C O V I D - 1 9 I N S O U T H A F R I C A

ADJUSTING FACILITY OPERATIONS TO PROMOTE SAFETY

AND MAINTAIN ACCESS TO ROUTINE AND ESSENTIAL

SERVICES IN JOHANNESBURG , SOUTH AFRICA

South Africa is a middle-income countrywith a strong governmental commitmentto improving primary health care (PHC).The country had its first documented caseof COVID-19 in March 2020, withJohannesburg Health District and GautengProvince at the epicenter of the SouthAfrican outbreak.To ensure the safety of patients and staffand maintain routine and essential PHCservice delivery, Johannesburg HealthDistrict has focused on restructuring clinicflow.Changes in facility operations were mostsuccessful in PHC clinics that had strongand committed leadership, adequate staff,and the financial resources needed forsupply procurement.

South Africa’s COVID-19 response has been focused on three main pillars: increasingtesting, declaring a National State of Disaster, and enforcing a national lockdown.Additional efforts have included mass screening through the deployment ofcommunity health workers, and a government mandate requiring private-publiccollaboration to share essential resources and supplies to reduce the cost of COVID-19diagnosis and treatment. South Africa has also focused on re-organizing facilities toprovide and capacitate dedicated triage and treatment centers: nine hospitals weredesignated as COVID-19 management centers and government aid went towardscapacitating inpatient units for an influx of COVID-positive patients, including initiatingan increased production of ventilators through the National Ventilator Project.

PHCPI is a partnership dedicated to transforming the global state of primary health care,beginning with better measurement. While the content on this website represents the positionof the partnership as a whole, it does not necessarily reflect the official policy or position of anypartner organization.

S o u t h A f r i c a ’ s n a t i o n a l h e a l t h s y s t e m i sd i v i d e d i n t o n i n e p r o v i n c i a l h e a l t hd e p a r t m e n t s w i t h 5 2 h e a l t h d i s t r i c t s .P H C i s f r e e a t p o i n t o f c a r e a n d S o u t hA f r i c a i s i n t h e p r o c e s s o f d e v e l o p i n g i t sN a t i o n a l H e a l t h I n s u r a n c e p r o g r a m .I n 2 0 1 7 , 3 0 % o f t h e g o v e r n m e n t h e a l t hb u d g e t w a s d e v o t e d t o P H C i n i t i a t i v e s .8 4 % o f P H C s e r v i c e s a r e p u b l i c l y p r o v i d e da n d p r i v a t e f a c i l i t i e s a r e a l s o c o m m i t t e d t op r o v i d i n g p r e v e n t a t i v e P H C a s a b e n e f i t .P H C i n S o u t h A f r i c a h a s a s t r o n g f o c u s o nn u r s e - p r o v i d e d c a r e , w i t h n u r s e s m a k i n gu p 7 7 % o f t h e h e a l t h c a r e w o r k f o r c e i n 2 0 1 5 .S o u t h A f r i c a ’ s P H C s y s t e m c o n t i n u e s t of a c e a h i g h b u r d e n o f H I V c a s e s , w i t h 7 . 7m i l l i o n p e o p l e l i v i n g w i t h H I V i n 2 0 1 8 .

COVID- 19 PROMISING PRACTICES

P o p u l a t i o n : 5 7 . 7 MG D P / C a p i t a :   $ 6 , 3 7 4 ( c u r r e n t U S D )H u m a n D e v e l o p m e n t I n d e x : 0 . 7 0 5L i f e E x p e c t a n c y a t B i r t h : 6 3 . 5 Y e a r s

EXECUTIVE SUMMARY SOUTH AFRICA PHC AT A GLANCE

As of 19 May 2020

17,200TOTAL CONFIRMED

CASES

7,960RECOVERIES

312DEATHS

1ST CONFIRMED LOCALTRANSMISSION; NATIONAL STATE OF DISASTER DECLARED

START OF NATIONALLOCKDOWN; CLOSURE OF ALL BORDERS

EASING OFLOCKDOWNRESTRICTIONS

15 M

AR 20

27 M

AR 20

01 M

AY 20

Question: What has been the role of PHC in SouthAfrica’s COVID-19 response? What has this lookedlike in Johannesburg, where your work is focused? Answer:  The initial “knee-jerk” governmentresponse was to close borders, impose a lockdown,and undertake top-down contact tracing. Onceinfections spread into the community, the focusshifted to developing hospital capacity and in-patient management while suspending PHCservices to avoid poorly-managed queues at PHCfacilities. However, it was quickly recognized that PHC--givenits ability to directly access communities--had acritical role to play in maintaining routine andessential services, as well as helping to identifypotential COVID-19 positive patients. This resulted inthe acknowledgement that PHC facility structures,including clinic flow and regular procedures,required adaptation to ensure the safety and well-being of both patients and providers. To make this shift in Johannesburg, I worked withfamily physicians and other specialists to develop aCOVID-19 Plan for the Johannesburg HealthDistrict.We worked with a team of infectious diseasespecialists with experience in Sierra Leone’s Ebolaresponse to refine the plan and developed adocument for the Infectious Diseases Society ofSouthern Africa. This was then implemented in sixPHC facilities with clinical site managers to improveCOVID-19 management in PHC clinics. Acomplimentary plan was developed to guide privatePHC facilities. Together, these three documentsprovide a comprehensive description of adaptingPHC facility operations for COVID-19.

