Action for health in Tonga and Shongwe 1997/98

Action for health in
Tonga and Shongwe 1997/98

Initiative for Sub-District Support
Technical Report #2e

Action for health in
Tonga and Shongwe 1997/8

Initiative for Sub-District Support
Technical Report #2e

H
ST

Published by the Health Systems Trust

504 General Building Tel: 031 307 2954
Cnr Smith & Field St Fax: 031 304 0775
4001 Durban Email: [email protected]
South Africa

Also available on the Internet:
http://www.healthlink.org.za/hst/isds

Compiled by Zama Nxumalo (Centre for Health and Social Studies, University of Natal)
and Steven Donahue (Dept of Health and Welfare, Mpumalanga).
Data collected and analysed by the district management teams of Tonga and Shongwe.

All photographs by Christina Stucky

ISBN # 1-919743-16-2
November 1997

The publication of this document was funded by the Henry J. Kaiser Family Foundation
(USA) as part of their support for the Initiative for Sub-District Support

Designed and printed by Kwik Kopy Printing, Durban

Preface

This publication is one of a number which together form the second technical
report of the Initiative for Sub-District Support. This second technical report
documents the planning process in each of the ISDS sites, namely Kakamas
and Kalahari (Northern Cape), Mount Frere (Eastern Cape), Tonga and
Shongwe (Mpumalanga), Underberg/ Pholela/ Impendle (KwaZulu-Natal) and
Bothaville (Free State).
This publication documents the outcome of that planning process in the districts
of Tonga and Shongwe in Mpumalanga, and charts a plan of action which
has already started. It is divided into two sections.
These are:
a description of the present situation regarding health status and

provision of services within the sub-district.
an outline of an action plan for 1997/8, detailing the strategies for

improving the quality of health care provision, and requirements for the
success of these strategies.

-1-

Introduction

The process of establishing the new Shongwe and Tonga Health Districts
was already well under way when the ISDS was launched in the area in January
1997. Both had recently completed their own Situation Analyses and
District Plans, in concert with plans for restructuring and program
implementation from the regional and provincial offices.
This report will present a summary of these large documents, together with
further background information and additional data. It will also record the
process of how the initiative started, key events and plans developed for the
ISDS. The strategies presented will be placed in an appropriate research
framework.
Developments in the area must be understood within the context of the
extensive restructuring of the provincial health department, major local trends
and events, and profound political and economic change in the communities
themselves.
It is to be expected that reports on the progress of the initiative within the two
districts will increasingly diverge, as the districts operate more independently.
Although this presents difficulties for co-ordinating the joint facilitation and
various support interventions, it also presents a unique opportunity to compare
the processes, decisions and responses to these at district and sub-district
levels.

-2-

Part 1: Situation Analysis

Background to the area

The Nkomazi / Onderberg area is a wedge of land neatly bounded by the
Mozambique border and Lebombo mountains to the East, the Swaziland border
to the South, mountain ranges to the north-west, and the Crocodile river and
Kruger National Park to the North. The wide valleys of the Komati and
Crocodile Rivers join at Komatipoort, the gateway to Mozambique.

This Lowveld area has a sub-tropical climate, with mild winters but a very hot
and humid summer wet season. The land is dry bushveld, used historically for
Nguni cattle. Where irrigation is available it can support farming of sugar
cane, bananas, tropical fruits and vegetables. Older plantations of coffee and
sisal are no longer profitable. The Drakensberg foothills are also used for
forestry. There are small mining operations for coal and Magnesite.

Most people in the area are Swazis. They subscribe to both traditional and
Western cultural and religious practices, including Christianity and strong
support of traditional healers and leaders. The English and the Afrikaners
were initially attracted to the area by gold in Barberton, trade to the coast,
missionary activities and subsequently by agriculture.

More recently war in Mozambique has led to large movements of Tsonga
speaking refugees into the area. The influx continues as illegal immigrants
try to access employment opportunities on the farms, and as a transit area
for many hoping to reach Gauteng. Abuse of illegal farm labour has led to
depressed wages, further unemployment, and shocking health conditions in
a group who try to remain invisible. Some degree of resentment and
discrimination against Mozambicans exists (health services follow a no-
questions-asked policy of free access). A large military presence seeks to limit
illegal immigration, smuggling and gun running. However the borders,
particularly with Swaziland, are quite porous for local people.

The Maputo Development Corridor will expand road and rail links between
Gauteng and its closest port, Maputo. Rapid population growth, trade and
economic development is expected along the N4 Highway, which runs along
the Northern fringe of both districts. However the supposed health benefits
of this are debatable.

-3-

Development of health services

The Southern half of Nkomazi was part of the impoverished Kangwane
homeland under apartheid. The area was subject to the usual overcrowding,
corruption, migrant labour and systematic underdevelopment. To the north,
large white - owned farms exploited more fertile land in the Crocodile valley,
under the Transvaal Provincial Administration. Small clinics were run by the
Local Authorities in the main towns of Malelane and Komatipoort.

