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HEALTH SYSTEMS TRUST INITIATIVE FOR SUB-DISTRICT RURAL DISTRICT HEALTH SYSTEMS PROJECT

EXIT REPORT
Chris Hani District Municipality (DC 13) Eastern Cape Province February 2002 September 2004

This report was compiled by: Dr Carmen Bez, ISDS-facilitator August 2004

This Publication will also be available on the Internet www.hst.org.za

This is an end of project report on the Health Systems Trusts commissioned role to facilitate the Rural District Health Systems Project (RDHSP) as per the European Union tender (Tender RT 1397 GP). The information contained in this publication may be freely distributed and reproduced, as long as the source is acknowledged, and it is used for non-commercial purposes.

CONTENT

ACKNOWLEDGEMENTS ACRONYMS AND DEFINITIONS SITE MAP EXECUTIVE SUMMARY


A: INTRODUCTION B: DISTRICT HEALTH SYSTEMS AND MANAGEMENT DEVELOPMENT C: HEALTH PROGRAMMES AND QUALITY OF CARE D: HEALTH SERVICE SUPPORT SYSTEMS E: OTHERS F: CONCLUSION AND RECOMMENDATIONS APPENDIX: KEY HEALTH INDICATORS DISTRICT HEALTH PLAN ORGANOGRAM

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ACKNOWLEDGEMENTS
The facilitator wishes to acknowledge with appreciation the invaluable support received from the Chris Hani District Municipalitys staff, managers and politicians, without which this project would not have been possible. The Intsika Yethu and Emalahleni LSA teams have also contributed to this project with their commitment and dedication; the achievements in this project are theirs. To all LSA managers and health workers in the district, who in one way or another benefited at some point from the project, I extend my thanks for their receptiveness to my ideas and experience. Finally I would like to acknowledge the Provincial Department of Health in the EC and the National Department of Health for their valuable support, both in initiating and ensuring ongoing motivation for the project.

ACRONYMS AND DEFINITIONS


HST ISDS ISRDP RDHSP NDOH EC DOH CHDM DC LM LSA IDP DHC DHAC DHP&RGs IDMT ISDMT DHER DISCA STI CSS SMART RTHC GM EPI PHC DHS CHWs SA TOR NGOs CHSR&D PHASA Health Systems Trust Initiative for Sub-District Support Integrated Sustainable Rural Development Programme Rural District Health Systems Project National Department of Health Eastern Cape Department of Health Chris Hani District Municipality District Council Local Municipality Local Service Area Integrated Development Plan District Health Council District Health Advisory Committee District Health Planning & Reporting Guidelines Interim District Management Team Interim Su-District Management Team District Health Expenditure Review District STI Quality of Care Assessment Sexually transmitted infection Client Satisfaction Survey Specific-Measurable-Achievable-Reliable-Time Road to Health Chart Growth Monitoring Expanded Programme of Immunisation Primary Health Care District Health System Community Health Workers Situation analysis Terms of Reference Non Governmental Organisations Center for Health Systems Research and Development Public Health Association of South Africa

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SITE MAP

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EXECUTIVE SUMMARY
Introduction
As part of the Integrated Sustainable Rural Development Programme (ISRDP), HST implemented a Rural District Health Systems Project (RDHSP) in one of the 13 rural nodes, the Chris Hani District Municipality, Eastern Cape from February 2002 to September 2004. This is a final progress report to the NDOH, the ECDOH, the DHC and the DHAC, and it documents the achievements, challenges and lessons learnt. As part of a Presidential project to address the inequities of the past, the objectives of the project were to support district health systems development and improve quality of care in the most previously disadvantaged districts in the country. A HST facilitator was appointed to work with district and sub-district health managers and with the Health Information Systems Programme (HISP) to achieve these objectives. For the purpose of this report, the eight objectives of the RDHSP are presented in four sections: District Health Systems (DHS) and Health Management Development; Health Programmes and Quality of Care; Health Services Support Systems; and Others.

1.

District health systems and health management development

The main objective is to build capacity to manage PHC and to support local government involvement in the DHS. The following were the main achievements: Integrated health management structures at district and sub-district level were promoted and established as one of the first steps in the introduction of the district health systems based on the principles of functional integration. The District Health Advisory Committee (DHAC) and District Health Council (DHC) were established (June 2002) and they met regularly to provide district co-ordination, planning and monitoring for health services, and to ensure participation of all stakeholders, including officials from LG and province, politicians, NGOs, hospitals and others. 3-year Local Service Area (LSAs) Plans were completed in May 2004 and a district plan will be completed by September 2004. The DHP integrates national and provincial priorities on a district level and it provides the district with 5 inter-related plans that should be implemented and monitored. The IDPs are also in harmony with national and provincial goals and objectives and there is active involvement of health workers from provincial authorities.

2.

Health programmes and quality of care

The main objective is to deliver comprehensive and quality PHC. The following were the main achievements: Available information shows that the district is improving on EPI and in some of the Child Health components (e.g. weighing rate under five). This is because special emphasis was placed by the facilitator on the use of the Road to Health Chart as a comprehensive tool in Child Health. STI interventions have already shown results after having institutionalised the use of the DISCA as an M & E tool for the programme. Most STI indicators have shown patterns of

improvement and, although it is in its early stages, there are some tangible results from the approach.(e.g. condoms distributed per man per month from increased from 0.3 to 1) VCT is still a new programme with a rapid quantitative expansion with scarce and unreliable information emerging. Special attention has been given to ensuring understanding of the scope of the programme by management team members. The quality of care of these services is definitely a challenge for the district. The District TB cure rate (58%) is far below the national average. In the two primary sites, namely Intsika Yethu and Emalahleni, cure rates and the community DOTS programme can be improved. Plans to carry out an in-depth TB situation analysis are still pending due to TB co-ordinators only being appointed towards the end of the programme. The Client Satisfaction Survey done in the Cofimvaba Hospital has paved the way on the one hand for the improvement of the services provided and, on the other hand, enhancing the role of the hospital board in decision making and concrete community participation. Plans are under implementation to address problems identified. A second CSS is planned for November 2004 to measure the impact of the interventions. Supervision has been reinforced by training for newly appointed and acting supervisors in the DHIS and priority PHC programmes. The delay in the implementation of a more comprehensive approach is due to the LSAs supervisors still having been appointed. The PHC principles were reinforced in each programme to emphasise prevention strategies and interventions, and a shift of attitudes in this direction has started to show.

3.

Health services support systems

The main objective is to build skills in planning, information, financial and human resources systems, as the fundamental pillars of a well functioning DHS. The following were the main achievements: a. Strengthening the Health Information System: HST was actively involved in this area, trying to inculcate a culture of using information for management. However the audit of the district health information system, carried out recently, showed different stages of development in LSAs (levels 1 and 2, and 3 in few cases), while all LSAs are submitting data directly to Bisho there is no combined data set for the Chris Hani district. Although significant progress had been made over the past year, with the input of the new HISP person, data remain of poor quality. Of concern is the lack of provincial support and the threat of a proposed new structure that will centralise information management at District Municipality level instead of decentralising it to LSA level. b. Contributing to the development of a District Financial System: The District Health Expenditure Review (DHER) was the key tool introduced. It was compiled and it has contributed to staff knowledge of the link between finances, human resource and service planning. The DHER showed starkly the unequal distribution of resources within the Chris Hani District. It was an essential tool for developing a realistic LSA plan and DHP. c. Contribute to District Human Resource system and development: Several managers attended courses at UWC on information, health promotion, GIS, management, etc. One-on-one support and advice was continuously given to LSA mangers, municipal mangers, politicians,etc. Human Resources is still centralised in Bisho. LSAs are still waiting for their organograms; decentralisation of specific HR functions is in the process of taking place but the HR staff are not trained on these functions; backlog of data capturing on PERSAL due to several reasons; no overall HR Manager for both the LSAs and District; few HR policies and guidelines available to the LSAs ; the main report and plan for HR is the Skills Development and Training reports and plans. This is the most important as this is the weakest system and needs urgent attention.

