ADDRESSING LEADERSHIP & MANAGEMENT CHALLENGES AT DISTRICT LEVEL WITH THE WARD BASED OUTREACH TEAMS (WBOT). PROF CC JINABHAI UNIVERSITY OF FORT HARE
THE SIX (6) BUILDING BLOCKS OF A HEALTH CARE SYSTEM According to WHO (World Health Organisation) a health care system has six (6) building blocks: 1. Leadership and governance; 2. Access to essential medicines and other Commodities; 3. Health workforce (Human Resources) 4. Health systems financing 5. Health information systems 6. Health service delivery 2
CONTEXT: The Ten Point Plan 1. Provision of strategic leadership and creation of a social compact for better health outcomes 2. Implementation of National Health Insurance (NHI) 3. Improving Quality of Services 4. Overhauling the health care system and improve its management 5. Improving Human Resources Management 6. Revitalization of physical infrastructure 7. Accelerated implementation of HIV and AIDS Plan and reduction of mortality due to TB and other communicable diseases 8. Mass mobilization for better health for the population 9. Review of the Drug Policy 10. Strengthening Research and Development 3
National Development Plan. The recently released South Africa National Development Plan (NDP) 2030 (2013: 332) states The national health system as a whole needs to be strengthened by improving governance and eliminating infrastructure backlogs. Human capacity is key. Managers, doctors, nurses and community health workers need to be appropriately trained and managed, produced in adequate numbers, and deployed where they are most needed.
National Development Plan(Cont.) GOAL 6: Complete health systems reforms Integrate the different parts of the health system. Develop an information system for managing diseases. Separate policy-making from oversight and operations. Decentralise authority and devolve administration to the lowest levels. Rationalise clinical processes and systematise the use of data, incorporating community health, prevention and environmental concerns.
Policy, Legislative & Strategy Drivers HRH strategy: leadership and management are required across the health workforce and at all levels of the health care system Gov t gazette August 2011: improve hospital function Ensure appointment of competent, skilled managers Provide for accountability frameworks Ensure training of managers in leadership, management and governance
Policy drivers Re-engineering PHC Quality assurance and OHSC Improved financial management Nursing strategy Strengthening AHCs Expanding health professions
An effective health system from a quality perspective Professionals and health care providers who are: Competent, knowledgeable, respectful and ethical Continuous learning and solution-focused and who work in a. Health establishment / a hospital where Managers are effective, efficient and accountable Support systems function Staff do their jobs and follow the basic rules Focus on core business
Strategic Goals of the National Health Grant NHI Component Strengthen aspects of the public healthcare system in preparation for National Health Insurance Strengthen the design of NHI based on innovating and testing of new reforms in pilot sites A public health care system that is better prepared to implement reforms necessary for NHI 11
RE-ENGINEERING PRIMARY HEALTH CARE FOR SOUTH AFRICA Focus on Ward Based Primary Health Care Outreach Teams 7 June 2012
THE MAIN FOCUS OF THE PHC RE-ENGINEERING LITERATURE REVIEW Strengthen the district health system (DHS) and do the basics better Place greater emphasis on population based health and outcomes a new strategy for strengthening communitybased services a team approach which includes community health workers (CHWs) as members of the team
WARD BASED PHC OUTREACH TEAMS PHC OUTREACH TEAM Team Responsible for health of 1500 Families HBC No. of teams in a Ward (determined by population size) Preventative, Community Services promotive, curative and rehabilitative services (work with EHOs) CHW 250 Families CHW 250 families CHW 250 Families Professional Nurse (Team leader) Health Promoter Environmental Health Officer CHW CHW 250 250 Families families CHW 250 Families 13
NHI Pilot District WBOT Required based on 1:1500 households Number of WBOT registered Amajuba DM 74 10 Dr K Kaunda DM 139 49 G Sibande DM 182 9 O Tambo DM 199 223 Pixley ka Seme DM 33 41 T Mofutsanyane DM 145 29 Tshwane MM 608 19 umgungundlovu DM 182 17 Umzinyathi DM 76 20 Vhembe DM 229 17 Eden 109 0 Grand Total 1976 568 15
WBPHCOT members provided with cell phones and trained on collecting and sending patient information by cell phone Advantages: This improves turnaround time for required patient interventions Improves data quality for monitoring and evaluation of the WBPHCOT programme 16
WARD BASED PHC OUTREACH TEAM SERVICES Offer an Integrated health service at a community, household & individual level Core components of the integrated service 1. Promote health (child, adolescent and women s health) 2. Prevent ill health 3. Ante and post natal community based support and interventions that reduce maternal mortality 4. Provide information and education to communities and households on a range of health and related matters 5. Offer psychosocial support 6. Screen for early detection and intervention of health problems and illnesses 7. Provide follow-up and support to persons with health problems including adherence to treatment 8. Provide treatment for minor ailments 9. Basic first aid and emergency interventions
PROFESSIONAL NURSE ROLE IN PHC OUTREACH TEAM SERVICES Plan, implement and evaluate health and wellness services to the catchment population Promotion, prevention, early detection, curative, rehabilitative and palliative service Develop a targeted plan to address the health needs of those that are vulnerable Act as an advocate for improving health services Deliver community component -PHC package of services
IMPLEMENTATION OF PHC OUTREACH TEAMS PHASE 1 ORIENTATION & TRAINING
WHAT IS REQUIRED? Production Education and Training Scope of Work Enabling Employment Framework Appropriate Qualifications CHWS Practice Health Services Recruitment Selection and Appointment Competence Orientation and training
Scope of CHW Conduct community, household and individual health assessments and identify if there any potential or actual health seeks and facilitate the family or an individual to seek the appropriate health service; Promote the health of the households and the individuals within these households Refer persons for further assessment and testing after performing simple basic screening tests; Provide limited health interventions in a household (basic first aid, oral rehydration and any other basic intervention that she or he is trained to provide) CHWs will also provide psycho-social support and manage interventions such as treatment defaulter tracing and adherence support.
