Re-engineering Primary Health Care in South Africa

Discussion document, November 2010

BACKGROUND
1. Following on a ministerial and MEC visit to Brazil in May 2010, the Minister requested Dr Yogan Pillay, DDG strategic programmes and head of PHC sub-committee on the NHI Ministerial Advisory Committee, to produce a strategy for re-engineering PHC in South Africa. A task team consisting of Peter Barron, Welile Shasha, Helen Schneider, Tracey Naledi and Hasina Subedar supported by Thulani Masilela, Ramphelane Morewane, Bennet Asia and Khethisa Taole was assembled to assist. The work of this task team culminated in a presentation to the Minister, MECs, Health portfolio committees and MECs at a round table meeting in Umhlanga Rocks on 2 November 2010. The presentation made a number of recommendations which appeared to be well-received but which need more discussion. This document provides more substance and background to these recommendations and serves as a discussion document for formalising those recommendations which are taken forwards into the policy process.

THE CASE FOR PHC

2. Over the past 16 years PHC has been theoretically the focal point of the health system and the following extract from the ANC Health Plan of 1994 illustrates: The PHC approach is the underlying philosophy for the restructuring of the health system. 3. Much has been done to gear up the health system to implement PHC. Nine provincial departments of health have been established out of the fragmented state of pre-1994 South Africa. Racial and gender inequalities in the managerial structures have been largely eliminated. There has been a large investment in infrastructure and building of new clinics and facilities to make health services more accessible. Services have been massively scaled up to deal with the burden of disease that includes HIV and associated TB epidemic. 4. However, insufficient attention has been given to the implementation of the PHC approach that includes taking comprehensive services to communities emphasising disease prevention, health promotion and community participation. For the most part there has not been a population focus and insufficient attention has been given to the improvement and the measurement of health outcomes. In addition the massive tsunami of HIV has diverted much energy, time and resources from focussing on PHC and improving health systems. 5. The case for focusing on PHC in South Africa now is compelling: 5.1. There is widespread global evidence that PHC is effective and makes sense. In addition there are case studies from a number of countries (e.g. Brazil and Thailand) with a long history of implementing PHC and with associated dramatically improved health outcomes.

5.2. South Africa has poor outcome indicators relative to the amount of resources that are being spent in the health sector compared to most middle income countries. Much of this is due to the overwhelming impact of the HIV impact, which itself requires a PHC approach. 5.3. Unless there is fundamental change in the way in which the health sector functions South Africa is unlikely to achieve the MDG health indicators for infant, under-five and maternal mortality rates. Nor is it likely to achieve the MDG goal related to HIV and TB. 5.4. The Minister has committed himself and the health sector to improving these indicators through his negotiated service delivery agreement (NSDA). 5.5. Many of the health problems are linked to the social determinants of health (upstream factors) such as education and water which require inter-sectoral collaboration which is one of the pillars of the primary health care approach. 5.6. There is the necessary political will to translate the theory of PHC into implementable action. 6. There have been numerous documents written on PHC for SA over the past decade. This document does not try and rewrite these documents but is focussed on making practical recommendations for implementation. The three key recommendations are essentially: 6.1. Strengthen the district health system (DHS), through the implementation of chapter 5 of the National Health act, and do the basics better. 6.2. Place much greater emphasis on population based health and outcomes, which includes a new strategy for community-based services through a PHC outreach team based on community health workers (CHWs) and mobilising communities. 6.3. Pay greater attention to those factors outside of the health sector that impact on health, the social determinants of health (upstream factors) 7. The bulk of this document is built upon making a range of practical suggestions for the reengineering of PHC in SA. These are largely structured around the WHO framework for health systems strengthening1 contained in Figure 1. In addition there are a number of community based initiatives in provinces which can provide additional lessons for PHC. These include, but are not limited to, the Premiers Flagship Project in KZN and the Letsema Circle Project in the Eastern Cape.

1 World Health Organization. Everybodys Business. Strengthening Health Systems to Improve Health Outcomes: WHOs Framework for Action. Geneva: World

Health Organization, 2007.

Figure 1

DISTRICT HEALTH MODEL

8. The district health system (DHS) is the vehicle by which all Primary Health Care (PHC) is delivered. A graphical illustration of rendering PHC services within the DHS is displayed in Figure 2. The district management team (DMT) is responsible and accountable for everything that happens in the district. 9. There are three main types of health facilities within the district viz district hospitals, community health centres and clinics. Each of these facilities will have a defined catchment population; norms and standards for the human resources allocated to each facility. Each clinic will have a PHC outreach team which will spend some of its time in the community and some of its time in the clinic. It is proposed that each community outreach team will be responsible for around 1500 households, approximately 6 000 people. 10. All the facilities will be supported by specialist support teams, which include e.g. mental health teams, oral health teams and rehabilitation teams. These support teams will function as crosscutting services. 11. It is recommended that all funds for the functioning of the DHS and the associated PHC should be under the control of the DMT both in terms of budgeting and financial management. The DMT should use these funds to purchase selected services from private providers (e.g. doctors, optometrists, audiologists) where these skills are not available in the public sector and where there are gaps. 12. With the NHI in mind it is also recommended that the DMT become the fund holders for any proposed PHC capitation and become responsible for allocation of budgets to ensure the necessary services. In the short term they will probably require provincial support and mentoring for contract management.

Figure 2 PHC model within the District Health System

SOCIAL DETERMINANTS OF HEALTH

13.Although this document is largely focused on the district health system and the role of the formal health sector it is well recognised that many of the factors that impact on health are outside of the health sector social determinants of health or upstream factors. Much of the work of the community based services team is linked to improving social determinants at the community level. However there are many other factors that need intervention at other levels. To illustrate a draft intervention strategy is presented. (This requires further work).
Short Term (6 months) The National Department of Health positions itself as a steward for health and sees intersectoral collaboration as a key tool to address up stream risk factors Medium Term (6 months to 2 years) Development of sub district mortality profiles which include prevalence of upstream risk factors shown in GIS Evaluate the functioning of the Cluster system to decrease the BOD and make recommendations for improvement Regular review of evidence of effective interventions for upstream risk factors Long Term (2 years to 5 years) Produce regular BOD and upstream risk factor "Barometer" and high lighting of successful interventions

Engage with the Department of Home Affairs and STATS SA to develop a plan that will see a production of sub district level mortality profiles to be used as advocacy tools to engage other departments. The use of Geographic Information Systems (GIS) would be a powerful tool to identify specific areas of inequities Use available data to identify areas of prioritization and specific areas of collaboration with other departments (use research already done by WC BOD Reduction project). Set very specific, time bound targets for the reduction of the burden and get buy-in at national level for the role of other departments. Use the cluster system as a vehicle to also monitor the implementation of this. Communicate these targets widely and lobby for these to be taken down to the provincial and district level Align the programme of the provincial clusters with that at National level with specific time bound targets. Use the provincial cluster system to agree on the program of action and oversee its implementation and monitoring of this. Communicate these targets widely and lobby for these to be taken down to district level

National

Provincial

Communicate and distribute the sub district mortality profiles which include prevalence of upstream risk factors shown in GIS Participate in the evaluation of the functioning of the Cluster system to decrease the BOD and implement recommendations for improvement Have regular implementation fora within the district and use the GIS tools as an advocacy and monitoring tool

Contribute to the BOD Barometer

District

Align the intersectoral programme at district level through the IDP process with that of the provincial and national clusters with specific time bound targets. Communicate these targets widely within the district

Contribute to the BOD Barometer

LEADERSHIP AND TEAMWORK

14. The single most important factor to re-engineer PHC is appropriate and strong leadership. South Africa has a large number of stakeholders working in the health sector. For PHC to be galvanised it requires that all the efforts and resources of these stakeholders are pooled. It is recommended that leadership take a number of decisive actions: 14.1. Develop standard, clear and unambiguous messages which are repeated by all managers over time. This should include a clear vision for PHC and where the health system is heading. 14.2. Ensure that the activities of the national and provincial DOHs are focussed on strengthening the District Management Team (DMT) by providing the required support, resources and delegations to ensure that it is responsible and accountable for PHC and the consequent health outcomes of the population of the district, including equitable health outcomes. 14.3. Harness the resources of stakeholders including teaching institutions, NGOs, private sector, donors and development partners, other government institutions, community leaders and the general public so that everyone has a focus on PHC and everyone knows their unique contribution to making this into a reality. It is especially important that development partners align their funding and plans with those of district, provinces and national departments of health 14.4. Focus on selected number of priorities which are built around achieving the Ministers NSDA targets. 14.5. Ensure that the DMT has the necessary capacity, skills and competencies to carry out their functions. 14.6. The National DOH should produce standardised organograms and standards for the DMT, the sub-DMT and the district hospital management teams. This should be accompanied by clear, standardised job descriptions and performance agreements. PDOHs should ensure that their current management teams be re-organised to fit with norms and standards provided by the NDOH. 14.7. All managers in the district management should have their skills and competencies assessed and if found to be deficient then appropriate remedial action should be taken.

SERVICE DELIVERY
DISTRICT HEALTH SYSTEM 15. The DHS is the vehicle that drives the implementation of PHC. Therefore to ensure that PHC is wellimplemented it requires a well-functioning DHS. There are a number of recommendations to improve the functioning of the DHS. 15.1. Chapter 5 of the National Health Act, which deals with the DHS, should be fully implemented. This requires that the MEC for Health ensures that the district and sub-district are well managed with respect to the principles of the DHS. These principles are the delivery of accessible, good quality services in an equitable manner ensuring that these services are comprehensive and not fragmented and that they are effectively and efficiently delivered. They also include the need for local accountability, community participation, a developmental and inter-sectoral approach accompanied by sustainability. 6

15.2. It also requires provincial legislation to provide for the formal creation of District Health Councils which provide oversight to the DMT. 15.3. All personal health services should be taken over by the provinces: the so-called provincialisation option. This requires that all provinces, with support from the NDOH, need to make the necessary arrangements to take over the remaining PHC facilities still under local government management, including the six metropolitan municipalities. The reason for this recommendation is that the split management of PHC by the DMT and the local government management has led to a situation where there is no clear level of responsibility and accountability for the health of the population of the district. PHC PACKAGE 16. The DHS provides a range of services in the community as well as in the facilities and district hospitals. It is important that health providers, communities and individuals know which services will be provided at which facilities. The current PHC package that was drawn up in 2002 is being revised to incorporate changes that have taken place since then. With the advent of the NHI, there will be an expectation from individuals that their common health care problems will be taken care of. 17. As a result work was commissioned for a new PHC package that would incorporate at least: 17.1. Community based services 17.2. Increased emphasis on preventive and promotive services especially at household level 17.3. Additional services related to HIV 17.4. Services related to common health problems not traditionally offered in clinics including those related to oral health, vision, hearing, mental health and disability 17.5. School health services 18. This draft PHC package with associated levels of care (excluding district hospitals) is attached as Appendix 1. 19. It is recommended that: 19.1. This PHC package should be reviewed and a new PHC package adopted and made widely known. 19.2. Every facility should advertise prominently the services that will be offered at that facility. The times when these services will be available should also be widely known (e.g. the days when oral health services will be provided) 19.3. The package should be formally costed and the results used for revising provincial and district budgets, which should be ring-fenced. 19.4. There is already a package of services for district hospitals. This PHC package needs review to ensure that there is a seamless continuum between services offered in the PHC package and that of the district hospital.

QUALITY IMPROVEMENT AND CLINICAL GOVERNANCE 20. One of the principles of the DHS is good quality health care. There are many elements that comprise quality and there are many ways to improve quality. For the re-engineering of PHC it is recommended that a number of systems issues, which are directly linked to quality, be put in place. 21. The system of supportive supervision should be fully implemented. This includes the regular use of the national Supervisory Manual which was updated and distributed recently. This manual should form the basis for supervisory visits to facilities, including district hospitals. 22. The PDOH should ensure that there are an adequate number of appropriately trained supervisors in each district. These supervisors should be provided with adequate resources, especially transport, to undertake their supervisory work which should be given the highest priority. In addition the PDOH should ensure there is a system where supervisors themselves have clear lines of accountability and supervision. 23. Every facility should have a minimum of one visit per month from a suitably trained supervisor. This visit should culminate in a written standardised report that states issues/problems and has a plan of action for each problem. These plans of action should be jointly drawn up by the facility manager and the supervisor. Each supervisory visit should deal with the plans of action of the previous supervisory visit. 24. All current specialised managers of the DMT and sub-DMT, (e.g. HAST managers, TB managers, MCH managers) should be re-designated as PHC managers. This will assist in the integration of programmes at facility level; it will also assist in improving supervision for all PHC services. A significant component of the job of these PHC managers will be to undertake supervision themselves as well as well as supervise the supervisors. One of the key areas of quality improvement is through clinical governance. 25. Family physicians, as part of the District Specialist Support Team in line with national policy and guidelines, should take the primary responsibility for developing a district specific strategy, implementation plan for clinical governance and provide technical support and capacity development for the implementation of clinical governance tools, systems and processes for clinical service quality in the district health system that includes the community based services, PHC facility services and district hospital services. Family physicians should also take overall responsibility for the monitoring and evaluation of clinical service quality for the entire district. 26. District hospitals need to have a clinical operations officer, who will be responsible for implementing clinical governance tools, processes and systems for district hospitals. He/she will also monitor and evaluate clinical service quality for the district hospital. In addition, especially in rural areas doctors from district hospitals will have a significant outreach role to health facilities.

27. Primary health care supervisors at the sub district level should in addition to supportive supervision also monitor the clinical service quality at PHC facilities. 28. For community based services the professional nurse should be responsible clinical governance processes and systems to ensure quality services. Similarly, in clinics the PHC nurse should be responsible for this task and at the CHC the medical officer should take this responsibility. REFERRAL SYSTEMS 29. The PHC package needs to be linked to the district hospital package and there needs to be clear referral systems from community to clinic to CHC to district hospital and outside of the DHS to more specialised services to ensure that there is a continuum of care to and from the community. These referral systems should be well-advertised to communities. 30. The referral system should be accompanied by an emergency and patient transport system. The workings of this transport system should be clearly advertised so that health workers and communities can know what to expect. (E.g. expected times for ambulance arrivals) ORGANISATION OF SERVICES 31. With an integrated approach to PHC it is expected that services will be integrated both horizontally and vertically. So for example vertical integration of services related to maternal and child health are contained in the Figure 3. This diagram shows a continuity of care from the community level, through the formal facilities of the district based services and the higher levels of care in secondary and tertiary hospitals. 32. Similarly there should be integration of services at every level of service (service platform) and that individuals and families should not be treated in a programmatic way but in a holistic way. This is illustrated in figure 4 where one level of service (viz that of community health workers at community level) is shown. In this figure it shows how the different roles of the CHW (e.g. assessment) are carried out across the most important programmes that impact on morbidity and mortality.

33. A number of recommendations are made in relation to the organisation of services: 33.1. Horizontal integration of services at every level of care. 33.2. Responsibility for outcomes for health (even when patients referred for specialised care) remains at the district level under the DMT.

Figure 3

10

Figure 4

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DIFFERENCE BETWEEN THE RE-ENGINEERED PHC APPROACH AND THE CURRENT PHC APPROACH 34. The re-engineered PHC strategy has essentially two fundamental differences to the current PHC approach. The first is that the current DHS needs to be strengthened; the basic systems need to be better implemented and the DMT needs to be given the responsibility and the consequent accountability for managing the district and being responsible for the health of the population. 35. The second fundamental difference is around the conceptualisation of interaction between the health services and the users of the health service. In the current approach the health services are largely passive and curative oriented and based on individual health care. In the re-engineered approach the health services are more pro-actively reaching out to families with the emphasis on keeping them well through health promotion and preventive activities. There is greater emphasis on outreach into communities and homes of families with family censuses; early identification of individuals within families at high risk; greater interaction with communities to get their support for participation in maintaining and improving their own health and most importantly amongst health workers much more of a team approach to health care.

HUMAN RESOURCES
THE PHC OUTREACH TEAM 36. Each PHC outreach team will be assigned a number of households within a specified geographic area for whose health the team collectively takes responsibility. For consistency the core functions, responsibilities and structure of the PHC outreach team will be centrally determined. However some flexibility and creativity is permitted at a local level to accommodate local contexts. 37. The PHC outreach team as depicted in Figure 5 provides in more detail the members of the proposed Primary Health Care (PHC) team: 37.1. Professional nurse, 37.2. staff nurse and 37.3. community health care workers 38. The PHC outreach team will provide comprehensive PHC health care services to a defined number of families. Each PHC outreach team will operate out of a PHC clinic which is based within the community that it serves. A PHC clinic may accommodate more than one PHC outreach team with a recommended maximum of three PHC teams per clinic. It is envisaged that the PHC outreach team will manage at least 80% of defined health problems of the catchment population at community level.

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Figure 5 PHC OUTREACH TEAM RATIOS Ratio of CHW/PHC Outreach Team/Clinic to Households/Population Households 1 CHW 250 1 PHC Team 1500 1 Clinic 4500 PHC outreach teams required for current uninsured population Number PHC Outreach Teams in South Africa

Population 1000 6000 18000 6907

39. The PHC outreach team will be led by the professional nurse and will be responsible and accountable for improving the health outcomes of their catchment population. RESPONSIBILITIES AND ROLE OF PHC OUTREACH TEAM 40. The proposed PHC teams will operate within a defined geographic boundary and be responsible for an assigned number of households and individuals. Staffing calculations estimate that a CHW can on average assume responsibility for approximately 250 households. Based on the staffing and workload calculations a PHC outreach team will comprise of 6 CHWs with approximately 1500 households per team (250 households x 6 CHWs). In addition to the 6 CHWs each PHC outreach team will comprise of a comprehensively trained professional nurse (who is also a competent midwife), a staff nurse (a mid-level nurse who will provide basic care to persons with stable and uncomplicated general health problems in a PHC setting, as determined by the new scope of practice stipulated in the Nursing Act 33 of 2005). Figure 6: The Primary Health Care Outreach Team

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Figure 7: The PHC outreach team: Roles and Functions THE PHC OUTREACH TEAM ROLES & FUNCTIONS
WHO WHAT

1 Professional Nurse

Clinic-Based Services Support/Supervision of Community-based Services Clinical Support: Early Learning Centres (ELC), Crches, Old Age homes, schools 2 Staff Nurses Clinic based services IMCI basic Antenatal Post natal care (normal pregnancies) Immunization Repeats stable chronic patients Treatment of minor ailments 1 Staff Nurse Support & supervise CHW services in the community School health services Community based programmes (e.g. antenatal, post natal care, immunization campaigns) Screening & support services to schools, ELC, Crches, Old Age Homes 6 CHWs Screening, assessment & referral, Information & education, Psychosocial support, Basic home Rx, Support community campaigns, schools ROLE OF PHC CLINIC SUPPORT STAFF (PER PHC OUTREACH TEAM ) Part-time Doctor (.1 FTE) Complex cases, clinical governance Part-time PHCN (.3 FTE) Complex cases, overall clinic management and supervision of support staff Part-time ENA (.6 FTE) Observations, tests support team members Counsellor (1 FTE) Main focus: pre and post diagnosis counselling; HIV/AIDS, TB, Chronic Diseases; treatment adherence support and counselling Post Basic Pharmacy Assistant (1 Dispense treatment, patient information FTE) 41. As illustrated in Figure 7 the CHW will spend at least 80-90% of their time in the community. They will gain a full understanding of their catchment population through compiling a map and profile of their community and registering the details of the families they are allocated with the clinic. The CHWs will initially conduct household assessments identifying potential and prevailing health problems and make appropriate referrals to health, social and other required services. The staff nurse will focus on supporting and supervising the work of the CHWs at a household and at institutional levels especially pertaining to health related work at schools, crches and early learning centres. 42. The PHC outreach team will collectively facilitate community involvement and participation in identifying health threats, vulnerable groups and individuals and appropriate interventions for addressing these. The professional nurse will spend around 10% to 20% of time in the community 14

supporting the work of the team visiting high risk households or persons and 80- 90% of the time will be spent in the PHC clinic providing health care services to the catchment population. 43. The medical doctor and PHC nurse will support the PHC outreach team to manage complex health problems, disease outbreaks or disasters. 44. Targeted health promotion and strategic interventions to address specific health problems and priorities will be the responsibility of the PHC outreach team together with the other district based health services. THE PHC CLINIC 45. The professional nurses of the PHC outreach team will provide health services at a PHC clinic for the estimated 1500 families for who they are responsible. Using a normative approach on average there will be 3 PHC teams based in a facility which will have a catchment population of around 18,000 people. In each PHC clinic there will be a part time medical practitioner, a PHC nurse practitioner, counsellors, nursing auxiliaries, post basic pharmacist assistants and administrative support in addition to cleaning and security services. MEDICAL PRACTITIONERS 46. For the curative component of primary health care, especially for the provision of acute and chronic medical care the medical practitioner is a necessary member of the PHC team. Whilst it is envisaged that nurses, especially primary health care nurse practitioners (PHCN) with advanced clinical skills will manage the majority of patients using protocols, the medical practitioner is required to provide clinical support, supervision and clinical governance and manage those patients that cannot be managed by the nurse practitioner. In many urban settings the availability of medical practitioners is not an issue, however in rural and underserved areas this is a serious challenge. Private GPs employed on a part-time basis are currently providing a useful service in some provinces. However there are some challenges with managing these contractual appointments and clear guidelines based on best practice can serve as a useful tool to manage part-time GP contracts. 47. It is recommended that a rapid review of existing contracting practices with GPs be carried out in order for best practices to be identified, as well as to identify lessons learnt in respect of issues that need to be avoided. PRIMARY HEALTH CARE NURSE PRACTITIONER (PHCN) 48. At the PHC clinic the services of the PHC outreach team will be supported by a part-time medical practitioner and a PHCN (a nurse who has advanced skills in clinical, assessment, diagnosis and treatment of health conditions). It is envisaged that this category of health worker will continue to make an important contribution to PHC services in South Africa. Since 1996 the number of nurses that have been trained and registered with the SA Nursing Council as a PHCN has increased fivefold from 1449 to 7307.