4.

Governance and NGOs


An assessment of the knowledge and needs of local government councillors was completed and presented to them in one awareness workshop. No further work was possible. However, a number of councillors that were part of the DHC have received information from and have been influenced by the RDHS project. The District Municipality hosted a successful and well-attended conference for the launch of their District Aids Council in Queenstown on 22-24 October 2003, with the participation of all stakeholders in the district. Due to different reasons, in particular elections, there was no continuity and some of the LM AIDS Councils are not active. The RDHSP played a very important role in co-ordinating health NGOs in the district. The NGOs that were working and liaising with HST were: Equity, South African Partners, ETU, NGO Coalition, Ukhamba, Valley Trust, Quality Assurance, NAFCI and HISP. A presentation on the principles of PHC, DHS and the RDHS was given to the EC Portfolio Committee on 5-6 June 2003 by the HST facilitators.

Other
Two cross-site visits to a well functional district in the FS (ex ISDS site) were organised in April 2002 and April 2003. The exposure and sharing of lessons on functional integration, improvement of systems, the team spirit of the whole district, the good preparation of managers at all levels and the high quality of care was highly motivating for the participants from the EC, who found the experiences very inspiring for the work at home. The Councillor for Health of the CHDM attended a course on Health Promotion at the Winter School of UWC in 2003, as a way of developing capacity in politicians. A paper on the process of implementing Functional Integration in the Chris Hani District was presented at the PHASA conference in March 2003, which has put Chris Hani on the map as one of the role models in the EC and the country on functional integration. As a result it has been invited to present the paper in other relevant provincial and national meetings. A cross-cutting objective is to share lessons across districts and nationally. The facilitator contributed to the NDOH Guidelines to Functional Integration, a document that promotes comprehensive PHC and co-operative governance. The case study on Functional Integration in the CHDM was published in Lessons Leant in Primary Health Care (Dec 2003) a HST publication that shares the achievements and challenges of improving PHC delivery in rural and urban areas of South Africa. A poster on the achievements of the CHDM was also presented at the Conference Celebrating Alma Ata 1978-2003 organised by the NDoH in 2003 A district and sub-district DHP template was developed with the assistance of HST facilitators A presentation was done by the facilitator at the Strategic Planning workshop organised by the EC DoH on Key ingredients for success in implementing DH Plans The facilitator participated in several DoH meetings, workshops and Lekgotla, making inputs and raising the problems identified on the ground Developmental issues give insight into the constraints and enabling factors in health care delivery and in the RDHSP project. These include the uncertainties and delays in provincial organogrammes and decentralisation in the EC, difficulties of partnership, the short duration of the tender and other factors.

Recommendations
1. The CHDM has the capacity, resources and commitment to improve the health of its community. 2. The leadership and guidance of the EC DoH is critical to success. 3. The DHAC and DHC are only sustainable if the process of functional integration continues and if they receive support from the ECDoH and other stakeholders. 4. Information management should be prioritised at all levels. 5. Human resource norms for PHC in rural areas are required to plan and manage services appropriately. 6. The Quality of care improvement cycle is a powerful tool, if implemented systematically, for building capacity and improving all PHC programmes and services at the same time. (e.g. DISCA tool). 7. The District Health Plan should be followed through to the implementation stage, and complemented by LSA operational plans that are owned by the implementers and are in harmony with IDPs. 8. Management capacity should be built among managers from provincial to facility and national level. 9. Political commitment is needed from Local Government councillors to take informed decisions on health issues. 10. District and LSA managers need to be allowed to spend more of their time in the districts/LSAs than in Bisho. 11. A shift towards more preventive approaches based on the PHC principles is needed. 12. External facilitation such as this RDHSP is an important method, but it should have realistic objectives and timeframes.

A.
1.

INTRODUCTION
Background

The Chris Hani District Municipality (CHDM), also known as DC 13, consists of 8 Local Municipalities and is one of the biggest District Municipalities in the Eastern Cape. The 8 Local Municipalities are grouped into 6 health sub-districts or local services areas (LSAs) as follows: Engcobo, Sakhisizwe, Emalahleni, Intsika Yethu, Lukhanji and Inxuba Yethemba. HST and UWC (HISPP) have been operating at district level for the past two years implementing the health component of the ISRDP programme. When the project started towards the end of 2002, there was a low level of knowledge and understanding of the implications for health services of the new demarcation of Local Government (2000). The situation in the newborn Chris Hani District Municipality was challenging, with different health providers offering services in a fragmented way without any means of communication and therefore there were no standardised health systems in place. The introduction of the District Health System was in its very early stages. According to World Health Organisation (WHO) criteria, the population of CHDM is too large for the establishment of a significant management structure to manage the delivery of comprehensive PHC (up to and including District Hospital services) and it could present a challenge. On the other hand, although the six LSAs or sub-districts vary in size, most of them are more of the right size (250 0000 pop.) for a WHO health district and therefore for setting up a management structure for the delivery of comprehensive PHC. In order to try and adhere to this principle, HST promotes the establishment of integrated health management structures at district and sub-district level as one of the first steps in the introduction of the district health systems. In the case of the CHDM, where prior to 1994 there were 7 different service providers, and currently 2 main ones, namely Local Government and Provincial authorities, integration was difficult and required quite a lot of facilitation work. Health service providers have to learn another way of working; they have to talk to each other and plan together in a more synchronised way. This was a mammoth task and most of the efforts were concentrated on this particular intervention, based on the experience of HST that there can be no sustainable improvement in the quality of care and the strengthening of the health systems, without an integrated, representative structure that oversees the district or LSA as a whole and makes decisions for it. As the Eastern Cape Health Bill requires, at district level the District Health Council (DHC) and the District Health Advisory Committee (DHAC) were officially established in 2002, as well as Interim Sub-district Management Teams in all LSAs. These are structures where councillors for health together with health providers from both authorities meet regularly to discuss health issues and take decisions.

2.

The Rural District Health System Project

The situation analysis done at the beginning of the project in 2002 revealed the consequences of the fragmentation of health services in the poor outcomes of the health programmes and services. The lack of health systems to enable the improvement of the quality of care was also identified, in particular the District Health Information System. In February 2002, Health Systems Trust was chosen to implement the Rural District Health Systems Project (RDHSP). The project was part of a broader presidential initiative to support

development in the 13 poorest rural nodes of the country, through the Integrated Sustainable Rural Development Programme (ISRDP). Funding was provided through a European Union grant, via the National Department of Health. There are eight project objectives with the overall goal of supporting district health systems development and improving quality of care at primary care level. The Chris Hani District Municipality is one of the four rural nodal sites in the Eastern Cape, due to its levels of poverty and poorly accessible health services. The project duration was from February 2002 to September 2004, approximately two and a half years. The Health Information Systems Project (HISP) from the University of Western Cape was responsible for Part B of the tender, developing the health information system. The HST site facilitator is Carmen Baez and the HISP facilitator was Gail Smith, for a couple of months, and later, towards the end of the project, Ntsiki Mashiya. The HST facilitator dedicated her time to supporting the CHDM on issues like functional integration, HIV/AIDS and other PHC programme interventions, DHER, developing planning skills and general support to district and municipal managers. From 2003, she started to focus on one LSA, Intsika Yethu; and, from March 2004, she started to provide support to the Emalahleni LSA. These LSAs were identified in the RDHSP as Primary Sites. It is important to acknowledge the commitment of the District Municipality to the RDHSP; they supported the project throughout by including its objectives in their IDP. By doing so, most of the workshops, AIDS conference and others were not only supported in terms of logistics but fundamentally in financial terms.

