Health Systems Trust (HST) is a leading force in the South African public health arena. Established in April 1992 on the brink of democracy in South Africa, HST has played a significant role in the evolution of the new national health system; today, our strength lies in the knowledge, insight and experience we harness through synergising our research and implementation outputs towards our vision of health for all through strengthened health systems.
With a founding mandate to support the development of the post-apartheid health system, our scope of operation ranges from regional and national levels, through provinces, districts and facilities and into communities, and is expanding into the southern African region. HST’s areas of expertise include information for decision-making, leadership and community engagement, human resources, and quality improvement of service delivery. In short, we support the health system and those who work in it.
With a strong and credible brand, extensive capacity for innovation, and unfailing passion shared by over 400 employees, HST offers a wealth of talent and powerful assets to health system enhancement. While our nuanced grasp of the challenges faced at primary health care level has led us to develop inventive, locally responsive solutions in support of the global health agenda, we provide effective assistance for the introduction of universal coverage in health services through South Africa’s National Health Insurance, and in initiatives such as the re-engineering of primary health care (PHC) and improving quality of care.
HST operates across its Programmes and Corporate Services directorates. The wide variety of projects managed by the directorates is arranged according to our five core business areas:
- Providing management and implementation support in health districts
- Supporting implementation of priority health programmes
- Conducting essential national health research
- Generating information for planning, monitoring, evaluation and decision-making
- Offering guidance, mentoring and training on good practice development
Our Programmes directorate comprises two health systems strengthening units – one focusing on research and the other on implementation perspectives – that together work seamlessly to deliver on our mission to be a partner of choice in building comprehensive and equitable health systems.
Corporate Services consists of a number of specialist units – finance, human resources, information technology, administration, and marketing and communications – that are fully resourced with the requisite expertise and infrastructure to both maintain and respond to new directions in HST’s operational mandate. Skilled management of large-scale grants awarded to HST ensure that donor funding is effectively and responsibly disbursed.
An independent Board of Trustees, comprising a diverse group of 12 professionals, guides and provides oversight of HST, thus ensuring efficient and vigorous corporate governance practices that have yielded a flawless record of unqualified audits since HST’s foundation in 1992.
Our projects are frequently interrelated in practice, foregrounding the multi-faceted nature of health systems and the dynamic relationships that drive healthcare delivery. Now renowned for accomplishments in research and implementation embedded in a culture of continuous improvement, HST is proud to partner with numerous organisations and funding institutions in South Africa and internationally.
Providing management and implementation support in health districts
In its early years, HST swiftly established benchmarks for excellence in building capacity and systems in health districts and sub-districts. The journey of improvement towards optimum health systems encounters perennial challenges, our approach in applying good practice in management and implementation support has resulted in far-reaching transformation of public health in South Africa, as the following projects illustrate.
South Africa Sustainable Response to HIV, AIDS and TB (SA SURE) provides sustainable technical support for health systems strengthening, with particular focus on HIV and AIDS and maternal, child and women’s health. HST’s mandate is to provide comprehensive district-level support in several provinces, ensuring that programmes are effectively delivered and integrated with other PHC interventions. This five-year programme is based on a consultative and mentoring approach involving district, sub-district and programme managers, extending to staff at facility level as well as communities.
Demonstrating the evolving process of strengthening health systems, SA SURE has generated several sub-projects which enable us to adapt, advance and innovate interventions. To address waiting times created by a growing number of patients on antiretroviral treatment (ART), the Chronic Medication Dispensing and Distribution (CCMDD) project is improving access to chronic medication. This is has been achieved by contracting service providers to supply stable chronic patients with fixed-dose combination medication at more convenient “pick-up-points”, close to their home or workplace. The Implementation of RxSolution project supports and facilitates a pharmacy information management system to assist pharmacists based in hospitals and clinics to effectively manage their drug stocks. The Implementation of the Ideal Clinic Dashboard will provide clinics with the means to proactively identify their own areas of low performance, and implement Quality Improvement Plans to ensure adherence to the National Core Standards established by the Office of Health Standards Compliance.
