Introduction
Before 1994, South Africa's public health services were racially segregated, highly
unequally distributed between the rural and urban areas and rich and poor communities,
overwhelmingly hospital based and curative in their emphasis. Management responsibility
was also fragmented between different authorities—national, provincial, local and
the former homelands. Since 1994 policies and structures have been put in place to
reduce the previous fragmentation by creating an integrated national health system,
based upon primary health care, and decentralized in terms of management to geographically
defined districts. The private health care sector, which caters for approximately
20% of the population, yet consumes almost 60% of the resources (financial and human)
devoted to health care, still remains largely unaffected by these changes in policy
and organization.
The challenge of transforming the public health care sector has raised questions about
the optimal approach to conceptualizing and providing comprehensive and integrated
health care in the present international and national policy climate. This article
interrogates some of the debates, which have marked the transformation process in
South Africa. In particular it explores the tension between a comprehensive primary
health care approach (CPHC) as elaborated in the Alma Ata Declaration in 1978 and
more recent approaches, variously termed ‘selective primary health care’ [1] and the
‘new universalism’ [2]. An attempt to develop comprehensive care and an integrated,
decentralized system is illustrated through the use of a case study, which centers
on implementation of nutrition policy in South Africa's Eastern Cape Province.
Selective primary health care and the primary health care package
The concept of PHC, codified in the Alma Ata Declaration explicitly outlined a strategy,
which would respond more equitably, appropriately and effectively to basic health
care needs and also address the underlying social, economic and political causes of
poor health. Certain principles were to underpin the PHC approach (PHCA), namely,
universal accessibility and coverage on the basis of need; comprehensive care with
an emphasis on disease prevention and health promotion; community and individual involvement
and self-reliance; inter-sectoral action for health; and appropriate technology and
cost-effectiveness in relation to available resources.
An important response to the challenge of transforming the South African health system
has been a recently proposed ‘Core Package of Primary Health Care Services’ [3]. Through
the identification of ‘critical’ services it is hoped that a set menu of services
can be offered at each level of care—community, primary (clinic and health centers)
and hospital. For instance, for malnutrition the core package consists of providing
nutrition messages in the community, growth monitoring in the clinic and treatment
protocols in the hospital. This approach is very attractive to health managers with
its neat outline of tasks, timetables and costs for each level of care.
This approach builds upon the legacy of ‘selective primary health care’ [1], which
was a response to the CPHC outlined at Alma Ata. The adoption of certain selected
interventions, such as growth monitoring, oral rehydration therapy (ORT), breastfeeding
and immunization (GOBI), it was argued, would be the ‘leading edge’ of PHC ushering
in a more comprehensive approach at a later stage. This approach was nurtured by the
prevailing conservative political ideology of the 1980s which encouraged a focus away
from the broader determinants of health—such as income in-equalities, the environment,
community development—towards an emphasis on health care technologies. The result
was the enthusiastic promotion of selected interventions, which received generous
funding to the detriment of more comprehensive approaches.
Selective PHC was given further credence by the World Bank's 1993 World Development
Report, “Investing in Health” [4], which recognized the importance of health to development.
Based on calculations of burden of disease globally and in different regions, it specified
the most cost-effective health interventions, and culminating in the formulation of
a core package of health services to be provided at the different levels of care.
The identification of core packages became a mechanism to ration the cost of health
services provided by the state, as other activities were to be taken up by non-government
organisations. This fitted in neatly with the Bank's wider economic and fiscal policies,
encouraging the privatisation of health care delivery and the cutting back of State
services.