Dr. Shabir Moosa is a Family Physician located in the Johannesburg Health District ofGauteng Province, the epicenter of South Africa’s COVID-19 outbreak. Dr. Moosa is thecurrent President of WONCA-Africa and is a Professor of Family Medicine at Universityof Witwatersrand. We interviewed Dr. Moosa to learn more about his experiences withdeveloping and implementing guidelines for restructuring PHC facility operations inlight of COVID-19.  Responses have been edited for length and clarity.

T H E R O L E O F S A F E T Y A N D F A C I L I T Y O P E R A T I O N SI N E F F E C T I V E P R E P A R E D N E S S A N D R E S P O N S E

COVID-19 IN JOHANNESBURG, SOUTH AFRICA:

AN INTERVIEW WITH DR. SHABIR MOOSA

COVID-19 PREPAREDNESS, RESPONSE, AND RECOVERY:

PHCPI is a partnership dedicated to transforming the global state of primary health care,beginning with better measurement. While the content on this website represents the positionof the partnership as a whole, it does not necessarily reflect the official policy or position of anypartner organization.

Question: What strategies did those guidancedocuments describe to change facility operations andincrease patient and provider safety? Answer: These guides describe a restructuring offacility operations, particularly clinic flow, to ensureisolation of symptomatic patients, appropriate socialdistancing, and sanitization of facility space andequipment. This is achieved by managing the generalflow of the clinic in three “zones” - yellow (mediumrisk), orange (high risk), and blue (low risk) - tofacilitate appropriate triaging and control one-wayclinic flow.  It starts with a single point of entry to the clinic (the“yellow zone”) that is equipped with a sanitationstation and then a screening station to identifypotential COVID-19 patients (see standardizedscreening criteria for potential COVID-19 patientshere). Non-COVID-19 patients are sent to the “bluezone” to receive routine services, while potentialCOVID-19 patients are sent to a temporary chest clinicin the “orange zone”. The “orange zone” also housesCOVID-19, Tuberculosis, and HIV testing stations. The guidelines also describe standardized changes topatient seating arrangements, and theimplementation of stringent PPE and sanitationrequirements. For example, in waiting areas, large Xsare placed over the seats that cannot be occupied toensure appropriate physical distancing, and patientsare asked to stay in one chair until it is their turn toreceive care. After the patient leaves from the waitingarea, that seat must be thoroughly cleaned with ahigh-grade disinfectant before being used again.

PHCPI is a partnership dedicated to transforming the global state of primary health care,beginning with better measurement. While the content on this website represents the positionof the partnership as a whole, it does not necessarily reflect the official policy or position of anypartner organization.

It is also required that all clinic staff wear masks, andall patients wear at least cloth face coverings. Nursesand physicians coming in direct contact to care forpotential COVID-19 patients must don at least asurgical mask, gloves and plastic apron. Thoseconducting COVID-19 testing outdoors are expectedto wear gloves, a plastic apron, a N95 mask, and avisor with regular changes of PPE.

Question: What factors facilitated the successfulimplementation of these guidelines in the pilotclinics? Answer: Implementation in the six pilot clinics hasgone well due to the overwhelming support fromthe broader Johannesburg community for theprocurement of appropriate supplies and additionalvolunteers. This collective environment, includingbuy-in from staff and support from managementand governing bodies, enabled facility restructuring,appropriate physical distancing, and enhancedpersonal safety. Necessary supplies included PPE,tape, paint, and sanitation equipment, amongothers to enable continued services and enhancedsafety. Strong, active clinical management andleadership enabled prompt changes to long-standing clinic culture and ways of practice to adaptto new procedures in light of COVID-19.Management activities included effectiveredeployment of personnel, enforcement of newsafety protocols, and assurance of continuedpersonnel attendance and availability. Involvementof senior district management assisted appropriateprocurement of supplies to enable the execution ofrevised clinic procedures, this also helped inbuilding appropriate clinic capacity and theassociated trust among managers, nurses,physicians, and patients. Question: What have been the challenges related toimplementing effective restructuring of facilityoperations? Answer: A major challenge to effectivelyrestructuring facility operations is developing thenecessary cultural and technical shift needed toappropriately carry out new guidelines andprocedures across all 120 clinics serving 5.5 millionpeople in Johannesburg. Such shifts require strongguidance from committed management, whichunfortunately has been lacking in many places.Furthermore, facilities often face a great lack inaccess to funds for the procurement of supplies andpersonnel. Despite adequate budgets on paper, thelevel of autonomy given to facilities to spend theirfunds is low unless a prolonged bureaucraticprocess is followed. 

