resources planning is to maintain and improve the ability of the health service to render effective health care to the people through the development of strategies that promote staff performance. HUMAN RESOURCES PLANNING In planning human resources for your district, you can use the following guidelines: Estimate the number and types of jobs to be filled at a future point. Visualise your district or health facility at some future point and estimate numbers and types of jobs that will exist. Ask yourself if currently you have the right number and mix of staff for: the technology and systems in use; and the service demands and changing workload based on the population s health needs. The staffing ratios and norms provided by the provincial level. Make a projection of personnel requirements for your district. Include all facilities (hospitals, health centres, clinics) as well as community based activities. Make an internal audit of the present human resources and their skills. For each member of staff, compile information on: age, job title, amount of experience, length of service, education and special skills. Using the information obtained from the Personnel inventory, you can forecast changes which are likely to occur in the present work force in terms of entries, exits and movements within your district. Your district will experience staff turnover due to, for example, retirement, transfers, discharges, moving to greener pastures or promotion to the Provincial or National levels. The patterns of these losses in the past can be extrapolated to indicate future patterns. Develop an action plan to assist the province and your team to fill those human resources needs through recruiting and hiring new staff or upgrading (training and development) of existing staff. JOB ANALYSIS AND JOB DESCRIPTION Job analysis and job description are important tools which form a good basis for selecting the right candidate for vacancies in your district. A job analysis is a description of the types of skills, experiences and training required for a job. It entails observing and studying a job to determine its contents (duties and responsibilities) and the conditions under which the work will be performed. Job analysis is useful in the following areas: when recruiting and selecting individuals for jobs; when employees are transferred or promoted; for career counselling; for staff appraisal; for training; and for dealing with grievance and discipline. A job description is a summary report of information relating to a particular job. The format contains: name of district; name of division or section; official title of the job; purpose of the job; a short description of how the job fits into the organisation; the job s main tasks and standards to be achieved; accountable to; responsible for; 127

other relationships; grade of the job; special provisions; and terms and conditions. All staff should have a job description. You, as supervisor should make sure that staff under your supervision have a job description. If job descriptions do not exist, prepare them with the staff you supervise. Job descriptions should be revised periodically. You need a job description so as to: identify the right individual employee for the appropriate job; recruit and place new staff; and train and develop staff. In addition to being useful in recruitment, a job description helps you organise work; lets you know clearly the duties and responsibilities your staff are expected to achieve and helps you to prevent arguments between staff concerning who will do what. A job description however, should not restrict the health worker from creative development of his/her role. RECRUITMENT In Mpumalanga the recruitment of senior professional staff is done by the Public Service Commission (PSC) initiated by the Department of Health, Welfare and Gender Affairs. Staff recruitment is not the responsibility of those who directly supervise and manage those recruited. At the district level, the DHMT, through the regional director, is responsible for the recruitment of lower cadres of staff. PUBLIC SERVICE COMMISSION (PSC) The Public Service Commission is charged with the responsibility for recruitment, promotion, training, accreditation (issuing of certificates) and discipline of Permanent Staff. The commission derives its powers from the Constitution. The commission may and indeed delegates some of its powers to Authorised Officers particularly the Directors-General and Deputies. Such delegated powers include the following: appointments; confirmation of probationary appointment; termination of probationary appointment; compulsory retirement; retirement on medical grounds; promotions; and discipline. PROBATION For the officer to be confirmed in a position he/she must have served in the appointed position for a specified period of time during which he/she has to: clearly demonstrate suitability for the position; and has complied with the relevant regulations regarding the passing of examinations where applicable. The authorised officer can extend or terminate a probationary appointment in the interest of the Civil Service. It is important to note that if an officer has completed the stipulated period of probation and has neither been confirmed nor informed in writing that the probationary appointment has been extended, such an officer is deemed to be confirmed in his/her appointment. ORIENTATION AND INDUCTION When new officers get posted or transferred to your district, it is important that you make the new staff feel welcome, wanted and an important member of your health team. Whether the new officer is a member of the DHMT or will take up any other position, you should make sure that the newcomer has been given orientation of the district. Prepare other staff for the arrival of the new comer. Make sure that they know when he/she is arriving and what he/she will be doing. The purpose of the orientation is to provide reassurance through support for the achievement of early and pleasant familiarisation with the work and its overall context. Arrange to: 128

