The National Primary Health Care Facilities Survey 2003

The public health sector is the main provider of primary health care (PHC) services in South Africa. It is important that these services are provided in an equitable, effective and efficient manner. Good informationand data are essential in making such an assessment. The 2003 PHC Facility Survey (like earlier surveys undertaken in 1997, 1998 and 2000), contributes to this endeavour by describing the status of South Africas PHC services.

Executive Summary

The public health sector is the main provider of primary health care (PHC) services in South Africa. It is important that these services are provided in an equitable, effective and efficient manner. Good information and data are essential in making such an assessment. The 2003 PHC Facility Survey (like earlier surveys undertaken in 1997, 1998 and 2000), contributes to this endeavour by describing the status of South Africas PHC services.

The sampling frame comprised all public sector fixed clinics, excluding satellite and mobile clinics (although these were included in some of the earlier surveys). Overall, 14% of all clinics and community health centres (CHCs) in the country were sampled, with a minimum sample size of 10% in each province.

Description of Facilities

Forty four percent of facilities are in rural areas. An additional 20% of facilities provide services in both rural and urban areas. Thirty five percent of existing PHC facilities were built in the last 10 years (since 1994). Virtually all facilities are managed by staff with a qualification of professional nurse or higher (although there is a 20% annual turnover rate among such managers). The majority of facilities open for 5 days per week. Facilities open for a median of 9 hours per day, with a third providing a 24-hour emergency service.

Services Provided

Contraception, trauma care, STI treatment and tuberculosis services are available in most of the facilities. Antenatal care, termination of pregnancy, voluntary counselling and testing (VCT) and immunisation are available in just more than half of the facilities surveyed. Few facilities provided dental services, prevention of transmission of HIV from mother to child (PMTCT) and anti-retroviral therapy (ARV). Half of the districts provide school health services. Basic on-site laboratory tests are also available in about half of the facilities.

Access to a range of laboratory tests is generally available, although this is not the case for CD4 tests for HIV positive patients. The median turn-around time to obtain results from laboratory tests such as tuberculosis sputum tests is more than 5 days, well above the national target of two days.

Human Resources

Health care personnel are inequitably distributed across provinces with shortages of certain categories of health personnel. Community-based service providers (Community Health Workers, HIV/AIDS workers, peer educators) are also few. There are regular training updates on various PHC topics provided to health personnel.

Equipment

Although essential equipment is generally available, emergency delivery kits and key equipment items (thermometers, stethoscopes, BP apparatus, and otoscopes) are seldom found in sufficient numbers. There is adequate refrigeration equipment for vaccines and drugs, although monitoring of temperatures is inconsistent. The safe disposal of medical waste has declined in several provinces since the 2000 facility survey.

Infrastructure

The physical space (consultation rooms, waiting areas, toilets, access for disabled people) should be increased. Urgent structural repairs and better security measures (particularly where high levels of crime were reported) are needed in 70% and 58% of facilities respectively. Almost all facilities have a water supply on site, and are electrified. However, interruptions in the supply of water and electricity are still common. There are wide provincial disparities in the availability and reliability of communication infrastructure.

Drugs and Pharmaceuticals

Although the majority of facilities have most commonly used drugs, less than 10% have a full complement of the 25 drugs on the Essential Drug List in stock. Antibiotics, contraceptives, condoms, vaccines and anti-tuberculosis drugs are almost universally available throughout the country. Nevirapine and acyclovir are available in a very small number of facilities. Drug registers are used to collect dispensing data in most facilities, but the data are often inaccurate. Very few facilities have expired stock on their premises.

Facility Management

Although most facilities have an official clinic supervisor, written feedback from the supervisory visits is generally not available. No improvements were found since the 2000 survey in the number of facilities with Clinic or Community Health Committees. The provision of appropriate Information, Education and Communication (IEC) materials for promoting health and preventing disease remains poor (especially materials written in local languages).

Clinical Management

Protocols outlining the syndromic management of STIs are available in almost all facilities. Staff demonstrate good knowledge about the prevention and management of key PHC conditions such as diarrhoea and TB. The EDL Standard Treatment Guideline booklet is widely available and protocols on the management of hypertension in pregnancy have been widely distributed.

Voluntary counselling and testing levels for HIV are very low. Preparedness for and management of HIVpositive people and HIV-related conditions is inadequate. Newly developed protocols on the management of HIV and related conditions, should be sent to all facilities. Nursing staff should be provided with basic and ongoing training on the management of HIV and related conditions.