Proponents of this approach have pointed to the successes in increasing immunization
rates, reducing infant mortality and the eradication of polio. However, closer examination
of these achievements reveals the shortcomings of an approach, which does not integrate
the different levels of care or situate health within a wider context. There is growing
evidence that immunisation coverage is stagnating and even declining in many countries
[5], infant mortality rates are rising in many Sub-Saharan countries [6, 7] and the
health of many children is now deteriorating [8]. Evaluations have raised questions
about the sustainability of mass immunisation campaigns [9], the effectiveness of
health facility based growth monitoring [10] and the appropriateness of ORT when promoted
as sachets or packets and without a corresponding emphasis on nutrition, water and
sanitation [11]. A recent review has even pointed out the lack of evidence for the
effectiveness of directly observed therapy for TB (DOTS) in the absence of a well
functioning health services and community engagement [12]. Evaluations at both national
and provincial levels have found that it is only when these core service activities
are embedded in a more comprehensive approach (which includes paying attention to
health systems and human capacity development) that real and sustainable improvements
in the health status of populations are seen [13–15].
A comprehensive strategy for health development1
CPHC, however, is based on the understanding that health improvement results from
a reduction in both the effects of disease (morbidity and mortality) and its incidence
as well as from a general increase in social well-being. The effects of disease may
be modified by successful treatment and rehabilitation and its incidence may be reduced
by preventive measures. Well-being may be promoted by improved social environments
created by the harnessing of popular and political will and effective intersectoral
action.
Of particular relevance to the development of comprehensive health systems is the
clause in the Alma Ata declaration stating that PHC “addresses the main health problems
in the community, providing promotive, preventive, curative and rehabilitative services
accordingly” [16].
Comprehensive health systems include, therefore, curative and rehabilitative components
to address the effects of health problems, a preventive component to address the immediate
and underlying causative factors which operate at the level of the individual, and
a promotive component which addresses the more basic (intersectoral) causes which
operate usually at the level of society.
Table 1 below illustrates, using some common health problems, the complementary role
of the different components in holistically tackling them. Such a matrix, which starts
from a disease focus, is useful for health professionals in providing them with an
understanding of both the health care as well as broader, developmental interventions
required to comprehensively address them.
Strategies for comprehensively tackling such health problems can be grouped essentially
under two complementary headings: promoting healthy policies and plans and implementing
comprehensive and decentralised health systems. Success of these strategies depends
upon the creation of a facilitatory environment through such actions as advocacy,
community mobilisation, capacity-building, organisational change, financing and legislation.
Below we outline the principles of implementation of comprehensive and decentralized
health systems. We first refer briefly to the strategy of health promotion whose operationalisation
is usually explicitly inter-sectoral from the outset. We then focus upon the key steps
in developing comprehensive, community-based programmes structured around common health
problems, and on the integration of such programmes into decentralized health systems.
Implementing comprehensive and decentralised health systems
The implementation of PHC has too often focused only on the (often facility-based)
curative and personal preventive components of comprehensive care, while the health
promotion initiative has stressed the broader social components. This gap needs urgently
to be bridged since they are clearly indivisible in the process of health development
and providing integrated care.
Health promotion in practice
The implementation of healthy public policies, which emphasise the role of intersectoral
activity, has been significantly enhanced since the late 1980s by the growth of the
health promotion movement. The Healthy Cities initiative [18], and subsequently a
focus on other settings such as schools, markets, work places and hospitals, demonstrate
an approach which takes forward the policy development activities described above.
These initiatives can garner political support and encourage local agencies and sectors
to reassess their policies and practices in influencing health. By 1997 there were
over 1000 communities participating worldwide in the Healthy Cities initiative.
Facilitating organisational change and encouraging (particularly government) staff
to be more flexible, innovative and responsive to local communities are key actions
in achieving success [17]. In the past many of the initiatives to promote community
participation in health have concentrated on inviting community people to participate
in activities established (and largely controlled) by the health services. A recent
WHO study uncovered a wide range of community groups or organisations—which have been
termed ‘health development structures’ (HDSs)—that play some role in promoting health.
A report noted that “the majority of HDSs owe their origins to age-old community traditions
of mutual support and cooperation and have a long history of community action” [19].
They include, in addition to representative health councils, women's groups, youth
groups, social clubs, cooperative societies, mutual aid societies and sporting clubs.
There are many roles, often invisible, played by such groups, that contribute to improving
health. This could be achieved more systematically in partnership with the health
sector, but has hitherto been largely unexploited. Settings-based health promotion
initiatives offer a perspective and mechanism for this kind of relationship. The concept
of health promoting districts holds much promise and should be developed as a means
of extending health services towards a more intersectoral and developmental role.