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POST BASIC PHARMACY ASSISTANT: (Pharmaceutical Services) 49. Currently there 685 pharmacy assistants and 1,814 pharmacists employed across all health services within the public sector (PERSAL). The projected staffing requirements for PHC are 8,418 post basic pharmacist assistants. 50. The motivation for a post basic pharmacist to provide services at the PHC clinics are based on the competence and skill required to render the pharmaceutical component of the package of PHC services at a PHC clinic and the community. The Pharmacy Council of South Africa (PCSA) registered the post basic pharmacy assistant as a mid-level health worker to address the challenges facing the health care system with regard to the shortage of pharmacists. Although training and registration of post basic pharmacists commenced as early as 2004 this category of mid-level health worker has not been fully embraced by the public health services. A concerted effort is required to increase both the production and employment of post basic pharmacist assistants in the public sector. COUNSELLORS 51. Currently there are a range of lay counsellors, adherence counsellors and DOTS workers, pre and post HIV testing counsellors. Based on the services offered at the PHC clinics there is a need for an integrated counsellor who will provide a comprehensive and integrated approach to treatment and psychosocial support. All the current counsellors will need to acquire the competence to provide a comprehensive and integrated counselling service. A skills development and support programme will be required to upgrade the services of existing lay counsellors. NURSING AUXILIARIES 52. The role of the nursing auxiliary is primarily to carry out the routine observations, weighing and measurements and basic diagnostic tests and basic support and care as and when required. The scope of practice and level of competence and skill of the nursing auxiliary is very limited. Therefore this category of nurse is unlikely to be able to render a more extended role in the PHC team. ADMINISTRATIVE SUPPORT (including Information Management) These roles still need to be unpacked and spelt out in detail.

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Figure 8: Comparison of Core Human Resources under Proposed PHC Re-engineering Model and Current Practice Category of Staff Community Health Worker (CHW) Home Based Carers (HBC) Professional nurses (PN) Community Based Services Proposed Yes PHC Clinic Current Proposed No formal link between clinics and Part of the PHC outreach team CHW located in the PHC clinic No formal link between NPO and clinics Yes. There are no requirements for a PN to be comprehensively trained including midwifery, psychiatry, community health Yes Improved co-ordination and linkage between NPO and PHC outreach services Yes. A PN must be comprehensively trained and registered in midwifery and psychiatric and community health nursing Yes role clearly defined in terms of observations, basic tests and basic nursing activities Yes. In terms of the new scope of practice of the staff nurse this category of nurse will be trained and competent to manage patients with stable presentations of chronic illnesses, normal post and ante natal care, basic IMCI, minor ailments, follow-up family planning.

Current NGO

NGO/NPO

NGO/NPO

Not directly responsible for CBS except health promotion activities and campaigns

Yes PN responsible for PHC outreach team & community based services No

Enrolled Nursing Auxiliaries (ENA) Staff nurses (SN)

No

No this category is a new category

Enrolled nurses (EN)

No

Yes it is envisaged that the staff nurse will play an important role in health promotion, school health, crches, ELC and old age homes and conducting post natal home visit and supervising the community based activities of CHWs No the scope practice of the enrolled nurse is too limited to fully utilize the enrolled nurse fully 17

No

Yes

No the scope of practice and training of the enrolled nurse severely restricts the range of services that can be provided by

Doctors (DR) PHC Nurse Practitioners (PHCN) Counselors (integrated counseling services)

No No

for community based services. The enrolled nurse requires direct or indirect supervision by the professional nurse. In the interim additional professional nurses are available to render the full package of PHC services required at a community level. No No

this category of nurse at a PHC clinic. It is therefore recommended that the skills of the enrolled nurse is upgraded to that of a staff nurse and in the interim additional professional nurses are available to render the full package of PHC services required at a PHC level.

No No (in few clinics)

Yes Yes

No

No

Currently there are a variety of counsellors 1. Lay Counsellors provide pre and post HICV testing counselling, 2. ARV adherence counselors 3. DOTS workers for Patients on TB treatment No

Post Basic Pharmacist assistants (PBPA)

No

No

Health promotors

Health promoters may be found in some PHC clinics and

There are no firm recommendations 18

Health promoters may be found in some PHC clinics and Community

Integrated Counsellors to provide counseling for: Pre and post testing counseling for all diagnoses Adherence counselling for treatment incl. ARV, TB, chronic disease and mental illness Post trauma counselling Yes preparation of prescriptions and issuing of medication by a post basic pharmacist assistant will improve access to medicines at PHC clinics and it will free the professional nurses who are currently issuing medicines to focus on rendering PHC services. There are no firm recommendations regarding the

Community Health Care Centres and they play a role in community based health campaigns. They play an important role in producing health promotion and marketing material.

regarding the role and function of health promoters. Health promotion is integrated into the function of the CHW, staff nurse, counsellors and professional nurses Schools form part of the responsibility allocated to the PHC outreach team

Health Care Centres. They play an important role in producing health promotion and marketing material.

School Health nurses

School health nurses are available in only very few provinces.

No

role and function of health promoters. Health promotion is integrated into the function of the staff nurse, counsellors and professional nurses. The development of health promotion and marketing material could be undertaken at a provincial level. No

53. Table 8 shows the roles of different staff categories for the proposed model split into community and clinic based services and current and proposed practices. 54. It is recommended that more work will have to be done to unpack the detail for each category of health worker but the principle should be to reduce the different types of health workers (e.g. health promotors are currently found in three provinces and it is recommended that their current functions be built into the work of other categories of health worker)

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Human resource requirements (PHC clinic and communities) 55. The availability and retention of health care personnel to render services in rural and underserved areas remains a challenge. In addition the lack of staffing norms and guidelines has resulted in large variations across facilities and districts. The implementation of the PHC outreach team model provides the opportunity for determining skill-mix and staffing norms for the delivery of PHC services. A model using a number of variables (including package of PHC services; skills and competencies) was developed. Using this model the staffing requirements for the delivery of PHC services for the uninsured South African population were generated. Figure 9 outlines the different categories of staff and the FTE for each category required. Through this modelling process it was confirmed that the Professional Nurse, the staff nurse and the CHW were the core members of the PHC team.

Figure 9: Full Time Equivalent (FTE) Staffing Requirements for PHC Teams and PHC Clinics: Staff Nurse Model
FTE Per PHC Outreach Team Professional Nurse Staff Nurse Counsellor Enrolled Nursing Auxiliary Staff Nurse Model Admin/clerk 6 6 1 1 18 18 Admin/clerk 3 3 Community Health Worker 4 4 Community Health Worker Post Basic Pharmacist Assistant 1.2 1.2 1 1 Post Basic Pharmacist Assistant PHC Nurse 0.3 0.3 PHC Nurse

Facility Community Total FTE Per Clinic

1 2 1 01 3 PHC Outreach Teams Per Clinic Professional Nurse Staff Nurse

0.6 0.6 3

1 1

Counsellor

Enrolled Nursing Auxiliary

Facility Community Total FTE

3 3

7 2 9

2 2

3 3

56. These recommended norms provide a guide for human resource planning at a PHC clinic and community based service level and require adjustment and adaptation for local contexts. Human resource requirements for each area will have to factor in the overall disease burden of the area, the age of the population and the health indicator targets that the PHC outreach team has to influence. Health service managers must ensure that they manage the skill mix required to render a health service and manage the health care needs of families that they are responsible for.

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Doctor 0.3 0.3

Doctor 0.1 0.1

57. Figure 10 outlines the number of the different categories of health and support staff required for the delivery of PHC services at the PHC clinic and community for the uninsured South African population calculated using the FTE staffing requirements. The aim is to move over time to a model where much of the work is done by staff nurses. This model will require more detailed work but suggests the general direction in which the PHC services should move. Figure 10: Projected Human Resource Requirements for PHC Clinics
Human Resource Requirements PHC Clinics (Excluding CHC & District Hospitals) st Numbers required for 1 3 Years. Numbers required after 3 years. Enrolled Nurse Model Staff Nurse Model 20,526 6,377 N/A 21,736 7,587 N/A 3,829 3,829 740 740 1,801 1,801 5,886 5,886 8,418 8,418 6,907 6,907 41,440 41,440

Category Health Worker Professional Nurse Staff Nurse Enrolled Nurse Enrolled Nursing Assistants Doctors PHC Nurses Counsellors Post Basic Pharmacist Assistants Clerks CHW

Professional nurses 58. The assumption made with regard to the skill and competence of the professional nurse is that they are comprehensively trained and are competent to provide general health care to persons who have communicable (including TB and HIV) and non-communicable diseases (including acute and chronic conditions), mental health, maternal and child health. Although the majority of the professional nurses are comprehensively trained their capacity to integrate their skills and render a comprehensive service currently is not the norm. The professional nurses and other members of the PHC outreach team will require extensive support, induction, orientation, training, supervision and mentorship. Staff nurses 59. One issue facing the provision of PHC services is the introduction of and redefinition of the scope of practice of the mid-level staff nurse. The South African Nursing Council, on the instruction of the Minister of Health and the NDOH, reviewed the scope of the enrolled nurse to meet the requirements of both a mid-level nurse and PHC delivery requirements. The new scope of practice addresses the limitations of the scope of the current enrolled nurse and expands the practice of the staff nurse to function independently as a mid-level nurse. The scope of practice of this new category of staff nurse includes ante natal and post natal care, IMCI, community based interventions, managing clients with stable and uncomplicated presentations of communicable and noncommunicable diseases.

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60. In the model developed to make the staffing projections two scenarios are presented. One is based on the new scope of practice of the staff nurse and the other uses the scope of practice and competence of the current enrolled nurse (Figure 11). These two scenarios result in significantly different staffing requirements, especially with regard to the numbers of professional nurses in relation to staff nurse and enrolled nurse requirements. 61. In the staff nurse scenario the number of professional nurses required is significantly lower than the number of staff nurses required. In the enrolled nurse scenario the opposite is true. Another significant difference in the two scenarios is that in the enrolled nurse scenario the enrolled nurse does not have the required skills and competence to fulfil the community based functions and 1 FTE professional nurse is required for the community based services. The two scenarios are provided to accommodate the transition from enrolled nurses to staff nurses and facilitate the upgrading of the competence of the current enrolled nurse to register and practice according to the new staff nurse scope. Figure 11: Full Time Equivalent (FTE) Staffing Requirements for PHC Outreach Teams and PHC Clinics: Enrolled Nurse Model
Staffing Per PHC outreach team(FTE) Professional Nurse Counsellor Enrolled Nurse Enrolled Nursing Auxiliary Doctor Enrolled Nurse Model Admin/clerk 1 1 Admin/clerk 3 3

Facility 2 Community 1 TOTAL FTES 3 Staffing PHC Clinic (FTE) Professional Nurse

1 1

1 1

0.1

0 .3

1 1

1 0.1 0 3 PHC TEAMS PER PHC CLINIC Counsellor PHC Nurse Doctor

0 6 6

Facility Community TOTAL FTES

6 3 9

3 3

2 2

3 3

0.3 0.3

1 1

4 4

18 18

62. The scope of practice and competence of the current enrolled nurse is far too restrictive for this category of health worker to function effectively at a PHC level. As an interim measure a development programme should be put in place over a period of 3-5 years to upgrade the current pool of enrolled nurses. The SANC must facilitate the education and training of staff nurses in public nursing colleges in all provinces (in terms of the NQF registered qualification this is a 2 year Diploma). 22

Community Health Workers

Pharmacy Assistant

Enrolled Nurse

Enrolled Nursing Auxiliary

Community Health Workers

Post Basic Pharmacy Assistant

PHCN

Post basic pharmacy assistants 63. The Pharmacy Council of South Africa (PCSA) has registered a mid-level health worker, the post basic pharmacist assistant. Based on the services offered at a PHC clinic the post basic pharmacist assistant is best suited to render the services and therefore they were included in the model. A pharmacist is required to supervise the pharmacist assistant. A physical visit once a month is required in terms of the PCSA rules. According to PERSAL there are approximately 680 pharmacists assistants and according to the staffing requirements 8,418 post basic pharmacists assistants are required. 64. Training institutions should be tasked with rapidly increasing the required number of post basic pharmacy assistants over the next 2-3 years. Posts for post basic pharmacy assistants need to be created at public PHC clinics. Clinical associates 65. The Clinical Associate programme was first launched in March, 2004. The clinical associate is a midlevel health care provider who is currently trained to work in district hospitals to fill the gap related to the shortage of doctors to provide emergency care, diagnostic and therapeutic procedures and in-patient care. The clinical associate will be regulated by the Health Professionals Council of South Africa (HPCSA). The scope of practice of the clinical associate differs from that of the practice of the PHCN practitioner at the clinic where prevention, first contact assessment, diagnosis and treatment of acute and chronic presentations of communicable and non-communicable health conditions are most important. 66. It is envisaged that clinical associates will relieve the doctors at district hospitals from routine and repetitive procedures and they will deliver health care in accordance with protocols under the supervision of a doctor. This will free up doctors from district hospitals to provide outreach services to CHCs, PHC clinics and community based services. 67. A number of recommendations are made in relation to this category of health worker Immediate interventions 1-3 Months 67.1. The first 24 graduates will qualify by the end of December 2010. There should be an urgent intervention to secure posts to employ them. 67.2. The district hospitals that employ them need support to develop protocols and standard operating procedures for their use. 67.3. Hospital management must regulate the manner in which doctors will supervise clinical associates. 67.4. There should be a communication strategy to publicise and inform the public and all relevant stakeholders including a recruitment strategy for new students. Short-Medium term Interventions 3-12 Months 67.5. There should be a calculation of the number of clinical associates required to provide services at a district hospital and a plan for training the required number of clinical associates. 23

67.6. The recommended minimum of 4 clinical associates per district hospital should be formally adopted. 67.7. Create bursaries for training at least 500 clinical associates over the next 3 years. 67.8. Establish a monitoring and evaluation system to monitor their effectiveness. 67.9. Conduct a feasibility study to assess their future role in PHC services. Specialised support to PHC outreach teams 68. The PHC outreach team will receive clinical support and clinical governance from a range of different specialized services e.g. the family health practitioner, specialized mental health teams, rehabilitation. The main aim of the specialized support is to support the PHC outreach teams and PHC clinics to manage more complex health and specialised health problems. 69.A glossary of HR workers is contained in Appendix 2 and HR recommendations in Appendix 3. A comparison of the scope of practice of enrolled nurses and staff nurses is contained in Appendix 4. COMMUNITY HEALTH WORKERS 70.CHWs form a central element of reorganised and proactive community based services shifting from a predominant focus on dehospitalized care through top down referral, to a systematic, bottom-up and comprehensive approach to households, in which community based services form part of coordinated inter-sectoral action at local/ward level. 71.A number of priority roles for CHWs have been shown in Figure 4. At the household level these include screening, assessment and referral; information and education; psychosocial (including adherence) support and basic home treatment. In communities, schools, early childhood centres the role of the CHW is to carry out community assessments, campaigns, and screening programmes. 72.In addition to the work of the CHW there is also a role for other lay workers or forms of community volunteerism and participation. These include traditional home based carers providing labour intensive palliative care and support for activities of daily living. It is likely that there will be an ongoing need for these home care functions and a residual role for a lower level home carer. Further there is a need for a facility based counsellor who does HIV counselling and testing; counselling for other needs and who can act as a case manager in chronic disease services. Finally, true volunteer contributions (without any expectation of fixed labour) and community mobilisation and participation will continue to be encouraged and enabled. 73.There is a need to move from the current situation where there are multiple CHWs working in parallel, fragmented and unstable work situations to one which is integrated, consolidated and stable. Integration is required at a number of levels: 1) in roles and approaches to households, 2) between community and facility based services and community based workers and other members of the PHC team 3) and in the managerial, budgeting, human resource and monitoring and evaluation processes of the health sector. There is a need to consolidate and standardise the basic training of CHWs, through national agreement on appropriate competencies, the development of 24

new/consolidation of existing unit standards, skills programmes and qualifications, and re-examining the most appropriate institutional environment for training provision. A key question to resolve is whether or not the CHW will become a registered national category corresponding to a clearly defined qualification, and the regulatory framework which will accompany the formalisation of the category. Related to this is the need to ensure that CHW qualifications allow entry into mid-level worker training opportunities in the fields of nursing, rehabilitation and pharmacy without requiring a separate matric qualification. Questions of roles, competencies, regulatory processes and career pathing will also have to be addressed for home carers and facility based counsellors. 74.For all lay worker categories, systems of in-service training are as, if not more, important than basic training and key to ensuring the quality of their work. The cascade training model through regional and district training centres provides a possible basis for the in-service training of community based workers. 75.If community based workers are to play a meaningful roles in revitalised PHC, the currently highly unstable nature of their employment and low levels of remuneration need to be addressed. There needs to be both an elimination of dry seasons and an immediate and tangible improvement in salaries and conditions of service. Ideally, all workers providing essential services through full-time employment should become part of the formal public health system. This requires that the long term roles of NPOs and the state as employer be reviewed and redefined. 76.Issues related to CHW selection and their relationship with the communities in which they live need to be clarified. 77.These issues will require an active process of learning by doing accompanied by intensive monitoring/evaluation in the early phases, and a gradual refinement of policy over time. But there are a range of immediate actions which can be taken. 78.At district level: 78.1. Map the numbers of CHWs, their training and their current roles and functions, do a gap analysis and identify priorities for training and deployment 78.2. Divide the district and sub-district into zones and allocate each CHW to a particular health facility 78.3. Start on the process of integrating the roles of CHWs, focusing on priorities identified in the gap analysis 78.4. Start orienting CHWs to the new model of PHC through in-service training, drawing on the regional and district training centres and other service providers 78.5. Prepare facility and other PHC staff for the new roles of CHWs 78.6. Develop support teams using available resources such as professional nurses, health promoters rehabilitation workers and non-profit organisations in the area.

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79.At provincial level: 79.1. Provide technical support to districts through mechanisms such as roving support teams 79.2. Set up learning sites to develop and evaluate different models of CHWs (including some impact assessments) 79.3. Experiment with monitoring and evaluation systems for community based services that include coverage, access and quality 79.4. Review and consolidate funding streams so that the financial resources for CHWs are integrated into core district budgets. 80.At national level: 80.1. Develop core national competencies and review training providers and options 80.2. Based on provincial experiences and good practices, develop and evaluate tools/checklists for integration and M&E systems 80.3. Negotiate agreements to ensure that existing training and qualifications are recognised 80.4. Investigate and develop the regulatory framework for CHWs, with Department of Public Service and Administration 80.5. Mobilise donor funds as well as mainstreaming funding to ensure sustainability 80.6. Fund learning sites and model development 80.7. Facilitate lessons learnt across provinces 80.8. Revise national policy and publicise this

FINANCES
81.The financial requirements for this proposed re-engineering of PHC need to be estimated in much greater detail and a budget needs to be submitted to Treasury for consideration and phased implementation. The cost of implementing the PHC package and the funds required to run district hospitals need better estimation. 82.It is recommended that the full budget for the running of districts should be ring-fenced in order to protect PHC as being the highest priority in provincial spending. 83.However in the short term there are considerable efficiencies to be gained. One of these is by the improved functioning of district hospitals where there are extremely wide variations in cost per patient day equivalents (PDEs). Another is through having clear referral policies to ensure that patients are seen at the appropriate level of care. A third is through improving the use of the DHERs and their impact on use of resources in the district. 84.Figure 12 shows the cost of two models for CHWs. In the first model CHWs are employed by NPOs at a cost of R30,000 per year giving a total cost for CHWs of R1.7 billion per year while in the second model they are employed in the public sector at a cost of nearly R75,000 per year with a total cost of R3.5 billion.

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Figure 12: Cost scenarios for CHWs

85.In Figure 13 the HR costs (which approximate 75-85% of the total cost) of the comprehensive PHC package for the clinic and community levels are shown. In this estimate the cost is R10 billion which is around 10% of the current public sector budget for health. Figure 13: HR Costs

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MONITORING AND EVALUATION

86.A much greater emphasis on monitoring and evaluation is required at every level of the service to ensure that the right things are being done correctly (effectiveness and quality) and for the lowest cost (efficiency). Every manager needs to have M&E built into their job description and it should become part of their daily work. The performance appraisal of every manager should be built around the M&E component. 87.Knowledge and information for M&E comes from routine services and support data; from surveys large and small; from interactions with health workers and clients and from observations. All must be used for decision making. 88.The DHIS is the backbone of the routine information system and is complimented by the BAS, PERSAL and other support services data (e.g. pharmaceutical, laboratory, transport). These data are currently under-utilised by managers and this neglect results in lowered quality. 89.It is recommended that there be a thorough review of the full DHIS and that this results in a streamlining and improvement of the existing system and processes. The full range of communitybased services needs to be underpinned by an M&E system that is incorporated into the DHIS. 90.In a sustained and phased manner, based on the successes of pilots, innovations into data management through the use of improved technologies (e.g. mobile phones) should be incorporated. 91.There should be an increase in the capacity for data analysis, interpretation and use for decision making at all levels and a sustained in-service training programme for all managers should be initiated. 92.It is recommended that there should be public health knowledge units established at the NDOH and PDOHs so that there is sufficient skills and capacity to support DMTs with the analysis and interpretation of information for population health outcomes and to carry out relevant health systems research. Because of the lack of capacity in the public sector the available skills and capacity (e.g. MRC, schools of public health; NGOs) in South Africa should be harnessed.

WAY FORWARD
93. The implementation of this re-engineering of PHC will take much effort, resources and time. Each province and to a lesser extent each district, will build from their current situation. Implementation will have to start from where the district is currently and therefore the recommendations made in this document may need some modifications.