Among our completed projects supporting South Africa’s PHC re-engineering initiatives are Re-engineering Quality Improvement (RQI) – which focused on training and mentoring with the Leadership Development Programme model for improving service delivery at facility level – and Strengthening Sub-district Health Management Teams’ Capacity for Service Delivery, covering management, planning and measurement of primary health care service performance.
In the realm of mobile health technologies (mHealth), HST has provided mentorship support and training for health workers and community health workers on MomConnect, an initiative offering information on pregnancy and accessible mother-and-baby clinics via free SMS messaging services to all South African pregnant women.
Supporting implementation of priority health programmes
Improved health outcomes for the uninsured population are the ultimate gauge for assessing South Africa’s health care delivery. Priority interventions include the response to HIV, AIDS and TB, as well as programmes to improve maternal and child health.
Building on the work undertaken in the HIV Counselling and Testing project, which raised awareness of HIV counselling and testing (HCT) through a targeted national media campaign, the HIV/AIDS and TB project involves the implementation of a HCT public-private partnership franchise model which seeks to expand HCT coverage in the Northern Cape and Limpopo Provinces. A core component of the project is continuous training and quality control for all service providers involved.
As a partner in the Reducing Maternal and Child Mortality through Strengthening Primary Health Care (RMCH), HST has developed and implemented the national induction and orientation training of district clinical specialist teams, including team leaders of community health workers. The project addressed the provision and monitoring of early antenatal care and neonatal services, and led to the development of educational resources to support the national contraceptive and fertility planning guidelines.
Consolidating a strong focus on maternal and child health, Maternal Events in Pregnancy (MEP) measured severe adverse events, pregnancy outcomes and congenital birth defects in infants of women receiving ART. This project arose from general advice to pregnant women not to take a large number of drugs because of potential or proven adverse effects on their unborn babies, which militates against adherence to antiretroviral medication.
The Programme for Economic Evaluation of Child and Maternal Health Interventions (PEECHI) focused on identifying, informing and establishing the most affordable, effective and scalable interventions for attaining the Millennium Development Goals (MDGs) for maternal and child health, HIV and AIDS, sexually transmitted infections and tuberculosis.
Conducting essential national health research
HST’s research contributes to informing and transforming public health policy and practice. Within the ambit of priority health programmes, we adopt a systems approach to cover a wide range of focus areas including leadership and governance, financing, service delivery, human resources and health information.
Recognising the need to understand the quality of care and the state of infrastructure at health care facilities ahead of National Health Insurance, the National Health Care Facilities Baseline Audit was commissioned to assess improvements required to comply with the National Core Standards. The Audit focused on the six ministerial priority areas for improving patient-centred care and recommended the future planning investments for strengthening the national health system. The report continues to inform quality improvement initiatives at implementation level in the health facilities.
Shortfalls identified in our health system are being addressed under the Primary Health Care Re-engineering Programme, a pivotal initiative that seeks to accelerate implementation of programmes and services through systematic building and strengthening of provincial, district and sub-district management teams’ capacity to implement the PHC re-engineering strategy.
The National Health Research Database (NHRD) is an electronic system established to track and monitor all health research being conducted and ethical approvals granted in health facilities across South Africa. The web-based database was funded by the NDoH and developed to facilitate efficient research administration and an easy application process for researchers.
The report entitled Documenting Good Practices in the Public Health Sector of South Africa: From policy to practice presented insights into the range of initiatives taking place within the South African public health sector, and facilitates understanding about good practice identification and knowledge-sharing for improved management and service delivery.
As part of a World Health Organization multi-country initiative to propel universal health coverage, HST co-authored the paper Monitoring and Evaluating Progress towards Universal Health Coverage in South Africa which was published in PLOS Medicine.
HST was commissioned to revise the Draft Policy Framework and Strategy for Disability and Rehabilitation Services Disability Strategy and Framework for providing access to services for the disabled at all levels of the South African health system.
The Injury Morbidity Surveillance in Khayelitsha and Nyanga has focused on establishing a risk profile for non-fatal injuries at district-level hospitals and community health centres.
