PROBLEM

South Africa faces four epidemics - Infectious diseases (especially HIV/AIDS and TB), non-communicable diseases (especially diabetes and cardiovascular diseases), high levels of violence and injury, and mother and child illness and death - linked to one another by persistent social inequality. Together, they account for the top ten causes of preventable death and avoidable ill-health in South Africa.

The National Department of Health (DoH) has recognised that the healthcare system is unable to meet this challenge due to the scale and complexity of the disease burden and the current structure of the healthcare system. Services and capacity development in SA’s healthcare system are skewed away from general primary healthcare, and towards specialist care.

While intensifying its efforts to tame the devastating effects of HIV/AIDS and TB, in 2010 the National Department of Health introduced policies designed to make primary healthcare more effective. Most importantly, these policies included National Health Insurance and an overhaul of primary healthcare to achieve universal health coverage. To achieve the second objective, the DoH introduced the concept of ward-based health teams, where community health workers (CHWs) take primary care to communities rather than keeping primary care in clinics and hospitals.

Source: StatsSA (2015);A Practical guide to Doing COPC, Marcus 2015

SOLUTION

The Department of Family Medicine at the University of Pretoria (UP) took this opportunity to integrate service, learning and research into a community health platform in a way that had not previously been possible. Professors Jannie Hugo and Tessa Marcus built their intervention on the principles of community-oriented primary care (COPC), a model of healthcare developed by Drs Sydney and Emily Kark in rural Kwa-Zulu Natal in the 1940’s.

COPC is a geographically-based collaborative approach to health that starts with individuals and families in their homes. UP’s Department of Family Medicine worked to establish a version of COPC that would work in South Africa in the 21st century. Supported by the Gauteng Provincial Department of Health (GPDoH), the University of Limpopo, and the Sefako Makgatho Health Science University, the process was started in 2011 in Tshwane District as a pilot. Teams were set up in nine communities in partnership with local NGOs. In 2014 the City of Tshwane Municipality entered into an agreement with the Department of Family Medicine to use a COPC approach to health in the municipality. Through this collaboration, the model has expanded and matured. Presently, there are 43 professional nurse led ward-based health teams with 370 CHWs deployed in defined geographical areas across the city from Mamelodi through the inner city to Atteridgeville, Soshanguve and Olievenhoutbosch. To date, community health workers have registered 230 000 individuals in 77 000 households, with community health workers providing immediate and follow up support to individuals and families in need. The number of households serviced by the programme is growing every day.

To support the COPC approach, Hugo and the Family Medicine team have collaborated with private sector partners to create AitaHealth™, a purpose-built data collection, support and management system. Using web and mobile phone technology, team leaders and CHWs assisted by doctors and other specialists work with real-time information to make decisions and provide care. Parallel to this, Marcus, Hugo and the team are developing a formal system of learning that is integrated into delivering services. The idea is to empower healthcare workers at all levels to deal with the complex demands of their work, - in this model, constant learning is an integral part of the service. The COPC curriculum addresses service providers working at all levels of the system. It engages CHWs, medical professionals and health system managers from the workplace through the classroom to post-graduate studies.

The School of Medicine’s existing undergraduate medical student community placement programme has been extended from clinics into people’s homes and places of work. Through it, medical students and community health workers learn from each other. The Department of Family Medicine links education, training and research to service through collaborations within the Faculty of Health Science and with the Institute for Food Nutrition and Wellbeing (IFNuW), the DST-NRF Food Security Centre of Excellence and the Department of Social Development, as well as with the National Department of Higher Education’s Technical Vocational Education and Training (TVET) programme. To date the Department of Family Medicine team has directly and indirectly contributed to the training of some 1000 learners in community oriented primary care. This education covers such diverse topics as the theory and practice of community-based healthcare, diseases and disorders common to South Africa, community health, and monitoring and evaluation. The power of COPC rests in comprehensive care that integrates the home, the clinic, the doctor’s practice and the hospital; and that consistently improves an individual’s ability to manage their own health. It will take time and persistence to realise the full impact of the approach; however, by combining service, research and education through technology-enabled data collection COPC is set to revolutionise health in South Africa.