KEY DIFFERENCES BETWEEN CURRENT AND PROPOSED MODEL for CHW Current role community based health workers Provide a varied range of services in communities Home based care, DOTS, Adherence counselling, lay counselling, peer education, Tracing of defaulters New role of the category CHWs Fulfill a role as a formal member of the PHC team Main focus prevention, promotion and support to communities and households; and Identify health needs of families and individuals Facilitate access to health and other services Integrated services based on quadruple burden of disease Report to and supervised by the PHC Outreach team leader 21
COMMUNITY BASED PHC OUTREACH WORK DEVELOPMENT & REVIEW OF IMPLEMENTATION TOOLS
HOUSEHOLD & COMMUNITY IMPLEMENTATION TOOLS EPIDEMIOLOGICAL & DEMOGRAPHIC PROFILES CHW booklet Key message booklet CHW household tools Kit bag Monitoring & Evaluation for HSS Household registration tool Individual record CHW Weekly check list PHC Team Leader monthly checklist Referral Forms
CURRENT RESEARCH PROJECT WBOT Peer Review Provinces/ Districts - NHI Pilot Sites NW-Dr Kenneth Kaunda Health district LP -Vhembe Health District EC -OR Tambo Health District MP -Gert Sibande Health district GP -Tshwane Health District FS -Thabo Mofutsanyana Health District NC -Francis Bard Health District
Review Commissioned for NDOH, Provincial, District Health Authorities 1. National Department of Health assess implementation and expand roll out 2. Province/District assess and improve performance, prepare for roll out 3. WBOT Site Teams assess and improve performance
Method: District-WBOT Self Assessment Report (SAR) A District/WBOT describes its own practices and assesses its performance against the WBOT Review Bench Mark (questionnaire). The SAR can also describe the context in which it is working. It should include any protocols, directives, plans, agreements, reports or other working documents (content) as Appendices.
Method: Peer Review Benchmarks 1. Framework/mindset/paradigm for taking primary health into the community, as per the Re-Engineering & other PHC / DHS policies 2. Preparation for taking primary health through WBOT into the community & Households 3. Implementation of primary care through WBOT 4. Relationships of primary care through WBOT. 5. The ways achievements are known, measured and used
Methods Phase II: Desk review: The Peer Review Team critically read and review the Self-Assessment Reports as well as any accompanying documentation prepared by the District WBOTS. This Team includes PEERs who are experiences and knowledgeable about the WBOT, PHC RE- ENGINEERING & HOUSEHOLD DYNAMICS. They will asses Progress, challenges, resource issues & Health impacts.
Methods Phase III: Peer Learning Site Visit: A team of Researchers & Peers are hosted by a District WBOT. The purpose of the visit is to understand how the WBOT approach & process is working on the ground During a 3 day visit the members of the peer review team Meet and interview between 15-20 local stakeholders from the host District (district managers, WBOT leaders, CHWs, NGOs.); Accompany CHW on her/his daily work Present what they have seen and heard back to stake holders in a peer exchange Seminar Peer exchange Seminar
Thematic Analysis, Evaluation & Future Planning: Peer Learning Site Visit Report The team prepares a site visit report. Submitted to the Stakeholder coordination team for Review, Corrections & comments. Consider Follow-up site Visits to address mutually identified Key Themes to Accelerate & Fast Track WBOT Implementation
Methods: Key Informants 1. Province 2. District 3. Team Leaders 4. CHWs 5. Local government services 6. Community organisations/households 7. NGOs 8. Other services/sectors
CONCLUSION PHC RE-ENGINEERING & THE WBOT OFFER A CO-ORDINATED STRATEGY FOR STRENGTHENING ACCESS TO PRIMARY HEALTH CARE SERVICES