3.

Aim of report

The aim of this report is to inform the provincial and national departments of health of the activities and progress of HST/ISDS in the Rural District Health Systems Project (RDHSP). The report documents the planned activities, the outcomes, achievements and failures, the challenges and the lessons learnt. It also seeks to reflect an evaluation of the district and provincial staff.

4.

Sources of information

This report was compiled based on monthly, quarterly and annual reports. The quarterly reports were signed and checked by the district managers. A formal evaluation via a questionnaire was carried with the key personnel who were involved in this project, and their views are captured in this report. In addition, a list of key health information indicators is provided in the Appendix, with information drawn from the District Health Information System (DHIS).

B.
1.

DISTRICT HEALTH SYSTEMS AND HEALTH MANAGEMENT DEVELOPMENT


Objectives

The following objectives were addressed in this section (see EU Goals for details): A1 & 3: Build capacity to manage PHC and DHS; Support Local Government involvement in DHS A2: Build knowledge and capacity of councillors A4: Develop appropriate strategic plans for PHC& integrate into IDP A5: Do capacity development through needs assessments and training.

2.

Planned activities and outcomes Outcome


Completed by team. Reflected inequities and gaps. It was used to prioritise problems Completed by Technical Advisor. Not presented to the district. IDMT, later DHAC at district level. IDMTs in all LSAs. All meet regularly and play pivotal role in health management. Culture and commitment towards functional integration developed. Provincial organogrammes still to be completed. Assessment completed and presented to councillors. One Health workshops delivered. Councillors for health participated in DHC and DHAC meetings, as well as HIV/AIDS Councils. Linked the National and provincial priorities. Review done in 2003. More active participation of health officials at review time. Cross site visits to the FS as a effective learning strategies Members of DHAC and IDMTs attended 7 courses at UWC management courses. Provided continuous on-site training on planning skills, programme content and quality assurance methodologies by facilitator Completed at LSA level by May 2004. District still to be compiled due to different framework adopted by the ECDoH. LSAs have for the first time implementable, owned and realistic operational plans based on info.

Activities (& objective) Level


1. Compiling a situational analysis (SA) (A1) 2. Completing a PHC staff training audit (A5) 3. Establishing District and sub-district management teams (A1 & A3) 4. Promoting Local government councillors health awareness (A2) 5. IDP collaboration (A4) District & LSAs District & LSA District & LSAs

District & LSAs

District & LSAs District & LSAs

6. District Management Training ( A1 & A3)

7. District Health Plan (A4)

District & LSA

3.
3.1.

Discussion and process


Situation Analysis (SA)

The situation analysis showed the unequal distribution of resources within the CHDM, the fragmentation of health services delivery, the lack of health systems and poor outcomes of the different PHC health programmes. It helped to give a picture of the newborn district and provided the necessary information for planning and prioritisation. 3.2. PHC Audit

The Technical Advisor from the NDoH completed the PHC audit in the district; however, results were not presented to the district management structure. 3.3. District and LSA Management Teams

Functional integration was the key intervention to achieve this objective as mentioned above. An Interim District Management Team (IDMT) at DM level was established in 2002 that became the DHAC in 2002. This structure holds regular meetings on a monthly basis, as well as Interim Sub-district Management Teams (ISDMT) in all health sub-districts. One workshop per sub-district was facilitated to establish the integrated teams and develop their plans. In both LSAs there is a monthly meeting of the Interim District Management Team (IDMT), which is intended as a sub-district meeting, where all stakeholders in health in the LSA meet to discuss common issues and also to try to co-ordinate efforts. These structures are an attempt to bring together PHC, hospitals, EHOs, admin staff, politicians and other stakeholders in health. Both LSA managers chair the IDMT and represent the LSA at the CHDM DHAC. From the provincial authority side, it is important to note that the LSA managers are practically new in their positions. The Intsika Yethu LSA manager was appointed in October 2000, while the Emalahleni was recently appointed in June of the current year. Most of the PHC programme managers were also appointed recently, and the supervisors, who are key elements for the sustainable improvement of care, are still in the process of being appointed. What is of concern is that the position of the LSA information officer has not been clarified yet by the provincial office, which means that the people implementing the task are acting in the post. 3.4. Promoting health awareness of local government councillors

This has been a difficult task due to lack of understanding of the need for councillors to be well informed about health related issues. An assessment of their knowledge and needs was completed and presented to a reduced number of them at the end of 2003 in a one day workshop. Their participation in the DHC, DHAC and IDMT at LSA meetings has improved over recent years and its members benefited form the knowledge and information provided by the RDHSP. 3.5. District Management Training

Managers from the district management teams were sent to summer and winter courses at UWC as part of capacity building (7 courses). Constant and systematic support is given to DM and sub-district managers.

Monthly workshops have addressed important components of the DHS like DHIS, planning, communication strategies, roles of governance and health management, etc. 3.6. LSA and District Health Strategic and Operational Plans

At the beginning of the intervention, based on the results of the situation analysis, draft plans were formulated per sub-district (one workshop per sub-district) and at DM level (three workshops). Specific HIV/AIDS plans for the district were also developed in a two day workshop and it was discussed at IDMT meetings. Support was given for the health component of the IDP in 2002 and for its review at the beginning of 2003, this has suffered changes to be in harmony with provincial and national sector plans. The EC DHP& RGs were launched in October 2003 and it was expected of districts and LSAs to implement straight away the framework with the objective of entering the cycle of the MTF. However, the LSAs management teams have encountered problems to follow them properly, and they have found the new guidelines difficult and complicated. Since planning is an essential step in district development, HST assisted the district in the development of a template, based on the DHP&RGs. This was done trough a participatory process to adapt it to the realities of the EC province, in particular to be more realistic in terms of availability of information. The priorities for the whole Chris Hani District were agreed by all LSAs and indicators were defined. After, or, in parallel with strategic plans there was a need to develop yearly operational plans. This was also facilitated by HST in both primary sites, Intsika Yethu from last year and Emalahleni from this year, for PHC programmes, information officers and supervisors. It is worth noting that, although goals and provincial objectives were revised, the ECDoH has not yet defined clearly what the framework to follow is; this creates confusion at ground level.

4.

Client perspective

The following are comments extracted from the client satisfaction survey: We have 6 well established, functioning sub-districts with functional integration in place. In areas of previous fragmentation, people have learnt to work under one LSA manager in spite of who the employer is, this is leading to sharing of resources (Manager at CHDM) HST is a change agent by orienting, benchmarking with already developed district/province, motivation and coaching us to develop meaningful operational and strategic plans and writing of narrative informative reports (LSA Manager from Provincial Authorities) I feel very happy now because I can support and assist my LSA as local government (politician). Ive learnt a lot, my role is clear and I can assist my constituency ( LG Councillor)

5.
5.1..