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CONSULTATION 94. This re-engineered PHC strategy should be discussed with as many role players as possible including provinces and other key stake-holders. 95. It is recommended that their inputs should be taken into account in finalising strategies and policies. 96. The various elements of the strategy (e.g. the human resource plans) should be subject to greater scrutiny and the gaps between the current situation and the desired outcome more clearly described and that the resource requirements to bridge the gap should be clearly described and quantified. 97. Each component of the re-engineered PHC strategy should have a detailed implementation plan (E.g. provincialisation. Every province and the NDOH should draw up a master plan for what it is to do about the take-over of personal PHC from local government) COMMUNICATION 98. It is necessary to have clear, written communication so that everyone, (health workers, users of health services, training institutions and other stakeholdrs) needs to understand and share the same vision of PHC. This will require multiple levels of communication with standard and clear messages tailored to suit different stakeholders. 99. Specifically the users of health services, individuals, families and communites, need to get positive messages about the intention of the health services to respond to their needs and that the likely outcome of this re-engineered approach will be better access to a wider range of services of higher quality and that this is one of the steps along the way towards a NHI. 100. The communication strategy should also be used to engender innovation and enthusaism amongst health workers for the the positive and innovative role that they can play by working more as a team and taking responsibility for the people of their catchment area. MOBILISATION 101. All available resources need to be harnessed and focussed on improving PHC. The budgets for Programme 2 (district level services) together with the relevant conditional grants and other sources of external funding need to be given to the DMT for their control and resposibility. 102. In addition capital budgets need to be made available so that the necessary infrstructual improvements (clinic upgrades, water, electrivity, sanitation) and equipment are made available. 103. It is recommended that the budget for district level services be ring-fenced based on a formula, largely based on a capitation fee per person living in the district. 104. All the human resources need to be aligned to the new PHC model and that there is a gradual but steady move from the current situation to the norms and structures, competency and skills and responsibility and accountability of the new model. 105. To assist in achieving this all stakeholder resources need to be mobilised and each and every training institution needs to have a strategic plan to re-orient what it is doing now to what it should be doing in the future to provide sufficient quantity of the appropriate type of health worker who has the appropriate competencies and skills. 106. Similarly the other stakeholders such as partners, donors, private sector, NGOs need to align their plans and activities with those of the re-engineered approach. 29

IMPLEMENTATION 107. It is likely that to achieve the move from the recommendations contained in this document to action that at least in the short to medium term (12-24 months) most provinces and districts will require some support to help get changes initiated. 108. To assist with this it is recommended that high level support teams (one per province) be set up and that these teams combine staff from NDOH/PDOH with outsiders/consultants with technical skills. 109. It is envisaged that the role of these teams is to assist DMTs with at least: 109.1. Problem solving especially those that need provincial and national changes. For example drugs out of stock may require improvement of the functioning of the provincial drug depot which is beyond the sphere of influence of DMT 109.2. Support for improvement of quality of care and improved health outcomes 109.3. Capacity development 109.4. Ensuring that all support to formal health services is coordinated and harnessed (especially thos development partners already working at district level e.g. PEPFAR) 109.5. Implementation of new approach (e.g. CHWs) 109.6. Documentation of best practices and sharing of these 110. It is also recommended that a support team be set up in the national DOH to support the implementation of this re-engineering process. MONITORING AND REVIEW 111. It is recommended that there should be institutionalisatioon of the review of this PHC approach at the highest level with the DG at the NDOH and the HODs in the province having PHC implementation as their most important dashboard indicator with monthly, quarterly and annual reviews. 112. These reviews should be subject to written feedback and performance improvement measures 113. In addition the new PHC approach should be subject to formal health systems research with the subject matter linked to implementation models and provincial differences and differences of efficiencies, efficacy and quality. Both failures and successes should be describes so that the best is adopted and the worst avoided. 114. Population based monitoring should be institutionalised and health outcomes be the focus of this monitoring. 115. Districts should be subject to constant peer review and there should be annual conferences and sharing of best practices with awards and recognition for good performance.

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APPENDIX 1

REVITALISING PRIMARY HEALTH CARE IN SOUTH AFRICA:

Review of primary health care package, norms and standards

Laetitia Rispel, Julia Moorman, Matthew Chersich, Jane Goudge, Nonhlanhla Nxumalo & Tshipfuralo Ndou

Centre for Health Policy School of Public Health University of the Witwatersrand, Johannesburg

11 November 2010

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CONTACT DETAILS

Centre for Health Policy, School of Public Health University of the Witwatersrand, Johannesburg Private Bag, Wits, 2050, South Africa Telephone: +27 11 717 3420 Direct phone: +27 11 717 3436 Fax: +27 11 717 3429 laetitia.rispel@wits.ac.za

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TABLE OF CONTENTS

LIST OF TABLES .................................................................................................................... 35 ACKNOWLEDGEMENTS ........................................................................................................ 36 ACRONYMS AND ABBREVIATIONS ....................................................................................... 37 EXECUTIVE SUMMARY ......................................................................................................... 39 SECTION 1: CONTEXT AND BACKGROUND ............................................................................ 43 1.1 INTRODUCTION ........................................................................................................................ 43 1.2 SPECIFIC OBJECTIVES OF THE REVIEW ............................................................................................ 43 1.3 OUTLINE OF THE REPORT ............................................................................................................ 44 SECTION 2: APPROACH AND METHODS................................................................................ 45 2.1 2.2 2.3 2.4 INTRODUCTION ...................................................................................................................... 45 LITERATURE REVIEW................................................................................................................ 45 CONTACTING EXPERT KEY INFORMANTS....................................................................................... 46 TELEPHONE INTERVIEWS .......................................................................................................... 46

SECTION 3: INTERNATIONAL CONTEXT ................................................................................. 47 3.1 SERVICE-DELIVERY PACKAGES WITHIN INTERNATIONAL PUBLIC HEALTH STRATEGIES ................................ 47 3.2 CRITIQUE OF THE CONCEPT OF A PACKAGE ................................................................................... 47 3.3 METHODS FOR CHOOSING INTERVENTIONS .................................................................................... 48 3.4 THE OPTIMAL SIZE OF A PACKAGE ................................................................................................. 54 3.5 EXPERIENCE WITH IMPLEMENTATION OF PHC PACKAGES .................................................................. 55 SECTION 4: THE SOUTH AFRICAN CONTEXT .......................................................................... 57 4.1 BURDEN OF DISEASE .................................................................................................................. 57 4.2 MINISTERIAL PRIORITIES .......................................................................................................... 59 4.3 SOUTH AFRICAS EXPERIENCE WITH A COMPREHENSIVE PHC PACKAGE, NORMS AND STANDARDS ............. 59 4.4 RAPID REVIEW OF CURRENT STATE OF PHC PACKAGE IMPLEMENTATION .............................................. 60 SECTION 5: A NATIONAL PHC PACKAGE FOR SOUTH AFRICA ................................................. 66 5.1 INTRODUCTION ...................................................................................................................... 66 5.2 NORMS FOR CLINICS AND COMMUNITY HEALTH CENTRES ................................................................ 66 5.3 CORE STANDARDS FOR CLINICS AND COMMUNITY HEALTH CENTRES .................................................. 66 5.4 HUMAN RESOURCE ASSUMPTIONS ............................................................................................. 71 5.5 THE PROPOSED PHC PACKAGE .................................................................................................. 72 5.6 MATERNAL, NEWBORN, WOMEN AND CHILDREN......................................................................... 73 5.7 HIV/AIDS AND TUBERCULOSIS................................................................................................. 77 5.8 NON-COMMUNICABLE DISEASES................................................................................................ 80 5.9 VIOLENCE AND INJURIES............................................................................................................. 82 5.11 MENTAL HEALTH ............................................................................................................... 85
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5.12 ORAL HEALTH.................................................................................................................... 86 5.13 SCHOOL HEALTH SERVICES .................................................................................................... 87 5.14 REHABILITATION SERVICES .................................................................................................... 87 5.15 OPTOMETRY SERVICES ......................................................................................................... 90 5.16 BASIC CURATIVE SERVICES .................................................................................................... 90 5.17 EMERGENCY CARE .............................................................................................................. 92 5.18 ENVIRONMENTAL HEALTH .................................................................................................... 93 5.19 HEALTH EDUCATION ................................................................................................................ 93 5.20 CLINICAL SUPPORT SERVICES ..................................................................................................... 94 SECTION 6: TOWARDS PHC PACKAGE IMPLEMENTATION ..................................................... 96 6.1 INTRODUCTION ...................................................................................................................... 96 6.2 PREREQUISITES FOR PACKAGE IMPLEMENTATION .......................................................................... 96 6.3 SUGGESTED NEXT STEPS ........................................................................................................... 97 LIST OF APPENDICES .......................................................................................................... 100 REFERENCES ...................................................................................................................... 106

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LIST OF TABLES Table 1: Factors to consider in formulating a PHC service package ........................................................... 49 Table 2: Cost effectiveness and annual cost per capita of selected interventions..................................... 50 Table 3: Leading 10 risk factors in developing countries ............................................................................ 50 Table 4: Conclusions on cost effective interventions against risks ............................................................. 52 Table 5: Interventions with a large potential impact on health outcomes ................................................ 53 Table 6: Risk factors and conditions accounting for South Africas burden of disease .............................. 57 Table 7: Required improvements in health outcomes ............................................................................... 59 Table 8: Progress with implementation for a selection of key PHC package indicators............................. 63 Table 9: Reported challenges with PHC package implementation ............................................................. 64 Table 10: Core clinic and CHC standards..................................................................................................... 67 Table 11: Key assumptions about human resources for the PHC package................................................ 71 Table 12: Community based PHC services .................................................................................................. 72 Table 13: Criteria for selection of the proposed package of services ......................................................... 72 Table 14: Maternal, newborn, women and children services .................................................................... 75 Table 15: HIV/AIDS and TB services ............................................................................................................ 79 Table 16: Non-communicable disease services .......................................................................................... 81 Table 17: Services to combat violence and injuries .................................................................................... 84 Table 18: Clinic-based nutrition services .................................................................................................... 85 Table 19: Mental health services ................................................................................................................ 86 Table 20: Oral Health Services .................................................................................................................... 87 Table 21: Rehabilitation services ................................................................................................................ 89 Table 22: Optometry services ..................................................................................................................... 90 Table 23: Basic curative services ................................................................................................................. 91 Table 24: Emergency services at CHCs........................................................................................................ 92 Table 25: Environmental health services .................................................................................................... 93

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ACKNOWLEDGEMENTS

This review has been conducted with funding from the Henry J. Kaiser Family Foundation. We wish to thank Dr Peter Barron and Hasina Subedar for facilitating access to key individuals and relevant documents. Thanks to the provincial members of the National District Health Committee and senior managers in the National Department of Health for the valuable insights provided during the telephone interviews. Dr Duane Blaauw commented on earlier drafts of sections 3 and 4. We also wish to thank Elma Burger and Professor Helen Schneider for making available documents on rehabilitation and community health workers respectively. The views presented in this report are those of the authors and are based on an analysis of the documentation located and the inputs received during the interview process. These views do not necessarily represent the decisions, policy or views of the national Ministry of Health, government officials and/or the Henry J. Kaiser Family Foundation.

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ACRONYMS AND ABBREVIATIONS AIDS ART ARV BOD CHC CHP CHW DALY DALYs DOH DOTS EDL EPI FEFO HAART HCT HIV HOD HR HSS IEC IMCI LMICs M&E Acquired Immunodeficiency Syndrome Anti-retroviral Therapy Anti-retroviral Burden of disease Community health centre Centre for Health Policy Community Health Worker Disability adjusted life year Disability adjusted life years Department of Health Directly observed treatment support Essential drug list Expanded Programme on Immunisation First expired, first out Highly active anti-retroviral treatment HIV counselling and testing Human Immunodeficiency Virus Head of Department Human Resources Health Systems Strengthening Information, Education, Communication Integrated Management of Childhood Illnesses Low and middle income countries Monitoring and Evaluation 37

MCH N/A NDOH NGO NHI NHLS ORT OVC PHC PMTCT STI TB TOP UNICEF WHO

Maternal and Child Health Not available/ not applicable National Department of Health Non-Governmental Organisation National Health Insurance National Health Laboratory Services Oral rehydration therapy Orphan and vulnerable children Primary Health Care Prevention of Mother-To-Child-Transmission Sexually Transmitted Infection Tuberculosis Termination of Pregnancy United Nations Childrens Education Fund World Health Organization

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EXECUTIVE SUMMARY

Introduction The accompanying report contains the background, methods, results and recommendations of the review conducted by the Centre for Health Policy (CHP) of the primary health care (PHC) package of health services, as well as PHC norms and standards in South Africa. The review was commissioned at the beginning of October 2010 by the Ministerial PHC revitalisation team, established at the initiative of the honourable Minister of Health, Dr Aaron Motsoaledi. The aims of the review was to conduct a rapid review of PHC package of health services and the PHC norms and standards and make recommendations for a revised comprehensive PHC service package, such that the proposed services: Assist with the achievement of health outcomes and a reduction of mortality and morbidity from the major causes of ill-health; Have a population orientation, focusing on priority health needs of geographically diverse populations; Include prevention, promotion and good quality, essential care. The approach to the desktop review of the PHC package of services, norms and standards consisted of three strands, highlighted below: A review and synthesis of the literature on PHC packages in low and middle income countries (LMICs); peer reviewed journal articles and/or expert commentary on the advantages and challenges of formulating packages and norms; and evaluations of implementation of service delivery packages in LMICs. Contacting expert key informants in South Africa (six) and in four other African countries (Ethiopia, Kenya, Tanzania and Uganda), requesting information on PHC service packages and progress and challenges with implementation Telephone interviews with provincial representatives on the National District Health System Committee and experts in the national Department of Health (DOH).

Highlights from the literature review on PHC packages In recent years, many LMICs have defined service packages as a key strategy to improve health system effectiveness and the equitable distribution of resources. However, the concept of PHC packages remains contested and has attracted criticisms at the level of: the underlying philosophy; the approach and processes used in their formulation; and the tendency for packages to be top-down centralised processes, ignoring the autonomy of health professionals and the varying needs of communities. Successful implementation of service packages is often accompanied by comprehensive health care reforms; a clear outline of service provision at primary, secondary and tertiary levels of care; accurate costing of resource requirements; institutionalized mechanisms for review of the interventions within the package, and pre-specified plans to update these reviews; and community participation. 39

Highlights from the review of PHC package implementation in South Africa Eight out of nine provinces responded to the telephone survey on PHC package implementation. The PHC package has provided a vision of service delivery for health workers and managers at the district level. Reported progress includes the availability and accessibility of a wide range of PHC services and the addition of new services, such as ART provision and rehabilitation. The PHC guidelines have also facilitated planning and negotiation of additional financial resources in some instances; served as a catalyst for the development of clinical support services (e.g. laboratory services); enabled further and ongoing training of health care providers; and facilitated monitoring and evaluation of service provision. At the same time, the assessment also highlighted wide variation in the implementation of the package across the nine provinces, illustrated by variations in the estimated provincial performance on the selected indicators. The provision of all PHC services on the same day ranges from 70% in Northern Cape, North West and Gauteng to 100% in Kwazulu-Natal and the Western Cape. The initiation of ART at eighthour clinics is an encouraging development. However, ART initiation at CHCs varies from a low of 38% in Mpumalanga to 100% in Gauteng, Kwazulu-Natal and Western Cape, perhaps reflecting better staffing in the urban settings. The availability of a nurse with specialised mental health training appears to be a problem in all provinces, with either low reported performance, or respondents equating the existence of a professional nurse with specialised mental health skills. Only Mpumalanga and Western Cape reported that fast queues for elderly people were available in all facilities. There was also variation on awareness/ existence of organisational structures and budgets at CHC and clinics. Lastly, the existence of functioning clinic committees is an important indicator of health system responsiveness and/or accountability to communities. This varied from zero functioning clinic committees in North West province to 100% functional community structure in the Western Cape, albeit at a cluster/sub-district level. Human Resource challenges were consistently mentioned by all provincial respondents, as a factor hampering full implementation of the package. Similarly, a range of infrastructure, financial and other constraints were mentioned by provincial respondents. These issues have to be addressed to ensure successful implementation of the revised PHC package, norms and standards.

Key recommendations on an essential PHC package for South Africa Section 5 of the report contains the recommendations on an essential package of PHC interventions for South Africa. The proposed services have not been costed. Prior to formal adoption of the PHC service package, accurate costing should be done to ensure affordability and feasibility of implementation. Using the key health system building blocks of the health system, a set of generic norms and core standards for clinics and community health centres is proposed. The main criteria for the selection of the proposed package of PHC services are listed below: Address priority health problems in South Africa Improve health status and focus on morbidity and mortality from the major causes of ill- health 40

Comprehensive approach, with a focus on prevention and promotion as well as cure Achieve intended health outcomes envisaged in the Ministerial service delivery agreement Target vulnerable populations e.g. disabled individuals Achieve a balance between a family and population focus, while responding to the demands of the population Focus on services that are practical, essential and comprehensive and cost-effective Promote equity Staff availability and working as a team at community-based, clinic and health centre levels

A number of key interventions and four priority focus areas within PHC are proposed. 1) Maternal, women and child health a) Immunisation, b) Antenatal care c) Postnatal care d) School health 2) HIV and tuberculosis 3) Chronic non-communicable disease 4) Violence and injuries

For each of these areas, a comprehensive approach, with a focus on prevention and promotion, is proposed. Health care activities at community, clinic and community health centre are given. Services at clinics have been defined by the level of skills of staff and not by the size of the facility. An outline of services provided in each of the focus areas is then given. Service delivery targets are given where available in the current National Strategic Plan or in recent policy documents. Given the considerable variation in capacity and availability of resources, each district should have the flexibility and capacity to offer additional services in order to address the burden of disease in their area, as well as the demands of its population. The proposed PHC package, norms and standards should be seen as a guiding document, rather than a rigid, one size fit all prescription. The team wishes to stress the following: 1. The proposed package of services should be flexible and tailored to the particular needs of the province and area of implementation. Priority setting and planning processes at sub-district and district levels should highlight local priorities and a profile of services should then be developed that is based on the particular profile of need in that area. 2. A broader public health approach, which emphasises prevention, is critical. 3. Prioritising specific areas does not imply that treatment of minor ailments and specific conditions is unimportant. These services are important and remain in the package. 4. The PHC system can only achieve the desired outcomes if it is supported by other levels of the health system in a coordinated and integrated manner. The delivery of good quality essential care relies on effective referral relationships with and support from district hospitals, (in addition to clinical competencies to identify when these referrals are needed). 5. The delivery of a comprehensive primary health care package requires adequate resources: funding, adequate, committed and motivated staff and the necessary infrastructure and clinical support 41

services (e.g. pharmaceuticals) in order to deliver high quality and efficient services. These resource requirements are part of separate components of work, and should be completed prior to any implementation of the proposed package. 6. Addressing the social determinants of health, in particular, requires action at multiple levels. Although we have suggested a number of opportunities for inter-sectoral, these are indicative only, and meant to highlight an approach rather than provide a prescription. 7. Consultation with key stakeholders, flexibility in the application and implementation of the guidelines and determined efforts to strengthen implementation are needed; 8. It is essential to develop an ongoing monitoring, auditing and evaluation framework for the proposed PHC package of services, with mechanisms built in for period revisions of the PHC package, norms and standards.

42

SECTION 1: CONTEXT AND BACKGROUND

1.1 Introduction Since 1994, several initiatives have been implemented to promote the development of the district health system and to strengthen primary health care (PHC) in South Africa.1-4 These initiatives include, inter alia, the promulgation of the National Health Act, which formalised the legal status of the District Health System, structural and policy changes, removing access barriers through free PHC services and the clinic building programme, and implementation of health programmes for priority conditions.1-4 Although many of these initiatives increased access and care for the majority of poor South Africans, the early gains and improvements have been compromised by a multiplicity of factors, including a quadruple burden of disease, low morale among health personnel, inadequate management systems and huge gaps between policy intentions and actual implementation.1-2, 5-9 Consequently, health outcome indicators such as infant mortality, immunization rates, early childhood malnutrition, and maternal mortality are poor and not commensurate with the per capita rates of health expenditure.5, 1012

The current health political leadership has committed itself to a substantial overhaul of the public health sector, in order to: address the complex burden of disease; improve health outcomes, access and affordability; and ensure responsiveness to the needs of the population.2 The central elements common to all these efforts are the revitalisation of PHC and the implementation of a national health insurance (NHI) system.2 The revitalisation of PHC is one of the key outputs of the service delivery agreement signed between the Minister of Health and the President of South Africa during October 2010 and is at the core of revitalising and strengthening of the South African health system.13-14 It is envisaged at the proposed NHI fund will provide an evidence-based comprehensive package of services, which includes all levels of care, namely primary, secondary and tertiary to all citizens and legal residents.13 During the first half of 2010, the Minister of Health established a task team to advise him on the reengineering of PHC in South Africa.15 As part of the PHC revitalisation initiative, the Centre for Health Policy (CHP) at the School of Public Health, University of the Witwatersrand, Johannesburg, was requested to review the 2001 PHC package of health services and the PHC norms and standards to ensure that the revised PHC services are: outcomes-based; have a population orientation, and assists with the reduction of mortality and morbidity from the major causes of ill-health. CHP was contracted on 8 October 2010. 1.2 Specific objectives of the review 1. Review the principles, approach and methods used to develop PHC packages, with particular focus on low and middle income countries (LMIC) 2. Undertake a desktop review of the PHC package of health services, and the PHC norms and standards, specifically: Official/draft documents from national and provincial departments of health and from programme clusters or divisions (e.g. maternal and child health; HIV&AIDS; tuberculosis; chronic 43

disease cluster, the office of standards compliance) on PHC service package, norms and standards; Official/draft documents from a limited selection of non-governmental and community-based organisations to provide examples of good practices; An analysis of peer reviewed literature on package of PHC services, norms and standards; An analysis of grey/unpublished documents obtained from the main organisations/experts that focus on PHC or district-level services (e.g. Health Systems Trust). 3. Submit and present a draft report of national, provincial and literature findings 4. Formulate an initial set of recommendations on comprehensive PHC services, norms and standards

1.3 Outline of the report The next section of the report summarises the approach and methods to the review of PHC service package(s). Section 3 summarises the international context and debates on PHC packages, norms and standards. Section 4 provides an overview of the South African context, including a brief discussion of the burden of disease, the history of PHC packages in South Africa and the experience of implementing packages in South Africa. It concludes with a summary of current state of implementation based on a telephone survey of provincial health departments. Section 5 proposes an essential package of PHC services for South Africa, and a set of generic norms and standards for PHC facilities. The concluding section suggests some first steps to be taken to finalise the PHC package for South Africa and highlights key aspects that need to be taken into account in the successful implementation of the PHC service package.