Generating information for planning, monitoring, evaluation and decision-making
Information, communication and dissemination of key health-related information have formed a cornerstone of HST’s work, driven by our commitment to monitor health service equity and to manage various channels and platforms for sharing such findings.
HST produces two annual flagship publications: the South African Health Review and the District Health Barometer.
The South African Health Review is an accredited peer-reviewed journal of critical analysis and commentary by specialists on key issues relating to health systems policy and practice. Containing South African perspectives on health policy developments and their implementation, as well as monitored changes and challenges in the provision of equitable and accessible health care in the country, the Review has gained increasing prestige as an authoritative and comprehensive resource.
The District Health Barometer is a comprehensive statistical and analytical resource providing an overall view of district health performance at the primary healthcare level, including hospitals. Covering 52 health districts in nine provinces, the Barometer is used as a resource by the NDoH to develop strategy, monitor district performance, and inform planning at national and provincial levels.
The Annual Health Statistics compilation offers key health data reflecting aspects of service delivery across national, provincial, district and sub-district levels. This work has included the development of the database and data collection tools, as well as building capacity within the NDoH to maintain outputs.
To decrease the burden on healthcare workers when collecting vertical programme data, the Rationalisation of Registers project has sought to relieve them of manually completing up to 54 different facility registers. By reducing this number to six registers per facility, healthcare workers are now able to devote significantly more of their working day to patients’ needs.
In the area of practical applications of Health Management Information Systems, HST provided technical assistance in the computerisation of the Electronic Medical Record (EMR) system for the Lesotho Health Systems Strengthening Project. In a ground breaking initiative, HST was one of the lead partners in developing a full electronic medical record system for some NHI districts in KwaZulu-Natal. Additionally, new EMR modules have been developed and implemented which effectively allows community health workers to register patient details at their homes.
Stories of Change is a publication series presenting quality improvement case-stories that describe how SA SURE Project teams are translating policy into practice in health facilities across the country, and thus achieving sustainable responses to HIV, AIDS and TB.
HST also issues a regular digest and manages several discussion groups to encourage dialogue between key public health stakeholders. The HST Bulletin is a twice-monthly digest of key public health news, peer-reviewed journal articles and other important primary health care resources compiled from a wide range of local, regional and international sources and transmitted to a subscriber list. Acknowledging the feminised HIV/AIDS epidemic estimated to affect 60% of women in southern Africa, the 60percent List is a moderated electronic discussion group which shares current peer-reviewed and media articles on HIV/AIDS within a gender, women's rights and sexual and reproductive health and rights lens through the continuum of prevention, treatment and care. HST’s DrugInfo moderated list is a lively discussion group which aims to keep health practitioners at all levels abreast of drug information, developments in drug policy in South Africa, and targeted pharmacological information. The HST website, accessed by approximately 40 000 visitors monthly, has become a respected hub of health and socio-economic indicators and public health information in South Africa.
Offering guidance, mentoring and training on good practice innovation
Continuous innovation and improvement in health service delivery can only be realised when health workers and community members are empowered and capacitated to become active participants and decision-makers in the process.
Being accredited by the Sector Education and Training Authority (SETA), HST offers officially recognised skills training in HIV/AIDS management to primary health care workers.
The Research Training Manual Project comprised the development of a training resource on research methodology aimed at provincial and district managers and staff members. So far, the two- or three-day workshops have been conducted in the Northern Cape and Gauteng Provinces, with notable growth in demand for such capacity-building.
The Resource Manual for the Capacity Strengthening of Health Governance Structures, as a response to the requirements of the National Health Act, brings accountability to structures such as hospital boards, clinic committees, community health centre committees and district health councils. The Manual supports the induction of new members into governance structures and is a valuable resource for strengthening community capacity to engage in leadership of health service delivery.
The innumerable changes taking place in the South African health system have profoundly affected the people on whom we rely to execute new programmes and services. Frontline managers who participate in the Wellness for Effective Leadership (WEL) programme report the immense value derived from learning new methods of coping with day-to-day challenges in an ever-changing work environment.