The development of comprehensive, community-based programmes
Whereas health promotion activities, recognising the fundamental contribution to health
of equitable social and economic development, commence with a multisectoral focus,
programmes originating around diseases or health problems start from a health care
or service response. While curative, preventive and caring actions are very important
and still constitute the core of medical care, comprehensive PHC demands that they
be accompanied by rehabilitative and promotive actions. By addressing priority health
problems comprehensively as indicated in the table above, a set of activities common
to a number of health programmes will be developed as well as a horizontalised infrastructure.
The promotive activities will necessarily involve other sectors and, if successful
and widespread, create pressure for supportive policy responses.
The principles of programme development apply to all health problems, whether specific
communicable (e.g. diarrhoea) or non-communicable diseases (e.g. ischaemic heart disease)
or health-related problems (e.g. domestic violence).
Much experience has been gained internationally in the development of comprehensive
and integrated programmes to combat undernutrition: these experiences can provide
useful lessons for other programmes.
After the priority health problems in a district or local level have been identified,
the first step in programme development is the conducting of a situation analysis.
This should identify the prevalence and distribution of the problem, its causes, and
potential resources, including community capacities and strengths, which can be mobilised
and actions which can be undertaken to address the problem. The more effective programmes
have taken the above approach, involving health workers, other sectors’ workers and
the community in the three phases of programme development, namely, assessment of
the nature and extent of the problem, analysis of its multilevel causation and action
to address the linked causes (Figure 1).
This approach to implementation has thus been termed the “Triple A cycle” (Figure
2).
Similar minimum or core service components can also be identified for other health
programmes e.g. activities in the Safe Motherhood Initiative, the Integrated Management
of Childhood Illness, DOTS, technical guidelines for the management of common non-communicable
diseases etc. There is an advantage in standardising and replicating these core activities
in health facilities at different levels, thus reinforcing their practice throughout
the health system.
The development of a decentralised health system
There are at local level in most countries a number of programmes, often vertically
organised and centrally administered, with specialised staff who performs only programme
functions. The development of comprehensive programmes which are integrated into a
decentralised district service inevitably requires transformation of both management
systems and practice. Making the transition from a centralised bureaucratic system
to a decentralised, client-oriented organisational culture calls for a significant
investment in developing both management systems and structures and the management
capacity of health personnel. District level staff must be able to support decentralised
development of comprehensive programmes with clear roles, goals and procedures.
The case study which follows illustrates a number of the principles described above
of the process of development of a comprehensive programme and the impact of such
a programme on the creation of an integrated district health system (Photo 1).
Nutrition programme and health systems development in Mount Frere
Mount Frere health district is one of the poorest districts in the country. It lies
100 km north of Umtata in the old homeland region of Transkei and is home to approximately
300,000 people. The whole area is a beautiful part of the country full of magnificent
scenery. However, the terrain is also very rugged and inaccessible. There are only
two tarred roads in the whole district. At times of heavy rain, or after heavy snow
some roads can become totally impassable. In 1999 it was declared a national emergency
area following devastation by a tornado and, more recently, by veld fires.
A recent local survey found the crude birth and death rates to be significantly higher
than those for the rest of the Province. More than two thirds (71%) of households
use water from unprotected sources for drinking purposes. More than two fifths of
births (45%) occurred at home and were therefore not attended by health professionals.
Regional surveys have found more than one in three children to be stunted in their
growth and a majority of children and women probably suffer from undernutrition.
Being a health worker in Mount Frere is not easy. Years of neglect and poor resources
have resulted in a health system which is barely functional. If the poor of Mount
Frere are to become empowered they need a health service which delivers adequate quality
services and also seeks to involve them in tackling their health and development challenges.
This in turn requires public sector workers to gain the confidence and skills to optimise
the quality of service they offer and to understand and reach out to the people they
serve. Transforming the public sector to deliver high quality services is one of the
major challenges of the new South Africa.
