Cape TCJW!l
SECOND CAltMEGIE INQUIRY INTO POVERTY AND DEVELOPMEN'l' IN SOUTHERN AFRICA
Do the pdmIIry health care IJ.Jl1JeS
in GazanJculu ptOV1de seocn:l elaaD dIec:p
care
to the poor?by
Ene axh, Clive Ev1an, Shirley MasIIangIInyi, 'lb:ito Maluleke I
R:>bert waugh
cameg1e Qlnfannce Paper !b. 197
13 - 19 April 1984
ISBN 0 7992 0717 9
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mfACEI
Garaohl. h 00. 0' South A'ri .. 's .o-called "block statu". rho "hala di~tritt Is aft holltld i~hnd .idw.y b.t •••••• hprllit and ,... It i. t"itll h.h .. ld with Ii.itod wator ... d poor .'Iriculturll potutill. 152,000 ,.ople Iiv. i. IIhlll'. 57 .ill •••• whith vary in ,i'u •• d i.fr •• tr.ehro. 1I .. lth ser.lc .. Ir. uod.rdev.lop.4 Ind cooprh. on. 2'0-1104 ho.pltli (Tintswlio), ou h .. lt~ centr., te •
• linics 1.41 I 80bile .linie.
lIlly did Mit. Modi.1i Sch •• 1 bet ••• invol •• d h.r.? It WIS by,both design and
,.tt.
At Mitt we hdp.oplo int.rested I. r.rli h .. lth ... 41 • h •• foetor (A.glo A •• ritan Ch.i .. I,,'s hnd) ,r.,I .. d to .,o.s.r rural health work, Th. gowernunt has .ncoura •• d the .. rious IIdi •• 1 schools to hen. i.v .... 4 In rural htllth .... and hiS designated schools t. ,.rtieular "hollhnds".
So v. bee ",. involved i. G.llnkulu .nd tho Htllth S .. vicu D ••• I.p ••• t Unit (HSOU), • ,rojott .f tho lIits O,plrt .. "t .f C ••• unity Health, wll utabl Ishod. The .bjectivu of the U.it Ir. tb. trlinl"t of .ppropriate health servic. st.ff, the .. p.ns" • • nd develop •• nt of clinic ser.ices .041 the ertltion of I health .... ic. which i. cOl.unity supportiv • • nd ruponsi .. to local ... d.. To .ueeetd w. nttd the goodwill, •• pport and resp.tt of tho tOlOuity Ind the wh.leh .. rt.d b.cking of the ulsti.g htllth sorvic •.
'hi. p.por and the other. of the HSOU ... r.fltctions, ••• ly .... r.c ••••• d.ti ••• Ind id ... a.4 ar. the product of our first two years' uperlence. Opi.ion. uprused ar. bas.d on the critical .naly.is of h.rd data on tho on. hand and on per,onal ilprts"on, on tho other. Whatev.r the .,i.io., it h .. bun acquired by first hl.d and ,u.tain.d p ... onll u,.ritnc ••
Th. pap ... cover thr .. a.p.cts of .ur experienct:
1. Th. State of Health and H .. lth Clr. in IIhal.
I. Hulth and Health Clrt in "hah an ovorview.
b. Tht Nutritional Stahs of Children I - 5 y ...
2. A Critiqu • • f So.e H.I1th Service Interv.ntion, In "hala
a. Co •• unity H.Ilth 1I0rk.r. in IIhlla : Ptrvor,lon of a Pr.gress ... Concapt?
b. 110 ••• 11 do our Rural Clinic. Function?
c. R .. itw~~g the Htllth, C.ntrt Policy.
d. lIoblle Clinics Mhat can and do th.y Achi ... ? 3. Health Strvica Intornntlon. by the lIits HSOU
a. O. Prillry Heal th Cart Nursts In Gizankulu provide S.cond Cla .. Ch • ., Car. to the '00r1 b. Can good Tuberculosis Strvices be provided in the Flte ,.f Povorty?
c. School Htllth Services 1 '~oble .. a.d PrO'Plct ••
d. "ass l ... nis.tlon Ca.paign, - Tho Hntsnlo Exp.ri.nc ••
Th . . . g. is that:
Health car. in IIhala i,' i.ad.qult ••
This car. con be i.pro .. d with.ut pr ... ding changes in the pres.nt .cono.ic and politicol s,.t ....
Such i.pro .... nt i. 'Ii.ittd by .ocial, .eono.ic I.d political con.trarnts which ar. the r •• t caust of .uch il h.ss.
- It is worth .orking in "ho •• land" health servicts becau ••• f whit Cln b. Ichiev.d.