Women and their children wait outside Schoemansdal Clinic

Shongwe Mission Hospital originally served a much larger area of Swaziland
in the 1930’s. Despite its abrupt nationalisation and Homeland administration,
the Nkomazi Health Ward had a reputation for being well managed over a
number of years. One aspect of good health planning was the attention to
developing a network of clinics in the area, staffed by at least one ‘PHC’
trained nurse.

-4-

Shongwe has almost always been subject to severe budget and staffing
shortages, and administrative incapacity. Surprisingly, the Kangwane
drug / consumables supply system was remarkably efficient.
Unfortunately, Shongwe Hospital now lies at the far South Western
corner of the two districts, a few kilometres from the Jeppe’s Reef
border post.

Due to the large population size, the Mpumalanga Department of Health and
Welfare split the Nkomazi area into two new health districts in 1996 -
Tonga, to the East of the Komati river and a North / South line through the
farms; and Shongwe to the West (including a ‘tail’ of territory behind the
mountains from Kaapmuiden toward Louisville, the administrative complex
for former Kangwane. Due to local demand and compelling logic these clinics
have remained under the control of Barberton District).

The new districts correspond to some Local Authority boundaries, but not
the administrative units of any other sector, including welfare. A political
decision to build an additional hospital at Tonga was taken in 1995, despite
a pressing need to upgrade PHC services. The new hospital site is next to the
Komati river boundary, but at least more accessible to the people in the
Nkomazi sub-region. The building should be completed by mid 1998.

Demography

Population estimates are subject to a large degree of error and the various
sources differ widely. Most are extrapolations from the imperfect 1991 census
which used different boundaries in the first place. Rates of population growth
are unknown because migration is probably significant, and birth and death
statistics not available. The following figures are inflated for 1997, from
conservative 1996 estimates recently obtained from DBSA:

Shongwe District 155,470

Tonga District 131,700

Note: Local projections based on observed numbers of structures have been
used to produce figures of approximately double this size!

55% of the resident population are female, and half the population is 15
years and younger. 47% are in the economically active group (16 - 64 years)
and only 3% of the population is 65 years and older. This has implications for

-5-

planning, where resources need to be channelled toward young people. A
cumulative 20% population growth is anticipated by year the 2000, possibly
more due to influx from the neighbouring countries and the anticipated
employment opportunities in the Maputo corridor.

Nurse Agnes Hluyeko examines a child at a Shongwe clinic

Using the same unreliable sources and assumed patient flows, catchment
populations of the selected ISDS clinics are estimated as follows:

Tonga District

Block B 10 248 (including people from Block A)
Block C 19 934 (but many use nearby Naas CHC)
Steenbok 13 038

Shongwe District

Phiva 9 945 (including people from Vlakbult)
Mzinti 9 104 (including people from Ntunda)
Sikhwahlane 2 914

-6-

Socio - economic status

The Nkomazi districts are officially the poorest in the province, based
on measures such as the Human Development Index. The literacy
rate is estimated at 64%. The average standard of education attained
is standard 4.

Unemployment is very high, and approximately 60% of employed males are
migrant labourers. Major sources of income are remittances, pensions, farm
labour, informal trading, and the wages of state employees.

Most people in these districts are living below the minimum subsistence level
that was defined as R1 500 per month for Nelspruit in 1996.

Infrastructure

Water and sanitation

A patchwork of fragmented, old and poorly maintained water supplies exists
in the districts. These consist of bore holes and a few river water purification
/ reticulation plants. Due to population growth and movements, only a handful
of about 30 communities have greater than 50% access to safe water.

Most of the population fetches raw water from rivers and dams, often several
kilometres from the village. Many communities rely on water brought by trucks.
About half of all households have a toilet, the majority of which are unimproved
pit latrines.

There are NGOs (i.e. Mvula Trust and the IDT) working with local partners
trying to improve water and sanitation in the area. One of the programs is
subsidising households to build VIP toilets in the villages.

Plans for water supply from the Department of Water Affairs envisage majority
coverage only after about 10 years. Plans are severely constrained by
inadequate state and community financing, community disorganisation and
conflict, and lack of capacity. Several large dam projects such as the
Driekoppies Dam are proceeding, but aimed at provision of water for irrigation
on the farms. No environmental or health impact assessments have been
done on these schemes.

-7-

Education

The area has extremely poor standards of educational achievement, and
facilities typical of a homeland area. About 10% of children are thought to be
not attending school. Most schools do not have adequate sanitation or water.

Tonga

Primary schools 54
Secondary schools 13
Tertiary Education
1

Shongwe

Primary schools 54
Secondary schools 15
Tertiary education
1

A few schools of a good standard exist in the formerly white towns. In addition
there are a number of small farm schools.

