The District Health system is well established and reasonably resourced. The problem is despite a large amount of expenditure on management structures and vertical programmes, the health outcomes and experience of patients is unsatisfactory. Resources are not logically distributed; the health care is delivered in an uncoordinated manner. What is needed before any more resources is put in, that the planning is done from a population-based needs approach and that implementation is focused firstly on coordinated clinical care.
The best way to achieve much more functionality in the DHS is to work on coordination of care, between levels of health care, between health workers patients and families and between different care sectors at all levels including the community.
This should be based on a thorough scientific assessment of the community that needs to be served as well as the available services. The IHPS tool kit developing by the UP COPC Research Unit is doing just that: working from the full set of StatsSA data set using socio economic data and adding disease burden and health facility data it creates a geographic based model that indicated the population in terms of nearest facility and divide them in clinic draining areas. It also identifies the communities in most need that can be prioritised. This then creates a workload per facility and calculates the number of CHWs and WBOT teams needed to serve each facility’s draining population. This works off the 2011 census adapted data. The challenge is that this data set do not accommodate for the major population movements since 2011 especially large informal settlements in the urban area. This can be overcome with a data set that can be obtained from GeoTerraImage. This company assessed the whole country and provides updated data indicating changes since 2011.
The assessment, planning and implementation should be based on subdistricts and parts of subdistricts where the geographic area of focus is determined by population size and distribution, clinical needs and the existing health facilities and health care workers. The iHPS tool can then determine what is necessary, what is available and where are the bottlenecks and gaps. Planning and budgeting must then be done within the existing possibilities and constraints. Shifting and addition of resources is then done to create maximum efficiencies and best outcomes.
An important change that is necessary is to move the focus from bureaucratic programmes to coordinated, patient centred clinical care where the best possible care is coordinated and are supported to and from the home. This process needs to happen under the leadership of a family physician, who can move through all levels of care including district hospital, CHC, Clinic and home (WBOTs and NGOs). All clinicians, which includes doctors, nurses, allied health workers, clinical associates, social workers, pharmacists and community health workers (CHWs) work as in different teams in this subdistrict or part of the subdistrict. These workers join different teams and different levels and should move where necessary between teams. Each team has a purpose (Task), a geographic area of responsibility, team members and have a specified practice list for whom they take particular care and their work is enabled with the provision of the necessary resources.
Important in coordinated care comes from the complexity concept that in a complex system, the interaction between entities is more important than the entities themselves. That means that in this geographic areas (Subdistrict or part of subdistrict), care frameworks are developed that guide teams on what to do, how to refer to each other and how to interact with patients, family and other teams to achieve the best possible quality of care, outcomes as well as patient satisfaction. The experience in Tshwane is that there are major inefficiencies, bottlenecks and fragmentation between health care workers, teams, facilities and patients. This leads to significant wastage, frustration for patients and health workers and poor outcomes. Building of relationships and coordination of care has a dramatic effect with exponential reduction of wastage, improvement of care and outcomes and satisfied patients and health workers. The multi-disciplinary team lead by a family physician participate in this endeavour. For this to be successful functional teams needs to exist at all levels, hospital, clinic and community. Coordination of care means that the patient should arrive at the right place at the right time with the necessary information available to the responsible clinician.
Cuban Trained Practitioners
Cuban Trained Practitioners is a valuable resource in implementing coordinated care. The have experience and learning in an integrated system. At the moment they will be well placed at clinics and CHC and do emergency care after hours work in the district hospital. At the clinic they will clinically support the WBOTs and do home visits where appropriate. For this they have the understanding of COPC, and they have the ability to relate functionally with patients, families, CHWs, nurses and other staff. Doing emergency and other work at the hospital will give them the opportunity to participate in the coordination of care between the levels, for example arranging to see a patient from their community at the hospital for investigation, consultation and admission. (After hours at the CHCs can in turn be done by doctors who mostly work at the hospital)
Clinical Associates
Clinical associates are well trained and have the experience and understanding of communities in need. The fill an important role and can function at all the levels of the DHS. At the moment they will be well placed at the clinics or CHCs where their main task can be to support the WBOTs in the homes and in the clinic. They also form part of the coordination of care at all levels as they can see the patient at and inform the rest of the team about the situation.
Allied Health Workers including Social Workers
A crucial part of coordinated clinical care and able to lead care and coordination at all levels.
Intersectoral Coordination
This is important. It is important though to first of all ensure that the health system is coordinated and functional and then to engage other sectors in the comprehensive health care and wellbeing of the community. This coordination is again done within the geographical area of the subdistrict or part of subdistrict. What was learnt from Saki Sumi (wrong spelling) process will be valuable here. Important to note that the municipal ward is not a functional service delivery unit and the coordination of care should be at subdistrict or part of subdistrict level. The NGO, CBO and FBO sectors are important.
School Health
School health is typically a community service and should become an integral part of the care team in the subdistrict or part of subdistrict. Flexibility is needed where some screening at the schools can be done by other health workers while school health professional nurses will be part of the clinical staff and support clinics and WBOTS where necessary.
Education and Learning
ICT
Information, point of care testing and devices and the digital movement of information between the different levels of a care to ensure close monitoring best decisions.
DCST
The biggest challenge with the District Clinical Specialist Teams (DCST) is that they had too large a geographic area to care for. In this proposal well-functioning DCSTs can continue and support Subdistricts (or part of subdistricts).
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