In aCknowledging III who hlv. vorked in .r with HSOU it .ust b . . . b ... d thlt hulth serviet developaent i • • tel' .ffort. lIan, of the people of "hala, the ho.pital ,taff, prilldly Dlv. Steph.n.on as sup.rintend.nt and the c.lOunity h .. lth .urses, Dr Erica Sutter and th., .up.rintend.nts Ind stiff of Ga .. nkolu's 'oth .. ho.pit.ls. the health d.part .. nt led by Dr Roo ••• d, .ore .. cantly, Dr Robert. Ind the Chief "ini.t .. of Gallnkulu hay. III Contributed to tho establhh.nt and develop •• nt of the Unit. Th. Chair .. n" fund of Anglo A •• ric.n an4 the Uni •• r,ity .f the
lIitwltersrand h ... provided the infrastructur ••
Th. action h .. co •• fro. Anita a.d lob "chnto ... Eric hch, A.b' Collio., C."ie d. ' .. r, Cl". hian, Vic Gord.uk. hrryl Ha ••• od, Thoh ""!altka. Shirle, lIa.wanganyi, Sa.lledw. "tttwa, Oipu "esow •• Rebort hugh a.d "orrick Zwa .... ttin.
JOHN GEAR DIRECTOR - HSDU
"ARCII Uh
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DO TH£ PRIMARY HEALTH CARE NURSES IN GAZANXULU PReYlo[ SECOHO CLASS CHEAP CARE TO rifE POOR?
Erfc Buch, Clive Evflll, ShfrlOJ Mlswlft9lnyf, Thoko I-1Iluleke, Robert Vaugh
INTRODUCTION
Priaary Health Care Nurses (PHeNs) were fntroduced into Soweto after doctors had been withdrawn because of polftfcil violence during 1976. Those introducing the new service believed that PHeNs supported by doctors would provide a better service. Reports fndicate thatPHCNs hive, flourished in Soweto. 0,2,3). This success gave fillpetus to IIIOves in the Nursfng Council to recognise Prillllry Health Care nursing as a post-graduate qUllificltfon. Thh has succeeded, and the NurSing Council now gives a diplOlll fn -Clinfcil Clre Nursing Science. Health Assessment, Treatlent and Care.- (4)
Tintswalo hospftal first began trafning PHCNs' in July 1980. We Ire now training our third cllss and must face up to the question: Do PHC~s in Gazlnkulu provide a means for delivering second class cheap care to the poor?
Our experfence thus far has led us to conclude that:
1. PHCNs are the most appropriate category of health worker for the task of deliverfng accessible high quality primary, health care to rural vi 11agers.
2. PHCNs can only fulfil their role effectively I!:
a. There are enough PHeNs.
b. The best possible students get selected.
c. Training ensures that workers are skilled for their,;Job.,, d. Graduates are well supported.
e. Graduates have favourable work conditiolls.
3. We can only be partially successful because of, the Hai tltio,lIs , of ho=eland health services.
Thfs paper looks at the experiences that led us to these conclusions, but before we do thfs we should cllrffy wMt the role of the rural PHeN is.
2.
~!lAr IS THE COIlRECT ROLE OF THE RURAL PHCN?
The first training programme at Tintswalo followed the urban model developN at :},)ragwanath Hospital. The urban PHCN is only trained to diagnose and care for the ill people that arrive at her clinic. If she has a problelll, she asks the doctor next door for help. Her role is essentially curative. (point a. below)
The rural PHCN works under completely different circumstances. Her tasks are much broader and she is responsible for the primary health care of 10-15 000 people. She must be skilled in clfnical care and in cOlll11Unfty health. As there is no doctor to hel p, she must al so be abl e to provi de emergency care.
O:Jr experience has led us to the following job description for a rural PHCN.
She should:
a. Diagnose and provide care for patients with comoon health problems and refer those problems beyond her competence.
b. Provide chronic disease care.
c Provide emergency care.
d. Ensure a safe pregnancy, labour, and delivery for mothers.
e. Provide comprehensive child care.
f. Inform patients and communities about health.
g. Undertake health work in the community.
h. Support community development in her area.
i. Administer and manage her clinic.
j. Function as the leader of the health care team at her clfnic.
k. Form a link between her community and the health service.
In the practice of her work the PHCN should show respect, caring, and warmth for her p~tients; and be self-reliant and hardworking. She should share her knowledge and skills with her co-workers and with her conmunity. The PHCN should also strive to build her community's awareness of their health problems, and if possible assist in developing community-based efforts to overcome them. She will spend time in her clinic and in her community.