Lessons learnt & recommendations


Situation analysis

The participatory approach adopted was the right way to start to bring people together and to discover by themselves the realities of their district. It also contributed to developing a district spirit. 5.2. PHC audit

This exercise was done but has not influenced the district or even informed it of the outcome. Exercises like this that requires lots of time, effort and resources should be done differently in the future, not just sending questionnaires by fax to the LSAs. 5.3. District management and district systems development

The functioning and sustainability of the DHC and DHAC will continue since commitment was built and there is consciousness that a structure is fundamental for district co-ordination, monitoring and evaluation of services for the whole district. To fulfil this role, the DHAC and DHC should continue to meet regularly and managers should be measured against how well they follow through the targets set in their plans. LSA managers need to spend more time in their sub-districts than in Bisho where they are called in an un-cordinated manner. The introduction of the provincial district office should not be a reversal of the gains of functional integration, just a complement to the work already done and to reinforce unity and enhance communication between different health authorities. 5.4. Promoting health awareness of local government councillors

On the one hand, this intervention was not as successful as envisaged, since in general, the commitment towards health in councillors has not changed, and the process of empowering them did not happen. Even the district councillor for health did not make use of the facilitators skills and inputs for different reasons. On the other hand, LM councillors for health participated in the DHAC/DHC meetings and have learnt trough the process. It is of great regret of the facilitator that there was no relevant involvement and political commitment towards this component of the ISRDP from the politicians. When the preliminary results were shared with the Exec Mayor he expressed interest in addressing this gap after the culmination of the project. 5.5. Management training

Training is an area of huge relevance but unfortunately it is not planned properly and in spite of lots of training being carried out over the past few years, it has not shown major impact. The project has shown that systematic, ongoing and need based support and training have much more impact than ambitious programmes or un-coordinated training. A reflection should be done on this regard and solutions should be part of the district Skills Development Plan, at all levels, but in particular for managers. 5.6. LSA and District Health Planning

Planning is an underlying skill that managers are usually assumed to possess. The HST facilitators experience, in this district and previously, is that this is the most important and needed skill in district development. Usually the process is very slow yet enriching since

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managers does not have the basic skills of planning. In the CHDM as well it was fascinating to introduce the new dimension of using available information to plan and define realistic, achievable targets whereas in the past it wasnt feasible due to lack of information. Another gap identified, was that most of the new programme managers have not been trained in the area/programme they are occupying; therefore they could not plan appropriately. Going through a process of learning to plan in a basic though scientific way teaches people not to be unrealistic at the time of developing plans and also provides ownership of plans and targets that will ensure their implementation. However, there are factors that will limit the successful impact of a DHP. The implementation of district and LSA plans will depend of the degree that provincial officials understand the importance of decentralised, locally owned plans to improve PHC service delivery and outcomes. However, the problems of having two service delivery authorities, of parallel supervision through vertical programmes, will limit this. There is also a need to build a culture of improving quality of care, of going beyond the current system of merely monitoring health information without action plans for improvements. Building knowledge and practice on how to improve quality of care must be accompanied by a system to motivate managers and to measure their efforts. This can help to address this gap between policy, plans and implementation.

C.
1.

HEALTH PROGRAMMES AND QUALITY OF CARE


Objectives

The following objectives were addressed in this section: A 6: Develop strategies to deliver comprehensive and quality PHC

2.

Planned activities and outcomes Activities Level


District and LSAs level

Outcome
Assistance in the development of operational Child Health plans. Introduction of the comprehensive approach of the Road to Health Chart (RTHC). Lecture at district PHC course for nurses. One workshop in each primary site for front line clinicians. Research ongoing by Liverpool student to assess use of the RTHC in 3 LSAs. See graph , pg. Assistance in the development of operational STI Health plans. Create awareness of managers of AIDS National Plans 2000-2005 Introduction of concept of STI comprehensive control programme. 2003- 2 workshops run for the whole district with impact shown in some LSAs (e.g. Inxuba Yethemba) STI quality improvement cycle initiated by programme

Child Health intervention

Initiate an STI quality improvement cycle (A5 and A6)

District an subdistrict

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TB control programme (A5 & A6)

District LSA Intsika Yethu

Initiate an VCT quality improvement cycle (A5 and A6)

To assist with establishing an HIV/AIDS Council (A 6 & A7) Making links between district health and HIV Coordinating NGO (A7) Improving the supervisory system (5 & A6)

District &LMs

District and LSA

managers in the IY and Emalahleni LSAs. Team set up, DISCA & action plans completed. Good results already visible, plan to repeat DISCA by end 2004. See graph Assistance in the development of operational TB plans. Assessment planned by CHSR & D Assessment done in the Intsika Yethu (IY) LSA showed gaps in 2002. Stumbling block was the late appointment of TB co-ordinators. Some of the problems identified were poor register, low suspicion rates, long TAT at the beginning and poor/lack of supervision on community DOTs volunteers. Assistance in the development of operational VCT plans. Research done by another Liverpool student on the quality of VCT in the CHDM showed problems. Introduction of concept of VCT as an entry point for different services. Lecture and workshops run by facilitator in both primary sites, involving managers. Plans to develop 3 VCT learning sites with assistance of tools to improve quality of care and roll out lessons learnt In 2003 District AIDS Conference to create awareness and establish AIDS Council was of big success as part of IDP projects with participation of 200 stakeholders, pledge done and TOR agreed. Good NGO network fostered and promoted by HST played important role at the AIDS Conference and others HIV related activities. Assistance given to Lukhanji for integration of supervisors. LSAs participated in Provincial and rural nodes workshops on the importance of the Supervisory system and policies development in 2003 and 2004. District workshop planned for Sept 004. Supervisors appointment not completed is a concern. Still fragmentation exists to be address by Functional Integration. Client Survey Satisfaction tool implemented at Cofimvaba District Hospital. Gaps identified are on the course of being addressed. New CSS will be repeated in Nov 004.

Provincial, District and LSA

Improving quality of care at district hospitals

LSA level

3. Discussion and process


3.1. Child Health intervention

Operational plans were developed in a SMART way taking in consideration the information available. The project emphasised the universal and comprehensive use of the Road to Health Card (RTHC) which includes GM, EPI and developmental screening for children under five at clinic level for curative and preventive purposes. This was done at workshops and presentations to clinicians. It is possible to say that the intervention that started earlier in 2003 show some results in 2004 where more children that are coming to the clinics are

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weighted in comparison with the previous year, this reflects an improvement in the attitude of health providers in relation to the management of children.

3.2.