Transport

Main roads are the N4 highway to Mozambique which is being upgraded, and
sealed roads southward to the two Swazi border posts at Jeppe’s Reef and
Mananga. Other tar roads pass through larger villages such as Langeloop,
Mzinti, Tonga, Mangweni, Block B and Block C. Most are gravel roads, which
due to clay soil can become impassable in the wet season.

Public transport is mostly combi taxis, plus a few bus services on the main
roads. Railways along the N4 and into Swaziland are mostly concerned with
freight.

Communications

Telephone lines reach most villages except isolated areas. Most clinics have
been on party-lines until recently, through very unreliable manual exchanges,
Those with direct lines often go through a radio link (routel) which is also
subject to faults. Cell phone services are only available along the N4 highway.

Clinics have had to rely heavily on radiophones for emergency services. This
service tends to be affected by the weather. Radio and television reception is
poor, and those who can afford it use satellite dishes. Radio Swazi is the most

-8-

popular radio station while Mpumalanga News and the Sowetan
are widely read newspapers.

Word of mouth remains an important means of communication in
villages.

Electricity

While the whole farm area is served by Eskom, the former homeland is subject
to a small parastatal called the Transitional Electricity Distributor (TED).
Electricity supply is erratic with long and frequent blackouts, brownouts, and
power surges. This affects health services by, for example, interruptions to
the cold chain. Several villages and clinics are not yet connected to the grid,
relying on gas fridges and solar powered radios.

Health status

In both the farming and former ‘homeland’ areas, the picture is one of diseases
of malnutrition, poverty, and social instability. Problems related to lack of
clean water and sanitation are extremely common. In addition, the tropical
climate and migration from even poorer neighbouring countries means that
infectious diseases are prominent.

Most available data is facility based, and birth and death registration are
rudimentary. Catchment populations for use as denominators are also
inaccurate. Therefore key community indicators such as IMR, birth and
mortality rates are unknown. Even facility based statistics were largely absent
from the District Plans.

Clinic and hospital statistics show a predominance of ARI and diarrhoeal
disease in children, with high rates of water washed diseases such as scabies
and skin sepsis. Household accidents such as burns and paraffin poisoning
are common in winter.

Most children are infected with a cocktail of parasitic worms, including endemic
schistosomiasis. Hematuria in children is seen as normal by some communities.

Large numbers of children are stunted, and acute malnutrition is common,
particularly in times of drought and among the refugees. The area has endemic
moderate vitamin A deficiency. Immunisation coverage is thought to be about
70% at age one year.

-9-

With young people, sexually transmitted diseases and teenage
pregnancy are acknowledged as major problems. HIV seroprevalence was
15% in ante-natal unlinked surveys in the first half of 1997 in Mpumalanga.
TB diagnoses are rising, with about half of new cases being HIV positive. The
AIDS epidemic has still not entered the consciousness of the community as
a whole.
Violent injury is particularly associated with alcohol abuse at month end, and
appalling rates of road trauma exist as traffic volumes grow. Other contributing
factors are unlicensed drivers, unsafe vehicles, poor road design, and cattle
wandering onto roads from unfenced grazing land.
Seasonal malaria is a major problem, particularly in the Tonga District, despite
an intensive provincial spraying and control program. Following good rains,
about 10,000 cases occurred in the region in the 1996 - 97 wet season.
Chloroquine resistant falciparum is now seen in about 30% of new cases.
Typhoid is endemic, with over 60% of all typhoid notifications in the province
coming from the Nkomazi area.
About 5% of the population have some disability that would require
intervention, including mental retardation and cerebral palsy, plus the results
of injuries at home and at work. Acute and chronic psychiatric illness is a
largely unrecognised problem. Alcohol and drug abuse are expected to increase
as incomes rise.
Farm worker populations in particular are exposed to high rates of work
injuries, pesticide poisoning, and snakebite. They also tend to live in very
poor sanitary and housing conditions, with poor access to health services in
general.

- 10 -

Health services - general

Most health services are inherited from the Kangwane Health
Department. These were centred at the old Shongwe Hospital, with
clinics in larger villages, visiting points for day clinics in other villages
(and some farms), and mobile clinics in the farming areas. Local Authority
clinics at Malelane and Komatipoort were originally only for preventive care,
but have begun to offer a more comprehensive service.

Shongwe

Hospital 1
Clinics 13 (Excluding area run from Barberton)
LA clinics
Private / farm clinics 1
Visiting points 2
Mobile clinic Approximately 100
2 (Turn-around about 4 weeks)

Tonga

CHCs 2
Clinics 8 (One not yet open)
LA clinics 2
Private / farm clinics2
Visiting points 119
Mobile clinic 2 (Turn-around about 6 weeks)

Community outreach and participation relied mainly on a network of
Clinic Committees, and volunteer Care Groups - women’s groups for self
help and community based health promotion. The numerous small Care
Groups had structures at clinics that were provided by MSF (French NGO).
Environmental health ‘inspector’ services were always severely understaffed
and failed to address the underlying or structural causes of poor health. Malaria
control was a vertical program. Attempts at providing a school health service
were intermittent. Specialised outreach staff provided very basic services for
mental health and TB control.