A local NGO—Health Systems Trust—contracted the Public Health Programme, University
of the Western Cape to work with the local health services to devise a comprehensive
programme to tackle malnutrition which had been prioritised by the local health management.
The aims of this project are:
To increase the capacity of provincial, regional and district health workers and the
district health system to improve the quality of care and service that they provide.
To bring together a multi-sectoral team and empower them to initiate community-based
nutrition programmes.
To help develop appropriate systems, structures and policies for the smooth and integrated
functioning of different sectors and programmes, at the different levels (provincial,
regional and district) of the public sector.
To assist in the development of an efficient district health system.
To develop processes and tools to assist in the implementation of the Integrated Nutrition
Programme in other districts
Forming partnerships, teambuilding and advocacy
For innovation in the public sector to be successful, sustainable and replicable it
must have the support of all role-players at all levels of the service. The management
of the project is through a partnership between the Eastern Cape Department of Health,
the Health Systems Trust and the Public Health Programme, University of the Western
Cape.
An Eastern Cape Provincial Steering Committee oversees the project. This committee
has provincial representatives from the following sectors: agriculture, education,
environmental health, maternal, child and women's health, nutrition and welfare and
a national representative from the nutrition directorate.
At the district level this is mirrored by the Mount Frere Nutrition Team which includes
representatives from nutrition, maternal and child health, agriculture, education,
local government, water affairs and environmental health. They have fostered teambuilding
through a series of workshops which have aimed to come to a common understanding of
the causes of malnutrition and to apply a planning cycle of assessment, analysis and
action.
Performing an assessment
The district nutrition team has used the research skills acquired in the above workshops
to conduct rapid assessments of key nutrition services and the nutrition situation
in communities in the district. By developing observational checklists and interview
guidelines they have assessed the quality of care of severely malnourished children
in the paediatric ward, the performance of growth monitoring and promotion (GMP) at
the local clinics, the environmental situation of selected communities, and the implementation
and operation of the primary school nutrition programme at local schools.
For example, in examining the performance of GMP the team drew up an observation checklist
of what they would expect to see. This starts with the nurse greeting the mother and
ends with the nurse having a dialogue with the carer about the growth of the child.
From the observations, it was clear that there were many things that could be improved.
Few of the mothers were greeted, there was little or no feedback to the mothers and
opportunities for group discussions were not taken up (Photo 2).
The team also assessed the ability of nurses to interpret the growth chart and what
kind of advice they give for different growth curves. To do this a series of growth
charts were designed which showed normal growth, growth faltering, growth failure
and catch up growth. Nurses were asked to interpret the charts and state what advice
they would give the mothers based on the chart.
Finally, the possible reasons for the poor performance which was detected were explored
through a series of semi-structured interviews with a selection of nurses from the
clinics and hospitals. When asked about the reasons why GMP may not be done well in
the clinic, most clinic workers mentioned the heavy workload and number of tasks (especially
administrative). Only a minority mentioned a lack of training or supervision. Most
thought the main use of GMP was to find children who were undernourished and would
consequently qualify for a feeding scheme or require referral to the hospital. Some
felt that it was also done in order to ‘collect statistics’ for surveillance; only
a few mentioned that it was to initiate dialogue with the mother to promote growth
of the child.
Planning and implementing interventions
The above assessment was followed by an analysis of the results and the implementation
of nutrition-related interventions in the hospital, clinics and local communities.
In the hospital practices to improve the in-patient care of severely malnourished
children have been implemented. In the clinics training workshops to improve the management
of diarrhoea and growth monitoring and promotion have been conducted. In some communities
the team has assisted a local NGO, the Mvula Trust, to redesign water improvements
and prioritise hygiene education programmes.
All of these interventions were critically informed by the situational assessment
the team performed. So in the case of growth monitoring the team stressed the importance
of practitioners being clear about the aims and objectives of GMP and to emphasise
this in training. More specifically, the use of GMP for tailoring individual nutrition
education messages, in the promotion of good growth and in the integration of services
was stressed.