meet the new staff; explain rules and standards of conduct including working hours; show him/her the buildings, facilities, departments etc; introduce him/her to other staff including those in other sectors; explain how his/her job relevant to others. Describe working relationships, particularly in terms of those with whom he/she is likely to be in direct contact; describe the role of the health sector in the district, its major activities and the objectives you are trying to achieve; take him/her on a tour of the district s facilities and projects; and organise the work place. 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 check whether he/she has settled well and whether there are any problems that need to be dealt with. Deal with housing and any other problems of settling in as quickly as possible. PERFORMANCE APPRAISAL As a supervisor or team leader, you assess what subordinates do to determine how close the staff come to achieving their work targets. There must be clear statements of objectives and targets that are: relevant to the community s needs; feasible; measurable; and known and agreed to by the staff whose performance is being assessed. When you carry out a staff appraisal, bear in mind that the appraisal is beneficial to the organisation, the individual worker and to you, the supervisor. Purpose of the appraisal to encourage staff to work towards the highest levels of performance; to provide feedback on performance; to change things to support the employee s work and improvement; to develop and maintain a climate of trust; and to provide a forum of expressing mutual expectations. Who appraises and who is appraised? the immediate supervisor appraises the supervisee; and self appraisal is encouraged for purposes of bringing out strengths that may have escaped the attention of the supervisor. When you appraise, what do you look for? how the subordinate is doing and what needs to improve; how the job is going and how it can be improved; how the worker can develop; what you can do to bring identified changes; and positive change in performance and behaviour and not personality. Performance appraisal should not be: seen as a chance for the supervisor to punish the supervisee; and treated as,or equated to an interview. Treat it as a discussion; a two way communication between the supervisor and the person being appraised. In the Civil Service, staff appraisal is done annually. The period of assessment is from January to December each calender year unless an officer was appointed in the Government Service in the middle of the year. However, it is better to do it more frequently. Twice a year is advisable but it should be a time to provide feedback on ongoing observations by the supervisor. 129

The reporting officer is normally the officer s immediate supervisor and the Countersigning Officer, will normally be the immediate supervisor of the reporting officer. For example: A District Health Manager is the reporting officer of a Health Centre Manager and the Countersigning Officer is the Regional Director. Principles underlying performance appraisal shared responsibility; shared commitment (by supervisor and supervisee to health sector objectives); openness (stating the facts as they are); specifics (focussing on issues of concern); agreed work plans; building on strengths; and follow-up mechanisms. PROMOTION In selecting candidates for promotion, the relevant authority empowered to approve the promotion, will consider: efficiency in the service; merit and ability; and experience and relevant qualifications. There are mechanisms for rewarding exceptional service within the public service, for example, out of turn promotions. District Health Managers should encourage initiative, innovation and excellence among subordinates with the knowledge that these qualities can be practically and financially acknowledged. DISCIPLINE Rules governing discipline in the Civil Service and the procedure to be followed in cases of breach of discipline can be found in the Public Service Commission Regulations. Guidelines for management of disciplinary cases can be obtained from the Regional/Provincial Health Office. BENEFITS The common benefits to employees include health insurance, medical allowances, pension, insurance, leave allowance. Information on all these benefits and how they apply to you can be obtained from the District/ Regional/Provincial health office. WHEN EMPLOYEES LEAVE (EXIT) Employees leave employment for reasons such as better job opportunities elsewhere, retirement, discharge or death. When the member of staff leaves, make sure that there is proper handing over of any equipment, keys, files and other records entrusted to the staff. Assist the staff member to process his/her final dues particularly his/her pension. Retirement Retirement in the civil service falls under the following categories: compulsory retirement at attaining specified age; voluntary retirement at attaining specified age; retirement in public interest; retirement on medical grounds; and retirement on abolition of office. If an officer is confirmed in appointment he/she will be eligible for retirement benefits in accordance with the provisions of the pension legislation of the public service. An officer leaving the service should be cleared and a clearance certificate issued. 130