Context, stats & figures

What is wrong with modern healthcare?

In the last 150 years, healthcare has become increasingly hospital-centred, diseased focused and specialised. While this has led to major medical advances, has improved access to healthcare and has proven to be highly profitable, it also excludes large parts of the population and cannot provide universal access to healthcare. The system as it stands tries to categorise every patient very narrowly and find a narrow cure, effectively simplifying health issues by removing all context for a person’s health. Unfortunately, this ignores the very obvious truth that specific health issues cannot be dissociated from the overall health of a person. This has the consequence of resolving health problems on the scale of disease, rather than on the scale of the individual.

What is community oriented primary care?

Sydney and Emily Kark were physicians working in Pholela, an impoverished, segregated reserve in what is now KwaZulu-Natal. For 15 years in the 1940’s, they together with a small team, were the de facto healthcare system for an entire population that had been denied access to Western medicine. They pioneered a brand new approach to primary care, which entailed surveying the health of the local population, establishing relationships with the tribal leaders in the area, and training local people as health workers. They took this model to the Hebrew University, where they taught the COPC approach to clinicians, public health workers and epidemiologists from around the world. After being forced to leave the country by the Apartheid government, they continued to build international capacity in COPC.

Community-oriented primary care (COPC) challenges the industrialised healthcare model by addressing health problems at the community level. It is defined as follows:

“COPC is primary care where professionals from different disciplines and approaches work together with organisations and people in defined communities to identify and respond systematically to health and health-related needs in order to improve health.” - Tessa S. Marcus Community Oriented Primary Care, 2013.

The five principles of COPC

Local health and institutional analysis: The people and organisations in a geographically defined area are the starting point for any COPC programme. In this case, each CHW is assigned 200-250 households in a ward. CHWs take an inventory of all visible organisations and facilities (including clinics, GPs, traditional healers and specialists) and build local working service partnerships from there.

Next, they register households, conduct a household assessment and categorise individuals and families according to national health priorities. These include detecting and responding to any emergency, pregnancy, risk of TB, request for HIV testing, and households with children under five or those in need of home-based care.

Comprehensive care: This means that community health teams are involved in and support every aspect of family and individual health. CHWs promote health and support disease prevention, treatment, rehabilitation and palliation.

Equity: In a society as unequal as South Africa’s, this ensures that people with greater needs are given greater attention while everyone with the same need gets the same attention. This means that access to care and health resources is determined by healthcare needs rather than money, power or privilege.

Practice with science: There are two aspects to this principle. First, it means that healthcare practices should be based on systematically collected evidence. Secondly, it means that science must be put into practice and tested. Because healthcare knowledge and practice changes all the time, effective healthcare requires the expertise of people from different professions and backgrounds.

Service integration around users: Finally, this principle is about continuous, partnership-driven and person-centred healthcare. It highlights the importance of treating a health problem by looking at the whole person, the people they live with and their environment.

“We’re not doing research for research’s sake, or publication’s sake; we’re doing it so that healthcare can be based on the best available evidence. We’re making sure that the person at the coal face has the best tools available, and that the research is linked to a delivery system.” – Tessa S. Marcus

Source: Mullan and Epstein, 2002; A Practical guide to Doing COPC, Marcus 2015

How does technology enable COPC?

Without a technological platform, COPC is difficult to achieve in a complex health system. This is why the UP Department of Family Medicine worked with private sector specialists to build the smartphone-enabled, web-linked AitaHealth™ platform.

AitaHealth™ is a smartphone app used by CHWs to do community oriented primary care. The CHWs use modules on the app to collect information and guide their responses, including scheduling follow up visits. The information collected by CHWs is available to team leaders via a centralised database. This enables them to support CHWs in real time. It also supports planning and management of individual CHWs and teams.

AitaHealth™ was designed and built by UP Department of Family Medicine in partnership with Mezzanineware, a mobile software company owned by Vodacom. All content was created by the UP Family Medicine team and the app has been rigorously tested both at the university and in the field to ensure that it achieve its purpose.