Initiate an STI quality improvement cycle

The most widely used tool to measure the quality of STI management of STI is the District STI Quality of Care Assessment (DISCA). This is a quality assessment tool that measures key input, process and output indicators related to STI care at PHC level. It is a short questionnaire and was developed after extensive consultation with nurses, public health professionals and health service managers. In Intsika Yethu 2 DISCA tools were implemented (one in 2002 and another in 2004) and one in Emalalheni recently. The quality assurance cycle framework was implemented and the new HIV co-ordinators together with the supervisors have developed plans after the DISCA based on its results. The problems identified were similar in both LSAs, and plans were developed to address gaps identified as a starting point of the intervention. The problems were, amongst others: Need for training of clinicians on Syndromic Management Lack of appropriate equipment for the implementation of the programme (couches, lights, speculums, torches, dildos,etc.) Lack of guidelines, policies on STI Lack of STI IEC material in Xhosa No outreach intervention No STI support groups Low detection of STI cases Action plans were developed based on the findings and conclusions of the DISCA. Some actions applied to individual clinics, while others may involve a strategy at district level. Both LSAs are implementing their plans and DISCA will be repeated to show the changes. Intsika Yethu has implemented it earlier and the achievements shown in the indicator above show good results already. 3.3. TB Control Programme

Operational plans for TB at LSA level are still a problem since they show the same objectives and targets as the provincial ones, therefore not very realistic (e.g. target of 85% for cure rate while the current is 58%). The information flow is also too slow for it to be used for managerial decisions. In addition the lack of TB co-ordinators over most of the period of this project was a barrier for the improvement of the programme. There were two studies undertaken that have show the poor outcomes and multiple problems of the TB programme in the CHDM. One study was carried by the CHSR&D in Sakhisizwe in 2002, and the other was a small in-depth assessment done in 2002 in Intsika Yethu. Some of the gaps identified are as follows: Case suspicion and finding remains a problem in adults in most clinics visited, with exceptions (e.g. Tsomo) Taxi driver project has drastically improved the turn around time of sputum results in the clinics that were part of Cofimvaba, while others still have a serious transport problem There isnt a standardised sputum container distribution policy in place (not registered in any place, just given to pts.) which leads to missed opportunities Children are not diagnosed at clinic level i.e. there is an under-diagnosis of TB in children

13

The training of DOTS supporters was very short and most of them dont have assigned patients for different reasons (too many supporters for few cases diagnosed, manuals are in English not in Xhosa, there are no supervision and support systems in place) Children of new cases are not provided with prophylaxis, with some exceptions There is no interpretation of TB indicators at clinic level Doctors are still doing radiological diagnosis

There are plans for the improvement of the TB programme with a situation analysis for the whole district commended to the CHSR&D for Sept 2004 to show the real gaps and plan accordingly. In addition the quarterly visits and the scoring method will be introduced. 3.4. Initiate a VCT quality improvement cycle

Due to very well known political pressure, during the course of this year, there has been an explosion of VCT sites in the districts. In most cases, they are undermining the preparedness of health staff and the respective communities, and the results below are a good example of this. The HST facilitator introduced to both IDMTs the concept of VCT as one of the most important public health and comprehensive intervention in the HIV/AIDS plans. The new HIV co-ordinator in Emalahleni has identified three clinics to develop VCT learning sites and the lessons learnt will be rolled out to the others in the district, a survey is on its way to determine needs of the three clinics and plans. 3.5. To assist with establishing an HIV/AIDS Council

HST facilitated the establishment of the AIDS Council in the CHDM by working closely with ETU in the process of establishing AIDS at LM level and organising a District Conference with all stakeholders as an IDP project to launch the Council. More than 200 people attended the Conference with presentations of provincial and district papers. The organisations have pledge commitment for the implementation of the recommendations and the composition and terms of reference for the council were defined at the conference. Special guests from the FS were invited to share their programmes. It was a big success and it marked the start of a process at district level.

3.6.

Making links between district health and Health and HIV Co-ordinating NGOs

HST promoted from the beginning of the project the synchronisation and harmony of NGOs activities within the district. A culture was inculcated to present any new project at the DHAC. The organisations that worked hand in hand with HST were: HISP (partner), South African Partners, ETU, Equity, NAFCI, NGO Coalition. Together with SA Partners, an initiative of strengthening the capacity of the CBOs that are involved in HIV related activities has been designed. At the above mentioned AIDS district conference they all worked together to achieve a successful outcome. HST also promoted that the NGOs work be included in the IDP. 3.7. Improving the supervisory system

The supervisory system is one of the most undermined of the health system, and HST has promoted its revival and revision. Although the process is not yet finalised, the contributing factor was that the EC for the first time appointed supervisors in proportion to population as part of the staff establishment. HST, together with the EC DoH organised two workshops to review supervision policies and practices. All LSAs participated in the process in which the

14

roles of programme managers and supervisors were clarified. A district training workshop is planned for the CHDM in Sept 2004 on CSM.

4.

Client perspective

HST has capacitated me in planning and implementing strategies, to start small in any programme, to concentrate on a two to three sites, then roll it out there after. To do mentoring and capacitate others as well(LSA HIV co-ordinator) When I was appointed as a programme manager I was not confident, now I am because Ive been capacitated by HST. Now I am impacting the skills of the co-workers, subordinates and communities The facilitator shared a lot of valuable information. She brought other people with deep knowledge of PHC programmes (e.g. STI). She facilitated workshops where capacity building took place and insisted on monitoring and evaluation (LSA manager from Province)

5.
5.1.

Lessons learnt / way forward


Child Health intervention

This intervention is unique in the sense that it promotes the RTHC as the entry point for curative care and promoting interventions in children under 5. The slight improvement is encouraging, but the inclusion of communities and CHWs is imperative to have major impact. A survey is currently being done by a volunteer student from the Liverpool School of Infectious Diseases (UK) to assess the use of the RTHC in the two LSAs. The results of this study will be utilised as a baseline to measure the impact of the interventions planned in the future.

5.2.

STI Quality of care improvement

The DISCA is only useful as a tool in the quality of care cycle. The critical intervention for success is whether we act on the results by making action plans to address the weaknesses. These action plans has to be followed up within a reasonable time to keep facility managers motivated, to help them resolve difficulties on the way. The DISCA should be repeated annually to monitor progress, to affirm efforts and achievements, and to keep addressing the weakness through new and continuous action plans. Only a perfect STI service will not require this to be a continuous cycle of improvement. The knowledge learnt can easily be applied to improving quality of other programmes. 5.3. TB control programme

This was the programme that has not benefited from any major inputs due to lack of management and other factors. There is a need to convert it into the number one priority for the district. 5.4. VCT programme

As already mentioned, this is a preventive strategy that will have different types of outcomes if well implemented. The quantitative roll out vs qualitative is the challenge of the district. Its

15

documentation for sharing the experiences with other districts in the country is imperative. It is important to note that the pressure of rolling out PMTCT programmes and now ARV, are a sort of distraction for LSA co-ordinators, not allowing them the time to concentrate and consolidate the basic elements of VCT services. However, through facilitation, appropriate training and good supervision, these three programmes can be integrated and develop into a model at LSA level. 5.5. AIDS Council

The role of the AIDS Council is pivotal in the struggle against HIV/AIDS. Its co-ordinating role is extremely important as well as its role as the decision making entity. Commitment of councillors towards the aims of the Council are fundamental to show real political commitment. 5.6. NGO co-ordination

The role that HST was playing should be played by the CHDM in the future to avoid fragmented, duplicated interventions, sometimes with little impact. 5.7. Supervision

It has been demonstrated that this cross intervention is the key for success in the improvement of the quality of care at LSA level. Efforts are required to make it a normal practice, with regular visits to the clinics and plans to address problems identified, and reports that are taken into consideration by management structures to resolve problems that are hampering development at clinic level.

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D.
1.

HEALTH SERVICE SUPPORT SYSTEMS


Objectives
A8. Build the DHS through providing or arranging training to build financial planning and management (Including 8.1 Assist in developing cost centre budgeting for PHC services and facilities.)2. Planned activities and outcomes Information and HR systems were implicit in other objectives but for the purpose of this report it is included and specified in this section.