TRAINING AND DEVELOPMENT Health workers require to have the right attitude, skills and knowledge (ASK) to carry out their duties. Most basic training is not by itself enough. Some of the things you learnt during your basic training may be irrelevant to your work but there are things that you require to know but were not taught. The job for which you were trained may also have changed due to certain circumstances, for example, new drugs and medical techniques may have been developed. If you have to keep up with the new technologies and to carry out your job effectively, the learning process has to be lifelong. It should not stop at the time of qualification. That is what is called Continuing Education (CE). It is that education that begins where basic education ends. The Department of Health, Welfare and Gender Affairs in Mpumalanga has conducted a needs assessment in respect of human resources development. The following challenges have been identified: maldistribution and inappropriate utilisation of resources; lack of management skills; lack of primary health care skills; inappropriate training e.g. curative orientation only; lack of health information management skills inappropriate societal attitudes; lack of skills in basic epidemiology; and lack of planning skills. In order to respond to these needs, the Department will: develop an action plan that will address the identified challenges; and reorient all health professionals in PHC. Training is important and necessary to the staff because it gives them a feeling of mastery over their work. The staff become motivated, more productive and improve the quality of their work. The need is greatest for workers who are isolated in the rural setting away from other health professionals and who may have limited access to reading materials. The following educational principles will help you when considering training programmes: team training/learning is much more effective than sending individuals on courses; learning based on actual problems is much more effective than teaching of subjects/disciplines; interactive groups learn better than passive classes of students; subject matter learnt should be applied/implemented or else it is quickly forgotten; and it is best to learn in the context where the subject will be applied. There should be promotion of free movement of staff such that available expertise is shared to the maximum at district level. In this context the health workers should constitute and operate as a team and plan work together. Training activities should be implemented jointly and networking among facilities should be encouraged. This chapter has exposed you as a service manager to most of the human resources development and management aspects of your work, particularly the practical rules and procedures that govern relationships between you and the staff. It has emphasised the importance of the health worker as an important resource that needs to be developed and managed in a caring manner in order to promote a culture of compassion and care for the patient/client. You should give them careful attention by motivating and encouraging them to work as a team. It is hoped that, you will familiarise yourself with the Code of Regulations and all amendments made from time to time by the relevant directorates. You should also familiarise yourself with the regulations of labour and professional bodies. Your regional director will guide you in this and other areas as you strive to provide a caring service through the development and management of the health worker in an equally caring manner. 131

ANNEXURE OF ACRONYMS AIDS ARI BCG CBOs CBR CDD CHWs CBHWs CMTs DC DD DDG DHIS DHMIS DHMT DPT EPI HC HCMTs HMTs HP IDHA IPHA KAPB MDR MDRU MEC MEDUNSA MJOC NGOs NPA NPPHCN PAS PHC Acquired Immune Deficiency Syndrome Acute Respiratory Infections Bacille Calmette Guerin (TB immunisation) Community Based Organisations Community Based Rehabilitation Control of Diarrhoeal Diseases Community Health Workers Community Based Health Workers Clinic Management Teams District Council Diarrhoeal Diseases Deputy Director-General District Health Information System District Health Management Information System District Health Management Team Diptheria, Pertussis, Tetanus immunisation Expanded Programme on Immunisation Health Centre Health Centre Management Teams Health Management Teams Health Promoter Interim District Health Authority Interim Provincial Health Authority Knowledge, Attitude, Practice and Behaviour Multiple Drug Resistance Multiple Drug Resistance Unit Member of the Executive Council Medical University of South Africa Medical Joint Operations Command Non-Governmental Organisations National Programme of Action for Children in South Africa National Progressive Primary Health Care Network Public Administration Standards Primary Health Care 132

