Tessa S. Marcus

Community oriented primary care in Tshwane District, South Africa : assessing the first phase of implementation

Abstract Background Re-engineering primary health care is a cornerstone of the health sector reform initiated nationally in South Africa in 2009. Using the concept of ward based NGO-run health posts, Tshwane District, Gauteng, began implementing community oriented primary care (COPC) through ward based outreach teams (WBOT) in seven wards during 2011. Objectives This study sought to gain insight into how primary health care providers understood and perceived the first phase of implementing COPC in the Tshwane district. Method Qualitative research was performed through focus group interviews with staff of the seven health posts during September 2011 and October 2011. It explored primary health care providers’ understanding, perception and experience of COPC. Results Participants raised organisational, workplace and community relationship issues in the discussions. Organisationally, these related to the process of initiating and setting up COPC and the relationship between governmental and nongovernmental organisations. Issues that arose around the workplace related to the job situation and employment status and remuneration of health post staff. Community related issues centred on the role and relationship between service providers and their communities. Conclusion COPC touched a responsive nerve in the health care system, both nationally and locally. It was seen as an effective way to respond to South Africas crisis of health care. Initiating the reform was inevitably a complex process. In this initial phase of implementing COPC the political commitment of governmental and nongovernmental organisations was evident. What still had to be worked through was how the collaboration would materialise in practice on the ground.

Assessment of service quality of public antiretroviral treatment (ART) clinics in South Africa: a cross-sectional study.

BackgroundIn South Africa the ever increasing demand for antiretroviral treatment (ART) runs the risk of leading to sub-optimal care in public sector ART clinics that are overburdened and under resourced. This study assessed the quality of ART services to identify service areas that require improvement.MethodsA cross-sectional study was carried out at 16 of 17 public ART clinics in the target area in greater Pretoria, South Africa. Trained participant observers presented as ART qualifying HIV positive patients that required a visit to assess treatment readiness. They evaluated each facility on five different occasions between June and November 2009, assessing the time it took to get an appointment, the services available and accessed, service quality and the duration of the visit. Services (reception area, clinician’s consultation, HIV counselling, pharmacy, nutrition counselling and social worker’s assessment) were assessed against performance standards that apply to all clinics. Service quality was expressed as scores for clinic performance (CPS) and service performance (SPS), defined as the percentage of performance standards met per clinic and service area.ResultsIn most of the clinics (62.5%) participant observers were able to obtain an appointment within one week, although on the day of their visit essential services could not always be accessed. The median CPS of the assessed facilities was 68.5 with four clinics not meeting minimum standards (CPS > 60). The service areas that performed least well were the clinician’s consultation (SPS 67.3) and HIV counselling (SPS 70.7). Most notably, clinicians performed a physical examination in only 41.1% of the visits and rarely did a complete TB symptom screening. Counsellors frequently failed to address prevention of HIV transmission.ConclusionsOverall public sector ART clinics in greater Pretoria were easily accessible and their services were of an acceptable quality. However, the time spent at the clinic to complete the services was found to be very long and there was considerable variation in adherence to performance standards within the services, particularly in respect of clinician’s consultation and counselling. Clinic management needs to ensure efficient clinic organisation and to improve adherence to performance standards in key service areas.

Prevalence of chronic pain in patients attending primary healthcare facilities in south-west Tshwane

Abstract Objectives: Despite the significant biopsychosocial impact of chronic pain on the health and quality of life of an individual, as well as on healthcare utilisation, no published data are available on the prevalence of chronic pain in the South African primary healthcare context. The aim of this study was to investigate the prevalence and intensity of chronic pain in patients attending primary healthcare facilities in south-west Tshwane. Design and setting: A prospective, cross-sectional study was carried out in four primary healthcare clinics, situated in south-west Tshwane. Subjects: The study was conducted on 1 066 adult patients, aged 18 years or older, over a nine-week period between October and December 2010. Outcome measures: The prevalence and intensity of chronic pain was determined. Results: Chronic pain prevalence was 41%. The confidence interval (CI) was 37.2–45.6. Chronic pain was most frequently experienced as lower back pain [prevalence 30.83% (CI: 19.56–42.09)] and joint pains [prevalence 23.48% (CI: 7.58–39.38)]. Chronic pain was significantly more prevalent with advancing age (p-value = 0.0014), in women than in men (p-value = 0.019), and in widowed and divorced patients, than in married and single patients (p-value = 0.0062). Patients with chronic pain reported their pain intensity over the previous month as maximum pain intensity (mean: 7.69 ± 0.99), minimum pain intensity (mean 2.54 ± 0.89), and average pain intensity (mean 4.57 ± 0.62). Conclusion: Chronic pain was highly prevalent in patients who attended primary healthcare facilities in south-west Tshwane. The intensity of pain was high in a significant proportion of patients.