Activities
Strengthening the Health Information System: (HST and HISP) Contributing to the development of a District Financial System (A8) Contribute to District Human Resource System and Development

Level
District & subdistrict District, subdistrict Provincial District and LSA level

Outcome
As part of Analysis and DHP, the lack of mortality data was evident. The district has now established their own system for collating annual mortality data. DHER compiled. Highlighted problems incl. Health information, gaps in the PHC package, utilisation and workload distribution, cost centre development and mobile services Involvement in the development of template for rural nodes on HR (NDoH) HR audit done (UWC)

3. Discussion and Process


3.1 Strengthening the Health Information System:

Initially it was stipulated that it was only HISPs task to address this area, but this was shown to be wrong right from the beginning where information was needed for the situation analysis. It was not feasible to draw a line between their work and ours. After the priority areas were identified and district and LSAs started to plan, information was scarce and of poor quality. Information utilisation at managerial level was also desirable; and, at facility level, although graphs were on the walls, people were not using that information for local decision making. On top of that, basic gaps in the reporting system were discovered, like the use of definitions was not standardised. It is important to note that there was no HISP facilitator for more than a year. However, towards the end of 2003, when the new facilitator started, a limited amount of appropriate training was provided for acting information officers from the disadvantaged LSAs that did not have appointed info officers. This small intervention was a breakthrough in information in the district; since then each LSA has started to collect, capture and use their information at local level. In 2004 a workshop was provided to all supervisors to equip them with the basic knowledge of DHIS, in particular data elements, definitions and indicators. Key personnel were sent to the Summer and Winter Schools at the SoPH in UWC, for capacity building in information. They found the training very exciting and relevant to their work, and they returned determined to apply the knowledge acquired.

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3.2

Contributing to the development of a District Financial System:

The process started in 2002 when the concept of the DHER was introduced to the interim CHDM management team by the Equity and HST facilitators. In 2002 DHER teams were established with the purpose of developing sub-district expenditure reviews. Only the Lukhanji LSA was able to complete the DHER 2001-2002 report. In 2003, it was recognised that the other LSAs needed more technical support. HST contracted The Valley Trust for this purpose. In September 2003 a process started with the re-establishment of the DHER teams per LSA. A series of four workshops were run by the Valley Trust and facilitated by HST. The training began with an introductory course on Financial Management, followed by an Excel course, during which the principles of the DHER were introduced, using an Excel spreadsheet to capture the information. Customised manuals were provided explaining step-by-step procedures on how to use Excel for capturing the data required for the DHER. The Valley Trust supplied a revised questionnaire for capturing information at each cost centre. This was distributed to various people in the finance departments and to other DHER members for completion. The information was entered into the DHER spreadsheet. The final workshops involved analysing and interpreting the data results and writing the report. 3.3. Contribute to District Human Resource System and Development:

The National Department of Health appointed a consultant to work on Human Resources for the District with particular focus on the rural nodes. The project involved developing PHC staffing norms and on this basis assist the nodes in developing an HR template. The approach is to look at the number of staff needed per facility and per category of staff (target staffing), in relation to the level of utilisation, using the DHIS information. Then to compare the target staffing and the current staffing, and from there to identify gaps and potential way forward. The model is simple to use but very useful to plan staff deployment, assess staffing gaps, and developing a human resource template. It needs to be finalised and presented to the DHAC. The HST facilitator assisted the consultant in terms of logistics, contributed in the development of the tools and organised the pilot phase of the project. An information audit on human resource development was carried out by interviewing all HR staff in the two LSAs and looking for other sources of information to provide a picture of the current Information System within the District

4. Client perspective
HST was very supportive, educational, capacitating in leadership and management skills, including health information systems and its importance in planning (DHIO from LSA) The LSA only managed to do a DHER after having assistance from the Valley Trust through HST, now we can do it on our own because we do understand it!! HST has contribute to development in the district to a very great extent, setting up systems to enable the LSA team to work meaningfully (LSA manager)

5.

Lessons Learnt

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5.1.

Strengthening the Health Information System:

The goal of the Health Information Systems Project component (HISP) was to support the development of a functioning district health information system. It was regrettable that there was no HISP facilitator for most of the time of the project. However, the inputs of the HST facilitator filled this gap. Towards the end of the project the arrival of an active HISP facilitator ensured the initiation of important processes that need continuity. The audit done recently by HST shows that there is still a lot to be done from within the health system, to improve the health information management capacity of all staff, starting with district programme and general managers and LSA managers and supervisors. Provincial direction and support is fundamental in this process. 5.2. The process of developing a District Health Expenditure Review

The District Health Expenditure Review (DHER) has contributed to staff knowledge of the link between finances, human resource and service planning. The process was very enriching for the participants and local capacity was developed throughout the process. Ownership of the process and the results was the most important achievement of this exercise. DHER members mentioned that for the first time they understood the importance of the DHER because they were able to go through the whole exercise step by step. However they feel minimally equipped to start with the period 2003-2004, on their own, using the tools and methodology provided by the Valley Trust and the Health System Trust.

E.
1.

OTHER
Objectives
Sharing of lessons from the district at national, provincial and district level Promoting functional integration as an interim model of health management Document developmental processes

These activities were, in general, not planned in advance; there were invitations to conferences, workshops, participation in publications and others. Although it happened in this way, it is part of HSTs approach of documenting and disseminating experiences gathered at sub-district and district level with the aim of providing good lessons for other districts and also to influence policy at different levels based on the realities on the ground.

2.

Discussion and process


Two cross-sites visits to a well functioning district in the FS (ex ISDS site) were organised in April 2002 and April 2003. The exposure and sharing of lessons on functional integration, improvement of systems, the team spirit of the whole district, the good preparation of managers at all levels and the high quality of care was very inspiring for the participants from the EC, and the experience motivated them for the work at home. A paper on the process of implementing Functional Integration in the Chris Hani District was presented at the PHASA conference in March 2003, which has put Chris Hani on the map as one of the role models in the EC and the country on functional integration. As a result it has been invited to present the paper in other relevant provincial and national meetings.

19

A cross-cutting objective is to share lessons across districts and nationally. The facilitator contributed to the NDOH Guidelines to Functional Integration, a document that promotes comprehensive PHC and co-operative governance. The case study on Functional Integration in the CHDM was in Lessons Leant in Primary Health Care (Dec 2003) a HST publication that shares the achievements and challenges of improving PHC delivery in rural and urban areas of South Africa. A poster on the achievements of the CHDM was also presented at the Conference Celebrating Alma Ata 1978-2003 organised by the NDoH in 2003 A district and sub-district DHP template was developed with the assistance of HST facilitators A presentation was done by the facilitator at the Strategic Planning workshop organised by the EC DoH on Key ingredients for success in implementing DH Plans The facilitator participated in several DoH meetings, workshops and Lekgotla making inputs and raising the problems identified on the ground.

F.