Shongwe Hospital consumes the greater part of the budgets in the Nkomazi
region. It has 350 beds including general medical, TB, surgical, obstetric and

- 11 -

A nurse immunises a child at a Shongwe clinic

paediatric wards, and clinical services such as lab, pharmacy, X-ray; and
rehabilitation and dental services when staff are available. The OPD department
is overcrowded with minor cases that have bypassed clinics in search of a
better quality of care. Support services at the hospital such as transport and
workshop fail to meet the needs of the hospital, much less rest of the two
districts.

Staffing with doctors, nurses, paramedical and technical staff has always
been problematic. Many doctors have been foreigners, and nurses have often
been attracted from Swaziland. In January 1997 the hospital had a
superintendent, fourteen doctors (one from South Africa and seven Cubans)
and two interns. A critical shortage of registered nurses affects both
hospital and clinics in both districts; wards are often left without a registered
nurse at night, and clinics may close while an absent nurse cannot be replaced.
The shortage of nurses means that sparing a few to attend training courses
puts a severe strain on the system. The small staff establishment of the Tonga
district means even more problems covering nurses who are absent for any
reason.

- 12 -

Difficulties in attracting and retaining professional staff relate to the
small numbers of local people who can reach these levels of
education, poor salaries, lack of decent schools, administrative
neglect, frustration at work, and lack of housing. The hospital usually
suffers from a housing shortage; many nurses cannot be
accommodated at hospital or clinics, and in any case most do not
have telephone, electricity or running water.

The integration of Transvaal and Kangwane emergency services has been
problematic. A few well-equipped ambulances with trained staff are available,
but most others are poorly equipped combis, with drivers having little or no
ambulance training. These have come to be known as patient transporters,
and are being split from the general hospital transport department. Ambulances
are managed and controlled from Nelspruit with little local input; response
times and quality of service are poor. The service tends to prioritise service
for emergencies in the community, rather than needs for urgent transfers
from health facilities.

All steps in the referral system are characterised by an almost total lack of
feedback. Due to inadequate tertiary services in the province, Shongwe has
had to refer to Ga-Rankuwa and more recently Pretoria Hospital. The two
Community Health Centres in Tonga have never really functioned as an
intermediate referral level, as is the experience elsewhere. (Despite this CHCs
feature prominently in both provincial and district plans).

There is a constant problem of people bypassing local clinics in the hope
of finding better care by a doctor in the hospital. In addition, a large population
lives closer to Shongwe than any clinic; the OPD area is always crowded,
resulting in calls by the hospital for an even greater share of available resources
and staffing.

Other providers of health services are large numbers of traditional and
religious healers, in two main rival organisations. Traditional birth attendants
probably exist in small numbers only, and tend to avoid health professionals.
A few GPs work in the white towns and larger township areas. Two GPs do
sessions at clinics or hospital, and another renders District Surgeon services.

- 13 -

Health services - clinics and CHCs

Clinics provide the bulk of primary care consultations and preventive services
in both districts. The provincial clinics are staffed by registered and assistant
level nurses in about equal numbers, with cleaners and sometimes a gardener,
watchman, or clerk. They are usually open from 7.30 to 4 pm, five and a half
days a week; the two CHCs are officially open 24 hours. In general,
comprehensive basic services are available, but these are fragmented for the
convenience of the service provider: ANC first visits, subsequent ANC visits,
child health, chronic diseases and family planning are usually on different
days. ‘Minor ailments’ and emergencies are seen every day, although the
waiting times can be long.

Children are weighed at a Shongwe clinic

Every clinic is equipped with a delivery room, although only the 24 hour
services deliver more than one or two babies per week. 95% of deliveries at a
health service take place at the hospital; an unknown proportion of babies
are born at home.

- 14 -

In addition to fragmented clinic services, there are several unofficial
barriers to access. There may be delays due to preparations
between the official opening time and when the first patient is seen.
Most clinics stop for an hour for lunch, and sometimes also for tea,
during which clients may be asked to leave the building. In addition,
clients are often strongly encouraged to attend early in the morning.
The result is that most clinics are crowded in the mornings and quiet
in the afternoons (busy clinics may be so all day, and quiet clinics may be
fairly empty all day).

About half of the clinics are less than 10 years old. They have a fairly standard
design with a large waiting area, consulting rooms, dispensary window, stores,
toilets, sluice, kitchen and a maternity room. They can be very hot in summer.

All clinics suffer from problems with maintenance and basic amenities such as
water supply, sewerage, waste disposal, communications, and electricity.
Transport of supplies, specimens and correspondence is also irregular and
unreliable.

Until recently clinics were managed by a system of clinic supervisors. These
matrons helped to solve logistic, staffing and administrative problems, but
generally did not provide much technical support or clinical supervision.