The clinical associate curriculum - the learning theory underpinning the BCMP programme at the University of Pretoria

The Bachelor of Clinical Medical Practice (BCMP) is a new degree at the University of Pretoria (UP), designed to create a new category of mid-level medical workers, namely clinical associates. UP produced its first 44 graduates in 2011. The BCMP created the opportunity to innovate learning and teaching through designing, monitoring and evaluating the transformation of the curriculum as action research. Drawing on the theories and practices of authentic learning, self-directed learning, whole-brain learning and collaborative learning, the curriculum has been transformed. The potential of this curriculum extends beyond the formal education part of the programme ‒ into clinical associate practice, healthcare practice and, potentially, general medical and healthcare education.

Which primary care model? A qualitative analysis of ward-based outreach teams in South Africa

Abstract Globally, models of extending universal health coverage through primary care are influenced by country-specific systems of health care and disease management. In 2015 a rapid assessment of the ward-based outreach component of primary care reengineering was commissioned to understand implementation and rollout challenges. Aim This article aims to describe middle- and lower-level managers’ understanding of ward-based outreach teams (WBOTs) and the problems of authority, jurisdiction and practical functioning that arise from the way the model is constructed and has been operationalised. Setting Data are drawn from a rapid assessment of National Health Insurance (NHI) pilot sites in seven provinces. Methods The study used a modified version of CASCADE. Peer-review teams of public health researchers and district/sub-district managers collected data in two sites per province between March and July 2015. Results Respondents unequivocally support the strategy to extend primary health care services to people in their homes and communities both because it is responsive to the family context of individual health and because it reaches marginal people. They, however, identify critical issues that arise from basing WBOTs in facilities, including unspecific team leadership, inadequate supervision, poorly constituted teams, limited community reach and serious infrastructural and material under-provision. Conclusion Many of the shortcomings of a facility-based extension model can be addressed by an independently resourced, geographic, community-based model of fully constituted teams that are clinically and organisationally supported in an integrated district health system. However, a community-oriented primary care approach will still have to grapple with overarching framework problems.

Patient- or person-centred practice in medicine? - A review of concepts

Background Person-centred practice in medicine may provide solutions to several pressing problems in health care, including the cost of services, poor outcomes in chronic care and the rise in litigation. It is also an ethical imperative in itself. However, patient- or person-centred care is not well researched partly because of a lack of conceptual and definitional clarity. Aim The aim of this review was to analyse essential elements, ethical principles, logic and the practical application of person-centred practice described in clinician- and researcher-defined conceptual frameworks, terms and practices. Methods A search of review articles on patient- and person-centred care or medicine was conducted using Medline and Google Scholar. Secondary searches were conducted using references and citations from selected articles. Results Five conceptual frameworks were identified in terms of their practical application of the ethical principles of beneficence, autonomy and justice. They converge around a few central ideas such as having a holistic perspective of patients and their illness experience, a therapeutic alliance between the patient and clinician as well as respectful, enabling collaboration with the patient. Conclusions Terminological differences appear to owe more to disciplinary origins than to substantive meaning. Beneficence needs to be balanced by and practised through respect for patient autonomy. Core ideas in existing conceptual frameworks of patient or person centredness can guide teaching and research. Considering the value and ethical imperative of person-centred practice, training institutions should train health care students and practitioners in its precepts.

Delayed breast cancer presentation: hospital data should inform proactive primary care

Abstract Background Breast (and cervical) cancer affects a growing proportion of women in South Africa. Although treatable, where health literacy is low, women typically seek medical attention only when their condition is at an advanced stage and difficult to contain. Objectives To understand the sociodemographic characteristics of women who present with advanced breast cancer in order to intervene proactively in primary care. Method A retrospective analysis of women with advanced breast cancer (Stage IIb and higher) at a Level 2 regional hospital in South Africa (2007–2010). Results The average age amongst the 103 women enrolled in this study was 59. One-third of the women had secondary education, 35% were unemployed and two-thirds were not married. Nearly 11% (n = 11) of the women had previously had cancer. Lumps (n = 87) were the most common reason for seeking healthcare and were, together with axillary lymph node abnormalities (84.5% and 19.4% respectively), the most common clinical symptoms. Symptoms were noticed by 52% (n = 54) of the women more than six months prior to their first consultation. A personal history of cancer increased threefold the odds of presenting within three months. Middle-aged women were twice as likely as those < 45 and > 65 to report within three to six months. Secondary education increased the odds of presenting within three to six months by 56%. Employment and marital status were not significant. Conclusion The women most at risk for delayed detection and treatment were those without a history of breast cancer, aged < 45 and > 65, with low education. They can best be reached through low-cost community-orientated primary care that proactively provides health education and promotes self- and clinical examination at the individual, family, clinic and general practitioner level.