PJOC POHC PSC PTDS RDC RDP ReHMIS SANTA SASAs SASOs SAIMR STDs TB TLCs TPA TRCs Provincial Joint Operations Command Primary Oral Health Care Public Service Commission Part-time District Surgeons Reconstruction and Development Council Reconstruction and Development Programme Regional Health Management Information System South African National Tuberculosis Association Specialised Auxiliary Services Assistants Specialised Auxiliary Services Officers South Africa Institute for Medical Research Sexually Transmitted Diseases Tuberculosis Transitional Local Councils Transvaal Provincial Administration Transitional Rural Councils 133

DISTRICT DICTIONARY Access Accessibility Account Accountable Accountability Activity Adult Health Literacy Ambulatory Care Anthropometric Measurement Audit Basic Health Care Budgetary Cycle Budgeting Capacity building Capacity Development Catalyse Catchment Area Checklist Clinic Coherent Coincident Ease with which health services may be utilised; encompasses geographic access (the distance from facilities), financial access (refers to affordability of services) and social access (e.g., attitude of health workers). Indicator measuring access to the health centre, based on distance, time, cost and possibly socio-cultural factors. A record of money received or money spent, or both. Liable to be called to account, or to answer for responsibilities and conduct; people in decision-making positions are held responsible for their actions; mechanisms that should be used to ensure this. Liability to give account of, and answer for, discharge of duties or conduct; mechanisms to ensure this. A group of tasks with a common purpose. Ability to read and understand simple health messages. Care provided to patients who are not confined to bed; out-patient care. Measuring the size of different parts of the body e.g. arm circumference, to determine nutritional state. A calling to account, usually applied to the use of funds, but also applied to any function or action that has measurable consequences; hence clinical audit refers to an evaluation of the value of a clinical procedure in producing the desired result or consequence. Indispensable medical care and preventive services acceptable to individuals, families and communities. Period of time during which estimated expenditures are expected to be made. The process of matching proposed expenditures to available financial resources with a view to achieving desired results. Improving ability to undertake certain tasks, roles, etc. The creation of skills necessary to function more effectively; the process used is important as it should be empowering. To cause to happen; to bring about; to inspire. Geographic area that is served by a community health facility, e.g. health centre or clinic; a sub-unit of the health district. A list of items or descriptions of actions to be looked at, one at a time, to ensure that no item or action is overlooked. Fixed structure in which basic health services are provided, usually by nurses; linked to a community health centre. Things that hold together in a meaningful way; connected Occupying the same place or time. 134

Community Development Community Health Community Health Centre Community Involvement Community Participation Component Comprehensive Constraints Continuing Education Collaborate Co-ordinate Core Activities Cost Effective Coterminous Coverage Criterion (plural: criteria) Crucial Curative Care Decentralisation The process of involving a community in the identification and reinforcement of the aspects of everyday life, culture and political activity that are conducive to health; this might include support for political action to modify the total environment and strengthen resources for healthy living, as well as reinforcing social networks and social support within a community and developing the material resources available to the community. The organised co-operative efforts of all agencies in the community, directed towards the promotion of health in the community; it is based on the concept that all agencies and individuals have a role to play in promoting, maintaining and improving the health and well-being of people. Usually a 24 hour health facility providing a greater variety of services than is provided at a clinic. The active involvement of people living together in some form of social organisation and cohesion in the planning, operation and control of primary health care, using local, national and other resources. A process where people participate individually and collectively as part of their right and duty, in the planning, implementation and control of activities for their health and related social development. One of the essential parts; synonymous with element. The fullest possible range of, for example, primary health services; the provision of preventive, promotive, curative and rehabilitative care by a health care facility or authority. Restrictions or limitations of freedom to act. Courses of study directed towards maintaining and improving competence after initial training. Work jointly with others. To relate (arrange) the activities of different persons in the same or connected programmes with one another in such a way that their common goals can be effectively and efficiently achieved. Essential activities. Economical in terms of improvements or benefits produced by money spent. Sharing similar boundaries. Indicator measuring the effective access to a particular service. A guide or standard on which something is judged, or which is used as a basis for making a decision, assessment or an evaluation. Important or essential. Appropriate medical treatment of common diseases and injuries at a health facility. The process of shifting responsibility, authority and accountability for planning, management and the allocation (and raising) of resources to those who are implementing policy at the lowest level; the transfer of appropriate authority from central government to provinces, regional offices, district health authorities, local governments and/or non-governmental organisations. 135

