Summary Bulletin 9 - DHS-LG Discussion List

STAFFING NORMS FOR PHC

National norms

• Number of expected visits per person per year to a primary level facility – i.e. utilisation rate of facilities. This may vary between provinces and within provinces.
• Number of clients per professional nurse per day – should this be 30 or 35? And how to factor in time required for management and other duties, such as collection and collation of statistics?
• Number of other nursing personnel required e.g. ratio of nursing assistants to professional nurse.
• Other professional staff, such as district pharmacists, pharmacy assistants.

Norms can be used as guidelines, but may change overtime according to changed demands on the service.

Scope of practice of categories of staff

Consideration needs to be given to scope of practice of different categories of staff who need to be considered separately e.g.

• Nursing assistants
• Administrative staff
• General assistants
• Community health workers

Professional nurses should not be expected to do work that can be done by other cadre. In small and mobile clinics other cadre may not be available to assist and therefore nursing staff may have to work outside of their normal scope of practice, such as dispensing of medicines. Time for dispensing, and other functions, must be factored into the calculation.

Doctor vs nurse orientated clinics

Provincial variation is noted – some Western Cape clinics provide a doctor orientated service, whereas in the Eastern Cape many clinics are never even visited by a doctor. This can change the norms for the facility. Doctors, where they are in excess, are doing nurses work, which is expensive use of manpower.

Other cadre of staff

Other health workers, such as pharmacists are often left out of the calculation for staffing at PHC level.

For pharmacists, hospitals norms are available from the Pharmacy Council, but not confirmed for the districts, community health centres and clinics. In small clinics, particularly in rural areas, nurses are dispensing, even though this is not part of their normal scope of practice.

The Pharmacy Council had suggested 1 pharmacist per district as a norm. This was for a smaller unit (Health Sub-District) than the proposed health district to be equivalent to a District Municipality. The norm may need to be adjusted. There is also a need to legalise the dispensing of drugs outside of the hospitals. Post-basic pharmacy assistants under indirect supervision from a pharmacist or direct supervision from a medical practitioner on site will be used where possible. In mobile and smaller clinics professional nurses will be required to have an appropriate dispensing licence; an addition to the professional nurse’s scope of practice.

The role of the pharmacist is changing to include improving the safe and cost effective use of drugs and drug supply management. These functions require new skills.

The district pharmacist’s role is a grey area. In one metro (Ekurhuleni) provision is being made for a Chief Pharmacist at the metro level, with one pharmacist in each of three regions for drug control and in service training of nurses and pharmacy assistants. This is expected to alleviate the nurses’ workload.

Management time

Management time must be taken into consideration when calculating staffing needs and assessing workload. Allowance also needs to be made for all the other tasks that are done each day e.g. food gardens, home based care, VCT, clinic committees etc. An appropriate skills mix of staff is required, but this may be difficult in some areas where there is only one professional nurse.

Management includes

• Staff support and training needs assessment
• Monitoring the quality of the service provided
• Efficient running of the facility – such as stock control, equipment, finances etc
• Linking with the district and other outside structures

How to allocate time for these functions is debatable, but work has been done on this with a proposed formula and tools. (See slide presentation from Emmanuelle Daviaud).

Responsibility for facility statistics

Clinic nurses report that they spend substantial time each week in compiling clinic stats, filling in forms and even filing. These functions could be allocated to a suitably trained administrative person.

But there is a strong feeling that daily statistics collection forms part of the consultation since these are collected on a simple tick register that requires totalling at the end of the day. This is a joint responsibility of all health workers and an administrative person may not be appropriate for the role, except for head count at the point of registration in the clinic.

Data could be sent to a central point for indicators to be calculated and the information interpreted and fed back to the facility to be used for management purposes, thus relieving some of the time pressure on the nursing staff. However, experience has shown that when indicators are calculated centrally few are used for management in the facilities. On the other hand in the Eastern Cape where indicators are calculated and interpreted in a local clinic there is a greater understanding of immunisation coverage and other public health issues. The dataset is small and integrated, which may not be the case in other provinces, such as the Western Cape.

Time for data collection and interpretation needs to be factored into the staffing level calculations, but it would seem that there is no consensus on how much time is required for this function. It is difficult to put a quantitative figure to the time. More work in terms of assessment and training may be required.

Conclusion

National staffing norms for PHC clinics have not been finalised. With the diversity of clinic size, location and services offered these might be difficult to standardise. Formulae have been developed and applied for specific clinics and this is a useful exercise when motivating for additional staff or change in skills mix.

Ongoing research is required.

Summary prepared by Wendy Hall (hstwendy@sai.co.za) 
Health Systems Trust, May 2003

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