1
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 YoganPillay, 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 byThulani 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 portfoliocommittees and MECs at a round table meeting in Umhlanga Rocks on 2 November 2010. Thepresentation made a number of recommendations which appeared to be well-received but whichneed more discussion. This document provides more substance and background to theserecommendations and serves as a discussion document for formalising those recommendationswhich 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 departmentsof health have been established out of the fragmented state of pre-1994 South Africa. Racial andgender inequalities in the managerial structures have been largely eliminated. There has been alarge investment in infrastructure and building of new clinics and facilities to make health servicesmore accessible. Services have been massively scaled up to deal with the burden of disease thatincludes HIV and associated TB epidemic.4.
However, insufficient attention has been given to the implementation of the PHC approach thatincludes taking comprehensive services to communities emphasising disease prevention, healthpromotion and community participation. For the most part there has not been a population focusand insufficient attention has been given to the improvement and the measurement of healthoutcomes. In addition the massive tsunami of HIV has diverted much energy, time and resourcesfrom 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 thereare 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.
25.2.
South Africa has poor outcome indicators relative to the amount of resources that are beingspent in the health sector compared to most middle income countries. Much of this is due tothe 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 SouthAfrica is unlikely to achieve the MDG health indicators for infant, under-five and maternalmortality 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 indicatorsthrough his negotiated service delivery agreement (NSDA).5.5.
Many of the health problems are
linked to the social determinants of health (“upstreamfactors”) 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 documentdoes not try and rewrite these documents but is focussed on making practical recommendations forimplementation. The three key recommendations are essentially:6.1.
Strengthen the district health system (DHS), through the implementation of chapter 5 of theNational Health act, and do the basics better.6.2.
Place much greater emphasis on population based health and outcomes, which includes a newstrategy for community-based services through a PHC outreach team based on communityhealth workers (CHWs) and mobilising communities.6.3.
Pay greater attention to those factors outside of the health sector that impact on health, thesocial
determinants of health (“upstream factors”)
7.
The bulk of this document is built upon making a range of practical suggestions for the “re
-
engineering of PHC in SA”. These are largely structured around the WHO framework for health
systems strengthening
1
contained in Figure 1. In addition there are a number of community basedinitiatives in provinces which can provide additional lessons for PHC. These include, but are not
limited to, the Premier’s Flagship Project in KZN and the Letsema Circle Project in the E
astern Cape.
1
World Health Organization.
Everybody’s Business. Strengthening Health Systems to Improve Health Outcomes: WHO’s Framework for Action. Geneva: World
Health Organization, 2007
.
3
Figure 1
DISTRICT HEALTH MODEL
8.
The district health system (DHS) is the vehicle by which all Primary Health Care (PHC) is delivered. Agraphical illustration of rendering PHC services within the DHS is displayed in Figure 2. The districtmanagement 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, communityhealth centres and clinics. Each of these facilities will have a defined catchment population; normsand standards for the human resources allocated to each facility. Each clinic will have a PHCoutreach 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 healthteams, oral health teams and rehabilitation teams. These support teams will function as cross-cutting services.11.
It is recommended that all funds for the functioning of the DHS and the associated PHC should beunder the control of the DMT both in terms of budgeting and financial management. The DMTshould 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 thereare gaps.12.
With the NHI in mind it is also recommended that the DMT become the fund holders for anyproposed PHC capitation and become responsible for allocation of budgets to ensure the necessaryservices. In the short term they will probably require provincial support and mentoring for contractmanagement.
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Draft 2010 document on the Re-engineering of Primary Health Care in South Africa
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…
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