Delegation Demography Deployment (personnel) Devolution District Council Area District Health Authority District Health Plan District Health System District Hospital Donors Economies of Scale Effectiveness Efficiency Emergency Preparedness Ensure Epidemiological Equitable Equity Essential Drugs Evaluation External Partners Facility The process of shifting authority and responsibility over specific issues and defined functions to other administrative structures or individuals; responsibility remains with the delegating authority. The study of the characteristics of human populations, such as size, growth, density, distribution and vital statistics. Making the best use of available personnel. The creation or strengthening of sub-national levels of government (such as local authorities) that are substantially independent of national level with respect to a defined set of functions; there is normally geographic responsibility for a range of services and the power to raise revenue; accountability is usually to the electorate. Area controlled by a district council; may be larger than a health region; may contain a Transitional Rural Council and Transitional Local Councils. Governance structure which is responsible for ensuring the delivery of all primary health care in the health district. A course of action to be followed in order to meet the set objectives and targets. All the interrelated elements that contribute to the health of individuals, families and communities at district level. First level non-specialist hospital to which patients from clinics or health centres may be referred. Agencies or individuals providing financial assistance. Term used to explain the fact that under certain conditions, it is more efficient to operate at a higher level e.g. a team of 10 nurses conducting mass immunisation campaign is more efficient when 100 children get immunised as compared to only 20 children. The best possible outcome or result. The attainment of the best outcome or result at the lowest possible cost. Ability of a community to cope with sudden disasters or epidemics To make it happen; to co-ordinate. Frequency and distribution of disease in a given community. Without favouring certain regions, communities or groups of individuals, i.e. socially just. The universal provision of services on the basis of need rather than any other criterion. Medicines that are the most needed for treating the most common diseases in a given population and should therefore be available at all times. The measurement of performance, based on established criteria, to ensure that the objectives are being met. Agencies from outside a country, region or district willing to work jointly with local agencies or citizens to achieve common goals. A building, a room or site that makes an activity possible, e.g. a clinic, health centre or hospital. 136

Feedback Follow-up Food Security Frame Front-line Function Goals Governance Health Health Development Health District Health Problem Health Region Health Services Health Status Health Team High-risk Pregnancy Indicators Indicators (health) Information which helps to evaluate an activity. Maintaining contact with a person (e.g. patient) or watching over the development of a process. Ensuring availability of basic food required for adequate nutrition; food hygiene. The basic outline or idea. Where the majority of the population live and work, i.e. at district(village) level. A group of activities with a common purpose. These are large direction-setting wants or needs which provide overall direction for planning. The processes used by governing structures to make and implement laws and provide services. State of complete physical, mental and social well-being, not only the absence of disease or infirmity. Process of improving the state of physical, mental and social wellbeing of the individual, the family and the community within the more general framework of socio-economic development. Geographic area that is small enough to allow maximal involvement of community participation so that local health needs are met, but also large enough to effect economies of scale. A departure from the accepted norms in the health status of a community; sometimes also an underlying cause of such a departure. Geographic area into which a province is divided and within which secondary hospital services are available to health districts which may fall within its boundaries. A system of institutions, people, technologies and resources designed to improve the health status of a population. The degree to which the health of a specified population meets accepted norms (of mortality, morbidity, etc). Health workers having a common goal, with each member contributing to its achievement in accordance with his or her competence and skills and in co-ordination with the functions of the others. A pregnancy that carries a higher than average risk of illness or death to the mother or baby. Maternal age, number of children previously born, chronic illness, previous complications during delivery, etc. are all considered in estimating the risk. These are observable, quantifiable criteria which would be measured as part of monitoring and evaluation in order to determine the extent to which objectives and targets have been met. Variable data that help to measure the present state and any future changes in the health status of a community; statistic (usually expressed as a rate or ratio), e.g. an infant mortality rate of 90/1000 indicates a low level of community health whereas a fall in the neonatal tetanus rate from 40/1000 to 10/1000 indicates an improvement in community health. 137