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SECTION 2: APPROACH AND METHODS

2.1 Introduction The approach to the desktop review of the PHC package of services, norms and standards consisted of three strands, highlighted below: A review and synthesis of the literature on PHC packages LMICS; peer reviewed journal articles and/or expert commentary on the advantages and challenges of formulating packages and norms; and evaluations of actual implementation of service delivery packages in LMICs. Contacting expert key informants in South Africa (six) and in four other African countries (Ethiopia, Kenya, Tanzania and Uganda), requesting information on PHC service packages and progress and challenges with implementation Telephone interviews with provincial representatives on the National District Health System Committee and experts in the national Department of Health (DOH).

In both the desk review and interviews, particular attention was given to examining the process and implementation outcomes of the 2001 South African PHC Package and Norms and Standards.16-17 Although these strands overlap, each is described briefly below. 2.2 Literature review The MEDLINE database was searched using the Pubmed interface with the following terms: Primary Health Care [mesh term] AND (package* OR norm* OR standard*). We were interested in obtaining information on PHC packages of other countries, examining the criteria used to select interventions; estimated costs of package; and level of attention given to an implementation and monitoring plan for the package. A search was also done with the key words well used in a previous review on this topic: primary care, primary health care, evaluation costs, cost-effectiveness, and effectiveness.18 Several websites that contain sources of relevant grey literature were searched, such as the World Health Organization (www.who.int), the Disease Control Priorities Project (http://www.dcp2.org), and local organisations, such as the Health Systems Trust (www.hst.org.za). National DOH clinical guidelines were reviewed and we extracted the interventions that these guidelines stated should be provided at PHC level. We paid particular attention to the following documents: The Primary Health Care Package for South Africa a set of norms and standards. 2000 (Last printed 2002). This document provides norms and standards for a number of priority health condition for PHC facilities and for district hospitals (Appendix 1).16 Standard treatment guidelines for PHC (2008 edition): a number of conditions (Appendix 1) are covered in terms of a description of each condition / symptom, diagnosis, treatment and criteria for referral ( www.doh.gov.za/docs/facts-f.html). This document includes a list of essential drugs to be available at each level. Available Fact sheets and Guidelines for the management of clinical conditions. Since 1994, treatment guidelines for a number of specific clinical conditions have been printed. Those available on the National DOH website were reviewed. This list is available in Appendix 2. All 45

guidelines were reviewed and in instances where specific activities should take place at the PHC level, these are included in the essential package of interventions. Documents available on the websites of Provincial Departments of Health were also obtained to determine how many were still making use of the South African 2001 PHC package in developing their strategic plans.

2.3 Contacting expert key informants Ten expert key informants were contacted (six in South Africa, one each in Ethiopia, Kenya, Tanzania and Uganda), who have in-depth knowledge of PHC, or have been involved in development of PHC packages, burden or disease and/or cost-effectiveness analyses. The experts were asked for published information on PHC service packages as well as documented evidence on progress and challenges with implementation.19-22 2.4 Telephone interviews The aim of the telephone interviews was to get a helicopter view of implementation of the 2001 PHC package implementation in the nine provinces. A semi-structured interview guide was developed to assess the following: awareness of the 2001/2002 PHC package and norms and standards developed by the national DOH and formal adoption by the provincial DOH; whether the Province has developed its own PHC package, norms and standards; progress with the implementation of the national PHC package; perceptions of whether the PHC package is a useful tool to improve ambulatory health care services; estimates of percentage implementation at community health centres (CHCs) and eight-hour clinics of a selection of key elements contained in the PHC package, norms and standards; successes with and challenges of implementation of the PHC package/ norms and standards; existence of provincial policies on referral system and clinical support services for PHC (e.g. laboratory, drug supplies, etc); stakeholders that should be consulted and involved in developing an updated PHC package; opinions on the balance between preventive/promotive and curative services in the revised PHC package; and advice to the CHP team on developing a revised PHC package The list of names of the members of the national District Health Systems Committee was obtained from the national DOH. Each provincial representative on the list was contacted, the project was explained to the person and their voluntary participation was sought. In those instances where the team was referred to another individual, the same procedure was followed. Once the person agreed to be interviewed, a suitable time for the interview was arranged. Interviews took between 20-30 minutes each; the interviewer completed the questionnaire during the interview and wrote down the verbatim responses. Two members from the Ministerial PHC task team and one national DOH senior official was also interviewed, covering only those areas in the interview schedule that were relevant. Once all interviews were complete, one member of the research team analysed the interview findings, and used the same categories in the interview guide to record the responses in tabular form. In some instances, illustrative quotations from respondents are provided.

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SECTION 3: INTERNATIONAL CONTEXT

3.1 Service-delivery packages within international public health strategies More than 30 years after the Alma-Ata PHC Declaration, the goal of health for all, remains off target in many countries and huge inequities remain between and within countries.23-26 The 1978 Alma-Ata Declaration on PHC, the first international declaration underlining the importance of PHC, expressed the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world.24 The declaration articulated an overall philosophy, principles and strategies for organising health systems, underpinned by the values of equity, social justice and health as a fundamental right. The strategies of PHC include providing access to good quality health care as well as preventive and promotive services for priority health needs, inter-sectoral action at local level to address the root causes of ill-health, and enhanced community participation and accountability.27 In the early 1990s the concept of service packages was put forward as a means of moving away from the vertical programming which had characterised the preceding decade and achieving positive impact on the health of people in developing countries.18, 28 The concept was also seen as a means of redressing the continued skewed allocation of resources towards curative services, especially hospital-based care.26 The first edition of Disease Control Priorities in Developing Countries was published in 1993,29 and its findings were incorporated in the 1993 World Development Report, which advocated for minimum packages of care.28 These documents, of major influence in global health policy, brought together the concepts of burden of disease, disability-adjusted life years (DALYs) and cost-effectiveness analysis and provided theoretical tools for health care priority setting.18, 28 Nevertheless, despite these efforts, in large part vertical services remained, perhaps reflecting the difficulties of delivering and monitoring a wide range of services.18 In recent years, many LMICs (55 out of 69 countries in one review) have defined service packages as a key strategy to improve health system effectiveness and the equitable distribution of resources.26, 30 Service packages are also seen as tools for planning and prioritisation, assisting with a shift of resources between different levels of services (e.g. hospitals to PHC) and/or to under-resourced geographical areas and facilities.26, 31 In South Africa, the PHC package was seen as tool for quantifying staffing, infrastructure, equipment and financial requirements, providing a solid foundation for a single unified health system and contributing to greater social justice and the reduction of health inequities.17 3.2 Critique of the concept of a package The concept of PHC packages has attracted criticisms at the level of: the underlying philosophy; the approach and processes used in their formulation; and the tendency for packages to be top-down centralised processes, ignoring the autonomy of health professionals and the varying needs of communities.32-34 Critics have suggested that the concept is counter to the principles of PHC enshrined in the Alma Ata Declaration.32-33 Others have argued that the package approach may be best suited to a world of insurer-purchasers where activities and outputs can be well specified and where appropriate

47

incentives are in place to ensure that health workers carry out these activities.35 This is because most public health systems in LMICs do not resemble an insurer-purchaser arrangement.35 A defined package of services may also be seen as restricting the autonomy of health workers, diminishing the delivery of beneficial services for the individual patient.18 Critics have also raised objections to the methods used to construct packages of services.36-37 Burden of disease estimates, for example, incur the hazards of discounting future benefits, age weighting and placing values on different states of ill-health.18 Further, the analytical approaches used in cost-effectiveness estimates are criticised for their frequent exclusion of patient costs (such as transport costs and waiting time) when calculating the total costs of an intervention. Perhaps most importantly, burden of disease, costs, effects and therefore cost-effectiveness vary markedly between settings, limiting the transferability of findings across different contexts. The limited availability of locally applicable data to guide decisions is exacerbated by the dearth of information about the distribution of the burden of disease across socio economic groups, and the costs of addressing this burden in different socio-economic groups.18 Focusing too closely on constructing an efficiency-oriented package of services risks narrowing the scope of PHC to a set of technical interventions and ignoring the social determinants of ill-health.37-38 This can resemble the over-technical emphasis that underscored selective PHC, and can downplay the considerations of social justice and empowerment that characterised an Alma Ata primary health care approach.39 Moreover, though presented as a package, the listing of individual interventions promotes vertical programming, either subtly or overtly.40 Some argue that a locally (rather than nationally) devised package of services is preferable, based on an understanding of the local community health profile.41 A final argument against simply using cost-effectiveness as a predominant criterion in priority setting is that this ignores community expectations of health service delivery, beyond merely the reduction of death and disability.38 Proponents of service packages have argued that a defined package might well reduce the provision of some ineffective therapies (such as antibiotics for the common cold) and could also counter the tendency of health workers and other interest groups to over-emphasise the importance of addressing complex conditions and of applying new sophisticated treatments.29 Furthermore, verticalisation is not the intention of service packaging 42 and in some settings a package has had the opposite effect.35, 43 Bringing all programme areas together in one document and developing one unified process across programme areas might well reduce the persistent fragmentation of service planning and implementation. Overall, while formulating packages of services is often a necessary planning step, their implementation is contingent on the strength of the underlying health system. The main challenge faced by health managers is not choosing which services to be delivered, but rather is figuring out ways of providing an ongoing set of services within existing capacity and resource constraints. 3.3 Methods for choosing interventions To date, a range of methods have been used in the process of formulating a package of services. These include a cost-effectiveness and burden of disease approach; expert opinion; a pragmatic approach of adopting the package of services provided in best practice sites; or a hybrid approach combining some or all of the other options. Formulating a package must, as far as possible, be based on explicit and 48

objective criteria and focus on addressing unmet needs (Table 1). These criteria can be classified as national contextual factors (e.g. the health status of the population, values of equity and social solidarity, etc); issues specific to the methods selected to guide formulation of the package; considerations stemming from the possible health care interventions; and health system factors. Table 1: Factors to consider in formulating a PHC service package
National context 1. Characteristics of possible interventions Burden of disease and demand for services Financial resources available to the health sector Interventions already agreed for implementation in national-level guidelines Historical structure of the health system and traditions of health practices(such as nurse versus doctor led) Commitment to values of equity and social solidarity Availability of high-quality local data on burden of disease and costeffectiveness, or generalisable regional estimates of these The weight given to patient and public health perspectives Completeness of data and the provision of interventions which only accrue benefit at a much latter point in time Availability of evidence about services and methods of provision most likely to ensure that the poor accrue most benefit Effectiveness of interventions and their impact on the burden of disease Cost-effectiveness of interventions Development of new technologies Social and cultural acceptability of interventions Focus on health promotion and prevention as well as curative and rehabilitation services Planned health sector reforms Decentralisation of services from hospitals to PHC Financial resources for the package Human resources and capacity (ability to attract and retain staff) Present efficiency of service delivery Coverage with existing services Extent to which services are already integrated Available physical infrastructure Geographic, financial and cultural accessibility of services Management and logistical support Functionality of referral system

Methodology

Health system factors 2.

In the cost-effectiveness approach, best health buys are identified, based on evidence of the most successful and cost-effective interventions. This approach highlights opportunities that are ignored or underfunded, and draws attention to current investments that consume unnecessary resources. Developing and implementing packages thus provides one means of operationalising a cost-effective approach to health.29 Table 2 highlights the cost effectiveness of a cluster of interventions proposed by the World Bank as the minimum package of services.18, 28 49

Table 2: Cost effectiveness and annual cost per capita of selected interventions
Interventions Cost per DALY ($) middle income countries (2001) Annual cost per capita ($) 2001 prices

Public Health Expanded programme on immunisation (EPI) School health programme Tobacco and alcohol control programme AIDS prevention programme Other public health interventions (information, communication and education, vector control, disease surveillance Clinical services Chemotherapy for TB Integrated management of Childhood Illnesses (IMCI) Family planning STI treatment Prenatal care and delivery care Limited care (treatment of infections, trauma) 69 63 127 0.3 1.4 32-38 48-54 57-70 16-23 Not known 1.0 0.8 0.4 2.5 3.9

127 190 13 19 76 139 507 - 760

2.8 0.4 11.1 2.7

Adapted from Doherty & Govender.18 The ongoing WHO CHOICE (CHOosing Interventions that are Cost-Effective) project aims to provide policy makers with evidence to guide selection of the interventions and programmes which maximize health for the available resources.44 WHO-CHOICE reports the costs and effects of a wide range of health interventions by WHO sub-region, which can then be adapted to the demographic, epidemiological and economic situation in a country. In such an adaptation, all parameters of the model should be scrutinised and revised based on disease incidence and prevalence, intervention coverage and effectiveness, and rates of service utilization. Tables 3 and 4 give the leading ten selected risk factors as percentage causes of disease burden measured in DALYs and a summary of conclusions on the costeffectiveness of interventions against these risks. Table 3: Leading 10 risk factors in developing countries
Risk factor Cause of disease burden (%) measured Risk factor Cause of disease burden (%) measured

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in DALYs High Mortality countries Underweight Unsafe sex Unsafe water, hygiene and sanitation Indoor smoke from solid fuels Zinc deficiency Iron deficiency Vitamin A deficiency Blood pressure Tobacco Cholesterol 14.9 10.2 5.5 Low Mortality countries Alcohol Blood pressure Tobacco

in DALYs

6.2 5.0 4.0

3.7 3.2 3.1 3.0 2.5 2.0 1.9

Underweight Overweight Cholesterol Indoor smoke from solid fuels Low fruit and vegetable intake Iron deficiency Unsafe water, sanitation and hygiene

3.1 2.7 2.1 1.9 1.9 1.8 1.7

Source: World Health Organization, 2002:10245

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Table 4: Conclusions on cost effective interventions against risks

Strategy Protection of the childs environment Assessment of cost effectiveness Cost effective in all settings Very cost effective components Some form of micronutrient supplementation Disinfection of water at point of use to reduce diarrhoeal diseases Treatment of diarrhoea and pneumonia Very cost effective although care needs to be taken when extrapolating the effectiveness of behaviour change from one setting to another Use of some types of antiretroviral therapy in conjunction with preventive activities is effective in most settings DOTS combined with testing for resistance is not cost effective in all settings although there may be other reasons to pursue this strategy Cost effective in regions with high child mortality At least one type of intervention cost effective in all settings Population wide salt and cholesterol lowering strategies are always very cost effective singly and combined Combining them with an individual risk reduction strategy is also cost effective, especially with interventions to reduce risk based on assessment of absolute risk The cost effectiveness of absolute risk approach could improve further if it is possible to assess accurately individual risks without the further need for lab tests. Increased physical activity was not evaluated but should be considered as an additional strategy

Preventive interventions to reduce the incidence of HIV infections

Improved water supply Interventions to reduce the risk of CVS

Source: World Health Organization, 2002:10245 The interventions with a large potential impact in health outcomes as identified by the World Health Report 2000 are shown in Table 5.46

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Table 5: Interventions with a large potential impact on health outcomes

Treatment of tuberculosis

DOTS. Administration of standardised short course chemotherapy to all confirmed sputum positive cases of TB under supervision Family planning, prenatal and delivery care, clean and safe delivery by a trained birth attendant, post partum care and essential obstetric care for all high risk pregnancies and complications Information and education, availability and correct use of contraceptives Health education and nutrition interventions, including anti helminthic treatment, micronutrient supplementation and school meals Case management of acute respiratory infections, diarrhoea, malaria, measles and malnutrition; immunisation, feeding counselling, micronutrient and iron supplementation, anti helminthic treatment Targeted information for sex workers, mass education awareness, counselling and screening, mass treatment for STI and safe blood supply Case management using the syndromic approach As per schedule Case management and selected preventive measures Tobacco tax, information, nicotine replacement and legal action Selected early screening and prevention

Maternal health and safe motherhood interventions

Family planning School health interventions

IMCI

HIV / AIDS prevention

Treatment of STI Immunisation Malaria Tobacco control Non-communicable diseases and injuries

Source: World Health Report 200046 The dynamic interplay, however, between cost-effectiveness, burden of disease, health system performance and equity considerations means that the process of constructing a package is more complex than a simple prescription of a set of cost-effective interventions. Nevertheless, in more than ten packages of PHC services reviewed, each had broadly similar contents, indicating a surprisingly high degree of consensus on the range of activities to be provided at primary level.17, 19-22, 26, 28-29, 31, 45, 47-49

A lengthy and labour-intensive process of formulating a service package may fail to return proportional gains. Longer processes with broader consultation may, however, increase buy-in and the likelihood of subsequent implementation of the package. A package developed quickly and at low cost, taking advantage of what is already done in the field, is perhaps the most sensible approach.33 Ultimately, the approach depends on the country context and circumstances, and recognising that a defined PHC package is only the starting point and that implementation of any health policy is brought alive by the 53

ways in which actors, including service providers, interest groups, patients and community members, translate their understanding of legislation/ policies into their behaviours and practices.50-51 There are several risks to avoid during formulating a package of services. Resource allocation tends to follow socio-political processes rather than evidence and equity considerations, and firm negotiation plays a central role in health planning.33, 51-52 Moreover, selection of interventions can be overly influenced by interest groups and cultural considerations, and face considerable challenges in altering a previous, often long-standing, (mis)allocation of resources. Ultimately, care is needed to avoid packages merely containing all the services seen as desirable by health professionals, experts and established programme areas, without being cognisant of the resources required. Lastly, key elements of the PHC approach equity, decentralisation and community participation need to receive adequate attention during construction of the package. 3.4 The optimal size of a package The main tensions in formulating a package of services are: deciding on the number and range of services to be included in the package; and distinguishing between the activities that might be decentralised to primary level and those that would best occur elsewhere. In principle, given the comparative advantages of PHC services in access and their potential for personalised continuous care, services should be provided at the primary rather than hospital level wherever possible. The optimum size of the PHC package requires consideration of whether to aim for a minimum, essential or a comprehensive package. A minimum package is able to control a large portion of the disease burden, has a higher likelihood of being implemented evenly across the country, but will address a narrower range of conditions.18 A minimum package also risks ignoring the high value that society places on having a wide range of services available. For example, the private sector in South Africa is characterised by the provision of a defined, minimum benefit package, with additional services paid outof-pocket or from top-up insurance. An essential package, by contrast, adopts an incremental approach, and was originally defined as the addition of services that can be afforded to the minimum set.28 At the other extreme, a fully comprehensive, very large package, may incur much variation in the range and quality of services implemented, and exacerbate inequities. The larger the range of services funded the larger the variation in service provision, while conversely it might be more likely that all facilities can provide a minimum set of interventions at adequate standards. Another approach is the phased implementation of interventions, where several packages of services of varying size are defined. Once a district, for example, implements a package at sufficient quality and coverage, additional larger packages are then incrementally added until the full package is delivered.53 There is often political pressure to expand the contents of packages, and to avoid explicit rationing of services, even when these additional services are unlikely to be implemented. Other factors driving a larger package include the higher satisfaction of the public with having access to a wide-range of services, and the gains in wellbeing arising from the knowledge that such services are universally available. However, a smaller package that aims to maximise health gains from a focused set of interventions at high coverage might economise on the present scarce managerial and administrative 54

capacity. Ironically, where health systems function poorly, it may be preferable to aim for a smaller package, provided at high coverage, followed thereafter by gradual expansion of the package informed by ongoing monitoring of its outcomes. Overall, a balance is required between aiming for a minimum package with fuller coverage, targeted at the poor, or a larger package with more variation in coverage and larger inequities.54 It can also be argued that a small package may be inequitable as those wealthier are more able to purchase additional services not included in a minimum package, and that the poor may suffer catastrophic expenses when suffering from a condition excluded from the package. Overall, it may be best to construct a realistic and practically-achievable package, matched as closely as possible to the available resources and health care delivery systems.

3.5 Experience with implementation of PHC packages Developing packages, norms and standards for care has been one of the key strategies used to improve the effectiveness of health systems and the equitable distribution of resources.26 On the whole, attempts to alter service delivery by defining packages have not been particularly successful to date. 26 In most cases, their scope has been limited to maternal and child health care, and to health problems considered as global health priorities. The lack of attention, for example, to chronic and noncommunicable diseases confirms the under-valuation of the demographic and epidemiological transitions and the lack of consideration for perceived needs and demand. The packages rarely give guidance on the division of tasks and responsibilities, or on the defining features of primary care, such as comprehensiveness, continuity or person-centredness. Successful implementation of PHC packages is often accompanied by a comprehensive health care approach and reforms, a good example of which is provided by Brazils national health system Sistema nico de Sade (SUS).55-58 Key elements of the Brazilian SUS include the constitutional right to health, , thus requiring the state to provide universal and equal access to health services; PHC as the foundation of the national health system; and a broader public health approach that includes the prevention of disease; promotion of health; treating the sick and injured, and tackling serious disease.55-58 Other prerequisites for success include the coordination and integration of activities of all three levels of government in Brazil; the creation of the Family Health Programme as the main PHC strategy that seeks to provide a full range of quality health care to families in their homes, at clinics and in hospitals; and improvement in resource allocation for the programme.55 Similarly, Thailands health reforms in 2001 combined universal coverage with a relatively comprehensive package of services.26 Elderly, children and the poor are exempt from user fees, while others make a small co-payment. Government pays primary care providers for delivering services in the defined package. The package contents were revised over time. By 2004, just less than half the population was covered by this scheme. Financing mechanisms were specifically configured to reduce historical geographic inequalities in access to services.59 The country has the highest average yearly reduction in under-5 mortality, universal coverage of immunization and skilled birth, and low levels of inequity. In Tanzania, the Tanzania Essential Health Interventions Project (TEHIP) constructed a package predominately using burden of disease concepts rather than cost-effectiveness evidence as part of 55

focused efforts to improve the efficiency of existing health system inputs and interventions and to optimize the functioning of the district health system.19

Box 1 summarises the key lessons to enhance implementation of PHC packages19, 26, 55-59 Box 1: Ensuring implementation of essential PHC packages The package should be part of comprehensive health care reforms It should take into account demand as well as at the full range of health needs. It should ideally specify what should be provided at primary, secondary and tertiary levels. Implementation of the package should be costed so that political decision-makers can be made aware of what will not be included if health care remains under-funded. There have to be institutionalized mechanisms for evidence-based review of the interventions within the package, and pre-specified plans to update these reviews. Community participation is key to successful implementation and people need to be informed about the benefits they can claim, with mechanisms of mediation and redress when claims are being denied. Staffing norms and financial resources need to be linked with the service package, norms and standards Ongoing monitoring and regular review of both the contents of the package and its implementation Sources: 19, 26, 55-59

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SECTION 4: THE SOUTH AFRICAN CONTEXT

4.1 Burden of disease South Africa quadruple burden of disease, consisting of HIV and AIDS, other infectious diseases, injuries and chronic diseases, has been well described.5, 10-12 The first South African National Burden of Disease study and the South African Comparative Risk Assessment identified the underlying causes of premature mortality and morbidity in 2000 and their risk factors.60-61 The findings are summarized in Table 6. An updated appraisal of the burden of disease is planned to begin in 2011.