Circumcision weeks: making circumcision part of routine training and service delivery at district-level hospitals in South Africa

Abstract Background: Medically safe, elective male circumcision supports traditional and cultural rites of passage by reducing the risk of adverse events and death among men undergoing initiation. It is a way of preventing penile conditions that arise from being uncircumcised. It also protects against various sexually transmitted infections, playing a particularly important role in human immunodeficiency virus (HIV) prevention, as it protects against HIV infection in men by up to 60%. It also helps reduce herpes simplex virus type 2, a key biological co-factor thought to account for some human susceptibility to HIV infection and human papillomavirus. To address these needs and to meet the World Health Organizations call to upscale male circumcision to 80% in HIV/AIDS epidemic-gripped sub-Saharan Africa, there is a need to provide male circumcision as standard care in district health. Method: A retrospective review of three years of circumcision services, using the sleeve method, and not the high-volume, forceps-guided method, and training at a Level 1 district hospital in South Africa. Results: Two hundred and twenty-one medical circumcisions were performed, increasing significantly in each successive year. Mostly, they were carried out under local anaesthetic, and there were only four complications, all of which were successfully resolved. The average age of the patients was 20, and generally, they elected to have medical circumcision carried out for cultural reasons. Some 60 students and clinicians were trained in safe medical male circumcision. Conclusion: To meet the growing demand for male medical circumcision, especially among teenagers and young adult men at district-level hospitals, there is a need to significantly expand the surgical competency of clinicians in this field. “Circumcision weeks” are one way of routinely upscaling surgical skill levels, while simultaneously responding to increased patient demand for safe medical circumcision.

Scaling community-based services in Gauteng, South Africa: A comparison of three workforce-planning scenarios

Background The introduction of community-based services through community health workers is an opportunity to redefine the approach and practice of primary health care. Based on best-practice community oriented primary care (COPC), a COPC planning toolkit has been developed to model the creation of a community-based tier in an integrated district health system. Aim The article describes the methodologies and assumptions used to determine workforce numbers and service costs for three scenarios and applies them to the poorest 60% of the population in Gauteng, South Africa. Setting The study derives from a Gauteng Department of Health, Family Medicine (University of Pretoria) partnership to support information and communication technology (ICT)-enabled COPC through community-based health teams (termed as ward-based outreach teams). Methods The modelling uses national census age, gender and income data at small area level, provincial facility and national burden of disease data. Service calculations take into account multidimensional poverty, demand-adjusted burden of disease and available work time adjusted for conditions of employment and geography. Results Assuming the use of ICT for each, a health workforce of 14 819, 17 925 and 7303 is required per scenario (current practice, national norms and full-time employed COPC), respectively. Total service costs for the respective scenarios range from R1.1 billion, through R947 million to R783 million. Conclusion Modelling shows that delivering ICT-enabled COPC with full-time employees is the optimal scenario. It requires the smallest workforce, is the most economical, even when individual community health worker costs of employment are twice those of current practice, and is systemically the most effective.

Why high tech needs high touch : supporting continuity of community primary health care

Background Integrated care through community-oriented primary care (COPC) deployed through municipal teams of community health workers (CHWs) has been part of health reform in South Africa since 2011. The role of COPC and integration of information and communication technology (ICT) information to improve patient health and access to care, require a better understanding of patient social behaviour. Aim The study sought to understand how COPC with CHWs visiting households offering health education can support antenatal follow-up and what the barriers for access to care would be. Method A mixed methodological approach was followed. Quantitative patient data were recorded on an electronic health record-keeping system. Qualitative data collection was performed through interviews of the COPC teams at seven health posts in Mamelodi and telephonic patient interviews. Interviews were analysed according to themes and summarised as barriers to access care from a social and community perspective. Results An integrated COPC approach increased the number of traceable pregnant women followed up at home from 2016 – 2017. Wrong addresses or personal identification were given at the clinic because of fear of being denied care. Allocating patients correctly to a ward-based outreach team (WBOT) proved to be a challenge as many patients did not know their street address. Conclusion Patient health data available to a health worker on a smartphone as part of COPC improve patient traceability and follow-up at home making timely referral possible. Health system developments that support patient care on community level could strengthen patient health access and overall health.