'..Ii th this role in mind let us consider the experiences that have led us to the conclusions stated earlier.
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ARE
PIfCNs
THE MOST APPROPRIATE HEAlTH IfORKER FOR DELIVERING ACCESSIBLE HIGH qUALITY PRIMARY If[Al TN CMETO
RURAl VILLAGERS?It has been argued that an,thfng '.ss than care by a doctor constftutes second class care. (5) Thfs logfc was used fn Cuba and as a result care by doctors fs avaflabl. to all her cftfzens. (6)
However, the cfrcumstances fn Cuba are
verydffferent to those fn South Africa.
The developments fn Cuba were part of a broader politfcal process. Their doctors were speciffcally SChooled fn the provisfon of
pri~ryhealth care and in the need to serve the communfty. (6) In South Afrfca the present trafnfng, attftudes, language and class background of MOst doctors Make them fll sufted and unwilling to work fn a rural clfnfc. Although PHCNs May suffer from some of these drawbacks, they are far IIOre likely to fft fnto both' the cHnic sftuatfon and the communfty.
For thfs reason they wfll certafnly do better fn cOllClUnfty health care. From the clfnfcal pofnt of vfew, a PHCN is as competent as a doctor to dfagnose and treat common illnesses. (7)
If the possfbflity emerges for the trafning of large numbers of rural people as doctors, and they can be specifically trained for rural work, this debate should be re-opened. At present adequately trained and supported PHCNs are more approprfate than doctors for staffing rural c11n1cs.
ARE THERE ENOUGH PHCNs?
Based on two PHCNs per clinfc, 4 per health centre, .and 6 per hospital OPD;
Gazankulu needs 155 PHCNs. Leave requirements rafse thfs to 186. Do we have the posts available. and can we train thfs number?
Posts available
PHCNs' are appofnted agafnst regfstered nurse posts. The sftuatfon at
Tintswalo serves to deaonstrate the shortage of posts avaflable for
PHCNs. Tintswalo has 68 registered nurse posts,. and an immedfate need for
40 PHCNs. We cannot i "crease the nulllber of nurses doi ng PHCN tasks much
beyond the current 16 without serious disruption of other nursfng services.
4.
Trdining potential
There are 19 PHCNs in GilZilnkulu. and a further 9 arc in training. Our maximum class size is 16, so it will take us 10 years to meet Gazankulu's current need. By then needs will have increased. Because the hospitals are short of registered nurses we cannot fill our classes. As a result our second class had only 11 Gazankulu students and our third class 9.
The I Imi t on the number of nurs i n9 posts avai labl e for PHCNs and the number that we can train unfortunately leads us to conclude that we will not reach the needed number.
CAN THE BEST CANDIDATES BE SELECTED
FORTRAINING?
',/e are s I o',iI y ensuri ng tha tall nurses 1 ea rn about the poss i bfl ity of PHCN training. We have also developed an improved selection process, but this has not yet been tested.
We have spelt out the attributes that we are looking for and plan to hold training seminars for the staff that select our students. We are encouraging selection of nurses who want to live in rural villages, as many of our graduates have ended up in hospital out-patients departments. We accept non- matriculants because if we did not we would be excluding some of our best potential students.
When we have put all our selection plans into practice we will need to evaluate how successful we have been in getting the best candidates.
There is one further problem to address. We are trying to attract nurses who will work in the clinics, but work conditions and support systems are still very unsatisfactory and the image of the clinic nurse is very poor. These problems will be considered in detail later. For now, we can say that they limit the number of people who want to be trafned as PHCNs.
5.
DOES TRAINING ENSURE THAT PHCHs ARE SKILLED fOR THEIR JOB?
We have progressed from a stage of having too few trainers wfth too lfttle experience to one where we can build for the future. In addition to training our current class, we are developing course. materials and trainfng PHCN graduates as future PHCH teachers.
Let us briefly review our experience in curriculull design, teaching I31!thods, and evaluation of students.
Curriculum design
The initial course had three major curriculum desfgn flaws.
The first course taught clinical care only. We have since broadened the curriculum to include a wide range of community subjects to match the work that our graduates will do.
Subjects were initially taught according to medical dfscipli nes (surgery, medicine, etc.)
fora month each. We now allocate times spent on subjects according to their importance, and integrate our teaching as much as possible. Students are taught by systems (e.g. respiratory, gastro- intestinal) rather than by disciplines, and the connunity and clinical aspects of a subject are integrated wherever possible.
The third shift is related to the need to develop our students' attitudes, thinking skills, and ability to relate to people. These essential attributes were overlooked in the first course.