Table 6: Risk factors and conditions accounting for South Africas burden of disease
Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Disease, injury or condition HIV/AIDS Interpersonal violence injury Tuberculosis Road traffic injury Diarrhoeal diseases Lower respiratory infections Low birth weight Asthma Stroke Unipolar depressive disorders Ischaemic heart disease Protein-energy malnutrition Birth asphyxia and birth trauma Diabetes mellitus Alcohol dependence Hearing loss, adult onset Cataracts % total DALYs 30.9 6.5 3.7 3 2.9 2.8 2.6 2.2 2.2 2 1.8 1.3 1.2 1.1 1 1 0.9 Risk factor Unsafe sex/STIs Interpersonal violence (risk factor) Alcohol harm Tobacco smoking High BMI (excess bodyweight) Childhood and maternal underweight Unsafe water sanitation and hygiene High blood pressure Diabetes (risk factor) High cholesterol Low fruit and vegetable intake Physical inactivity Iron deficiency anaemia Vitamin A deficiency Indoor air pollution Lead exposure Urban air pollution % total DALYs 31.5 8.4 7 4 2.9 2.7 2.6 2.4 1.6 1.4 1.1 1.1 1.1 0.7 0.4 0.4 0.3

More recent information, up to 2007, is available about the causes of death in South Africa. As with the burden of disease, infectious diseases predominate. The contribution of mortality from the quadruple burden of disease in the country is also seen clearly in Figure 1. In addition to the infectious diseases, for example, cardiovascular diseases accounted for 13.7% of deaths in 2007 and 9.0% of deaths were attributed to non-natural causes such as transport incidents and assault. 57

These mortality figures do not adequately capture the burden of diseases from mental health conditions, which are very common in the country. A nationally representative survey in 2002-2004 found that 16.5% of the population had a mental disorder in the past 12 months. These were mostly depression, anxiety and substance use disorders, and about three-quarters of these conditions were untreated.62

Figure 1 Number of deaths by main groups of causes of death and year of death, 2006 and 2007

58

4.2 Ministerial priorities Four main areas constitute the essence of the Ministerial service delivery agreement: increase life expectancy at birth; reduce maternal and child mortality rates; combating HIV / AIDS and TB; and strengthening health system effectiveness.2, 14 A recent national workshop identified required improvements in health outcomes and set targets for 2014 / 2015, listed in the table below.63

Table 7: Required improvements in health outcomes

Indicator Life Expectancy at Birth Child Mortality HIV Prevalence (amongst 15-24 year old pregnant women Mother to child transmission rate of HIV Percentage of eligible HIV positive women initiated on ART Baseline 2009 53.5 years for males 57.2 year for females 69 per 1,000 live births 21,7% Target 2014/15 58-60 years 30-45 per 1000 live births Improved quality of life of People living with HIV and AIDS 0%-<5% All eligible pregnant women to be initiated on ART at a CD4 count of < 350 or WHO stage III or IV 85% 100%

10% 37%

TB Cure Rate 64% Percentage of HIV-TB co-infected patients 30% who are on ART Source: Kaiser Family Foundation, Ministry of Health, 201063

4.3 South Africas experience with a comprehensive PHC package, norms and standards A PHC package for South Africa was presented in 2001, after a three year period of planning and consultation.17 The stated intention was that the package would be implemented incrementally across the country by end 2005, and would contribute to greater social justice and equity.31 Milestones were set for measuring progress midway in this period. As in other countries, it was anticipated that the package would assist in quantifying resource requirements and inform budget negotiations between health managers and authorities. Efforts were made to estimate the costs of implementing the package at a national level and in some provinces.64-65 As part of concerted efforts to promote integration of services, the package was presented by level of service rather than by programme area or condition.31 A set of norms and standards were developed concurrently to direct the provision of services at acceptable levels.16 The 2001 PHC Package still constitutes the basis for planning of service delivery in some provinces today.47 The original intention was to audit all local authorities to quantify the gap between existing PHC services and the targets set in the package, but no evidence for this could be located. Neither could we find evidence that the milestones and final outcomes of this initiative had been systematically evaluated by the DOH as planned. A 2003 evaluation that assessed implementation of the PHC package in 66 facilities within eight Urban Renewal Nodes in five Provinces found that substantial progress had been made with: enhancing the scope of services; the capability to provide diagnostic tests; implementation of referral 59

systems and an increase in availability of infrastructure and equipment. In the Eastern Cape, the package helped to identify shortcomings in both equipment and available training and facilitated recognition of the need to provide more comprehensive services, including the provision and functional integration of promotive, preventive and curative services.66 The PHC package was also used as an instrument to highlight the need for more appropriate services in urban and peri-urban areas, thereby relieving the demand for hospital outpatient services.66 Implementation of the PHC package was found to be less problematic in relatively well-resourced areas. Overall, there was a 47% compliance with the norms and standards specified in the package, with marked variation in performance between the indicators assessed and in the implementation of the policies contained in the package.66-67 At facility level, there was little awareness of and no special resources for monitoring the PHC package, and no instrument had been developed to measure implementation of the package.66-67 In interviews, some PHC managers felt the package was dumped on them, without the necessary preparations and additional resources.66 Nurses had apparently been inadequately trained in the package interventions and some were not committed to its implementation, perceiving it as another burden on already overloaded staff. There were even reports of staff actively undermining implementation of the package, and its norms and standards, a situation perhaps worsened by a perceived lack of input from PHC service providers during development of the package. The norms developed and the timelines for their implementation were viewed as being over idealistic and impractical given the limited resources available. Respondents in some facilities reported that the actual PHC package documents had not been available at their facilities. The evaluation concludes that the gaps in implementation of the package were, however, not solely due to resource constraints. Many deficiencies could be ascribed to sub-optimum management and supervision of staff, and to low staff motivation and skill levels.66 An analysis of the experience with setting norms for the delivery of mental health services provides useful insights. Extensive work was done in the early part of this decade to develop norms and standards for integrated primary mental health care in South Africa, such as number of beds per population, staff to population ratios, admission rates and community/hospital ratios.68-71 That process was intended to support integration of mental health services with PHC and the de-institutionalisation of mental health patients. Little has been done, however, to monitor systematically whether these norms were met, or influenced service provision. A study on a district on KwaZulu Natal found that mental health services remained primarily focused on emergency management of psychiatric patients and there were insufficient numbers of key categories of mental health workers within PHC settings.72 4.4 Rapid review of current state of PHC package implementation We obtained responses to the telephone survey from eight out of nine provinces. In Eastern Cape, Gauteng, North West and Northern Cape; the interviews were conducted with the directors responsible for PHC. In the Free State, Mpumalanga and the Western Cape interviews were conducted with PHC managers, who are responsible for a cluster of PHC facilities in a sub-district and in Kwazulu-Natal a chief technical advisor was interviewed. In addition, one chief director at the national department of health and two Ministerial task team members were interviewed. 4.4.1 PHC package implementation: Benefits, progress and successes 60

The perceived benefits of a defined PHC package are to: set out a vision for service delivery; serve as a guide to managers, staff and communities as to services that should be provided; allow for benchmarking/ comparison of similar types of facilities (e.g. costs, staffing, outputs, etc); facilitate request for additional resources; and assist with monitoring and evaluation. One participant noted that: A PHC package is essentially a vision - it spell out what our vision for service delivery is. It spell out to managers what we think should be done, what we think is aspirational. (Key informant 1) A defined PHC package guides managers, staff and communities on service provision, as can be seen from their following responses: It *the PHC package+ is extremely useful because there needs to be terms of reference or a guide which outlines the norms and standards that need to be followed.... so that everyone does not apply his/her own rule. It has helped facilities to function within certain guidelines...even the community sometime you can use it to make them understand what is needed by the protocol based on evidence. It is good thing that you are revising it because things have changed example it [the PHC package] does not say much about HIV/ AIDS and there have been lots of changes on diagnosis, treatment, and care. (Mpumalanga respondent) Your community knows what is available; Staff knows what services to provide. The PHC package is in line with needs, and managers know what they are responsible for. (Western Cape respondent) It assists the department to implement PHC in a structured and standard way so that services can be monitored and evaluated; so that we can measure our performance. It also assists with developing plans.(Free State respondent). Participants were also of the opinion that the package facilitates some standardisation and allows clients to know what services to expect. In line with Batho Pele principles, clients/ communities could have redress if they do not get the services specified in the package (key informant 3). The package allows for comparison of similar types of clinics in terms of costs, outputs and efficiencies. It was also felt that a package: Gives health workers a clear picture of what services they should be offering; and legitimises requests for resources from managers if working at high capacity and not providing all the services; it provides patients and communities an expectation of what they can legitimately expect to receive at which type of facility. It provides guidance on access points and referrals. (Key informant 2)

A package is also useful for measuring/ judge what we do so that we know where we can improve (North West) and gives both the district, service [providers] and public an indication of services available, and provides a means of monitoring service development in the Province (KZN). In terms of 61

implementation, participants indicated that in some provinces, PHC has become the corner-stone of service delivery. There has been a gradual expansion of the range of services provided, the package has facilitated programme development and the standard treatment guidelines have assisted health care providers and managers. It has also assisted with a common understanding among all stakeholders of what essential/ critical PHC services to provide. Other reported successes of PHC package implementation include: Improved access (geographical, affordability) ( all provinces) Improved quality of care (Free State, Gauteng, Western Cape) Outreach services (e.g. oral health) and doctors visits (Northern Cape, Mpumalanga, Free State) Clinic supervision (Mpumalanga, Northern Cape) Essential drug availability (Mpumalanga, Northern Cape) Training of nurses (Mpumalanga, Northern Cape) Implementation of Batho Pele principles, patients rights charter (Mpumalanga) Provision of additional financial resources (Western Cape) Partnerships (Northern Cape, North West)

Table 8 shows implementation progress for a selection of key indicators contained in the 2000/01 PHC package, norms and standards.

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Table 8: Progress with implementation for a selection of key PHC package indicators
Indicator
2

Eastern Cape CHC- 99% 8-hour clinics99% (80% of package) CHC- 50% 8-hour clinics2%

Free State CHC- 90% 8-hour clinicsBased on referral system CHC- 95% 8-hour cliniconly designated CHCs CHC- 85% 8-hour clinics85%

Gauteng CHC- 7078% 8-hour clinics76% CHCs100% 8-hour clinics: 40-45% CHCs: recently formed Clinics80-90% CHCs100% 8-hour clinics-5060% Not sure

Kwazulu-Natal CHC- 100% 8-hour clinics100% (provincial clinics) CHC- 100% 8-hour clinics45%

Mpumalanga CHC-100% 8 hour clinic100

Northern Cape CHC-70% 8 hour clinic60%

North West CHC-70% 8 hour clinic70-80%

Western Cape 100% of facilities in district, except reproductive health clinics 75% of facilities in the sub-district

Provision of PHC services on the same day

Initiation of antiretroviral therapy for AIDS

CHC & 8hour clinic: 38%

CHC-60% 8 hour clinic40%

CHC-70% 8 hour clinic70%

A functioning clinic committee

CHC- 50% 8-hour clinics2%

CHC- 88% 8-hour clinics68%

CHC & 8hour clinic: 85%

CHC-40% 8 hour clinic10%

Zero-not existing

100%, but done as a cluster, rather than individual facilities 25%; this is a bit of a problem

A nurse with mental health training

Not readily available in CHCs and clinics Not readily available in CHCs and clinics CHC- 100% 8-hour clinics100%

There is a trained PN in every CHC and 8 hour clinics 95%-dedicated days for elderly in CHCs and 8hour clinics CHC- 100% 8-hour clinics90%

All nurses have mental health training

CHC & 8hour clinic: 50%

CHC-30% 8 hour clinic30%

CHC & 8-hour clinic: 40%

Fast queue for elderly people

In theory 100%

CHC & 8hour clinic: 100% Not sure

CHC-50% 8 hour clinic40% CHC-50% 8 hour clinic40%

CHC & 8-hour clinic: 50%

All

Organisational structure (organogram)

Own budget

CHC- 100% 8-hour clinics0% as budget at sub-district level

CHC-100% 8-hour clinicsbudget at subdistrict level

CHC- 8090% 8-hour clinic-6070% CHC100%; 8-hour clinic-50%

CHC- 100% 8-hour clinics100%

CHC & 8-hour clinic: 50%

No, but people know what staffing available

CHC- 100% 8-hour clinics100% (but budget plundered by hospitals

CHC & 8hour clinic: 100%

CHC-90% 8 hour clinic100%

CHC & 8-hour clinic: 70%

Yes, facility manager knows budget and manages within delegations

These were separated in the questionnaire

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4.4.2

Reported implementation challenges

Participants reported difficulties with implementing the full package of PHC services, especially more specialised services such as termination of pregnancy (TOP) and rehabilitation. The reported challenges relate to five areas, listed below and summarised in table 9: 1. Human Resource (HR) challenges: this category includes staff shortages, skills shortages, difficulties with staff recruitment and retention; high staff turnover, with consequent loss of institutional memory; difficulties with teamwork; integration of staff between province and local government; staff attitudes and resistance to change 2. Infrastructure problems: category includes clinic infrastructure (e.g. space, lack of privacy, old infrastructure); equipment; lack of tarred roads in rural areas that damage ambulances and other vehicles; and lack of accommodation of staff 3. Financial resources e.g. insufficient capital budget; historical budget allocation; 4. Referral system e.g. lack of support from district hospitals 5. Other challenges e.g. inconsistent supply of information, education and communication (IEC) materials; problem of service provision by two different authorities (local government and province); patients bypassing PHC facilities; insufficient emphasis on prevention and promotion.

Table 9: Reported challenges with PHC package implementation

Province Eastern Cape Free State Gauteng Kwazulu-Natal Mpumalanga Northern Cape North West Western Cape HR challenges X X X X X X X X X X X X X X X Infrastructure X X X X X Finances X X Referral system Other X

As can be seen from Table 7, there is variation in the reported implementation of the selected PHC package indicators. Reasonably good progress has been made with implementation in the eight provinces that responded, but there is better reported progress in the urban provinces of Gauteng and the Western Cape. All provinces reported that human resource constraints were the most common reason that hampers PHC package implementation, followed by infrastructure challenges. Functioning clinic committees, a measure of accountability to users of services and communities, needs to be addressed, and in the North West it was reported that there is not a single functioning clinic committee.

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65

SECTION 5: A NATIONAL PHC PACKAGE FOR SOUTH AFRICA

5.1 Introduction This section proposes an essential package of interventions for South Africa, based on the literature review and information presented in previous sections. The proposed services have not been costed. Prior to formal adoption of the PHC service package, accurate costing should be done to ensure affordability and feasibility of implementation. This next sub-section presents a set of generic norms and core standards for clinics and community health centres. This is then followed by the key assumptions about staff categories, a generic list of community-based services, and the criteria and components of the proposed PHC package of services and interventions. 5.2 Norms for clinics and community health centres

1. Clinics should provide comprehensive integrated PHC services using a one-stop approach for at least 8 hours a day, five days a week. 2. The clinic should receive a supportive monitoring visit at least once a month to support personnel, monitor the quality of service and identify needs and priorities. 3. The clinic will have at least one member of staff who has completed an accredited PHC course. 4. Clinic managers should receive training in facilitation skills and PHC management. 5. An annual plan should be developed for each facility, based on a situation analysis of the communitys health needs, the routine health information data collected at the clinic and an on an evaluation of the provision of PHC services. 6. There should be a mechanism for monitoring services and quality assurance and at least one annual service audit. 7. Community perception of services should be tested at least once a year through patient interviews or anonymous patient questionnaires. 5.3 Core standards for clinics and community health centres

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Table 10: Core clinic and CHC standards

Health system building block Leadership and planning Finance Core standards Each clinic has a vision/mission statement and core values that are displayed in the clinic. An operational plan or business plan is written each year, and progress towards achievement of its goals should be monitored with the clinic supervisor. The clinic is a cost centre, with budget divided into main categories (e.g. personnel, operational, etc). The monthly expenditure of each main category is known. Under and over spending is identified and dealt with including requests for the transfer of funds between line items (where permitted and appropriate) The staff establishment for all categories is known and vacancies discussed with the supervisor. New clinic staff oriented. Availability of district personnel policies on recruitment, grievance and disciplinary procedures in the clinic Job descriptions for each staff category are in the clinic file. There is a performance plan/agreement which includes a personal development/ training plan for each staff member A performance appraisal is carried out for each member of staff at least once a year. The on-call roster and the clinic task list with appropriate rotation of tasks are posted. Attendance and absenteeism is monitored. There are regular staff meetings (at least once a month). Services and tasks not carried out due to lack of skills are identified and new training sought. In-service training takes place on a regular basis. Disciplinary problems are documented and copied to supervisor. Staff are able to Map the clinic catchment area and set specific and achievable PHC objectives using district, national and provincial goals Plan and implement district focused, community based activities, where health workers are familiar with their catchment area population profile, health problems and needs and use data collected at clinic level for this purpose. Organise the clinic to reduce waiting times to a minimum and initiate an appointment system when necessary. Organise outreach services for the clinic catchment area. Train community health care promoters to educate caretakers and facilitate community action. Caring for patients Health providers are able to follow available disease management protocols and standard treatment guidelines Staff provides compassionate counselling that is sensitive to culture and the social circumstances of patients. Health workers are positive in their approach to patients, evaluating their needs, correcting misinformation and giving each patient a feeling of always being welcome. Patients are treated in privacy and with courtesy and respect

Staff

Competence of Health Staff

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Health system building block

Core standards Patients are addressed in a language that they can understand The rights of all patients are observed. Running the clinic A clear system for referrals and feedback on referrals is in place. Facility staff clearly identifiable to service users (e.g. uniforms, insignia, etc) The PHC facility is clean with clear signposting The facility is organised and accommodates the needs of patients confidentiality and easy access for older persons and people with disability. Every PHC facility has a house keeping system to ensure regular removal and safe disposal of medical waste, dirt and refuse. The PHC facility has a written infection control policy on protective clothing, handling of sharps, incineration, cleaning, hand hygiene, wound care, patient isolation and infection control data. There is compliance with and monitoring of the infection control policy There is a schedule of monthly visits stating date and time of supervisory support visits. There is a written record kept of feedback or results of visits. There is follow-up on critical incidents reported Should monitor progress towards goals in business plan Staff are able to give appropriate education to patients and communities in order to improve health awareness. Availability of free culturally and linguistically appropriate patients educational pamphlets on different health issues Appropriate educational posters on the wall for information and education of patients. Educational videos in those clinics with audio-visual equipment are on show while patients are waiting for services Standard treatment guidelines and the essential drug list (EDL) manual All relevant national and provincial health related circulars, policy documents, acts and protocols that impact on service delivery. Copies of the Patients Charter and Batho Pele documents available. Supplies of appropriate health learning materials in relevant local languages All patients are referred to the next level of care when their needs fall beyond the scope of clinic staff competence. Patients with a need for additional health or social services are referred as appropriate. Every clinic is able to arrange transport for an emergency within one hour. Referrals within and outside the clinic are recorded appropriately in the registers. Merits of referrals are assessed and discussed as part of the continuing education of the referring health professional to improve outcomes of referrals. Suitably secured medicine room and medicine cupboards are kept. Medicines and supplies as per the essential drug list for PHC, with a mechanism in place for stock control and ordering of stock Medicines and supplies always in stock, with a mechanism for obtaining emergency supplies when needed. Stocks are secure with stock cards used and up-to-date.

Visits to clinic by unit supervisor

Patient Education

References, prints and educational materials

Referral

Pharmaceuticals and medical supplies

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Health system building block

Core standards Orders are placed regularly and on time and checked when received against the order. Stocks are kept orderly, with first expiry, first out (FEFO) followed and no expired stock. The drugs ordered follow essential drug list (EDL) principles. Reliable supply of clean, potable running water Reliable power supply or power back-up system Maintenance of the building attended to on regular basis Size of building appropriate for patient load Adequate number of consulting rooms with wash basins, diagnostic light (one for each professional nurse and medical officer working on the same shift) Consultation areas allow for patient privacy Washing facilities for staff inside consultation areas Adequate number of toilets for staff and users in working order and accessible to wheelchairs. A sluice room and a suitable storeroom or cupboard for cleaning solutions, linen and gardening tools. Suitable dressing/procedure room with washable surfaces. A space with a table and ORT equipment and needs Disabled access to entrance and movement of facility Every clinic provides comprehensive security services to protect property and ensure safety of all people at all times. A diagnostic set. A blood pressure machines with appropriate cuffs and stethoscope. Scales for adults and young children and measuring tapes for height and circumference. Haemoglobinometer, glucometer, pregnancy test, and urine test strips. A battery and spare globes for auroscopes and other equipment. Speculums of different sizes A reliable means of communication (two-way radio or telephone). Reliable emergency transport available when needed. An oxygen cylinder and mask of various sizes. Two working refrigerators one for vaccines with a thermometer and another for medicines. If one is a gas fridge a spare cylinder should always be available. Condom dispensers where condoms can be obtained with ease. A sharps disposal system and sterilisation system. Equipment and containers for taking blood and other samples. There is an up-to-date inventory of clinic equipment and a list of broken equipment. There is a list of required repairs (doors, windows, water) and these have been discussed with the supervisor and clinic committee.