Implementation of the provincial district
model

In 1995 the new district management system was begun in the combined
Nkomazi district. This broadly followed the provincial districts model as
described in ‘PHC in Mpumalanga: Guide for District - Based Action’. The
guide also contains detailed advice on community participation and governance
structures, health promotion, information systems, and management of
facilities, personnel and finances.

Mpumalanga is initially following the route of provincial control of
transformation, with districts reporting to a Regional Director (The Lowveld
Regional Director is Mrs Gladness Mathebula, based in Medsen Building,
Nelspruit). Policy and technical direction is provided by Directorates for PHC
Programs, and Policy, Planning and Information. Administrative services are
under a separate directorate, shared with the Welfare section of the Department
of Health and Welfare.

- 15 -

Each district has a full - time District Manager as part of the District Health
Management Team (DHMT). Other members are supposed to be:

District Information Manager

District Pharmacist

Finance and Administration Manager (usually former Hospital Secretary)

PHC Co-ordinator

Academic Support Representative (As yet there is no university contracted to
support the Lowveld).

The PHC Co-ordinator in turn leads a team of ten staff function Program Co-
ordinators.

Each health facility, including the hospital, is to have its own management
team, whose head reports directly to the District Manager. Staff of all
community - based services are on the establishment of one or other facility,
or of the District Office itself.

In 1996 the division into Shongwe and Tonga Districts commenced.
Appointees (mostly ‘acting’) to the various positions as of January 1997 were:

Shongwe Mr David Nkosi
Dr Ken Adae
DHMT: Mr Obed Ntimane
District Manager Mrs Elizabeth Ntuli
Hospital Superintendent Mr Dana Swanepoel
Finance and Administration Manager Mrs Marjorie Themba
District Information Manager
District Pharmacist -
PHC Co-ordinator
Academic Support Representative see superintendent
Mrs Agatha Nkosi
Co-ordinators: Mrs Samaria Ngwenya
Diagnostic and Curative -
Maternal Child and Women’s Health see Tonga Mental Health
Communicable Disease
Rehabilitation
Mental Health & Substance Abuse

- 16 -

Nutrition Mrs Rebecca Ngubane
Oral Health Dr Norman Alvie
Emergency Health Services -
Health Promotion Ms Connie Sekwane
Environmental Health Mr Elliot Dlamini

Tonga

DHMT: Mrs Jane Malaza
District Manager shared with Shongwe
Hospital Superintendent shared with Shongwe
Finance and Administration Manager Mrs Gertrude Mafothla
District Information Manager shared with Shongwe
District Pharmacist Mrs Ivy Sibiya
PHC Co-ordinator -
Academic Support Representative
shared with Shongwe
Co-ordinators: Mrs Annetjie Coetze
Diagnostic and Curative Mr Victor Gwebu
Maternal Child and Women’s Health
Communicable Disease -
Rehabilitation shared with Shongwe
Mental Health & Substance Abuse Mrs Margaret Mashele
Nutrition shared with Shongwe
Oral Health -
Emergency Health Services Ms Betty Khosa
Health Promotion Mr Thabo Nyathi
Environmental Health

These teams represented a new management layer and many of the members

- 17 -

had to maintain their existing service roles at the same time. Further acting
appointments after January included Dr Donohue as Diagnostic and Curative
in both districts, additional Rehabilitation co-ordinators, a second Mental Health
co-ordinator, and a District Pharmacist for Tonga.

A mother is handed her baby’s weight chart at Schoemansdal clinic

Problems

A guiding principle, that District Offices should not be too closely bound to
the hospital, has unfortunately been elevated to an 11th Commandment. The
Shongwe District Office was placed at the old Kangwane offices at Louisville,
over the mountains in the ‘tail’ of the district, on the way to Barberton. By
road the office is 75 km from the hospital, and even farther from the clinics.
In view of difficulties with transport and communications, the decision has
been a costly one for the district. Managers and co-ordinators spend almost
an hour commuting in each direction every day.

- 18 -

In addition, the Administration Directorate operates only from a
handful of sub-regional ‘One - Stop’ offices, in this case Louisville
for both Shongwe and the more distant Tonga. The distance, logistical
problems, lack of accountability, and inevitable duplication, have
made the administration and supply lines of both districts very fragile.

The Tonga District Office, in contrast, has been placed strategically
at a former malaria control office in Mangweni, a stone’s throw from the
Community Health Centre. Mobile offices are being used to relieve a lack of
space and communication systems put in place. The office will be a few km
from the Tonga Hospital.

Well after the start of the ISDS, neither district had confirmed staff
establishments, budgets, nor senior appointments. Administrative staff for
each district office consisted of one junior typist.

The planned appointment of 10 Program Co-ordinators, mirroring the 10
provincial programs, has been problematic. Most posts were allocated to
senior nurses or clinic supervisors, without particular technical expertise in
these fields; some key positions have remained vacant, while others are
represented by co-ordinators managing two roles.