CONCLUSION AND RECOMMENDATIONS

The HST experience has shown that sustainable change only takes place when, on the one hand, the attitude of health workers changes and, on the other hand, when health systems are in place and owned by those who use them. Firstly, for a new district to become functional, a spirit of being a team needs to be developed, and an understanding of the DHS and PHC principles and policies by key stakeholders is essential. Plans need to be not only realistic but also owned to ensure their implementation. A culture of monitoring (themselves) and evaluation needs to be inculcated at all levels. All these can take years to happen. The experience in the Chris Hani Municipality shows that many of these processes started to happen, however more time is needed to crystalise all these processes that have been initiated. This is why quantitative measurement is not appropriate for a short term project like this one. There are external factors as well that are stumbling blocks for the development of the most committed teams, such as confusion and lack of strategic direction from provincial offices and poor communication, amongst others. In conclusion, there is no doubt that the duration of the project was too short. It should have been a 5 to 10 year project to capitalise on the interventions. Some of the recommendations are as follows: The CHDM has the capacity, resources and commitment to improve of the health of its community. The leadership and guidance of the EC DoH is critical to success. The DHAC and DHC are only sustainable if the process of functional integration continues and receives support from the ECDoH and other stakeholders. Information management should be prioritised at all levels. Human resource norms for PHC in rural areas are required to plan and manage services appropriately. The Quality of Care Improvement Cycle is a powerful tool, if implemented systematically, for building capacity and improving all PHC programmes and services at the same time. (e.g. DISCA tool) The District Health Plan should be followed through to the implementation stage, complemented by LSA operational plans that are owned by the implementers and are in harmony with IDPs.

20

Management capacity should be built among managers from provincial to facility and national level. Political commitment is needed from Local Government councillors to take informed decisions in health issues. District and LSA managers need to be allowed to spend more of their time in the districts/LSAs than in Bisho. A shift towards more preventive approaches based on the PHC principles is needed. External facilitation such as this RDHSP is an important method, but it should have realistic objectives and timeframes.

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APPENDICES
I. KEY DISTRICT INDICATORS:

1. DHER key indicators 2. PHC programmes/DHIS indicators 3. CSS results/indicators

22

APPENDICES
I. KEY DISTRICT INDICATORS:

1. DHER key indicators 2. PHC programmes/DHIS indicators 3. CSS results/indicators 1. DHER indicators
Total expenditure per capita by municipality for 2002/2003
700

600

500

400

300

200

100

0 Chris Hani Exp per capita 373

Intsika Yethu LSA 151

Lukhanji LSA 315

Emalahleni LSA 469

Inxuba Yethemba LSA 493

Engcobo LSA 507

Sakhisizwe LSA 664

The SPS norm for PHC expenditure per capita is R182.00. The CHDM district PHC expenditure per capita in 2002/2003 was R103.28. This compares favourably with other rural districts, but is not equitable
PHC total expenditure per capita for 2002/2003
160.00 140.00 120.00 100.00 80.00 60.00 40.00 20.00 0.00 Chris Hani PHC total expenditure per capita 103.28 Engcobo LSA 99.73 Lukhanji LSA 114.59

Emalahleni LSA 101.00

Inxuba Yethemba LSA 129.17

Sakhisizwe LSA 138.12

Intsika Yethu LSA 75.59

An increased allocation of the budget must be made for PHC, if there is a commitment to achieve the norm and equity.

2. PHC programmes/DHIS indicators


This is a sample of some indicators that will give an idea of the district profile and performance. They are probably not directly linked to the performance of the HST facilitator but do give a perspective of what remain the focus areas for intervention and it is therefore useful to compare figures over the past three years. The selection of indicators is largely from the DHIS, comparing data from the Situation Analysis (SA) 2002 with the most recent available data. 2.1. Child Health and Nutrition.

The following graphs show different aspects of Child Health from 2002 for the two primary sites. This is routine information available on the DHIS, which quality, as previously mentioned, is still desirable.

Immunisation coverage (under 1) 2002 - April 2004


150.00 100.00 % 50.00 0.00 Emalahleni LSA Intsika Yethu LSA

2002 83.88 73.37

2003 75.49 88.16

2004 112.41 125.03

Data for 2004 is only up to April and already the indication is that the coverage will be over 100%. Possible explanations for this are firstly the denominator data (children under 1) that according to National indications has been undercounted between 16% and 21% for census 2001. Secondly, the data quality for the data element (Fully Immunised under 1) is suspicious. This can be substantiated by looking at next figure on BCG coverage which for 2004 is between 15% and 51% lower than Immunisation coverage.

Graph 2: BCG Coverage (Annualised) 2002 - 2004


80.00 60.00 % 40.00 20.00 0.00 Emalahleni LSA Intsika Yethu LSA 2002 11.78 21.76 2003 11.70 35.32 2004 74.47 73.56

Low BCG coverage showed in graph 2 in 2002 and 2003 is due to fact that no BCG data was received from Hospitals thus only data on BCG at PHC level where as 2004 data includes BCG from hospitals These discrepancies need to be discussed and addressed by both IDMTs and Child Health LSA managers. The measurement of EPI drop-out indicators can also be useful if well reported using the correct standarised definitions.

Graph 4: Not gaining weight rate in Children < 5 - 2002/ 2004

4 3 % 2 1 0 Emalahleni LSA Intsika Yethu LSA

2002 3.48 2.09

2003 3.18 3.07

2004 3.82 2.64

This graph shows the prevalence of not gaining weight children in the community. Nationally, there are not standards for this indicator for it is relatively useful for managerial purposes. Taking into account the levels of poverty in the area, as described earlier in this report, and the prevalence of HIV/AIDS, it should be obvious that high levels of not gaining weight and other nutritional problems should exist. To confirm this or not, it should be recommendable to run nutritional survey to determine the nutritional status of the community. This would be an intervention to consider for the project in the future. 2.2. Sexually Transmitted Infections(STI)

Graph 5: Incidence of Male Uretheritis Syndrome


4 % of males 15 and older 3 2 1 0 Emalahleni LSA Intsika Yethu LSA

2002 2.51 2.41

2003 1.60 2.37

2004 2.23 3.87

Male Urethral Discharge (MUD) is one of the syndromes in the clinical management of STI. Although in both districts the incidence has increased from 2003, in Intsika Yethu the number of cases nearly doubled from 2003. This is again, product of the intervention that started earlier in 2003 with a DISCA tool assessment which created awareness on STIs in health worker that have definitively improved the diagnosis capacity at clinic level. (see DISCA report annexed).

Graph 7: STI partner notification rate


150 100 % 50 0 Emalahleni LSA Intsika Yethu LSA

2002 99.92 105.21

2003 94.26 117.62

2004 94.47 140.27

A significant proportion of people with STIs will have more than one partner. Clinicians should try to motivate STI clients to recognise the importance of all partners being treated. Notification slips should be issued for each partner. A tick should be entered for each notification slip issued. This means that the number of slips issued should exceed the number of clients treated. (When partners come to the clinic, remember to issue notification slips for any other partners they may have.). This is the reason why Intsika Yethu shows results over 100%. This is also a sign of improvement of the quality of services provided since new techniques are used to get the information from the patient. It seems to be also a good implementation of this policy in Emalahleni.

