Putting primary health care into practice
Successfully managing the challenges posed by diseases such as TB and HIV depends on the establishment of a strong and well-integrated health system.
Primary health care (PHC) re-engineering is the cornerstone of the national health insurance (NHI) plan. In the Eastern Cape, a Service Delivery Improvement Plan (SIDP) has prioritised the revitalisation of primary health care (PHC) services. Improvement is urgently needed. The Peddie Region case study describes problems that are common across the province: the PHC system is fragmented and many of the activities and services provided are poorly coordinated. As the Plan acknowledges, the PHC system in the Eastern Cape has been hampered by issues such as critical staff shortages (especially in rural areas), poor infrastructure, and inefficient internal processes relating, for example, to supply chain management.
Overcoming these barriers requires addressing all these factors in order to strengthen the PHC system. This should include outreach programmes offered by district hospitals to PHC clinics. The focus should be on preventing disease, which requires an active health promotion program, and better deployment of mobile clinics to areas without permanent clinics. It is important to recognise that each health district is different and has specific disease priorities and implementation challenges. While the strengthening of the area’s PHC system needs to be overseen at the provincial level, it is also important that power is not too heavily centralised so that district specific strategies can be developed and implemented.
Ideally, a PHC system must function as an integrated unit. Referring patients from clinics to hospitals must be a smooth and simple process, and reports should be sent to clinics afterwards to allow for continued, seamless management by PHC nurses. PHC clinics should be nurse-led, but regular doctor visits provide a safety net for nurses when patients present with conditions that lie beyond their scope of nursing practice. They also provide opportunities for onsite training and mentoring. Onsite doctor visits also contribute to a reduction of unnecessary referrals to hospitals because many conditions can be investigated and treated in a PHC setting instead. Not having a doctor onsite leaves both nurses and patients more vulnerable and leads to patients traveling large distances to receive further treatment at hospitals.
However, improving the Eastern Cape’s PHC system requires more than just increasing the number of clinic outreach visits by doctors. District hospitals and local clinics must be embedded within the communities they serve. All health team members should be involved in collecting and responding to data so that they are able to see improvements directly and identify challenges. Motivating staff in this way allows for better monitoring and improved patient management. Active community participation should also be encouraged. This can be achieved through involving communities in the planning and delivery of healthcare initiatives and by employing teams of well-trained and supported community health workers.
The Peddie region:A case study
The Peddie region has 23 clinics and one district hospital. On average, fewer than 15 of the clinics are visited by a doctor on a regular basis. Some of the clinics that no longer receive visits were previously attended by two primary health care (PHC) doctors. In 2012, one of the doctors passed away and the other retired. Neither has been replaced. Currently, most of the outreach to the clinics in the area is conducted by doctors from the Nompumelelo Hospital. Staff shortages at the hospital, however, mean that the number of clinics visited by doctors will be reduced further to just ten from 2014. This means less than half of the clinics in the Peddie region will be receiving regular visits.
An informal anonymous survey has revealed that the majority of the clinics in the Peddie region are visited only once a month and that, on average, doctors see 10-15 patients per visit. Drug shortages at the clinics are still ongoing and doctors bring their own supplies so that they can provide adequate treatment. Very little nurse training is done during the clinic visits. Feedback during the survey indicated an overwhelming desire for more frequent doctor visits and for more onsite nurse training. It should also be noted that many of the clinics chose not to participate in this survey.
The PHC system in the Peddie area is clearly inadequate but it has improved significantly over the past ten years. In 2000, clinics lacked even basic drugs and (according to the survey) had not been visited by a doctor in years. It is important to acknowledge that progress has been made, much of which could be attributed to the rapid scale-up of HIV services. While approaches to the HIV epidemic have been disease-specific, these positive changes have created a platform on which to build a stronger health system that delivers services in a more comprehensive and sustainable way.
Many thanks for the contributions made by doctors, nurses and community health workers in the Peddie region, the identities of whom shall remain anonymous.