Infrastructure/ Building

Equipment

Facilities and equipment

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Health system building block Records

Core standards The PHC facility utilises an integrated standard health information system that enables and assists in collecting and using data. The PHC facility has daily service registers, road to health charts, patient treatment cards, notification forms, and all needed laboratory request and transfer forms. All information on cases seen and discharged or referred is correctly recorded on the registers. All notifiable medical conditions are reported according to protocol. All registers and monthly reports are kept up to date. The clinic has a patient carry card or filing system that allows continuity of health care. New patient cards and medico-legal forms are available. The laboratory specimen register is kept updated and missing results are followed up. Births and deaths are reported on time and on the correct form. The monthly PHC statistics report is accurate, done on time and filed/sent. Monthly and annual data are checked, graphed, displayed and discussed with staff and the health committee, and used in the business plan There is a catchment area map showing the important features, family census information, location of mobile clinic stops, DOTS supporters, CHWs and other outreach activities. There is a functioning community health committee in the PHC facility catchment area. The PHC facility receives support from the community health committee. The clinic has links with other stakeholders in the facilitys catchment area e.g. civic organisations, schools, workplaces, political leaders and ward councillors in the catchment area. Staff conduct regular home visits using a home visit checklist. A family census is conducted and information kept at clinic level The community is involved in helping with clinic facility needs. The community health committee is in place and meets on a regular basis (at least quarterly) Health care providers collaborate with social welfare for social assistance and with other health related public sectors as appropriate. Health care providers collaborate with health orientated civic organisations and workplaces in the catchment area to enhance the promotion of health.

Information and documentation

Community and Home Based Activity

Community Collaboration

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5.4

Human resource assumptions

Although the development of staffing norms and standards is a separate work stream, the proposed PHC package is based on the human resource assumptions listed in Table 11. Furthermore, teamwork is critical to successful implementation of the PHC package, norms and standards (Table 11). Table 11: Key assumptions about human resources for the PHC package
Level of service delivery Community-based services Clinics Health personnel Community Heath Workers Health Promoters Social worker Professional Nurses Enrolled nurses Assistant nurses Primary health care nurses Support staff Visiting medical officer Visiting specialised services Nurses Primary health care nurses Medical Officers Family Physicians, dentists and rehabilitation personnel (may work throughout the district) Pharmacists Social workers Oral Hygienists Services provided See below

Provide services 8 hours per day All basic services provided daily

CHC services

Usually 24 hour centres providing all services provided in clinics as well as Maternity (for normal labour) and emergency services Emergencies X ray, laboratory services, physiotherapy , TOP (if accredited) and occupational health Medico-legal services Minor operations Dental services Rehabilitation services

Community Health Workers (CHWs) are part of the primary care team and it is envisaged that they will form part of community outreach teams, headed by a professional nurse.73 They also form an important component of community based PHC services which encompass activities in the communities and households. The generic roles of CHWs are to: Conduct structured and comprehensive household screening and assessment relating to health priorities, and refer appropriately Provide education and information and support preventive action (e.g. through condom distribution) Provide psycho social support across the life cycle, including an integrated approach to adherence support for TB, HAART and other chronic diseases Provide basic home management of common health problems e.g. ORT in diarrhoea, foot care in diabetes and first aid Support community assessments, campaigns and inter-sectoral action.73 The proposed community-based services are listed in table 12.

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Table 12: Community based PHC services

Sites Community Activities Community assessment of causes of ill-health (e.g. water & sanitation, substance abuse, poor nutrition) Assessment of community resources, including service providers Community based interventions, including inter-sectoral action Household Screening, assessment and referral across the life cycle (all age groups) Provide information and support for healthy behaviours and home care Provide psycho social support Identify and manage (including provide adherence support for) common health problems Schools & early childhood centres Screening, assessment and referral Targeted interventions (e.g. educational programmes, vitamin A, de-worming and immunisation campaigns) Referral and coordination of services provided in households with other sectors (in particular social development & early childhood development), non-profit organisations, community centres and any other service providers Focus on: orphaned and vulnerable children (OVC), elderly, mental health and substance abuse services, step down care

Other health and social providers: (through referral and linking)

5.5 The proposed PHC package The criteria for selection of the proposed package of services are listed in table 13 below.
Table 13: Criteria for selection of the proposed package of services Address priority health problems in South Africa Improve health status and focus on morbidity and mortality from the major causes of ill- health Comprehensive approach, with a focus on prevention and promotion as well as cure Achieve intended health outcomes envisaged in the Ministerial service delivery agreement Target vulnerable populations e.g. disabled individuals Achieve a balance between a family and population focus, while responding to the demands of the population Focus on services that are practical, essential and comprehensive and cost-effective Promote equity Staff availability and working as a team at community-based, clinic and health centre levels

A number of key interventions and four priority areas of focus within PHC are proposed. 5) Maternal, women and child health a) Immunisation, b) Antenatal care

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c) Postnatal care d) School health 6) HIV and tuberculosis 7) Chronic non-communicable disease 8) Violence and injuries For each of these areas, a comprehensive approach, with a focus on prevention and promotion, is proposed. Health care activities at community, clinic and community health centre are given. Services at clinics have been defined by the level of skills of staff and not by the size of the facility. An outline of services provided in each of the focus areas is then given. Service delivery targets are given where available in the current National Strategic Plan or in recent policy documents. Given the considerable variation in capacity and availability of resources, each district should have the flexibility and capacity to offer additional services in order to address the burden of disease in their area, as well as the demands of its population. 5.6 5.6.1 Maternal, Newborn, Women and Children Introduction

Decreasing maternal mortality to less than 100 per 100 000 live births is a key health sector outcome.2 Key interventions at the primary care level to reduce maternal mortality include increasing access to health facilities, increasing the percentage of women who book for antenatal care before 20 weeks, increasing the percentage of mothers and babies who receive post natal care within 3 days, increasing the percentage of maternity care facilities, such as community health centres, that review maternal and peri-natal deaths, address identified deficiencies and enhance the skills of health care workers and improve the use of clinical guidelines. 5.6.2 Goals and targets

Improving antenatal care Increase the percentage of pregnant women receiving antenatal care Reducing the proportion of pre-term deliveries and low birth weight babies Increase number of women who book before 20 weeks Ensuring that basic antenatal care (BANC) is implemented in 95% of primary care facilities

Reducing the number of children who are born with HIV Less than 5% of babies born to HIV positive mothers are HIV positive Reduce the proportion of births in women below 16 years and 16 18 years from the existing level (13.2% in 1998)

Improving delivery care Increase the deliveries in institutions by trained birth attendants 70% of facilities should have care providers trained in Emergency Obstetric Care Increase percentage of mothers and babies who receive post natal care within 3 days of delivery.

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With regard to improving child health, the target is to decrease child mortality from 69 per 1 000 to 30 per 1,000 live births. Key interventions, in addition to the one above that will impact on child health, are listed below 1. 2. 3. 4. 5. 6. Increase the number of infants who require dual therapy for PMTCT who actually receive it. Ensure that 90% of children are fully immunised Increase the number of districts in which 90% of children are fully immunised Increase the proportion of nurse training institutions that teach IMCI Increase the number of schools visited by a school health nurse at least once per year Provide penicillin for rheumatic heart disease

In order to achieve these targets, all clinics should provide immunization services at least for 5 days a week and if indicated, additional periods specifically for child health promotion and prevention. Every clinic should have a visit from the District Communicable Disease Control Coordinator every 3 months to review the EPI coverage, practices, vaccine supply, cold chain and help solve problems and provide information and skills when necessary. Every clinic should also have a senior member of staff trained in EPI who acts as a focal point for EPI programmes. Specific interventions to reduce childhood malnutrition include regular growth monitoring to reach 75% of children <2 years, increasing the proportion of mothers who breast-feed their babies exclusively for 4-6 months, and who breast-feed their babies at 12 months and ensure that 80% children under five receive 2 doses VA annually. Reducing mortality due to diarrhoea, measles and acute respiratory infections in children can be achieved by treating all children according to IMCI Guidelines and standard treatment guidelines. Every clinic should have at least two staff members, who have had the locally adapted IMCI training, based on the WHO/UNICEF Guidelines. A supervisor, who also evaluates the degree of community involvement in planning and implementing care, should undertake a six monthly assessment of quality of care. At least 85% of PHC facilities should have IMCI trained providers. Reducing maternal and child mortality requires inter-sectoral collaboration including 5.6.3 The provision of child care grants for those in need The provision of grants for orphans and vulnerable children Food security Access to clean water and sanitation Early childhood development opportunities

Service components

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Table 14: Maternal, newborn, women and children services

MATERNAL, NEWBORN, WOMEN AND CHILDREN: COMMUNITY BASED SERVICES Conduct structured household visits to: identify at-risk households and individuals assess need for services facilitate access to health and social services Identify vulnerable households Facilitate access to social grants (child care, disability, old age) and other social services (e.g. OVC, substance abuse) Assist with registration of births and deaths Identify households with children and women of reproductive age Assess need for and facilitate access to key preventive and care services: early ANC, immunisation, growth and development, HIV screening and care in pregnancy and childhood, contraception, TOP and cervical screening Promote key family practices: infant and young child feeding, newborn care, ORT, hand washing

Provide information, education and support for healthy behaviours and appropriate home care

Provide psychosocial support Identify and manage common health problems Conduct community assessments & mobilise around community needs

Support women with post natal depression Support HIV affected & youth and child headed households Identify and treat diarrhoea (ORT and continues feeding) Identify and refer pneumonia Address inter-sectoral issues, especially water and sanitation, and food security Support community campaigns which aim to promote healthy behaviours and improve coverage of key interventions Support immunisation, vitamin A and de-worming campaigns

CLINIC-BASED SERVICES

Maternal Antenatal care Diagnosis of pregnancy Antenatal visits and routine observations 3 5 times during pregnancy. Basic antenatal care should be provided as a minimum. Tetanus immunisation Detect a pregnancy at risk and refer Screening for risk factors Book for delivery Education and counselling Identification and treatment of concurrent conditions - STIs, TB, urinary tract infections and anaemia Recognition of complications and referral pre-eclampsia etc Micronutrient supplementation Routine offer of HIV counselling and testing of all pregnant women at each antenatal visit Provision of appropriate regimen to prevent mother to child transmission as per

Prevention of mother to child transmission (PMTCT)

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CLINIC-BASED SERVICES

of HIV

Delivery care

Postnatal care

protocols Treatment of opportunistic diseases Nutritional support Psychological support Counselling on safe feeding options Delivery of uncomplicated pregnancies Identification of complications and referral Reporting maternal deaths (confidential) Clinical observation of mother Screening of newborn for development impairment and genetic disorders Education on feeding / safe feeding practices Information on child preventive care Support breast feeding Advise on contraception Women

Family planning

Cervical cancer screening

Counselling Clinical examination Screening and treatment of STD HIV counselling and testing Provision of contraception as per national and provincial guidelines Breast examination as per fertility management guidelines Cervical screening as per protocol Distribution of condoms Emergency contraception Cervical screening as per national guidelines Follow up and tracing of women with abnormal smears Referral if necessary HIV counselling and testing Early detection of pregnancy, counselling and referral to accredited centre HIV counselling and testing Child Preventive Services Routine weighing, plot weight on road to health card, interpretation and feedback to care giver. Monthly until age of two and then every three months Routine immunisation services as per current immunisation schedule Measles and polio campaigns when indicated Special mass campaigns during outbreaks Disease Surveillance and case reporting Supplementation of children less than five years old In accordance with policy Routine de-worming of pre-school and school children as per national guidelines Child Curative Services

Termination of Pregnancy

Growth monitoring

Immunisation

VA supplementation De-worming

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CLINIC-BASED SERVICES

IMCI

Management of illnesses as per algorithms and national protocols Referral to higher level as per protocols Rehydration of children in a designated rehydration corner Management burns and simple injuries

Emergencies

CHC: In addition to clinic-based services

COMMUNITY HEALTH CENTRE Delivery care Family planning Delivery of uncomplicated pregnancies Ventouse and forceps delivery available Male and female sterilisation selected CHCs Infertility: limited initial investigations in specialised clinics Genetic counselling As per clinic Abnormal results seen by MO Early detection of pregnancy Medical and surgical TOP in designated facility HIV counselling and testing Orientation of services to suit adolescents, and especially those at school

Cervical cancer screening Termination of Pregnancy

Adolescent health initiatives

5.7 5.7.1

HIV/AIDS and Tuberculosis Introduction

HIV / AIDS and tuberculosis continue to account for a significant burden of disease. Prevalence figures suggest a stabilising epidemic but are still unacceptably high. New policies and strategies to strengthen prevention, treatment and care support the decentralisation of treatment and care to primary care level in order to expand access to anti-retroviral therapy. The targets for HIV / AIDS and TB are to: 1. 2. 3. 4. Improve the quality of life of people living with HIV and AIDS Reduce HIV incidence from 1.3% to 06% Ensure that all eligible pregnant women are initiated in ART Ensure that 100% of HIV-TB co-infected patients are on ART

Male medical circumcision is known to prevent a significant percentage of infections. Plan to increase access to this service are underway.

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The National Strategic Plan 2007 2011 aims to provide an appropriate package of treatment care and support to 80% of all HIV positive people and ensure that 550,000 HIV positive people on ARV by 2014.74 Particular challenges facing the public sector with regard to tuberculosis are low cure rates and increasing number of TB patients with multi-drug resistance TB.75 Current targets for cure and care are: 85% cure rate for tuberculosis (currently 65%) Decreasing TB defaulter rate to less than 5% Decreasing the number patients with multi drug resistant TB 100% facilities implementing TB guidelines

Recent policy documents are providing for the decentralisation of the management of MDR to the primary care level. Primary health care facilities will play a significant role in providing injectables and providing DOT to all drug resistant TB patients in the area.76 Orientation of the above services to suit adolescents, and especially those at school, is required, especially at community health centre level. A priority is to establish Youth Friendly Services in all primary care facilities by 2014. This would involve Ensuring that services are accessible and acceptable to adolescents Providing a physical environment appropriate for adolescents. Providing staff trained to deal with this particular age group Providing an essential package of services which should include the following. Information, education and communication on sexual and reproductive health IEC on violence / abuse and mental health Information on family planning Pregnancy testing Pre and post termination counselling appropriate for adolescents Management of sexually transmitted infections.

Strengthening HIV / AIDS prevention, treatment and cure requires a multi-faceted response including 1. 2. 3. 4. Building community AIDS competence. Gender sensitive school and youth educational programmes Improved housing and Access to social grants

5.7.2

Service components

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Table 15: HIV/AIDS and TB services

COMMUNITY- BASED SERVICES Conduct structured household visits to: identify at-risk households and individuals assess need for services facilitate access to health and social services Provide information, education & support for healthy behaviours and appropriate home care Identify vulnerable households Facilitate access to social grants (child care, disability, old age) and other social services (e.g. OVC, substance abuse) Assist with registration of births and deaths Identify HIV or TB: refer for HCT and screen for TB symptoms Ensure that households affected by HIV and or TB have access to appropriate services, including TB treatment, regular CD4 testing, timely HAART

Promote HIV prevention including HIV testing, condom use, partner reduction, circumcision, STI treatment Distribute condoms Advise on TB infection control in the home Provide an integrated approach to adherence support for TB, HAART and other chronic disease medication in close collaboration with facility based counsellors

Provide psychosocial support

Identify and manage common health problems Conduct community assessments & mobilise around community needs Address inter-sectoral issues, especially water and sanitation, and food security Support community campaigns which aim to promote healthy behaviours and improve coverage of key interventions Support HIV educational and treatment literacy campaigns Condom distribution in on-traditional outlets Support gender sensitive school & youth programmes

CLINIC BASED SERVICES HIV / AIDS Provider initiated HIV testing Diagnosis and management of opportunistic infections Initiation and follow-up of antiretroviral treatment Adherence and selfmanagement support Effective monitoring Tuberculosis Routine screening for Clinical suspicion as per protocols Offer HIV counselling and testing at all visits As per national guidelines for the management of HIV and AIDS in adults, adolescents and children Identification HIV positive individuals Initiation on treatment as per 2010 guidelines Regular follow up Strategy to find lost to follow up patients Support groups

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CLINIC BASED SERVICES tuberculosis Diagnosis as per protocols. Collection of sputum Information, education and counselling to families Testing HIV Follow up and accurate data collection Contact screening of close contacts Treatment according to national protocols Tracing of defaulters Short course (DOTS) Tracing TB contacts Data management and reporting Identification of high risk groups Screen and test symptomatic high risk groups Trace patients with a confirmed diagnosis of DR TB Notify the district coordinator Provide initial counselling and education of the family and patient Ensure monthly follow up at the clinic Provide DOT to all patients attending daily Follow up patients initiated to start community based treatment Sexually transmitted Infections Syndromic management of STI as per standard protocols Promote counselling and testing for HIV Referral according to protocols Syphilis testing according to protocols Health education and counselling Partner notification Provision of condoms

Initiation and follow-up of TB treatment

Management of drug resistant TB patients

Management of STIs

In addition to clinic-based services

COMMUNITY HEALTH CENTRE: HIV / AIDS

HIV prevention

Male medical circumcision in selected, accredited facilities

5.8 5.8.1

Non-communicable diseases Introduction

The increased contribution of non-communicable diseases to the burden of diseases is increasingly recognised. Enhanced programmes for the prevention and treatment of hypertension are a national priority to reduce the incidence of strokes, congestive cardiac failure and renal failure. Goals and specific targets: Increase by 50% the proportion of clinics providing comprehensive services for persons with chronic diseases. Assess patient satisfaction and quality of care 6 monthly by a supervisor who also evaluates the degree of community involvement in care planning. Minimise patient travel by prescribing supplies of drugs to last 1-3 months.

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Reduce the prevalence of overweight and obese clients and specifically to reduce the number of people with BMI greater than 30.

Prevention and treatment of non communicable diseases should include a long term care model and the promotion of a healthy lifestyle in line with national guidelines. Hypertension and diabetes are the most common non communicable diseases and focus shall initially be on these priorities. Other chronic conditions asthma, epilepsy, and arthritis will be management according to standard treatment protocols. Community based interventions should focus on 1. Risk factor reduction 2. Community mobilisation 3. Reaching targeted groups in schools, workplaces and recreation areas. Promoting food outlets and food gardens, provision of amenities for exercise, especially in schools Table 16: Non-communicable disease services

NON-COMMUNICABLE DISEASES: COMMUNITY BASED SERVICES Conduct structured household visits to: identify at-risk households and individuals assess need for services facilitate access to health and social services Provide information, education & support for healthy behaviours and appropriate home care Identify vulnerable households Facilitate access to social grants (child care, disability, old age) and other social services (e.g. OVC, substance abuse) Assist with registration of births and deaths Screen adults for hypertension, diabetes and depression Identify other chronic diseases and disabilities, oral health or visual and hearing impairments, and break through pain Facilitate access to facility or specialist care Provide information on risk factors for chronic diseases Information on chronic disease medication and importance of adherence

Provide psychosocial support

Identify and manage common health problems Conduct community assessments & mobilise around community needs

Provide an integrated approach to adherence support for TB, HAART and other chronic disease medication in close collaboration with facility based counsellors Provide basic stroke support and rehabilitation Treat dehydration and provide oral care in the elderly & sick Support foot care in diabetics and elderly Address inter-sectoral issues, especially water and sanitation, and food security Support community campaigns which aim to promote healthy behaviours and improve coverage of key interventions

Support exercise, diet and smoking cessation campaigns

and designating smoke free areas are important areas for inter-sectoral collaboration.

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CLINIC-BASED SERVICES Hypertension Screening Early treatment Monitoring adherence Identification of high risk populations Screening Appropriate, cost effective and comprehensive management as per national guidelines Education of patient and family Support groups Tracing of defaulters Early diagnosis of complications and referral when appropriate Appropriate follow up Diabetes Screening Early treatment Monitoring adherence Management of complications and referral Identification of high risk populations Early diagnosis Appropriate treatment Education of patients and their families Maintaining good patient records Prevention, detection and management of complications Apply principles of nutrition, physical activity and weight control Follow up as per clinical guidelines Referral for foot care are per guidelines Self monitoring of glycaemia

Management of complications and referral

Self management support

In addition to clinic-based services

COMMUNITY HEALTH CENTRE Management of complications and referral Range of services enlarged by presence of the MO. Interpretation of common laboratory and X ray results More accurate screening for complications Screening of mental health problems More specialised geriatric care including foot care Palliative care consultation

5.9 Violence and Injuries 5.9.1 Introduction Coordinated inter-sectoral interventions are required to reduce unintentional and intentional injuries. In order to mitigate the long term health consequences of violence and injury, Community Health Centres will provide a trauma and emergency services. Both clinics and community health centres will provide counselling services, as well as immediate treatment following intentional injuries

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Priorities are to Increase the proportion of emergency health staff who has basic ambulance assistance qualifications, and who are able to provide emergency care to victims of poisoning, injuries and maternal emergencies. Ensure that in every clinic there is at least one person trained in counselling and the management of victims of violence and rape. Every clinic has established working relationships with the nearest police officer and social welfare officer by having visits from them at least twice a year. A member of staff of every clinic has received training in the identification and management of sexual, domestic and gender related violence. The training includes gender sensitivity and counselling.

Alcohol harm constitutes one of the most significant health risk factors in South Africa after unsafe sex. Preventing alcohol abuse requires a multi-faceted inter-sectoral response. At a primary care level, activities should be focused on shifting prevailing norms about alcohol misuse. Identification of at risk populations and individuals especially adolescents Community level programmes for alcohol prevention, starting at schools and involving a broad range of community stakeholders. Turnaround time for blood alcohol samples reduced to six weeks (baseline 12 weeks) Reduce school attendees admitting to drink alcohol and smoke tobacco.

Inter-sectoral action should include: 1. 2. 3. 4. Provision of sexual assault services multi-sectoral Pedestrian and community safety initiatives Reducing the availability of drugs and alcohol Comprehensive approach to neighbourhood renewal.