Two key points about how AitaHealth™ works are worth highlighting. Firstly, the app guides CHWs through a process and information entered into the app prompts the CHW towards action. If a person reports TB-associated symptoms and he or she is not on treatment, AitaHealth™ prompts the community health worker to advise the patient to go to the clinic for testing.

Second, AitaHealth™ is backed up by a sophisticated, web-enabled infrastructure. All information and interventions are available to managers to help with service planning and delivery. AitaHealth™ information is linked to a patient record system through Synaxon, another partner in the programme. This infrastructure provides continuity of information and care by linking people in their homes to professionals in clinics and hospitals.

The platform also provides robust data on the real health situation and services in defined geographical communities. This means that ward-based healthcare teams can tailor healthcare to individuals and defined places, while at the same time the data can be used for basic and applied research. In time, AitaHealth™ will provide some of the most robust clinical and epidemiological data ever recorded.

Is there precedent for this type of approach?

Community oriented primary care has been around for about 75 years. While it has had sporadic appeal in different parts of the world at different times, everywhere it has been difficult to shift well-entrenched, traditional healthcare systems. Inspired by Brazil’s primary healthcare system, the Department of Health’s primary care reengineering provided UP’s DFM with a chance to test the concept in South Africa. In its current iteration, however, the system at work here has no precedent anywhere in the world. The combination of academic rigour, public health focus, clinical care and technological innovation has yielded a novel and transformative platform for improving society-wide health outcomes.

What role does education play?

As much as the technological platform helps healthcare providers deliver services, it does not substitute for individual capability that comes from learning, doing and experiencing. Education therefore plays a critical part in all healthcare, and in COPC in particular. It is there to equip healthcare workers and professionals with the knowledge and skills required to carry out the complex tasks of COPC. To this end, the Department of Family Medicine and the City of Tshwane have built continuous work integrated learning into the COPC implementation plan. This learning is supported by curricula, face to face training and specially developed learning materials. These are designed to support learning in the workplace and to help CHWs transition into further qualifications. In addition, through the UP COPC Research Unit Marcus is driving a major community health education research initiative. With NRF funding, some 14 masters and 12 doctoral students are working on various aspects of learning in community health in order to improve the model, quality of care and the general level of capability in health, including in health research.

What projects are involved in the COPC initiative?

The AitaHealth™ platform is designed to allow research projects to ‘slot in’ to the system, provided that they can help develop the community based healthcare platform. Research in the COPC initiative includes using Umbiflow (developed by the CSIR) to detect growth delays in pregnancy, under the leadership of Prof Robert Pattinson (Department of Obstetrics and Gynaecology and MRC’s Maternal and Infant Health Care Strategies Unit); Hearscreen™ - an on-site hearing test developed by Prof De Wet Swanepoel (Department of Speech-Language Pathology and Audiology); screening for substance abuse and addiction (with City of Tshwane Department of Social Development) as well as health education research through the Community Health Education Research Initiative (CHERI). In addition, individual health status assessment modules on the AitaHealth™ app are collecting information on reproductive health, general health and lifestyle, non-communicable diseases and infant and child development.

Who benefits?

The project has begun to support healthcare in the communities around Tshwane where it has been rolled out. The approach is replicable and scalable, which means that it can be extended to all parts of the city as well as across districts and provinces throughout the country in time. Through research and education, the benefits of this initiative extend well beyond the communities where COPC is being implemented. Taken as a whole, the COPC initiative will result in a sustainable and affordable community-based health system that is integrated across multiple sectors of society and puts community health to the fore, benefitting millions of South Africans.

What’s next?

Technology-enabled COPC has proven to be a successful approach to improving health in the City of Tshwane. Based on this success, a version of the AitaHealth™ app called StudentAita, is being made available to medical students across the country. The Department of Family Medicine hopes that it will be possible to roll out COPC with AitaHealth™ nationally and that UP and other medical schools and students will be an integral part of this process.

Lastly, a thorough assessment of the impact that COPC is having on community health will be key to ensuring this initative’s long-term success.

At the University of Pretoria, the solutions to change the world can be found in the research we do today; much like COPC, which empowers communities to be able to care for themselves. A necessary contribution in making healthcare accessible to those who need it most.

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