Deliberately marked “Xs” on waiting room seats to ensure appropriatephysical distancing. Photo: Chris Collinridge for the Daily Maverick

Question: How is the reorganization of clinicoperations being utilized to maintain essential in-person services during COVID-19? Answer: Reorganization of clinic operations wereeffectively achieved in six pilot PHC clinics acrossthe Johannesburg Health District. Entire clinicswere reorganized by drawing out anddemonstrating safe distances and best practices onthe premises, using tools as simple as paint, hazardtape, and masking tape. This helped to demarcatethe three clinic zones, and to minimize physicalcontact between patients and providers. Anxietyover the safety of both patients and staff werealleviated through implementation of thesemeasures, and many services including, women’shealth, family planning, and child health serviceshave been able to continue. This is in contrast tomost of South Africa, where services such asimmunizations and chronic disease management have decreased overall. While restructuring hasworked well among these six clinics, others arestruggling to apply the same techniques resulting inlong, concerning lines and crowding in publicspaces. Lessons from the successes and struggles ofthe six pilot clinics will be essential in expanding thismodel of reorganization to other PHC clinics acrossthe province and country.

RELEVANT RESOURCES

PHCPI is a partnership dedicated to transforming the global state of primary health care,beginning with better measurement. While the content on this website represents the positionof the partnership as a whole, it does not necessarily reflect the official policy or position of anypartner organization.

Such shifts require strong guidance fromcommitted district health service management,which unfortunately has been lacking in manyplaces. As a consequence, facilities are relying oncommunity donations and university assistance instocking supplies and manning clinics. This is seenthrough donations of technical supplies and PPE, aswell as university students volunteering as triageleaders in clinics. There is also a lack in coordination with othersupporting agencies to allow clinics to efficientlyfunction and provide essential services. Thisincludes a lack of guidance from the centralgovernment on the restructuring of community-based PHC facilities, as well as minimalcommunication with local non-health agenciessuch as road development or traffic police to helpenforce physical distancing guidelines. While thecentral government advocates for private-publiccollaboration in light of COVID-19, this is less likely tooccur at the local level. Question: What has adapting the PHC system forCOVID-19 taught you, and where do you seeopportunities for longer term health systemsstrengthening? Answer: COVID-19 has spotlighted several gaps andchallenges in the broader South African healthsystem, however this allows for identifying directedefforts for long-term health systems strengthening.The guidance documents created, while specific toCOVID-19, have the potential to be further

developed as standing documents for futureepidemics and health emergencies and hopefullywill enable future restructuring efforts to be quickerand more efficient. This pandemic has also underscored opportunitiesfor broader changes in PHC service delivery. Forexample, the Chiawelo Community Practice Model(CCP) my team has developed proposes a physician-led effort to provide community-oriented primarycare by adopting concepts of empanelment andintegrating new payment mechanisms into SouthAfrica’s National Health Insurance plan. The CCPmodel could have provided a means ofsystematically screening patient panels, trackingsuspected patients, undertaking contact tracing,and providing general education and communityprotection efforts using community health workers.This might have proved to be more effective thanearly efforts to use CHWs who were not linked toany clinic in random communities--efforts whichhave demonstrated limited success and are nowbeing abandoned. The challenges we are facingwith PHC service delivery highlight the need forfurther experimentation and implementation withmodels such as these. While COVID-19 has resulted in widespread concern,it has also led to collective action to strengthen thebroader health system and has underscored theimportance of maintaining primary health careservices during this time. If delivered safely andeffectively, PHC can help to mitigate the impact ofCOVID-19 while continuing to minimize the burdenof other ongoing endemic health issues.

Primary Health Care PoliciesQuality Management InfrastructureInnovation & LearningFacility InfrastructureWorkforce, Funds, and SafetyFacility Management Capability and LeadershipPerformance Measurement and Management

RELEVANT IMPROVEMENT STRATEGIES

Operational Considerations for Non-US SettingsNon-COVID-19 Care FrameworkWHO Coronavirus (COVID-19) Technical Guidance:

Essential Resource PlanningMaintaining Essential Health Services andSystems

GLOBAL LEARNING TOOLS