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Table 17: Services to combat violence and injuries

VIOLENCE AND INJURIES: COMMUNITY BASED SERVICES Conduct structured household visits to: Identify vulnerable households Facilitate access to social grants (child care, disability, old identify at-risk households and age) and other social services (e.g. OVC, substance abuse) individuals Assist with registration of births and deaths assess need for services Screen for domestic violence & substance abuse facilitate access to health and social Facilitate access to sexual assault and mental health services services Provide information, education & Provide information on substance abuse Provide information on prevention of injuries in homes support for healthy behaviours and appropriate home care Provide psychosocial support Provide post-trauma counselling Identify and manage common health Provide first aid problems Conduct community assessments & Address inter-sectoral issues, especially water and sanitation, and food security mobilise around community needs Support community campaigns which aim to promote healthy behaviours and improve coverage of key interventions Support pedestrian safety initiatives Support campaigns to reduce the availability of drugs and alcohol CLINIC-BASED SERVICES Post sexual assault services Counselling and referral to medico legal services for consultation HIV testing Emergency contraception STI prophylaxis Counselling and referral As per national guidelines

Post trauma counselling Abuse of elderly

COMMUNITY HEALTH CENTRES Trauma and emergency services Care of trauma of limbs (excluding fractures (temporary immobilisation only) Treatment of minor fractures Management of acute psychiatric cases and referral Preparation for urgent referral of serious trauma proper immobilisation, IV therapy, clearing of airway Care of medical conditions which can be stabilised within 24 hours Immediate management of emergencies a) Basic emergency obstetric care b) Respiratory / cardiac emergencies c) Diabetic emergencies d) Allergic emergencies e) Suspected poisoning f) Trauma g) Bleeding Medico legal services for consultation Counselling; HIV testing Emergency contraception; STI prophylaxis

Post sexual assault services

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5.10

Nutrition

5.10.1 Introduction Malnutrition impacts negatively on morbidity, mortality, educability and productivity.77 Currently the country is faced with a number of nutrition related problems: increased prevalence of micronutrient deficiencies (e.g. Vitamin A and iron), malnourished children and high levels of overweight and obesity. Mild and moderate malnutrition, although not visible, continue to have public health significance. Efforts to address nutritional disorders should focus on the promotion of proper nutrition, the prevention of malnutrition and the treatment of malnutrition. Nutritional support should be provided to patients with HIV / AIDS and TB. The National 10 Point Plan states that 90% of all primary care facilities should provided nutritional support to people with HIV / AIDS and TB by 2013. Additional targets are that 80% of children under the age of five will receive Vitamin A twice a year.2 Table 18: Clinic-based nutrition services
Promotion of proper nutrition Prevention of malnutrition underweight Promote use of iodised salt Promote use micronutrient rich foods Vitamin A supplementation Support early initiation of breast feeding Promotion of appropriate complementary feeding for young children Growth monitoring identification of at risk children, and counselling of caregivers. Iron / folate supplementation of pregnant women Control and prevention of diarrhoeal disease. Regular weighing by health care workers, recording of weight and feedback to patients Nutrition education and information on healthy diets and health risks associated with poor diets. Refer

Prevention of malnutrition obesity

Treatment of malnutrition

5.11 Mental Health 5.11.1 Introduction Mental health services at primary health care level will focus on education and awareness raising, case detection, psychosocial management and referral. In every clinic there will be at least one member of staff who has had continuing education in psychiatry or mental health (including community aspects) in the last year. All clinics will also have regular visits (for patient care, training, supervision and support) from dedicated mental health or psychiatric nurses from community health centres, hospitals or mobile teams based in the district. Specialist mental health expertise (psychiatrists, psychologists, occupational therapists) and social workers are available in community health centres. The main mental health problems include: Depression Psychosis Substance abuse Management of the victims of violence

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Table 19: Mental health services

Clinic level Education and awareness Identification of patients in need of mental health care Referral to mental health services Triage of patients needing to be seen by psychiatric nurse or more specialised staff Identification, assessment, management and referral Screening for common problems: trauma, abuse, depression, anxiety, substance abuse Initiate individual, group and family therapy Establishment of management plans for patients

Community health centre

5.12 Oral Health Oral health is central to well-being and exerts a fundamental influence on the quality of life of South Africans.78 The most prominent oral conditions encountered in the community are tooth decay, pain, tooth loss, early childhood caries, bleeding gums, loose teeth and bad breath. Other conditions that are present include oral HIV lesions, oro-facial trauma, jaw fractures, oral cancer, mouth sores, fluorosis and oral tumours. There is evidence that exposure to optimal levels of fluoride and reducing sugary foods and drinks in the diet, have a powerful impact on reducing tooth decay. Reducing tobacco exposure dramatically alters oral cancer morbidity.78 Basic oral care consists of three elements 1. Pain relief 2. First aid for oral infections and dento-alveolar trauma 3. Referral of complicated cases.78 National goals for the provision of oral health services include: 1. Increase the percentage of children age 6 who are caries free to 60% 2. Reduce the number of Decayed, Missing and Filled Teeth (DMFT) at age 12 to 1.0 3. Prioritise child oral health with a focus on school- based prevention programmes. Specific activities at primary care level include Offering all antenatal women an oral health educational package All community health centres should offer the prescribed oral health care package. Mobile dental units should be considered in areas with poor access to health care services.

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Table 20: Oral Health Services

Prevention and promotion Examination Cleaning of teeth Fissure sealants Fluoridated toothpaste tooth brushing programme Oral health education and promotion targeted at selected groups such as children, youth, pregnant women, mothers and the elderly. Pain relief Referral Basic curative services, including relief of pain and infection control Extraction of badly decayed and severely peridontally involved teeth under local anaesthesia Treatment of post extraction complications such as dry sockets and bleeding Drainage of localised oral abscesses Palliative drug therapy for acute oral infections First aid for dento-alveolar trauma Referral of complicated cases to the nearest hospital

Treatment

5.13 School health services Priorities in the provision of school health services are to increase the number of schools that are visited by a PHC nurse and provided with appropriate school health services. The School Health Policy and Implementation Guidelines are currently being revised, but services should include at least:79 Micronutrient supplementation; De-worming where appropriate as per current policy; School feeding where appropriate, and in collaboration with the Department of Education; Screening for obstacles to learning, including for hearing, vision and speech impairment Physical examination for gross loco motor dysfunction Oral health checks, education and health promotion Anthropometric assessment Provision of penicillin for the prevention of rheumatic fever. Mental health assessment and identifying and responding to internal injuries and child abuse Support for life-skills education programme in schools.

5.14 Rehabilitation services The goal of rehabilitation is to enable individuals to return home to their communities with the highest possible level of functional independence and the best possible quality of life, while at the same time reducing, as far as possible, the burden of care on family members and significant others.47, 80-81 Rehabilitation includes measures to compensate for a loss of function or a functional limitation (for example by technical aids) and other measures intended to facilitate social adjustment or readjustment. Community-based rehabilitation aims to:81-82

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Promote equal opportunities for people with disabilities, through inter alia, facilitating IEC activities; ensuring access to health and rehabilitation services; support establishment of selfhelp and support groups; Emphasise prevention, through the development and distribution of appropriate and up to date media on disabilities and promoting adherence to health and safety regulations, road safety tips, prevention of burns in the home. Provide access to rehabilitation programmes, including assessment of physical, emotional, sensory or communication disorders; provision of assistive devices; counselling and /or education of client and family or caregiver; receiving and sending out referrals to local resources and hospitals.

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Table 21: Rehabilitation services

COMMUNITY BASED REHABILITATION SERVICES Conduct structured household visits to: Identify vulnerable households, including people hidden because of physical disabilities identify at-risk households and individuals Facilitate access to social grants (child care, disability, old age) assess need for services and other social services (e.g. OVC) facilitate access to health and Facilitate access to assistive devices social services Assist with registration of births and deaths Screen for domestic violence & substance abuse Promote equal opportunities for Raise awareness in educational institutions, places of employment, sports and recreation facilities, religious people with disabilities institutions, etc Distribution of up to date information on available programmes and services to persons with disabilities, their families, professionals in the field and the general public. Facilitate establishment of self help and support groups with full participation of people with disabilities Create awareness and provide knowledge regarding mental illness and anti-stigma and non-discrimination Provide information, education & Provide information on substance abuse, adherence to health and safety regulations, road safety tips, prevention of support for safety, healthy behaviours burns in the home and appropriate home care Provide psychosocial support and facilitate and support the development of self help groups Conduct community assessments & mobilise around community needs Provide counselling Networking with rehabilitation and disability forums, CBOs and NGOs Address inter-sectoral issues, especially access for disabled individuals, equal opportunities, etc Support community campaigns which aim to promote human rights, improve coverage of key interventions, safety, etc

Screening

Assessment

Support pedestrian and other safety initiatives (e.g. for children, women Support campaigns to reduce the availability of drugs and alcohol CLINIC-BASED SERVICES Early detection of people with disabilities through screening and observations at the clinic and/or home visits Assessment of physical, emotional, sensory or communication disorders Basic assessment by means of formal diagnosis by visiting professional team and issue of basic assistive devices Early detection, assessment and treatment of impairment Of client and family/care giver Receiving and sending out referral to local resources and CHC COMMUNITY HEALTH CENTRES Identification, assessment, management and referral Screening for complications e.g. contractures, pressure sores, Establishment of rehabilitation management plans for patients Provision of assistive devices, including wheelchairs, walking aids, hearing aids, prostheses

Counselling and/or education

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5.15 Optometry services The correction of refractive errors forms a significant part of the World Health Organisation's Vision 2020 initiative to eliminate avoidable blindness. A district based programme should aim to identify, refer and provide services for children and adults who would benefit from refractive correction by:83

Providing screening services Providing refractive services Providing cost-effective correction devices Establishing the appropriate referral channels

Table 22: Optometry services

Screening Adults - in health care facilities. The focus should be on adults over the age of 60. Children as part of school health services Affordable and/or fully subsidised spectacles should be provided to those in need, preferably at the site of the screening or refraction. The spectacles should be of acceptable optical and safety quality. Criteria for the provision of glasses o Anisometropia less than 0.50D o Astigmatism in both eyes less than 0.75D. o The acceptable limit for prism is considered to be 0.50 Such as diabetic retinopathy, glaucoma and cataracts.

Refraction

Screening for major ocular diseases Referral

To appropriate eye services

5.16 Basic curative services Although the focus of the proposed PHC package is on four critical areas, basic curative services remain a critical component of PHC. Most common illnesses should be treated as per national standard treatment guidelines. These were updated in 2008 and are (or should be) available in all PHC facilities. In line with the teams and categories of staff available at clinic and CHCs, more specialised services will be available at the CHCs.

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Table 23: Basic curative services

Curative services Clinic-based services First visit: history taking, BP, urine testing, full examination Clinical assessment and management of illness as per protocols Refer if necessary Opportunistic screening HIV counselling and testing BP Weight Urine for glucose Cervical screening Ensure availability of all vaccines Conduct routine immunisation services Outreach immunisation and campaigns if indicated (measles and meningococcal meningitis) Immunisation of high risk groups (H1N1) when appropriate Disease surveillance and notification Recognition and referral Management of complications Early diagnosis and management as per national guidelines Referral where necessary Selected preventive measures as per national guidelines Every clinic considers itself part of the Provincial and National Diarrhoeal Disease Control Programme. All staff should be trained in the management of diarrhoeal disease and have continuing education every 6 months or when there are reports of cholera outbreaks in neighbouring countries or regions. Every clinic is able to contact and works with the environmental health officer in whose area it falls. Reduce mortality due to diarrhoea in children by 50% (Year 2000 Health Goals and Objectives) Every clinic has a member of staff conversant with the "Guidelines for Medical Management of Rabies in South Africa. Decrease the current prevalence of leprosy in order to move towards its eradication. Each clinic has each year at least one staff member who has had some continuing training in Leprosy from a supervisor. Prevention of disability through early detection and screening as per protocols where available (ageing and prevention of blindness) Screening and basic assessment Referral

Vaccine preventable diseases

Leprosy Malaria

Cholera and Diarrhoea control

Rabies

Leprosy

Rehabilitation

Occupational health

Ophthalmology

COMMUNITY HEALTH CENTRES Render occupational health promotion services Sensitise workers to specific occupational health problems Primary risk assessment of occupational health exposure Facilitate the formation of occupational health and safety committees in the workplace Support data collection Early identification of eye diseases. Identification of all cases with reduce visual acuity and refer

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Genetic services Community health centre

Fundal examination of all diabetic patients once per year and refer all cases of diabetic retinopathy Treatment of eye disease and trauma in line with national guidelines for the Management and Control of Eye Conditions at Primary Care Level Optometry Prevention of disease complication Psychosocial support to affected individuals Occupational therapy Physiotherapy Rehabilitation Speech therapy and audiology Assistive devices Outreach by rehabilitation workers to community and clinics

5.17 Emergency Care Emergency care and resuscitation services will be provided at CHCs. The aim is to provide initial management, stabilise the patient and arrange for transfer to an appropriate facility. Emergency services should include Basic emergency obstetric care Respiratory / cardiac emergencies Diabetic emergencies Allergic emergencies Suspected poisoning Trauma Bleeding

Table 24: Emergency services at CHCs

Trauma and emergency services Care of trauma of limbs (excluding fractures (temporary immobilisation only) Treatment of minor fractures Management of acute psychiatric cases and referral Preparation for urgent referral of serious trauma proper immobilisation, IV therapy, clearing of airway Care of medical conditions which can be stabilised within 24 hours Immediate management of emergencies a) Basic emergency obstetric care b) Respiratory / cardiac emergencies c) Diabetic emergencies d) Allergic emergencies e) Suspected poisoning f) Trauma g) Bleeding Medico legal services for consultation Counselling HIV testing Emergency contraception STD prophylaxis

Post-sexual assault services

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5.18

Environmental health

Environmental health services are provided through regular activities carried out by environmental health officers in community health centres. Table 25: Environmental health services
Clinic level Information on environmental health services Contact number of officers to lodge complaints Information on waste management and water quality Chemical and food safety Environmental health promotion services Environmental health training programmes Monitor environmental health legislation enforcement Food safety and food hygiene services Services in respect of public conveniences Non-specialist impact / risk assessment and environmental evaluation Non-specialist occupational hygiene / indoor environmental quality evaluation services Environmental health services in formal sector and at care centres Services in respect of keeping animals, nuisances Services in respect of the collection and collation of environmental health data Services in respect of outbreak investigations, communicable diseases investigation, as part of a team Monitor health aspects of housing, water and sanitation Environmental health planning, zoning and license applications Vector control services Pollution control services, inspection and monitoring Monitor waste management services: litter control, waste storage and collection Environmental health services in respect of pauper burials Monitor food safety services

CHC

5.19 Health education Health education activities should be integrated into all services provided at primary health care level. All clients should receive appropriate health education, information and support. Services should be provided through: Face to face meetings Health education campaigns in high risk areas Social mobilization for different health programmes Health education material Media

Specific attention should be paid to a number of areas Reduce the use of illegal substances Reduce the consumption of alcohol and other drugs

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5.20 Clinical support services 5.20.1 Equipment Community health centres may have X ray and ultrasound facilities in order to support the delivery of effective health care. Operating theatres would allow minor operations to be performed.

5.20.2 Essential Medicines A list of essential medicines at each level is available from the Department of Health. It is expected that all medicines are available at all times, in adequate amounts. 5.20.3 Diagnostic Services Community health centres access to laboratory services.

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Haematology Blood film Haemoglobin Haematocrit Red Blood Cell Count White Blood cell count and platelet count Differential blood count Erythrocyte Sedimentation Rate Coagulation screening tests Reticulocyte count Blood grouping and RH factor

Bacteriology Direct Microscopy General urine examination General stool examination

Staining Smears Gram stain Zeil Nelson stain KLB stain

Serology Widal test Rose Bengal C Reactive protein ASOT Rheumatoid factor Toxoplasmosis RPR TPHA Infectious Mononucleosis SLE G6PD assay Cooms Iron and TIBC

Culture Urine Swabs Stool Throat Sputum Blood CSF STD culture swabs

Rapid bacteriological tests Anti microbial susceptibility

Biochemistry Blood glucose Renal function tests Liver function tests Lipid profile Hormonal assays

Parasitology Malaria parasite General Stool examination

Cytology Pap smear Urine cytology

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SECTION 6: TOWARDS PHC PACKAGE IMPLEMENTATION

6.1 Introduction The renewed emphasis on PHC as the cornerstone of health care delivery and the major reforms envisaged by the NHI provide exciting opportunities for health system change in South Africa, rarely available in most countries. Although the rapid review provided a snapshot of implementation of the existing package in eight provinces, the overall package review was limited by time constraints and the inability to cost the PHC service package in the time available. Furthermore, the information obtained from provincial respondents was self-reported, and there may have been some socially desirable responses provided. Nevertheless, valuable insights were provided. The PHC package provided a vision for health service delivery to health workers and managers at the district level. Reported progress includes the availability and accessibility of a wide range of PHC services and the addition of new services, such as ART provision and rehabilitation. The PHC guidelines have also facilitated planning and negotiation of additional financial resources in some instances; served as a catalyst for the development of clinical support services (e.g. laboratory services); enabled further and ongoing training of health care providers; and facilitated monitoring and evaluation of service provision. At the same time, the assessment also highlighted wide variation in the implementation of the package across the nine provinces, illustrated by estimated provincial performance on the selected indicators. The provision of PHC services on the same day ranges from 70% in Northern Cape, North West and Gauteng to 100% in Kwazulu-Natal and the Western Cape. The initiation of ART at eight-hour clinics is an encouraging development. However, ART initiation at CHCs varies from a low of 38% in Mpumalanga to 100% in Gauteng, Kwazulu-Natal and Western Cape, perhaps reflecting better staffing in the urban settings. The availability of a nurse with specialised mental health training appears to be a problem in all provinces, with either low reported performance, or respondents equating the existence of a professional nurse with specialised mental health skills. Only Mpumalanga and Western Cape reported that fast queues for elderly people were available in all facilities. There was also variation on awareness/ existence of organisational structures and budgets at CHC and clinics. Lastly, the existence of functioning clinic committees is an important indicator of responsiveness and/or accountability to communities. This varied from zero functioning clinic committees in North West province to 100% functional community structure in the Western Cape, albeit at a cluster/sub-district level. Human Resource challenges were consistently mentioned by all provincial respondents, as a factor hampering full implementation of the package. Similarly, a range of infrastructure, financial and other constraints were mentioned by provincial respondents. These issues have to be addressed to ensure successful implementation. In the light of the assessment and the literature review, we now turn to key issues that have to be taken account in moving forward with the recommendations in this report. 6.2 Prerequisites for package implementation The proposed PHC package, norms and standards should be seen as a guiding document, rather than a

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rigid, one size fit all prescription. The team wishes to stress the following: 1. The proposed package of services should be flexible and tailored to the particular needs of the province and area of implementation. Priority setting and planning processes at sub-district and district levels should highlight local priorities and a profile of services should then be developed that is based on the particular profile of need in that area. 2. A broader public health approach, which emphasises prevention, is critical: all provincial respondents were of the opinion that there should be positive bias towards prevention and health promotion in the revised package, which should include empowering communities with essential health knowledge and literacy. 3. Prioritising specific areas does not imply that treatment of minor ailments and specific conditions is unimportant. These services are important and remain in the package. 4. The PHC system can only achieve the desired outcomes if it is supported by other levels of the health system in a coordinated and integrated manner. The delivery of good quality essential care relies on effective referral relationships with and support from district hospitals, (in addition to clinical competencies to identify when these referrals are needed). 5. The delivery of a comprehensive primary health care package requires adequate resources: funding, adequate, committed and motivated staff and the necessary infrastructure and clinical support services (e.g. pharmaceuticals) in order to deliver high quality and efficient services. These resource requirements are part of separate components of work, and should be completed prior to any implementation. 6. Addressing the social determinants of health, in particular, requires action at multiple levels. Although we have suggested a number of opportunities for inter-sectoral, these are indicative only, and meant to highlight an approach rather than provide a prescription.

6.3

Suggested next steps

We use the participants suggestions on the development of the revised package to conclude the report. Five main issues need to be addressed/ and or taken forward: flexibility in the application and implementation of the package; consultation with stakeholders; costing of the package and implementation requirements; efforts to strengthen implementation; monitoring, auditing, evaluation and revision. Each of these is highlighted below: 6.3.1 Flexibility

The recommendations must be seen as flexible guidelines, rather than a rigid prescription. Almost all the provincial respondents mentioned the need for flexibility both in the application and the implementation of the package, as can be seen from the quotes below: You should not make it *the package+ prescriptive. Set a minimum to allow people to go beyond. Visit some of our facilities and see what is possible and impossible do not make assumptions that clinics are the same.(Gauteng) The task team should pilot the package in some of the provinces (Mpumalanga) You should take into account unique circumstances of each province (Northern Cape)

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Be practical: South Africa does not need international standard but its own. Focus on the basicsTake into account rural challenges; and look at the situation of allowing certain professional to perform certain functions e.g. nurses (North West) 6.3.2 Consultation of stakeholders

The recommendations contained in this document should be consulted with key health stakeholders in government (local, provincial and national); a selection of PHC/district experts and community stakeholders. Respondents suggested that stakeholders that should be consulted should include clinicians/ front-line staff; facility managers at sub-districts; clinic committees and managers at district and provincial head office levels. As two respondents noted: Community and staff inputs are important as these activities are many times top-down approach. (Provincial respondent) You have to ask: who are the key players. We also have to ask how we as a country can get more reliability at the level of delivery- That means that we have to consult with our staff-we have to deal with the distortions that arise from obtaining the views of staff, while embarking on the necessary process of consulting with them (Key informant) 6.3.3 Costing of the package and implementation requirements

The rapid assessment pointed to many of the implementation challenges, the vast majority that were directly or indirectly linked with finances. Costing of the proposed package is a critical component to ensure sustainability and successful implementation. As one respondent noted: A number of issues should be addressed, including organisational structures, occupational health, infrastructure and space constraints (Northern Cape) Baseline costing of the package is critical, and how to cost the package in order to influence the activity based budgeting. The calculation formulas should also be included (Eastern Cape) 6.3.4 Concerted efforts to strengthen implementation

Suggestions included the following: Recognising the importance of clinical support systems e.g. pharmaceuticals availability, space, infrastructure The need for integrated referral pathways and ensuring that people access services at appropriate levels Developing norms and standards for staffing, and defining level of skills for different health and allied professional categories and support staff. Avoid making contradictory recommendations e.g. the existing PHC package recommends the distribution of condoms in nearby schools, whilst the school policy promotes abstinence and prevent condom use by school children. Address accountability issues at sub-district, district, provincial and national levels

98

6.3.5

Monitoring, auditing, evaluation and revision

Many respondents point to the need for a clear monitoring and evaluation (M&E) framework that specifies compliance issues and consequences of non-compliance, the role of health governance structures in M&E; periodic reviews and revision of the package. As a key informant noted:

Official documents are often seen as set in stone. There is no formal process of updating them or no formal review process. We have to be more flexible and build in period reviews and revisions into the policy documents we produce.