Information Information System Immunisation Impact Implementation Infrastructure (health) Initiative Integrate Interface Intermediate Level Intersectoral Action Intervention Job Description Local Authority Local Government Logistical Support Management Mobile Services Mobilising Monitoring Morbidity Data Mortality Data Motivation Multidisciplinary Multiplier Effect Data processed for a purpose (e.g. decision making). A group of people, procedures, methods and perhaps machines and other equipment for the collection, processing, storage and reviewal of information. Preventing serious attacks of communicable diseases in individuals by producing them in a mild form, usually by vaccination. Overall effect of a programme on the health status and socioeconomic development of a community, for example the outcome of an immunisation intervention is reduced child mortality. Carrying out a planned activity or programme. All the facilities, institutions, organisations, material and resources required for providing health care. Steps taken towards starting a programme or activity. Putting different parts together to form a whole. In the field of health care, it applies to activities, programmes, plans and services. The place at which independent systems interact or communicate with each other. Provincial or regional level of administration. Action in which various sectors collaborate for the achievements of a common goal. Action taken to improve or change a health situation. A document indicating what a worker is expected to do, the extent of his/her authority and working relationships. Administrative structure that is responsible for the provision of a service within a local government. Third tier of government; most suitable for a village, rural setting, town or city. Providing the means of carrying out an activity, e.g. transportation. Getting things done. Management includes planning, organising, directing, monitoring and control, supervision and evaluation. Health care provided to distant populations by using transport e.g. vehicles, motor cycles. Becoming prepared to undertake an activity. Keeping track of the way activities are being implemented to meet the objectives set and undertaking corrective measures, if necessary. Statistical information about the incidence of disease in a community. Statistical information about the number of deaths in a given time or place. Whatever stimulates an individual to make an effort or take action. Involving more than one area of knowledge or training. Intensification of an effect through repetition of the process leading up to it. 138

National Health Service National Health System Network Non-governmental Organisations Objective Operational Plan Operational Research Operational Support Operational Unit Orientation Organising Outreach Health Services Package (health) Parameters Polychemotherapy Polyvalent (health workers) Power-brokers Pragmatic Prevention Primary data Primary Health Care Primary Health Care Approach Health services provided by a country for all its citizens. The organization of the country s health service (including services provided by central government, the provincial governments, local government, the NGOs/CBOs and the private sector). An interconnected group of individuals or institutions. An organisation which is independent of any national authority; a private agency. The intended result of the achievement of a programme or activity. An educational objective defines what students should be able to do at the end of a learning period that they could not do beforehand. Description of action to be undertaken and the resources necessary to achieve stated goals and objectives. Application of scientific methods to the study and analysis of problems. Assistance with carrying out activities. This could be logistical or technical. Where the activity will take place. Process of becoming acquainted with the existing situation, environment, direction of though or interest. Process of structuring activities, materials and personnel for accomplishing assigned tasks. Provision of health care for populations living far away from health facilities. Essential medical and public health interventions to be undertaken to improve the health status of a community. Characteristics elements. Treatment of a disease using several chemical agents at the same time. Trained or expected to carry out more than one function. People in a position to exert great influence on account of their wealth or of the numbers of individuals they control. Practical To ensure that diseases or illnesses do not occur. Information obtained by carrying out surveys or censuses. Essential health care based on practical, scientifically-sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. The underlying philosophy for the provision of health care services that are based on the Alma Ata Declaration, i.e., comprehensive care that includes curative, preventive, promotive and rehabilitative care within the context of, amongst others, community participation and intersectoral collaboration. 139

