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

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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

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.

• 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.

National Development Plan(Cont.) GOAL 6: Complete health systems reforms

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

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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 community- based services

– a team approach which includes community health workers (CHWs) as members of the team

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WARD BASED PHC OUTREACH TEAMS PHC OUTREACH TEAM Team Responsible for health of 1500 Families No. of teams in a Ward (determined by population size) Preventative, promotive, curative and rehabilitative services (work with EHOs)

Community Services

CHW 250 Families

CHW 250 families

CHW 250 Families CHW

250 Families

Professional Nurse (Team leader) Health Promoter

Environmental Health Officer CHW CHW 250 250 Families families

HBC

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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

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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

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

ORIENTATION & TRAINING

PHASE 1

WHAT IS REQUIRED ? Scope of

Enabling Employment Framework Recruitment Selection and Appointment

Work CHWS Practice Health Services Competence Orientation and training

Production Education and Training Appropriate Qualifications

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.

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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

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