The reengineering of primary healthcare in South Africa

Amid much speculation, 11 October saw the unveiling of the human resources in health (HRH) and revitalisation plan headed by the South African National Department of Health. In his speech at an event hosted by WITS, Health Minister, Dr Aaron Motsoaledi, explained that: “South Africa is facing a quadruple burden of diseases that will only be addressed if we have adequate human resources for all our programmes and interventions”. This groundbreaking revitalisation plan was largely driven by the “broader vision of improving health outcomes and attaining the millennium development goals (MDGs)”. The minister went on to say:

“Improving human planning, development and management is instrumental in the overhaul of the health system…[with which] we have embarked on a process of reengineering primary healthcare (PHC)”.

What has driven the development of such an ambitious plan? It is no secret that there is an enormous burden on the South African public health system, particularly in rural areas which are faced with a lack of resources and staff. However, in recent years the public health system has become even more crippled by the ever increasing burden of HIV/Aids, infant and maternal health and non-medical-related issues including corruption, poor management and ineffective human resources. The lack of progress around key health indicators is indicative of an extremely poor primary healthcare system in desperate need of re-evaluation. Therefore, the HRH and revitalisation plan.

From international experience it is clear that a decentralised system is necessary to improve healthcare indicators as suggested by the MDGs, and that strengthening health systems, particularly in the case of primary healthcare, is key to improving health outcomes. As such, for the purposes of the HRH and revitalisation plan, Dr Motsoaledi indicated several key points that need strengthening including management, accountability, supervision of junior doctors, planning, information/research, monitoring and evaluation and quality of care.

At present the National Service Delivery Agreement is in place to:

·         Increase life expectancy

·         Decrease child and maternal mortality

·         Decrease the burden of disease from HIV/Aids, TB and other chronic diseases

·         Improve the effectiveness of the health system overall

In an effort to enhance the indicators listed above, the department plans to employ three streams to each of the 52 districts namely:

·         Primary healthcare outreach (community-based care)

·         School health services (a centralised manner of ensuring child health)

·         Specialist teams (with a focus on maternal and child health, as well as HIV/Aids, TB and other chronic illnesses)

1.      Primary healthcare outreach

Under this plan, each PHC outreach team will cover one ward, which constitutes on average 7 660 of the population/1 620 households. Each team will be composed of a PHC nurse and six community health workers (CHWs) – each CHW will be ‘responsible’ for 250 households. Their responsibilities will include:

·         Knowing the demography of the catchment population

·         Knowing the epidemiology

·         Health promotion and prevention (household and community)

·         Screening and referral

·         Palliative care

·         Social mobilisation

·         Linking resources to community needs to improve health

2.      School health services

This initiative abides by the mandate to ‘have health presence in every school’. This entails the employment of more school health nurses/teams and deploying them at schools in each district. This particular proposal is to start with schools in quintile 1 districts equating to over 10 000 pilot schools.

According to Dr Motsoaledi the initial focus [of the reengineered PHC] will be on the poorest schools where learners have limited access to health services. These schools will be sent “nurses and other team members [who] will screen the pupils in lower grades for hearing, vision and dental problems. Those learners found to be in need of clinical intervention will be referred to an appropriate facility. In high schools, the nurses will provide health education for sexual and reproductive health, with a view to address HIV/Aids prevention and the high number of teenage pregnancies. They will also deal with other social problems such as alcohol and drug use.”

3.      Specialist teams

This programme is aimed at the improvement of maternal and child health, along with other chronic illnesses and HIV/Aids. Each of the 52 districts will have a health team at their disposal. As indicated by the Health Minister; “As part of the reengineered of PHC, we are placing district clinical specialist teams with the aim of improving maternal and child health outcomes at district level. These district teams will comprise an obstetrician and gynaecologist, paediatrician, family physician, and an anaesthetist at principal level. Nursing staff will include a midwife, paediatric nurse and a primary healthcare nurse at an advanced level.”

Therefore, there is a strong argument that these specialist teams will go a long way to addressing inequalities in the health sector, especially in rural areas. As such, AHP is proud to be assisting the NDoH with recruiting healthcare workers for these teams, moving one step closer to AHP’s vision: Health for Africa: powered by people.

All in all, the potential of the HRH and revitalisation plan is huge! As it will focus on key issues which continue hampering the South African public health sector. As explained by Dr Motsoaledi, “as part of strengthening health systems and improving human resource capacity, the health sector needs to make a concerted effort that will ensure our policy objectives do not have ambiguities but are harmonised and complement each other.” However, even the Health Minister admitted there are still areas that require further attention including: exploring alternative ways to increase the training of health workers, moonlighting and RWOPS, developing a coherent policy on the issue of foreign workforce and the role of academic health complexes in the production of healthcare workers.”

The potential of this vibrant plan is obvious. However, questions remain: How realistic is it considering the current challenges in the area of HRH – namely, staffing shortages? The success of this initiative will most likely have significant implications for the National Health Insurance due to be launched in 2014 – will this plan bridge the gap? How far will this plan go to providing access to primary healthcare in rural areas and thus assist South Africa in reaching the MDGs?

AHP is committed to the staffing of underserved facilities throughout South Africa. This endeavour is therefore an exciting prospect to boost the quality and coverage of healthcare delivery in the public sector. AHP aims to assist the department in looking suitable candidates for these specialist teams. Click here for more information and the job specs of these dynamic new specialist teams.

Full HRH Plan: