Health policy

Progress Towards District Based Care

Series Name: 
HST Update
Published by: 
Health Systems Trust
This issue of HST Update documents progress towards district systems development from all three angles. First, we examine the policy environment in which district development is occurring, and assess the degree to which outstanding policy issues are being resolved. Second, we guage provincial efforts to restructure health services toward district-based care. Finally, we examine several initiatives which home in on service delivery, and describe how these initiatives help give practical meaning to district-based health care.

Health Information

Series Name: 
HST Update
Published by: 
Health Systems Trust
Our new constitution of the Republic of South Africa declares under Chapter 10, Section 195 on Basic Values and Principles Governing Public Administration that: Transparency must be fostered by providing the public with timely, accessible and accurate information. This mandate can only be realised if we have an appropriate and effective information system at all levels of the health system that provides accurate information on the health status and trends in health status of the population.

District Hospitals

Series Name: 
HST Update
Published by: 
Health Systems Trust
When I first worked in South Africa, it was as a medical officer in a 280 bed (but 400 patients) rural hospital in northern KwaZulu. There were five other doctors, and I was asked to look after the male medical ward as well as several OPD/casualty and theatre sessions. When on call, there were obstetric, surgical and paediatric responsibilities to deal with as well. The case mix was varied, interesting and challenging. But it was also a responsibility that at times was a source of great stress. The reason for this was that in a rural area one quickly becomes aware of how important hospital services are to the local population. A bad hospital service can lead to a high perinatal and maternal death rate children dying on the wards from preventable diseases surgical patients dying from post-operative bleeding or sepsis a fractured limb being permanently disfigured because it wasnt properly reduced a young boy losing a leg from a snakebite because a fasciotomy wasnt performed or an infant crying in agony because inadequate analgesia was provided for his/her second degree burns. In many parts of the country, the lack of skilled staff and equipment, as well as the unavailability of a back-up service means that there is a low margin for error. As a result, because of the inadequate standard of care in some district hospitals, there are many patients dying from treatable conditions, and from omissions or mistakes in health care. On the other hand, a good District Hospital is a source of pride for both staff and with community. In addition, my experience in Kwazulu also made me realise that a really effective District Hospital was one that did much more than provide medical and nursing services within its four walls. Amongst other things, the hospital that I worked in was central to the success of a district-wide TB programme using community-based supervised treatment points, and an obstetric service that provided support, training and referral guidelines to clinic nurses and midwives. The hospital also provided clinics with drugs, equipment and administrative support. This was how many District Hospitals, especially in the former homeland areas operated, and which explains the use of the term mother hospitals. Hospitals were actually seen as playing a maternal and nurturing role to clinics and mobile services. Ideally, the District Hospital, clinics and community-based health activities (such as CHW programmes) would be considered as different parts of a single and integrated system of Primary Health Care. In contrast, having separate management structures for your hospital and for clinics would be like a human body having one brain that controlled your legs and another brain that controlled your arms - it could work, but it would never be as good as one brain coordinating all limbs. However, in our move to establish the DHS in South Africa, there has been a tendency to draw a line between the District Hospital and Primary Health Care (PHC). This may be due to confusion between the terms Primary Health Care and primary level care. The former is an approach or philosopy whereas the latter refers to health care provided in clinics and health centres. Because of the confusion, PHC often has been mistakenly equated with clinic care, and there has been a misconception that the District Office is only for primary level care. While it is often argued that you need to separate the hospital from the primary level facilities so that the hospital will not end up consuming most of the districts resources at the expense of clinics and community-based health care, there are many other ways of ensuring that hospitals do not function to the detriment of clinics and comunity-based services without creating an artificial and inefficient line of separation between District Hospital services and the other PHC services. The tendency to separate hospitals from primary level care may also be due to the fact that as a whole, hospitals consume too much money. However, the major culprits for this are the academic, tertiary and secondary hospitals, and not District Hospitals. It would be much better to draw a line between Level 1 hospital services and other higher levels of hospital care, than to draw a line between Level 1 hospitals and primary level care. Finally, a message to any junior doctors or senior medical students who may be reading this. This country really needs fewer specialists and a greater number of generalist hospital-based doctors who can perform a range of different functions. At the moment, I cant think of many more satisfying jobs than to work as a District Hospital medical officer providing clinical services, training and support for other health workers and giving medical input into PHC planning and district development.

Focus on Rural Health

Series Name: 
HST Update
Published by: 
Health Systems Trust
If the principal aim of the public health sector is to improve the health of South Africans, then our focus must be the health of rural people. In other words, the reform efforts and upheavals which have left the South African health system creaking and groaning in protest must continue until it is turned on its head - and is explicitly biased towards rural health. Rural people bear the greatest burden of disease, mainly because rural people bear the greatest burden of poverty. But paradoxically, urban dwellers are better served by both public and private health care resources. Simply put, rural people are generally poorer and less healthy -and have less access to health care.

Equity

Series Name: 
HST Update
Published by: 
Health Systems Trust

Parents are usually instinctively aware of any of their children who are particularly vulnerable and if they are able to, take the time and trouble to give that child a bit of extra support and extra care. If we are to promote equity in our society we have to find ways of ensuring that our most vulnerable communities and individuals have access to more resources than those who are less needy. Only by doing so will the huge gaps between the haves and the have nots be lessened.

District Health Expenditure Review - Mount Currie Health District

Published by: 
Health Systems Trust

Introduction

This report documents the findings and conclusions of the first district expenditure review run for the Mt. Currie health district. The year under review is the government financial year, April 1997 to March 1998. Mt. Currie is a health district bordering on the Eastern Cape, in the southernmost part of the KwaZulu-Natal (KZN) province. Its close proximity to the Eastern Cape border, and the regions geography, have meant that the main towns in the district, Kokstad and Matatiele, have for years acted as commercial centres for rural areas extending into the Eastern Cape, or what was formerly known as the Transkei. This fact, together with the history of the regions administration, means that the health services in the district are well frequented by residents of the Eastern Cape. These cross-border flows made it essential to calculate the district catchment population, which was estimated at 247 537 people in 1997/98.

A full range of health services are rendered in the district, including primary health care services, environmental health services, district hospital level services and laboratory services. A number of health services to the district are still run directly by the province, or the regional office. In addition, as in many districts, there are two main public sector authorities running health services namely local governments (municipalities) and the KZN provincial government. The two local authorities in the district are Matatiele and Kokstad.

No Transport, No Primary Health Care! Monitoring and improving the use of health service vehicles

Published by: 
Health Systems Trust
In the Mount Frere Health District, the District Management Team (DMT) has made considerable improvements in the control and monitoring of vehicles. However, despite this, there is a common cry from programme managers, clinic supervisors, doctors and administrative staff that there is a shortage of transport for them to carry out their functions adequately. Because transport is so critical to so many functions, it is not surprising that there is a relative lack of transport, compared to needs. It is therefore important that districts make sure that they use their limited transport resources efficiently and effectively.