There has been a profusion of overlapping provincial workshops, and technical
and management training programs. These have been disruptive because all
team members were seldom available at the same time.

Other developments

Below are listed some of the changes taking place shortly before, or during,
the launch of the ISDS.

Hospital superintendent reverts from a district to purely facility
management role.

Team of 7 Cuban MO / specialists stabilises medical staffing.
Of these, there is only 1 Cuban family practitioner to visit clinics in each

district.
Combined Rehabilitation Unit attempts to develop community outreach

and links.
Abolition of ‘Community Health Department’ based at hospital.
Abolition of Clinic Supervisors. Facility managers report directly to District

Manager.

- 19 -

Demise of Rural Foundation CHW program in farming areas.
Intake of large group of assistant nurse trainees strains capacity of

teaching dept.
Separation of community and hospital budgets with attendant confusion

/ red tape.
Extension of new privatised security services to clinics.
Health Dept controls works budget, embarks on local ‘quick fix’ contracts,

attempting to short - circuit deficiencies in support from Dept. Works
and hospital workshop.
Large capital projects approved, including Tonga Hospital and Shongwe
extensions.
Long-standing reliance on foreign doctors and nurses threatened by
national policy.
Large net loss of nurses to urban areas / private sector over past two
years continues.
Completion of Ndindindi Clinic but unable to staff it.
Recent decentralisation of TB treatment / SAC to clinics.

In addition, other co-interventions and developments that occurred soon after
ISDS are relevant:

Tonga and Shongwe were among 9 districts selected from the province’s
21, as pilot sites for the provincial Well Child Initiative. This was to
involve local planning and implementation of a broad package of
improved child health and welfare services.

The introduction of Cuban doctors from mid 1996 as part of a national
plan to improve PHC delivery, by learning lessons from the ‘Cuban
Model’. In particular, the two family physicians visiting clinics were to
implement a system of community based primary care. The clinics chosen
overlapped the ISDS sites at Mzinti Clinic.

An program of cascading management training for the districts in the
Lowveld Region. These workshops, facilitated by CHESS (Durban) were
based on a problem based learning approach in key fields such as human
resources management, drug supply, transport, communications, and
community participation. As not all DHMT members or Co-ordinators
took part, the exercises were not fully integrated into ‘real’ operational
planning in the districts.

- 20 -

A brief policy guideline to ‘implement’ CHW programs
throughout the province, by paying a subsidy to NGO
employing agencies. Detailed proposals were left to individual
districts, which, not surprisingly, have tended to wait for more
technical and political direction.

Since the Local Government elections, Transitional Rural
Councils and the ANC Health Desks have been active in local health
politics. While details of governance structures and vehicles for popular
participation are being worked out, village Rural Development
Committees, supposedly umbrella bodies, have ousted older Health
Committees. These have been unilaterally replaced by inactive but
‘legitimate’ committees appointed by the RDCs.

The privatisation of all drug supply to new district stores, simultaneously
with decentralised delivery to facilities by districts, new ordering forms,
and the new Essential Drugs List and Standard Treatment Guidelines.
Upon commencement in April the system almost collapsed, exposing
severe deficiencies at all levels, from supplier failure to storage, transport,
distribution, prescribing, and ordering within districts.

- 21 -

Part 2: District priorities and plans

Formulation of district plans

The district five-year plans written in the second half of 1996 are very similar,
because the same people were involved before the districts divided, and because
they reflect the strong leadership of the provincial programs directorate.
A common planning framework was used, with a brief text description of
each program, followed by tables and columns as below.

MCWH STRATEGY OBJECTIVE INDICATOR MEANS OF ASSUMPTION
VERIFICATION
PROBLEM

1.1 ###### ## ### ### ##### ### ####### ###### ##### ####
1.2

Activities for each problem were then described in a time sequence:

MCWH Activity Output 1997 1998 1999
1 23 4 1 2 3 41 234
Problem Strategy xx x
#### ##### x xx x x x x xx xxx
##### ##### #### #### x xx
#### #### #### ###

Major areas of planning included the following issues:

- 22 -

MCWH

Health education on maternal disease
Risk approach to maternal services
Extension of maternal health services
Health education on childhood illness, nutrition
Increase immunisation coverage
Health education on child abuse
Health education on reproductive health
Midwifery training programs

Environmental Health

Health education on housing, sanitation and hygiene
Promotion of VIP latrine construction
Prevention of work injuries
Monitoring of food outlets, water, housing, hygiene

PHC nurses require continuing support and opportunities for personal development

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Health Promotion

Research health related knowledge and practices
Health education at community and clinic levels
Community mobilisation, inter-sectoral collaboration
Household level health promotion including CHWs

Nutrition

Health education on malnutrition, breast feeding, weaning
Promotion of food gardens
Implement nutrition rehabilitation, and national feeding schemes
Food supplementation to vulnerable groups

Emergency Services

Upgrade vehicles and skills of personnel
Expand services and communications
Increase awareness of services