Graph 8: STI Partner treatment rate


40 30 % 20 10 0 Emalahleni LSA Intsika Yethu LSA

2002 32.92 29.03

2003 32.35 31.04

2004 38.72 29.55

The fact of issuing STI partners slips to all patients does not guarantee that partners will return to be treated. If the person come, he/she should be treated for the corresponding syndrome whether there are symptoms or not. However, if there are symptoms, a tick should also be entered in the column for new STI episodes and where appropriate the column for MUS. The number of partners treated in both LSAs is good comparing to national standards of 40-50%. The improvement of this indicator depends of many factors, like patients preferring to go to sangomas and /or GPs and migration. This is why 50%is considered a good achievement. However, there is still room for improvement of this indicator. STI partners treatment rate measures the quality of STI care. After a patient is being diagnosed and treated, a slip is provided to be given to the partner. The quality of the health promotion component is measured within this indicator, where the partner will come to the clinic to be subjected to the correct management and care. It is interesting to note (noting the results of DISCA annexed) that Emalahleni has improved the indicator from30 to 40% without any intervention or HIV co-ordinator appointed. Trends need to be observed to confirm the validity of this data. Instsika Yethu has not shown improvement from last year which needs to be investigated.

Graph 9: Male condom distribution rate


12 Condoms per male 15 and older per year 10 8 6 4 2 0 Emalahleni LSA Intsika Yethu LSA 2002 6.98 6.72 2003 4.78 10.28 2004 7.79 11.90

Condom distribution is also a component of STI care and prevention of HIV/AIDS. Condoms are counted per box or carton once they leave the store. There are lots of confusion in the reporting, what need to be understood is that when a new box with 100 condoms from the store is taken, this should be entered as 100 condoms distributed to produce reliable data. Last year this indicator was used as an example: while managers were saying that condom distribution was well done the information showed that 0.25 condom per month were distributed in the whole CHDM per man. Since then, everybody became aware of this indicator and specific efforts have been made to improve it. Intsika Yethu has achieved their goal of distributing one condom per month per man for the year 2004!. This is a good example of managing with information.

2.3 Voluntary Counselling and Testing

Graph 9: VCT Testing rate

100 80 % 60 40 20 0 Emalahleni LSA Intsika Yethu LSA 2003 81.04 42.77 2004 63.09 45.83

This indicator measures the quality of the pre-couselling session where the patient is going through a process of assessing his or hers high risk situation and discuss theoretically, the possibility of getting a positive or negative result. The relevance of this intervention is that well implemented, negative cases should remain negative and this gives the character, amongst other aspects, of one of the most powerful HIV preventive strategies. The results are still very poor in Intsika Yethu where 42.77 and 45.83% only accepted the test after pre-counselling. Emalaheni data needs to be monitored, it is quite high and it was maybe because it was only one VCT center until January 2004.

Graph 10: HIV positive testing rate

100 80 % 60 40 20 0 Emalahleni LSA Intsika Yethu LSA 2003 72.00 54.07 2004 57.64 99.74

As mentioned earlier, VCT is the golden platform to provide continuous data on the prevalence of HIV/AIDS. it is interesting to note from the epidemiological point

Graph 10 shows very high positive levels amongst people that where tested at the VCT clinics. This is an alarming situation, the good aspect is the information emanate from this programme provides automatically the HIV prevalence per clinic and per district for all age groups (not only for pregnant women). Carmen, another issue that need to be investigated is how they implement VCT: With such a high number of positive cases in Intsika Yethu, it might also indicate that VCT is limited to patients that might display obvious symptoms of HIV. Thus indicating that VCT is a selective program and not offered to all clients?
2.3. Tuberculosis Control Programme

Major problem with quality and completeness of TB data in Chris Hani over all. Quarter 1 of 2000 is good example as cure rate for new PTB cases is given as 120% while just over 20% of patients defaulted. 14.8% of patients completed treatment, 3.7% died while on treatment and in 7.4% of cases, treatment failed.

New Pulmonal TB Cure rate Emalahleni


140.0 120.0 100.0 80.0

%
60.0 40.0 20.0 0.0 Q1 Q2 Q3 Q4

2001 2002

New Pulmonal TB defaulter rate Emalahleni


30.0 25.0 20.0

% 15.0
10.0 5.0 0.0 Q1 Q2 Q3 Q4

2001 2002

New Pulmonal TB defaulter rate Intsika Yethu


16.0 14.0 12.0 10.0

8.0 6.0 4.0 2.0 0.0 Q1 Q2 Q3 Q4

2001 2002

New Pulmonal TB Cure rate Intsika Yethu


140.0 120.0 100.0 80.0

%
60.0 40.0 20.0 0.0 Q1 Q2 Q3 Q4

2001 2002

Intsika Yethu as with Emalahleni, the data is of very poor quality. There is however indication that data is busy improving as can be seen in 2002 data. In quarter 3 of 2002, the cure rate is 40%, defaulter rate 3%,and death rate is 5.9% BUT the treatment completion rate has been given as 10.6%. Electronic TB register has only been implemented in 2004 (with problems) but the data presented here indicates problems with data collection at facility level, in particular as far as treatment outcomes are concerned. This might be an indication of lack of skills and knowledge at facility level in TB treatment and recording and also a lack of support by TB coordinators.

II.

Key health indicators: Definitions Description The proportion of children under 1 year of age who have received all immunisations. The proportion of children under 1 yr of age who have received BCG The percentage of children coming to the clinic for any services that are weighted Calculation No of fully immunised children under 1yr divided by the total no. of children under 1yr, multiplied by 100. BCG given to under 1 year under population under !yr Number of children weighted under number of children under five coming to the clinic No of STI partners treated divided by no. of slips issued multiplied by 100

III.
Indicators Immunisation coverage (%)

BCG coverage

Not gaining weight rate

STI contact tracing rate (%)

% correct treatment according to STI STGuidelines* VCT coverage

* DISCA:

Estimated HIV prevalence %* (where available per district ) Proportion PTB

TB New smear +ve conversion rate

Proportion of positive HIV tests in a sample of antenatal women (*As per annual HIV Antenatal survey) *Number of PTB cases in relation to totol no of all types of TB cases The proportion of new smear positive patients who were cured The proportion of pulmonary TB (PTB) patients who were cured, as proven by bacteriology The proportion of pulmonary TB patients who interrupted their treatment * *

*No of HIV tests done divided by the total population of reproductive age (15-49) No of positive tests in survey divided by total women sampled and multiplied by 100.

TBCure rate*

Interruption rate

Smear positive new cases cured divided by all smear positive new cases multiplied by 100. Number of patients cured divided by total known outcomes for PTB patients, multiplied by 100. No. of Treatment Interrupters divided by Total known outcomes multiplied by 100.

Sputum turn-around time % Essential drugs with stock outs

3. CSS results/indicators To facilitate the analysis the 5 point scale was used so that Strongly Disagree and Disagree became negative scores, neutral was scored as zero, and agree and strongly agree became positive scores. This can be tabulated as follows:
Level of satisfaction Strongly disagree Disagree Neutral Agree Strongly agree Level of satisfaction Score -2 -1 0 +1 +2 Score

Averages for CS-Cofimvaba Hospital - Nov 2003

Client Satisfaction per domain - All Patients


-0.86
Access Assurance Em pathy Gen Satisfaction

0.62 0.64 0.41

-0.07

Reliability

Responsiveness

0.52

-0.38 -1 -0.8 -0.6 -0.4

Tangibles

-0.2

0.2

0.4

0.6

0.8

Average score for related questions

The graph above suggests that clients using the hospital in Cofimbava range in level of satisfaction between neutral (scored as 0) and agree (scored as 1) on almost all the items from the CS tool. This suggests that clients are satisfied with their experience at this hospital. Hospital management could however take some satisfaction that on the whole clients are happy with the levels of service. High negative scores were found for access to the hospital and for tangibles. Plans to address problems identified (e.g. absenteeism) are on its way. A new CSS will be done in November to measure the impact of the interventions.