The team then thought about the skills and resources required to implement such a
programme. This involved drawing up a detailed plan of activities associated with
growth monitoring in the local settings. Local teams then planned how they would change
their work patterns and clinic organisation to optimise growth monitoring activities.
To complete the triple A cycle the teams have been collecting routine data to assess
the effectiveness of their interventions. In the hospitals there has been fall of
nearly fifty percent in deaths from severe malnutrition. Supervisors and outside evaluators
have confirmed much improved growth monitoring in many of the peripheral clinics.
It is important to feed this back to the team in order to encourage them to tackle
other nutrition problems as well (Photo 3).
Sharing the success
As a result of the success of the Mount Frere project the team members are already
being used to share their success with other districts in the region. All the hospitals
in this region of the Eastern Cape are now implementing the programme for improving
the hospital management of severe malnutrition. All four districts in the region have
also initiated training for improving nutrition services in the clinics. The community
participatory hygiene and sanitation tools developed by the team are also being adapted
nationally. In all these cases, the Mount Frere team has been centrally involved in
sharing their new-found skills and confidence.
Capacity development
The heart of this project has been the capacity development of public sector personnel
in some of the poorest parts of the country. The success of this has been partly reflected
above. Eastern Cape personnel have taken the lead in organising and presenting at
local workshops and many have already presented their experiences at national meetings
and conferences.
Conclusion
Given the historical legacy of wide inequalities in health and health care which persist
six years after the advent of democracy, the South African Government is facing increasing
public pressure to provide resources and quality services. In these circumstances
the allure of currently dominant policies with their apparently cost-effective packages
of care is understandable. However, the pressure for immediate responses needs to
be reconciled with the necessity to develop human capacity and integrated systems,
without which even the most robust and effective of technical interventions have been
shown to be unsustainable. This paper has attempted to argue for and illustrate a
more comprehensive approach in which tested technical interventions are located in
a broader process of capacity strengthening and systems development.
The key issues raised in this article relate to interpretation and implementation
of the Primary Health Care Approach. A tension which has informed international and
national policies and programmes has existed, almost from the time PHC was conceived,
between a more comprehensive and integrated approach and one which is more selective.
The former combines technical health care with intersectoral activities, and rests
upon and facilitates a long-term social process involving capacity development of
both communities and technicians. The latter selects technical health care interventions,
primarily on the basis of their cost-effectiveness, and often “delivers” these through
vertical programmes—with their own infrastructure, administration and personnel. The
latter “selective” approach, albeit in sophisticated form, is currently dominant in
international health policy and appears also to be highly influential in contemporary
South Africa, which is facing the enormous challenge of implementation following years
of apartheid neglect. The case study described in this paper outlines the early phases
of a programme to combat child undernutrition in a remote, impoverished rural district
in the Eastern Cape Province of South Africa.
The choice between a selective and a more comprehensive approach is one which is both
immediate and stark in present-day South Africa, where new policies and activities
are being engaged with on a daily basis. The authors contend, however, that the issues
raised in this article have broader application and profound implications for health
systems development. In the case of other complex, multicausal health problems, for
example, HIV/AIDS and T.B., it is already clear that narrow, vertical approaches are
having little impact on their spread. A case has been made for a more multi-faceted
and integrated approach, central to which is an action learning process whose outcomes
include improved understanding of the causes of particular problems and enhanced capacity
to address them (Photo 4).
Key questions to be answered revolve around sustainability and replicability, since
it is clear that impact can and does result from such approaches—in common with more
selective technical approaches. Thus, in the hospital-based component of the Mt Frere
nutrition programme it has been possible to substantially reduce the case fatality
rate from severe malnutrition among hospital inpatients. This has been accompanied
by demonstrable improvements in knowledge and skills amongst both nurses and doctors.
Moreover, some of these skills are “generic” and transferable to other aspects of
hospital child care. It is, however, important to demonstrate that this improved practice
is sustained without ongoing external support (from the UWC team) and that this experience
is replicable within the South African public health services. Such research is not
only necessary to justify past and continuing investment in the Mt Frere project,
but crucial for the longer-term development of comprehensive and integrated health
systems in South Africa and beyond.