As we have.bunt our curriculum to match our workers' job description we have created a new problem - we are overloading our students; and are thus·
considering increasing the course to 15 or 18 months.
6.
Teaching methods
We have shifted away from lectures 1n which students are pass1ve lfsteners and will later try to recall informat10n. Actfve learn1ng .ethods such as role plays, small group discussions, and projects are now used extens; vely. We have found that these increase our students abflft;y to understand, think, analyse, and solve problems; as well as their abflft;y to recall.
From the first course our training has included extensive practical work.
An average day has the students in class untfl tea-time, with outpatients from tea until lunch, and doing one of a variety of activities in the afternoon. These include reading, project work, seeing ward cases, and possibly further work in the out-patients department.
Evaluation of students
Our course is registered with the S.A. Nursing Council and is subject to tneir method of evaluation. Their exams test the students ability to write essays and to recall facts, neither of which are necessary PHCH attributes.
We prefer methods that test students ability to perform thefr job. These include problem solv1ng exercises, open-book examinations, and practical tests of their ability to do clinical and community work. We hope that the planned decentralisation of examinations will allow us to adopt these methods of evaluation.
In conclusion: we believe that we have proved that PHCNs can be well trained. However, the training programme is very labour 1ntensive and high standards are difficult to maintain. We still have to show that these efforts can be sus tai ned wi thout outsf de input. To this end we are traf ni ng PHCN graduates as teachers of PHCHs but we stf11 have to see if they are able to maintain the programme.
7.
ARE PHCN SUPPORT SYSTEMS ADEQUATE?
The support systeo refers to those aspects of the heal th service that help a worker do their job well. An adequate support systeq for PHCNs will start with a connftment frOll the health services to developlllent and support of thfs category of health worker.
It also includes supportive supervision; functfonfng cOClUnfcation, transport and referral systellls; adequate drugs Ind supplfes; In efffcfent record systea; and contfnufng educltfon.
We made the mistake of not ensuring thlt these support systems were developed before we started trafning. As I result we have been faced wfth a continuing uphf1l battle.
We have Managed to solve some of the problems, but .many stfll reQlfn. Let us look at each aspect of the support system in turn.
Health service commitment to PHCNs
No such commftment was initially IIIde, but a recent policy statement by the Gazankulu Health Policy Council has overcome this probl ....
Supportive supervision
PHCNs, like other clinic nurses, require extensive supportive supervfsion. We are aiming at the kind of supervision where the supervfsor trfes to help Ind encourage the worker fn their job, rather than sfaply look for faul ts. We are not there yet.
At present, visits to clinics are all too infrequent. We hope that doctors
and specialist nurses will visit the clfnics more regularly.
8.
Communication. Transport. and Referral Systems
The PHCN must be able to cO"llItmicate rapidly with her base hospital for advice in emergencies, or to call for an ambulance. This and other aspects of the referral systelR ensure that the PHCN Is not forced to practice beyond her limits. Good communication is also needed for adminfstratfve support and for continuing education. Good transport services Ire needed for emergencies, for referral of patients to hospital, to ensure supplies, for supervisory visits, and to enable the PHCN to do comMUnfty work.
We face ITIdny problems in these areas. Communication was prevfously based on
a
very inadequate telephone service, but has been improved by the introduction of radio cOrmlunication. Referral systems are improvfng, but few PHCNs get enough help in emergencies or feedback on theircases.
Transport remains a problem as hospitals have too few vehicles.
Drugs and suppifes
We started out without equipment or drug lists, or guidelines for patient care. These are presently being developed.
We expect significant problems in an area of supplies which we have not yet tackled. Thi s i s the development of adequate supply, mai ntenance and repair systems for the clinics.
Records
Essential information should be recorded at every consultation. Our PHCNs are taught to do this. However, no such records are kept at the clinfc.
We are therefore faced with the task of developing a new record system.
Continuing education
We fan in our responsibnfty for continuing education because of our workload. In the future we hope to run regular continuing education courses and produce a newsletter, but wonder if we have the resources to so.
9.
00 PlCtJts HAWE ADEQUATE CUtltS
co:DnUttS?
Good
workfng condftions fc:pro .. workers'
Jobsatisf.ctton.
0ft4thence tllefr work. PMClfs Ire faced wftll tile 1e::2 poor
workcondf tfons II cltafe Ihurs.
These fnclude fnadoqu.te acc«=oditfon. isolltfon. overwork. Ind
ftOoftrtfce
p~.