99

LIST OF APPENDICES Appendix 1 Review of clinical categories as per PHC Norms and Standards document and indication as to whether clinical guidelines are available in each category Category as per PHC Norms and Standards Womens reproductive health Service description Availability of guidelines to support service delivery

Services should be provided in an integrated comprehensive manner covering preventive, promotive, curative and rehabilitative aspects of care.

Cervical cancer screening programme Contraception guidelines for South Africa Saving Mothers. Essential Steps in the Management of Common Conditions Associated with Maternal Mortality (2007)

The focus should be in antenatal, delivery, post natal and family planning Management and prevention of genetic disorders and birth defects These services should form part of the integrated maternal, child and womens health care. They aim to assist individuals with a genetic disadvantage to live and reproduce normally Human Genetics policy guidelines for the management and prevention of genetic disorders, birth defects and disabilities (2001)

Clinical diagnostic services, counselling, laboratory support, prevention strategies and public awareness campaigns IMCI Promotive, preventive (monitoring and promoting growth, immunisations, home care counselling, de Road to health chart guidelines

100

Category as per PHC Norms and Standards

Service description

Availability of guidelines to support service delivery

worming and promoting breast feeding) Curative assessing, clarifying and treating) Rehabilitative Management of asthma Managing chronic asthma in infants, children and adults National guidelines on the management and control if asthma in children at primary level (1999) National guideline on the prevention of asthma in adults at primary level (2002)

Disease prevented by immunisation Adolescent (10 19) and Youth (15 24) Health Management of communicable diseases Cholera and Diarrhoeal Disease Control Dysentery Helminths STIs

Uninterrupted supply of vaccinations

Guidelines for the management, prevention and control of meningococcal disease in South Africa

Holistic approach with a focus on special needs

Prevention, early diagnosis and initiation of measures to prevent transmission Management and control

Management and control Schistosomiasis and cysticercosis Prevention and management Regular treatment of school going children for soiltransmitted helminths infections and bilharzia

101

Category as per PHC Norms and Standards

Service description

Availability of guidelines to support service delivery

Condom distribution HIV / AIDS Testing, counselling, treatment of associated infections and referral Clinical guidelines for the management of HIV / AIDS in adults and adolescents (2010) South African ARV treatment guidelines (2010) Guidelines for the management of HIV in Children Clinical Guidelines: PMTCT (2010) Guidelines for the prevention of malaria (2009) Guidelines for the treatment of malaria (2009)

Malaria Rabies Tuberculosis

Treatment Referral for PEP Diagnosis, treatment and management

Leprosy Prevention of hearing loss due to otitis media Rheumatic fever

Treatment Diagnosis and treatment

Guidelines for the programmatic management of TB Decentralised management f MDR TB. A policy framework for SA. Guidelines for leprosy control (2008) Prevention of hearing impairment due to otitis media at clinic level National Guidelines of the primary prevention and prophylaxis of RF and RHD for health professionals at primary level

Diagnosis of sore throat and rheumatic fever. Referral

Trauma and Emergency Oral health Mental Health

Emergency and resuscitation services Basic Primary Oral Health Care Services Assessment, counselling and support Prevention included in all services

102

Category as per PHC Norms and Standards Victims of sexual abuse, domestic violence and gender violence Substance Abuse Chronic diseases and geriatrics

Service description

Availability of guidelines to support service delivery

Counselling, referral, STD prophylaxis HIV testing, emergency contraception, care of injuries and mediclegal advise Prevention and management Early diagnosis, management and harm reduction National guidelines in the prevention, early detection and intervention of physical abuse of older persons at primary level (2000) Guidelines for the promotion of active ageing in older adults at primary level (2000) Primary prevention of chronic diseases of lifestyle National Guidelines of the management of osteoporosis at hospital level and preventative measures at primary level National programme for the control and management of Type 2 diabetes at primary level (1998) National guidelines on foot health at primary level Hypertension. National programme for control and management at primary level (1998) Prevention of blindness in south Africa (2002) Management and control of eye conditions at primary level

Diabetes

As above

Hypertension

Detection, treatment and control. Prevention of target organ damage and stroke Designing, implementing and monitoring of appropriate services Prevent disabling conditions, detect disabilities early and prevent complications Basic assessment

Rehabilitation services

103

Appendix 2 Conditions covered in Standard treatment Guidelines (2008) Dental and oral conditions Gastro-intestinal conditions Cardio-vascular conditions Skin Obstetrics and gynaecology Family planning Kidney and urological Endocrine Infections and related conditions HIV Sexually transmitted infections Immunisation Musculoskeletal Central nervous system Respiratory Eye Ear, Nose and throat Pain Trauma and emergencies

104

Appendix 3.

Fact Sheets and Guidelines available on department of Health website3 Clinical Guidelines for the Management of HIV & AIDS in Adults and Adolescents 2010 The South African Antiretroviral Treatment Guidelines 2010 Guidelines for the Management of HIV in Children 2nd Edition 2010 Clinical Guidelines: PMTCT (Prevention of Mother-to-Child Transmission) 2010 Guidelines for an Environmental Health Officer (EHO) engaged in food poisoning investigations October 2001 Guidelines for the Prevention of Malaria in South Africa - 2009 Guidelines for the Treatment of Malaria in South Africa - 2009 Saving Mothers - Essential Steps in the Management of Common Conditions Associated with Maternal Mortality Guidelines for the Management, Prevention and Control of Meningococcal Disease in South Africa Regular Treatment of School-Going Children for Soil-Transmitted Helminth Infections and Bilharzia Guideline for Leprosy Control in South Africa 2008 Road to Health Chart guidelines (Updated: 2003) National guideline on prevention of blindness in South Africa. 2002 National Guideline on Management of Osteoporosis at Hospital Level Preventative Measures at primary Level Guideline for the Promotion of Active Ageing in older Adults at Primary Level. 2000 National Guideline on Prevention, Early Detection/Identification and Intervention of Physical Abuse of Older Persons at Primary Level. 2000 Human Genetics Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects and Disabilities National Guideline on Prevention of Falls of Older Persons. 1999 National Guideline on Management and Control of Asthma in Children at Primary Level. April 1999 National programme for control and management of Diabetes Type 2 at primary level. 1998 Hypertension National programme for control and management at primary level. 1998 National Guidelines on Cervical Cancer. National Guidelines on Management and control of eye conditions at primary level. National Guidelines on Primary prevention of chronic diseases of lifestyle National Guidelines on Primary Prevention and Prophylaxis of Rheumatic Fever (RF) and Rheumatic Heart Disease (RHD) for Health Professionals 0at Primary Level Guideline for the prevention of hearing impairment due to otitis media at clinic level National guideline on management of asthma in adults at primary level. 2002 National Guideline on Management and Control of Asthma in Children at Primary Level. 2007 User's Guide to Primary Health Care Services Practical Guidelines for Infection Control in health Care Facilities. 2003 Guidelines for Environmental Health Officers in the implementation of the HACCP system. 2000 National Guideline on Foot Health at Primary Level.2000 National Contraception Policy Guidelines Decentralised Management of Multi-Drug Resistant Tuberculosis. A policy Framework for South Africa 2010.

Where no date is given for the guidelines, it does not exist

105

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Clinical Associate

GLOSSARY Current Role Currently the clinical associate does not exist as a category of health in both the public and private health care services

Community Health Worker

Community health workers are lay health workers that are deployed by communities to NPO/CBO services to support community based services. Currently most CHWs provide home based care services. Currently there are lay counselors that provide counseling services for pre- and post- HIV testing, adherence counselors, DOTS support workers. These usually provide counseling services in one of the aforementioned areas. These counselors are not formally employed by the Department of health however they are paid from conditional grants or other types of donor funding. Is a person who is enrolled by the SANC as a nurse after completing a two year further education and training certificate (Grade 10 + 2 years training further education and training) The enrolled nurse is not the same category as the staff nurse. Is a person who is enrolled by the SANC as a nursing auxiliary after completing a 1 year further education and training certificate (Grade 10 + 1 years training further education and training). The enrolled nursing auxiliary is also referred to as a nursing assistant Home based carer is a lay health worker that provides basic care and support for activities of daily living. Currently this category of health worker is employed by NPO/CBO/NGO to provide care and support to terminally ill, elderly and persons who have full blown AIDS. Although not employed by the public health sector the services of home based care are supported through conditional grants or donor support grants.

Counselor

Proposed role This is a new cadre of health care worker that is the midlevel worker of medical practitioners. The clinical associate is regulated by the Health Professions Council of South Africa and may only work under the direct or indirect supervision of a medical practitioner. The education and training of the clinical associate is currently prepares this category of health care worker to work only in district hospitals. The proposed role of CHWs is for them to play an active role in the formal health care delivery service. The CHW will not be providing care but will play a role in linking families to health services, identifying high risk families and individuals. The counselor proposed is a practitioner that will provide an integrated counselling service that will include pre and post diagnosis, treatment adherence, post traumatic and trauma counselling services.

Enrolled Nurse

The enrolled nurse category in terms of the Nursing Act (2005) will be phased out and replaced by the staff nurse.

Enrolled Nursing Auxiliary

Home Based Carer

The role of the enrolled nursing auxiliary will remain unchanged. In terms of the Nursing Act (Act 33 of 2005) this category of nurse is re-named auxiliary nurse. The scope of practice of a auxiliary nurse is a educated to provide elementary nursing care. The services of the home based carer remains unchanged expect that there should be sustainable funding mechanisms.

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PHC Nurse Practitioner

Post Basic Pharmacist Assistant

Professional Nurse

Staff Nurse

This is a professional nurse who has additional training in clinical nursing science, assessment, diagnosis, treatment and care. These nurses have been employed in PHC facilities especially where there are no doctors to conduct medical assessments, diagnose and treat patients. These nurses were authorized to fulfill this extended function in the public sector by the Director General in accordance with section 38 A of the Nursing Act (Act 33 of 1978). The Pharmacy Council of South Africa (PCSA) registered the post basic pharmacy assistant as a mid-level health worker to address the challenges facing the health care system with regard to the shortage of pharmacists. Although training and registration of post basic pharmacists commenced as early as 2004 this category of mid-level health worker has not been embraced by the public health services. A concerted effort is required to increase both the production and employment of post basic pharmacist assistants in the public sector. is a person that meets the qualifications and clinical requirements to practice as a competent professional nurse. The professional nurse may be registered as a general nurse, midwife, psychiatric and /or community health nurse. The registration of a professional nurse in all 4 basic disciplines in nursing enables the professional nurse to practice comprehensive nursing. Not all professional nurses are comprehensively trained; a professional nurse may register only as a general nurse and/or in any one or more of the 4 basic disciplines. The professional nurse may be a 4 year diploma offered by a nursing college (the majority of the professional nurses have this qualification), a degree offered by a university or a bridging course which is a 2 year qualification to upgrade enrolled nurses to practice as a professional nurse. The bridging course only leads to registration as a general nurse and this professional nurse does not have the qualification for comprehensive practice This category nurse is a new category of nurse and currently there are no staff nurses registered by the SANC

The function of this category of nurse remains unchanged. The conditions for authorizing the functions previously rendered according to section 38A of the Act 33 of 1978 are now replaced by section 57 of Act 33 of 2005.

The post basic pharmacy assistant will play an important role in providing pharmaceutical services at a PHC clinic.

According to the scope of practice of a professional nurse in Act 33 of 2005 the professional nurse is a person who is qualified and competent to independently practise comprehensive nursing. By implication all professional nurses are required to receive comprehensive training in the 4 basic areas of nursing (general, obstetric, mental and community health)

The scope and education and training of this new category of staff nurse was developed in direct response to the need for a mid- level nurse and other categories of mid-level health workers as per the policy of the department of

113

Health. The scope of this category of nurse in terms of the Nursing Act (Act 33 of 2005) is to practice basic nursing.

Appendix 2: Glossary of HR workers

114

APPENDIX 2: RECOMMENDATIONS ON HUMAN RESOURCES

National Broad Issue Specific application Comment Action Short Term 12 months Medium term 1-2 years Long Term 2-3 Years Responsible authority

1.

Implementation of the reengineered PHC service

1.1 Establish national, provincial and district implementation teams that will drive the implementation of a reengeneerd PHC service 1.2 Publish a detailed directive outlining the role, function, responsibility of the PHCT in providing PHC services 2.1 Conduct a HR audit determines the gap between the number of staff needed and those available.

DG and Heads of Health

National implementation team

2.

Determine HR required to implement the reengineered PHC service

2.2 Develop a HR recruitment strategy and plan for each province and district 2.3 Secure finances to fund the HR requirements from treasury 2.3 Recruit and/or Contract staff 3.1 Conduct a HR audit determines the gap between the number of staff needed and those available. 2.2 Develop a HR recruitment strategy and plan for each priority district 2.3 Secure finances to fund the HR requirements from treasury 2.3 Recruit and/or Contract staff

Provincial implementation team DG and Heads of Health Provincial implementation team Provincial implementation team DG and Heads of Health District

3.

Establish PHC teams in the 18 priority districts

115

National Broad Issue

Specific application

Comment

Action

Short Term 12 months

Medium term 1-2 years

Long Term 2-3 Years

Responsible authority

4.

Have an enabling Regulatory framework for professional practice and education and training

4.1 Professional Nurse

Partially Completed

4.2 Midwife

Partially completed

4.1.1 Publish new scope of practice regulations 4.1.2 Publish education and training regulations 4.1.3 Support training institutions through a generic training curriculum and training resources that can be adapted by individual training institutions 4.1.4 Develop a national strategy to provide support provinces and education institutions to implement the new qualification 4.2.1 Publish scope of practice regulations 4.2.2 Develop and register qualification based on revised scope of practice 4.2.3 Constitute an expert midwifery reference group 4.3.1 Publish education and training regulations 4.3.2 Support training institutions through a generic training curriculum and training resources that can be adapted by individual training institutions 4.3.3 Develop a national strategy to provide support provinces and education institutions to implement the new qualification

management team HR Directorate & Legal unit HR Directorate & Legal unit HR Directorate and SANC

HR Directorate and SANC

HR Directorate & Legal unit SANC SANC HR Directorate & Legal unit HR Directorate & SANC

4.3 Staff Nurse

Partially completed

HR Directorate and SANC

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National Broad Issue

Specific application

Comment

Action

2.4 Nurse Prescriber

Partially completed

2.5 PHC Nurse

Partially completed

2.6 Clinical Associate

Completed

2.7 Community Health worker

Partially Completed

2.4.1 Publish regulations to give effect to section 56 of the Nursing Act, 2005 2.4.2 Determine and publish the prescribed educational requirement for licensing a practitioner 2.5.1 Develop an scope of practice for advanced nurse practitioner 2.5.2 Develop and publish educational requirements for registration of an advanced practice nurse 2.6.1 Facilitate national mechanisms for creating clinical associate posts in district hospitals in provinces 2.6.2 Identify funds for funding clinical associate positions 2.6.3 Develop and implement a communication strategy to communicate the role and function of the clinical associate 2.7.1 Publish scope of practice Policy guidelines & directives

Short Term 12 months

Medium term 1-2 years

Long Term 2-3 Years

Responsible authority

HR Directorate & Legal unit SANC

SANC SANC & HR Directorate & Legal unit

HPCSA HPCSA & HR & Communication Directorates HR Directorate

1.7.2 Develop and publish education and training requirements for practice

HR Directorate

Provincial ISSUE

ACTIONS

5.

Scale up production

2.1.1 Conduct an audit to assess production capacity of

Short term Under 12 months

Medium Term Between 1-2 Years

Long Term Between 2-3 Years

Responsible authority Provincial HRD

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Provincial ISSUE

ACTIONS

Short term Under 12 months

Medium Term Between 1-2 Years

Long Term Between 2-3 Years

Responsible authority unit and training institutions

and recruitment to address shortage of health professionals

the training institutions in the province

2.1.2 Identify resources required to increase provincial training capacity 2.1.3 Identify annual training and recruitment targets for all categories of health professionals required 2.1.4 Identify funding mechanisms for supporting training of health professionals (training post, bursaries, scholarships) 2.1.5 Determine skill mix and training targets for each category of health professional 2.1.6 Develop and implement a short term training strategy (in-house and outsourced training, bursary and training posts) 2.1.7 Secure resources and funding for implementing the training and skill development strategy

Provincial HRD unit and training institutions HOD Provincial HRD unit HOD Provincial HRD unit

HOD Provincial HRD unit HOD Provincial HRD unit HOD Provincial HRD unit

District/Facility Level ISSUE 6. Mismatch between skills and competence of health professionals and requirements for the delivery of the primary health care 4.1 Skills and competence assessment and development

Actions 4.1.1 Conduct an annual/ periodic audit of the level of skills and competence of the staff of the facility against the required set of skills to determine the skills and competence deficit in the facility

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MTM

LTM

Responsible authority

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District/Facility Level ISSUE package

Actions

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MTM

LTM

Responsible authority Team leader/facility manager Team leader/facility manager Team leader/facility manager Team leader/facility manager Team leader/facility manager Team leader/facility manager Clinical Leader

4.1.2 Develop and implement a facility based skills development plan 4.1.3 Develop a mentorship/support programme for staff that do not the requisite skills and competence 3.2.1 Put in place a performance and personal development plans for each employee 3.2.2 Put in place team performance targets

4.2 Supervision and performance of PHC teams

3.2.3 Compile policies, procedures, SOP, and protocols for implementing the primary health package at the facility 3.2.4 Conduct regular review meetings to assess progress with performance targets 3.2.5 Conduct regular clinical audits and reviews to support good clinical governance

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Appendix 4: Comparison of Scope of Practice of enrolled nurse and staff nurse

Comparison of Scope of Practice of the Current Enrolled Nurse with the Scope of Practice of the New Staff Nurse Category THE SCOPE OF PRACTICE OF ENROLLED NURSES (CURRENT) THE SCOPE OF PRACTICE OF STAFF NURSES (NEW) The scope of practice of an enrolled nurse shall entail the following acts and It is within the competence of a staff nurse to assume full responsibility and procedures as part of the nursing regimen planned and initiated by a registered accountability for: nurse or registered midwife and carried out under his direct or indirect (1) The provision of basic nursing care and treatment of persons with supervision: stable and uncomplicated health conditions in all settings; a) The carrying out of nursing care to fulfill the health needs of a patient (2) Providing basic emergency care or a group of patients; (3) Assessing and developing a plan of nursing care for persons with b) caring for a patient, and executing a nursing care plan for a patient, stable and uncomplicated health conditions. including the monitoring of vital signs and the observation of reactions (4) The nursing care of persons whose health condition is stable and to medication and treatment; uncomplicated in a unit of an overall health facility or service. c) the prevention of disease and the promotion of health and family (5) Nursing care delegated by a professional nurse planning by means of information to individuals and groups; d) the promotion and maintenance of the hygiene, physical comfort and Including: reassurance of a patient; (1) The clinical practice of a staff nurse is to provide basic nursing care e) the promotion and maintenance of exercise, rest and sleep with a for the treatment and rehabilitation of common health problems for view to the healing and rehabilitation of a patient; individuals and groups. Such practice requires a practitioner tof) the prevention of physical deformity and other complications in a (2) Assess and screen the health status through basic observation, patient; interaction and measurement; g) the supervision over and maintenance of a supply of oxygen to a (3) Interpret data and diagnose basic nursing needs; patient; (4) Develop nursing care plans to meet basic health care and nursing h) the supervision over and maintenance of the fluid balance of a needs; patient; (5) Take responsibility for the implementation of the care plan he/she i) the promotion of the healing of wounds and fractures, the protection developed; of the skin and the maintenance of sensory functions in a patient; (6) Manage all aspects of delegated nursing care; j) the promotion and maintenance of the body regulatory mechanisms (7) Ensure timeous referral and appropriate consultation with a and functions in a patient; professional nurse or midwife or other health professionals; k) the feeding of a patient; (8) Promote health through the provision of relevant information; l) the promotion and maintenance of elimination in a patient; (9) Maintain continuity of care through reporting and communication to m) the promotion of communication by and with a patient in the care givers and members of the health care team; execution of nursing care; (10) Evaluate a health care users progress towards expected outcomes n) the promotion of the attainment of optimal health in the individual, and revise the nursing plan of care in accordance with such the family, groups and the community; evaluations; o) the promotion and maintenance of an environment in which the (11) Create and maintain an accurate record of nursing interventions; physical and mental health of a patient are promoted; (12) Establish and promote a supportive and helping relationship with a p) preparation for and assistance with diagnostic and therapeutic acts by health care user;

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a registered person; q) preparation for and assistance with surgical procedures and anaesthetic; r) care of a dying patient and a recently deceased patient.

(13) Maintain an environment that promotes safety, security and respect of the health care user; (14) Maintain a safe environment for nursing care; (15) Advocate for the rights of health care users; (16) Promote participation of health care users in their health care and empower them towards self reliance; (17) Demonstrate and maintain clinical competence to ensure safe practice as a staff nurse. (18) Render basic life saving interventions in an emergency situation The quality of nursing practice of a staff nurse requires the practitioner to(1) Participate in the maintenance of set standards to improve the quality of nursing care; (2) Utilize learning opportunities to improve own nursing practice; (3) Continuously review own performance against standards of practice; LIMITATIONS OF PRACTICE OF A STAFF NURSE (1) A staff nurse may not take responsibility and accountability for managing overall nursing care in a health facility or service. (2) A staff nurse may only provide nursing care and treatment to persons who have complicated health problems or are in an unstable condition under the supervision of a professional nurse. (3) May not conduct a private practice. (4) A staff nurse must comply with the provisions of section 56 of the Act to assess, diagnose, prescribe treatment, keep and supply medication for prescribed illnesses and health related conditions.

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