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
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.