Priority Setting Private Health Sector Programme Programming Promotive Activities Prophylactic Campaigns Provide Public Health Sector Quality Assurance Quantification Rationalise Referral Mechanism Regional Hospital Rehabilitation Render Reprogramming Resources Resource Mobilisation Restructure Revenue Deciding on relative importance or urgency according to given criteria. That sector of the health care industry which treats health and illness as a commodity; as a patient you must pay usually un-regulated fees to the health care provider or to the provider via a third party insurer (medical aid scheme, insurance company, etc.); the provider may be self-employed or employed by a non-profit organisation; most private hospitals belong to companies listed on the Stock Exchange, which must generate profits for their shareholders. All the activities directed towards the achievement of defined goals and targets. Formulating programmes to bring about changes needed in a country s health situation. Activities directed towards improving health. Series of activities directing towards encouraging individuals to present themselves for vaccination. To take fiscal responsibility for the provision of services; to pay for services. Services provided by and through government structures (national or provincial Departments of Health, Local Government), for the benefit of all citizens. A management system designed to ensure the provision of services that are of the highest possible standard. Measurement of quantity Process whereby resources are used most effectively and efficiently; often used to mean, especially in the civil service, a cutting back or reduction of resources. Procedures for and ways and means of sending patients to an appropriate facility, institute or specialist at the next level of the health care system. Usually a secondary hospital to which patients are referred from the district hospital (i.e. a hospital which services many districts and at which more specialised services are available); managed by the provincial Department of Health. A process aimed at enabling people with disabilities to reach and maintain their optimal physical, emotional and social level of functioning. To provide services directly. Revising a programme if, for instance, it is not going according to plan or it is not acceptable to the people for whom it is intended. The available means (personnel, equipment, time, money) to supply or achieve an objective or goal. Bringing together the means of achieving a certain objective (personnel, equipment, money etc). To change the organisation or pattern of something. Monies earned; income; usually refers to income earned by a government or authority, e.g. from taxes, or from user fees collected by a hospital. 140

Safe Motherhood S.A.S.A./S.A.S.O. Satellite Health Clinics Scheduling Secondary Data Sector Sensitisation Situation Analysis Soft Boundaries Staffing Strategy Structure Sustainability Target Target Population Technical Support Wellness Approach Workforce Child bearing without danger. Specialised auxiliary services assistant/officer. A post class in the public service. Health clinics dependent on larger and better equipped facilities, e.g. a health centre. Making a plan that indicates the time and sequence of each activity. Information obtained from health records, health surveys, reports, etc. as opposed to primary data. A distinctive part of the socio-economic organisation of a country, e.g. the health sector, the agricultural sector. Arousing awareness of a situation that needs to be changed. Description of the present state of affairs. Boundaries that are subject to change, to take into account changing circumstances. Function of selecting and training workers. Tactic or technique which could be devised or adopted and utilised to facilitate the achievement of objectives and targets. Pattern of organisation. Capacity to continue when external assistance ceases. A goal to be achieved, within a certain time, and which can be measured. Sub-group of the population of a health area defined as priority target for a given service. Assistance in connection with special knowledge, skills and technology. An approach to the provision of services that places an emphasis on creating all the conditions (i.e. not just health services) to enable people to become, and remain healthy, and thus contribute to the well-being of all. Number of workers available. 141

ADDITIONAL REFERENCES Demin K. Andrei Towards a Healthy Russia: Policy for Promotion and Disease Prevention: Focus on Major Non communicable Diseases. State Research Centre of Preventive Medicine: Ministry of Health and Medical Industry of Russian Federation Moscow 1994. Monekosso GL. District Health Management Planning: Implementing and Monitoring a Minimum Health for all Package: WHO Regional Office for Africa September 1994 Ministry of Health and Social Services: Integrated Health Care Delivery: The challenge of Implementation. Republic of Nambia, January 1995 Ministry of Health, and UNICEF Kenya: Manual for the District Health Management Information System 1st Edition; February 1991 Hospital Strategy Project for the Department of Health; Position paper on the Decentralisation of Hospital Management. (First draft) December 1995 Amando-Lartson R, Ebrahim GJ, Lovel H.J, Ranken JP District Health Care: Challenges for planning and Evaluation in Developing Countries: 2nd Edition 1992, ELBS with Macmillan SAMDI: The Training Task of the Supervisor: A Training Manual Fourth Edition: February 1995. Public Service Training Institute 142