By: Lunga Memela (Health Systems Trust Communications Engagement Lead)
HST and DoH staff sharing a moment #EndAIDS2030.
Congratulations to the Health Systems Trust's (HST) SA SURE Project, which is funded by the United States President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S Centers for Disease Control and Prevention (CDC). A community outreach initiative championed by the project's Nurse Clinicians has been featured in a Spotlights Compendium launched in May 2022 by the University of California San Francisco's (UCSF) Optimizing Performance by Improving Quality (OPIQ) Project for enhanced management of TB and HIV in South Africa.
The World Health Organization named 2021 the 'Year of Health and Care Workers' in special recognition of their unwavering dedication in addressing the COVID-19 pandemic. HST's Nurse Clinicians in uMgungundlovu Health District have been commended for their work in supporting KwaZulu-Natal's Department of Health (DoH) during the pandemic through satellite pick-up points (PuPs) where residents in Imbali Township (Pietermaritzburg) could collect much-needed chronic medication and receive clinical services.
Painting the context
A Nurse Clinician consults with a client inside a mobile unit stationed at a community site in Thornville.
It's a scenic 8km drive through the steep hills and valleys of Thornville Ward 17 uMsunduzi, to Impilwenhle Clinic – the isiZulu name of the facility meaning 'healthy living'. However, to receive healthcare services and collect their chronic medication there, Thornville residents have to take two taxis to reach the clinic.
The residents of Thornville work hard to make a living, and want the best for each other, visitors to their community and their overall wellness. Nomvula Radebe, HST's SA SURE Project Manager in uMgungundlovu, explains that for local residents, there are stark realities to be reckoned with. Poverty, youth unemployment and paying for transportation while living on a government subsidy is the primary challenge. "It's not affordable!" residents say. "What can be done to help us?"
SA SURE Project Manager, Nomvula Radebe, unpacks the spate of challenges faced by residents of Imbali Township.
"As a District Support Partner (DSP) to the Health Department," says Radebe, "we are committed to implementing people-centred approaches for ensuring clients' linkage to and continuity of care. A standard operating procedure for the Nurse-led PuPs intervention was developed and endorsed by the Department of Health, and the roll-out has been expanded to serve both Spaced Fast Lane Central Chronic Medicine Dispensing and Distribution (CCMDD or Dablapmeds) and non-CCMDD patients at designated community sites, or at workplaces."
In the Thornville community, a significant number of residents are farm workers. "They could forfeit wages if they take a day off to go to the clinic, and so they opt to miss clinic appointments rather than lose out financially," Radebe explains. "During the lockdown periods, people either could not or were reluctant to leave their homes for fear of COVID-19 infection."
Recognising the need for employees to receive consistent health care, farm owners have opened their gates and welcomed the Nurse-led PuPs to operate at the farms on certain weekdays for a set period. This access means that farm workers can receive the services at their workplace without losing time or money.
The Nurse-led PuPs came as an incredible blessing to 59-year-old Zandile Mpehle (pictured above). She was severely beaten by criminals who broke into her house demanding the stokvel money they thought she had at home. She suffers from dizziness, has poor eyesight, experiences tremors, her knees hurt, and apart from her high blood pressure, she often needs painkillers. With Nurse-led PuPs being available in the community, she need not worry about the difficult task of commuting to Impilwenhle Clinic.
Sister Zondi, Impilwenhle Clinic's Acting Operational Manager, praised the level of diligence and commitment displayed by HST staff at the facility and during outreach initiatives. Although still short-staffed, the facility now opens on Saturdays as well, so that clients do not have to miss work during weekdays to visit the clinic, and all the work is driven by passion. Patients prefer to be seen by clinicians they already know, so the teams make a consistent effort to avoid rotation of staff.
HST's Sister Khumbuzile Phungla (left) is among the Nurse Clinicians working closely with Impilwenhle Clinic's Acting Operational Manager, Sister Thembi Zondi (right).
The DoH and HST outreach collaboration also entails conducting monthly health education visits in hard-to-reach areas, identifying missed opportunities for COVID-19 vaccination and immunisations for young children, Pap smears, and targeted care for patients with TB whose treatment has been interrupted. These joint efforts demonstrate the benefits gained by using grant funds to improve patients' health outcomes and strengthen the health system.
HST staff are proud to be part of the Nurse-led PuP journey.
Contextualising Nurse-led pick-up points in KwaZulu-Natal
A history of the PuP journey was documented in a blog article written by SA SURE's Copy and Content Editor, Judith King. She explained that in the past, in order to access existing DoH facility-based PuPs through registration in the CCMDD/Dablapmeds programme, patients must have been virally suppressed for at least 12 months. A community-based PuP, by contrast, broadens the population of patients who can receive medication within their community by deploying a Nurse Clinician to manage the patient's basic clinical needs at varying stages of viral suppression.
In January 2020 − before the COVID-19 pandemic took hold in South Africa − the SA SURE Project team in uMgungundlovu had launched Nurse-led PuPs as an innovative solution to improve clinical service delivery for patients who are not yet stable on their medication, and those who experience barriers to visiting a fixed clinic.
By the end of May 2020, four of the project's supported facilities were implementing these PuPs, and Impilwenhle Clinic in Edendale (which was the first facility to offer this option), had 12 pick-up points serving an average of 28 patients per site. By June 2020, the number of sites had increased by 138% from 13 to 32, tripling the number of patients provided with community-based clinical services, and by October 2020, 17 000 medicine parcels had been issued through this modality.
When lockdown restrictions on physical movement and proximity intensified the need for community-based HIV and other health services increased, especially in the district's hard-to-reach areas. Nurse-led PuPs also supported COVID-19 prevention and control measures by decongesting the facilities and reducing the numbers of people travelling to clinics.
The Nurse Clinicians work with the team's Case Managers and Linkage Officer to ensure that patients – especially those who have missed their scheduled appointments – are maintained in care and can make appointments for clinical services in the community. The Clinicians take the CCMDD patients' facility-stored medicines and deliver them via the PuPs. Facility-based patients are clustered geographically, registered in an appointment system, and traced via telephone call or SMS. These patients then meet the Nurse at a central point in the community, where the patient's medication is issued and other service elements such as HIV Testing Services (HTS) including index case contact testing, initiation on antiretroviral therapy (viral ART), load monitoring, and script renewal are provided.
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