Pharmaceutical services

Decentralised drug distribution
Essential drug list / standard treatment guidelines

Curative and Diagnostic

Expansion of PHC services
Improved laboratory / radiology services to districts
Clinical skills training
Medico - legal service development

- 24 -

Communicable Disease Control

Health education on HIV, STDs, immunisation
Training on clinical management of communicable diseases
Ensure supplies of drugs, condoms and waste disposal
Improved coverage of TB services

Mental Health and Substance Abuse

Health education on mental health, issues
Liaison with traditional healers
Expansion of services

Oral Health

Obtain adequate personnel / equipment
School oral health program

Rehabilitation

Health education on prevention and management of disability
Mobilise community organisations for disabled people
Expansion of personnel and services
Other plans relate to the expansion of staffing, health facilities and service
hours, and health information systems

Problems

The planning framework tends to neglect the integration and prioritisation of
different programs. The Co-ordinators concentrate on new things rather than
the maintenance or improvement of existing services; they may feel that they
personally must implement the plans. A heavy emphasis is placed on health
education, as opposed to structural causes of ill health.
Programme based planning may also overlook essential administrative and
resource needs, or interventions that cut across the brief of several programs.

- 25 -

Support for district development

The Health Systems Trust, in support of the efforts of the Department of
Health, aims to strengthen local capacity to effect changes in health care
delivery. This will involve communities through a deliberate, systematic
programme of support to sub-district health services, hence the Initiative for
Sub-District Support.

ISDS works on the premise that many factors influencing the standard of
care can be addressed locally, by stretching resources so that they be accessible
to primary health care workers. This initiative seeks to identify these factors
amenable to change and systematically address them through planned support.

The chosen districts, Shongwe and Tonga, have been the poorest and most
under-served parts of Mpumalanga. Apparently this decision was taken at
head office / regional level with Health Systems Trust, and then the two
districts brought on board.

The choice of sub-district sites was motivated by the need for fairly contiguous
areas on both sides of the Komati River boundary. The six clinics chosen lie
in the North of the former homeland area, which is quite densely populated,
including many refugees. There are reasonable roads and the sites are fairly
close to the main bridge at Tonga. They are also near the CHCs at Naas and
Mangweni, and will all drain to the future Tonga Hospital.

(See map of clinics)

The external facilitator, Zama Nxumalo, is an experienced field worker and
social scientist seconded from CHESS in Durban to HST. A local facilitator
was chosen, Dr Steven Donohue, a Community Health Specialist interested
in rural PHC. Initially Ms Nxamulo was only available half time due to
commitments in Northern Natal; Dr Donohue had recently transferred from
Gauteng in November.

Initial workshop and ISDS plans

The first workshop to introduce the initiative to the districts and clinics was
held on 28/01/97. This full day workshop included staff from the six clinics,
District Management Teams, provincial staff, HST, and broad representation
from the local health services.

- 26 -

To Malelane To Komatipoort
Richtershoek
Komati
Lomati Kamhlushwa Phiva

Block B Block C
Naas

SHONGWE Driekoppies Langeloop

Schoemansdal (TONGA)

Mzinti

Jeppe's Reef Middelplaas Steenbok
Boschfontein
Mangweni

Sikwahlane

- 27 - Jeppe's
Rust

Swaziland Sihlangu Fig
Mgobodi Tree
Mozambique

Mbangwane

Clinic Hospital Komati (Ndindindi)
Health Centre Masibekela

Nkomazi South: Komati
Shongwe and Tonga Clinics
Mbuzini
Map by Dr Steven Donohue, July 1997

After summarising the aims of the initiative in the context of the District
Health System, the focus on improved service delivery was explained. The
need to research and standardise details of service and efficiency was compared
to the successful ‘Chicken Licken’ restaurant franchise.

Health workers were grouped according to their facilities to look at problems
that specifically affect service delivery. They brainstormed the headings to be
explored, which were then organised as follows:

1. EFFECTIVENESS

a) Skills of personnel
b) Proper skills
c) Proper supervision and support
d) Full range of services
e) Clear policies/vision
f) Understanding of community
g) Community involvement
h) Proper referral system
i) Feedback and evaluation
j) Assessment of needs and evaluation
k) Assessment of needs and how to meet them (research)
l) NGO participation
m) Accountability
n) Logical organisation of services
o) Outreach
p) Working with other sectors
q) Opportunities for staff development

2. EFFICIENCY

a) Better communication
b) Minimum paper work / maximum time with people
c) Proper management systems:

- transport - drugs/supplies - information - finances
- personnel
d) Integration / co-ordination of services

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e) Monitoring and evaluation
f) Streamlined organisation and administration of service
g) Good productivity
e) Co-operative governance
3. EQUITY
a) Better distribution of resources
b) Joint planning
c) Integrated delivery
4. ACCESSIBILITY
a) Transport to facilities
b) Attitudes of staff to clients
c) ? hours of opening
d) Affordability
e) User friendliness
f) Service satisfaction re-: expectations, wants, needs
5. AVAILABILITY
a) Adequate resources
b) Distribution of resources
Each clinic generated a similar list of problems and proposed solutions. These
included a need for better supervision and support, and improved links with
local communities.
Subsequent to the workshop, the initial interventions to develop within the
project were summarised (below):

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A plan for support 1997/8

These are interventions and supports which should achieve some
early success. They can also create opportunities for later
improvements in quality and accessibility of our services.

