APPENDICIES
2.6. The Re-Engineering of Primary Health Care
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implementation (e.g. nurses) who have been largely absent from discussions surrounding the implementation of a NHI scheme and the Re-Engineering of PHC.
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the health system is based on a Primary Health Care approach as defined by the WHO in 1978.
According to the NHI Green Paper, PHC services will be Re-engineered to focus mainly on community outreach services, as well as provide a more comprehensive community primary care package as noted in Figure 2.1 (Department of Health, 2011a).
These services will focus primarily on health promotion and preventative care, while simultaneously ensuring that “quality curative and rehabilitative services” are provided (p.
24). Furthermore, the Re-Engineering process will require District Managers, Sub-District Managers and CEOs of hospitals to monitor and evaluate the performance of the services provided under the new Re-engineered PHC system.
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Figure 2.1. Proposed Primary Health Care Model. Adapted from Pillay and Barron, 2011.
The comprehensive services that the Re-engineered PHC system aims to deliver will follow four basic streams:
i. District-Based Clinical Specialist Teams (DCST). These teams will support the delivery of priority health care programmes at a district level in order to address the high levels of maternal and child mortality. These district teams will consist of a principal obstetrician and principal gynaecologist, a principal paediatrician, a
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principal family physician, a principal anaesthetist, midwife and PHC professional nurse. This specialist team will afford comprehensive service within the PHC system (Department of Health, 2011a, p. 24-25). In addition, the team will provide a network of support for specialists working in primary care (Department of Health, 2011a). The NHI White Paper reports on the development and advancement of these teams. In particular, all 52 districts in South Africa have appointed DCSTs, with 90% of districts having at least three of the required seven team members. In addition, the decrease in institutional maternal and neonatal mortality rates in selected districts is attributed to the DCSTs (Department of Health, 2015, p. 34).
ii. Integrated School Health Programme (ISHP). This programme includes services such as health promotion and prevention and curative health services for school children. According to Brand South Africa (2012), child health programmes such as the Prevention of Mother-to-Child Transmission (PMTCT) programme has had a positive impact on the HIV prevalence rate among infants with a decrease being reported in numbers since the inception of the programme in 2006. Hence, within the Re-Engineering of PHC, further improvement on child health through services such as immunisation, regular deworming and growth monitoring will go a long way in promoting and protecting child health. While these services will be rendered by a School Nurse, due to the shortage of school health nurses, some provinces will be assisted by mobile health services (Pillay, 2012). The DoH has deployed 70 mobile school health services in the pilot districts which have identified over 200 000 learners who are inflicted by physical barriers (i.e. speech, hearing, eyesight and oral health) to learning (Department of Health, 2015, p. 33).
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iii. Municipal Ward-based Primary Health Care Agents (WBOTs). Each ward will have either one or more PHC outreach teams, known as Ward Based Outreach Teams (WBOTs). The WBOTs will comprise of a professional nurse, environmental health and health promotion practitioner and Community Health Workers (CHWs), as noted in Figure 2.2. Their major function will be to promote good health and prevent ill- health through community interventions. Ideally, each team should be linked to a PHC facility through a professional nurse (Department of Health, 2011a).
iv. Contracting Private Health Care Providers. After the publication of the Green Paper on NHI and the subsequent piloting of the proposed PHC system, a fourth stream was added. Private health practitioners will be contracted to render health services in an effort to address the health needs of the population and to reduce the burden of disease (Department of Health, 2015).
These four streams differ from previous PHC strategies, as the focus of the current strategy is upon strengthening the DHS in order to promote the better implementation of basic systems. Moreover, the DMT will be given the responsibility of managing districts and being responsible for the health of the population. Furthermore, the way health services are conceptualised differs from the largely curative approach to a more preventative and promotive approach to health care (Asmall & Mahomed, 2013). The Re-engineered PHC approach emphasises community-based services as opposed to individual health care, taking health care services to the community to promote healthy living, assist in early identification
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of individuals within families at high risk, and ultimately engaging the community in maintaining and improving their own health (Department of Health, 2010).
Figure 2.2. Primary Health Care Outreach Team. Adapted from Department of Health, 2011a.
In support of these four streams, an Integrated Chronic Disease Management (ICDM) (now referred to as the Integrated Clinical Services Management (ICSM)) model has been developed to assist in improving health outcomes for patients with chronic diseases in response to the growing burden of disease facing South Africa (Mahomed, Asmall &
Freeman, 2014). Leveraging the HIV platform, the ICDM is an innovate model designed to improve the management of chronic conditions through a public health approach aimed at empowering patients to take responsibility for their own health (Mahomed et al. 2014).
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Finally, the synergistic understanding between PHC, NHI and ICDM is that they all concentrate their efforts on decreasing the burden of disease by embracing a preventative ethos of care. This approach again asserts a PHC system with a focus on preventative care while ensuring quality curative and rehabilitative services (Department of Health, 2011a).