Poor support IYsteas fncreaso frustrltton Ind le.ve PKCttl wftltout
thoencourlgeant th.,.
1IftcI.Thera Is In fncrease fn concOl"ft about the workfng condftf!)ns 0' c1fnfc
sisters. ThQ
w111soon got
s~overtfC2 p., .nd pllns lro Ifoot to fc:prove thefr ICco:::odltfon.
It is cruthl
~hatwe h:prove PHCN work cOflditfons. If we
donot. then the potentfll fl low for thea to work
.011Ind to reaafn It
thocliftfcs.
COlCClUSION
This paper set out to evalulte Whether tile use 0' Priairy Hellth Caro nurses fA cHnics fn GaZlnltulu provfded • ctlns for deliverfng second cllss cheap Clro to·
the poor.
Wo
c~to the following conclusions:
PHeNs are the DOst 'pproprfate category of worker for the
jobtha1 are oJtpected to perfora. ThQ have the abtlft,y to provfde faproved Dledf cal care and can help to
bufld a heal th systeRa tIIlt Is on
tipto . the communfty. rather than on top of them.
Our experience shows that a PHCN prograllllle fn a
h~landcan Dike reasonable progress up to I point. but after that tIIere Ire factors th.t hinder sltisflctory developn:ent of a PHC .. progrlr:::::e. These are thlt:
We are unlble to train sufffcfent PHCNI to staff cltntcs .dequately.
The workload tIIlt insufficient PHCHs puts on theso
wtIoare trained prevents
th~froa provfdfng satis'actor,y care and places severe constrafnts on the tflllt thQ can spend wortfng in the coaunfty.
We cannot clafa to have establfshed adequate
~hanfsMSfor
selectfng candfdates. 'or trainfng. or for support
sys~s.10.
TtH're i'; <1 rl.-.n'l"r th.lt the pre,~lIr(' M.rl hfrr(lrchic.)l structures under which PHCNs work, will erode the caring approach developed during their training.
W~ are not yet sure that living and working conditions for PHCNs will improve. Even if they do, nurses may not be attracted to the training course and the prospect of service in an isolated clinic with a poor support system.
Finally. it is clear that the introduction of one new category of health worker wi 11 not change ei ther the society or the health service. PHCNs may illlprove the quality of care to those who get to the clinics. However, they will not overcome such problems as the shortage of services, or the inaccessibility of
;lCalth care resulting from cost of treatment and distance from the clinics.
Their constraints will also not allow them to provide adequate community health care.
It need hardly be said that PHCNs will make no impact on the extent of poverty;
the basic cause of most ill health in rural South Africa, including Gazankulu.
REFERENCES:
1. Wagstaff L.A and Beukes P.J. "The Paediatric Primary Health Care Nurse Project in Soweto".
South African Medical Journal, 52, 1977, 1086-1088.
2. Wagstaff L.A "The Changing Role of Doctors in the Soweto Clinics' Health Care Teams"
South African Medical Journal, 53, 1978, 805-806
3. Duncan M.O. and Gear J.S.S "Training the Primary Health Care Nurse The Baragwanath Experience."
South African Medical Journal, 58, 1980, 207-210 4. r1inister of Health. "Notice R48 of 22 January 1982,"
Government Gazette, Government Printer, 1982
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11.
5. White A. ·Medicine for a Second Class : A Review of Ideas on Co=:untty Participatfon and Yillage Health Workers.-
DeveTop!ent Research Digest. No.5. 1981. p29-36 5. &o=Iz 5 •• Lifsberg E •• Robles A Ind Tlbibzadeh I.
·Cuba's Health Clre Systea- fn
Alternatfve Approaches to Heeting Basic Health Needs fn Developing Countries. Geneya. World,Health Organisation. 1975. p29-35
7. Irwigh L.M •• Porter B •• Wilson T.D •• Saunders l.D •• Wagstlff L •• Lfesch N ••
Refnach S.C •• Hakhll)'a M.S •• and. Gear J.S.S.
Clinic of Competence of Paediatric Prfmar,y Health Care Nurses
(Nurse Practfoners) fn Soweto. Awdtlng publfcatfon.
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These papers constitute the preliminary findings of the Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa, and were prepared for presen- tation at a Conference at the University of Cape Town from 13-19 April, 1984.
The Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa was launched in April 1982, and is scheduled to run until June 1985.
Quoting (in context) from these preliminary papers with due acknowledgement is of course allowed, but for permission to reprint any material, or for further infor- mation about the Inquiry, please write to:
SALDRU
School of Economics Robert Leslie Building University of Cape Town Rondebosch 7700 '
Edina-Griffiths
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