Strategies which work well can be adopted district - wide.

PROBLEM AREA ADOPTED STRATEGY

Basic services Sikwahlane Clinic to push for connection to electricity

Water, electricity Improve water deliveries by Dept Works

Repairs ‘Quickfix’ contracts for repairs to clinics

Communication Forum: clinic staff from selected sites communicating with
each other on how they see ISDS is functioning.

Newsletter: including articles written by participating staff
Process: Discussion and suggestions from all staff on what
to do next.
Channels of communication in the transition period. Finding
out who to contact for different problems encountered e.g.
repairs, electric bulbs.

Means: District Offices and Steven Donohue have been
connected to Healthlink (Electronic mail via computers)
- Telkom will be invited to be partners with ISDS by

presenting the initiative to them (Telkom Headquarters)
- Pressurise the local Telkom office for direct phones for

clinics
- The provincial Information authorities have promised

satellite link-ups for electronic and telephonic
communication through computers in the clinics. The ISDS
sites will be prioritised.
- If this fails we should implement Healthlink at the clinics
anyway.
- Get the radiophones working / serviced

- 30 -

Support for Staffing: try to unfreeze and fill important posts
health workers Workload: find what can be stopped or made easier
Development: Start inservice support programs at
ISDS sites
Help all staff to plan their future studies
Help to provide information to those who are
studying
Support: Run specific short skills courses, eg using essential
drugs
Professor Karlssen can help from Head Office
Improve doctor visits at ISDS clinics

‘Supervision’ Ensure clear lines of accountability and management.
Clarify the roles of various co-ordinators at the ISDS clinics
Review all policies which could stand in the way of the
project
Discuss and work toward a better type of ‘supervision’

Participation Hold meetings with local communities to hear their input
Form local facilitation teams including community members
District managers to inform wider community / structures:
Inform about ISDS and why those clinics / communities
were chosen.
Though they seem to getting more resources, they will also
be making changes and doing extra work.

Delegate responsibilities for community liaison

Information Conduct a thorough situation analysis at each clinic, to allow
progress and changes to be measured (baseline information)

Collect all available clinic and community statistics:
Population, health status, service statistics
Detailed review by clinic staff on how their clinic is working,
both successes and problem areas.

Make an inventory of local community structures /
organisations

Developing a simple information system
Rationalise the forms and records (paperwork) needed at a
clinic
Improve usefulness of information to local staff

- 31 -

Intersectoral Inform other departments and sectors about the ISDS, at
top level, to gain their co-operation

Local Find more efficient practices in all areas, such as patient flow,
organisational dispensing, records, paper work.
issues Triage / sorting (arrange patients in queue and put those
more sick first)

Ongoing review of clinic schedules, toward comprehensive
care

Team building: Involve all levels of staff including cleaners).
Solving problems in a participatory manner. Process of
learning how to plan and manage at facility level

Management Administrative: specific support commitment for the project
via issues District Managers, regional and head offices.

Resources: obtain essential equipment

Programs: local level role of co-ordinators

Information: have a local level information facilitator.

All relevant staff need to be informed about ISDS by
participants

Facilitation Team: facilitators will get to know the health
workers better, keeping them up to date with the project.

Request that the facility choose a registered nurse to
represent the facility as a member of the Facilitation Team
(there will be one facilitation team for ISDS)

These strategies should be discussed with your colleagues and
community. They will be added to and modified by the district
management team, as support strategies are implemented.

- 32 -

References

PHC in Mpumalanga: Guide for District - Based Action
A Pocket Guide to District Health Care
Tonga District Health Plan 1997 - 2000
Shongwe District Health Plan 1997 - 2000
Mpumalanga Province 1997/98 Operational Plans for PHC Programs
Health Care in Mpumalanga: Implications for Planning, 1997
Health Implications of the Maputo Development Corridor (discussion paper,
S Donohue)
Minutes of first ISDS workshop, 29/1/97
ISDS Management minutes, 6/2/97

- 33 -

References

PHC in Mpumalanga: Guide for District - Based Action
A Pocket Guide to District Health Care
Tonga District Health Plan 1997 - 2000
Shongwe District Health Plan 1997 - 2000
Mpumalanga Province 1997/98 Operational Plans for PHC Programs
Health Care in Mpumalanga: Implications for Planning, 1997

Health Implications of the Maputo Development Corridor (discussion paper,
S Donohue)
Minutes of first ISDS workshop, 29/1/97
ISDS Management minutes, 6/2/97