bohlabela - Health Systems Trust

HEALTH SYSTEMS TRUST
INITIATIVE FOR SUB-DISTRICT (ISDS) EXIT REPORT
FOR
BOHLABELA DISTRICT MUNICIPALITY
LIMPOPO PROVINCE
FEBRUARY 2002 –AUGUST 2004
This report was compiled by:
Orgrinah Ntombikayise Ngobeni
ISDS-facilitator: Bohlabela district
August 2004
This Publication will also be available on the
Internet
www.hst.org.za
This is an end of project report on the Health Systems Trust’s commissioned role to facilitate the
Rural District Health Systems Project (RDHSP) as per the European Union tender (Tender RT
1397 GP).
The information contained in this publication may be freely distributed and reproduced, as long
as the source is acknowledged, and it is used for non-commercial purposes.

TABLE OF CONTENTS
No Item Page
1 Executive summary 1 &2
2 Introduction 2 &3
3 Aim of the report and Project objectives 3
4 Sources of information 3
5 District Health Systems and health management development 1 - 12
6 Health Programmes and quality Care 13 -18
7 Health service support systems 19-20
8 Conclusion and recommendations 21
9 Acknowledgements 22
10 Appendix one - Key indicators 23- 25
11 Appendix 2: Feedback from the managers 26 & 27
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ACRONYMS AND DEFINITIONS
DOH:
SALGA:
MOU:
NGO:
CBO:
SAN Park:
BBR:
HSDU:
PHC:
LG:
HST:
DHMT:
DM:
DH&WC:
DH & WA:
CEO:
DHS:
DTT:
Programme manager:
Devolution:
PHCN:
DHIS:
Department of Health
South African Local Government Association
Memorandum of Understanding
Non-Governmental Organization
Community Based Organization
South African Parks (Kruger National Park)
Bushbuckridge
Health Systems Development Unit
Primary Health Care
Local Government
Health Systems Trust
District Health Management Team
District Manager
District Health & Welfare Council
District Health & Welfare Advisory committee
Chief Executive Officer.
District Health System
District Task team
Deputy manager.
Transfer of services to the district Municipality.
Primary Health Care Nurses
District Health Information System
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SITE MAP
iii

1. EXECUTIVE SUMMARY
Bohlabela district is one of six districts of Limpopo Province and it is one of the 13 rural
Nodes that have been identified by the President for development. The district is
situated in the Eastern side of the former Transvaal and next to Kruger National Park.
The district has both rural and urban features but it is predominantly rural. The
topography of the area varies from hilly terrain with slopes in the South Eastern parts of
the gentle slopes with isolated mountains and ridges to the middle of the of the
Southern parts. The Western Parts borders on to Drakensburg escarpment. Almost
70% of the population resides on less than 10% of the area.
Bohlabela district is a cross boundary district and in addition it is also expected to
provide Primary Health Care services in Kruger National Park. These services have not
been initiated in KNP due to the delay in the signing of the Memorandum of
Understanding between the two Provinces i.e. Mpumalanga and Limpopo Province. The
MoU serves to clarify the roles and responsibilities of the two Provinces. Bohlabela
district has been identified as a nodal area due to its poor resources and being remote
in origin. This district is mainly rural and is constituted of two-sub districts/local
Municipalities namely Bushbuckridge and Maruleng .It is situated in the South Eastern
part of Limpopo Province and it is one of the poorest districts.
Bushbuckridge sub district/Local Municipality has a bigger population size i.e. more
Urban features and more health facilities. It has intended to attract more attention and
support than Maruleng sub district. How ever efforts have been made to address the
imbalances. Busbbuckridge has nine Local areas and Maruleng has two.
The district has a total population of 727130 i.e. 83 % of the total population is in
Bushbuckridge and 17% is in Maruleng sub district. There are 159 villages scattered all
over the district. There are four hospitals in Matikwane (Partly Private government
hospital). Tintswalo and Sekororo (district hospitals) and Mapulaneng hospital (regional
hospital). There are approximately 184,000 people per hospital. Each hospital has a
hospital board.
Referral systems: Patients were supposed to be referred from the district hospital to the
referral hospital (Mapulaneng) but due to lack of some of the specialists and also due to
the rural setting, some of the patients are referred directly from the district hospital to
the Provincial hospital.
There are 44 clinics in Bohlabela district i.e. 9 in Maruleng sub district and 35 clinics in
Bushbuckridge Sub districts of the 44 clinics. 19 clinics render 24 hours services. There
are two health centres in the Bushbuckridge area and 13 mobile clinics. Each clinic has
a clinic committee.
District health and welfare advisory committee and district health council. The Executive
mayor chairs the health council and the advisory committee is shared by the municipal
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manager steering committee: this is the forum, which comprises of all the heads of the
department. This forum is steered by the IDP manager and meetings are held on
quarterly basis to discuss issues.
District AIDS council: This forum deals with Aids issues within the district. Launching of
this council is responsible for the development and implementation of the district AIDS
plan.
Socio economic status: Because of Bohlabela’s rural setting, the socio economic status
is very low. There are very few people (36 %) who are working and the majority are the
migrant workers. With only 36 % of the population employed, the majority of
households have a total income of less than R12, 000.00 per year. Employment rate is
54 % and poor infrastructure is the main problems in the area.
The roads leading to the Primary health care facilities are mainly gravel and this creates
problems especially during rainy seasons.
The implementation of the rural district health systems has provided an opportunity to
address some of the rural health problems.
The cross boundary nature of this district has had implications in the delays in the
planning process as some of the problems to be cleared at political level about the
responsibilities and ownership between the two Provinces, Mpumalanga and Limpopo.
There are obviously very minimal resources (staff, office, office space, furniture and
equipment) available for the operation of the district office and this has been viewed as
on of the major obstacles hindering progress in DHS development.
The indicators are consistent with poverty prevailing throughout the district. For the past
three years, the initiative for district support has been working closely with the district
management team, clinic supervisors, clinic nurses, District Municipality, Local
councillors, Provincial DHS and devolution manager, Provincial Environmental health
manager in an effort to improve district development.
2. INTRODUCTION
This report describes the activities of the Rural Health Systems Project and it outlines
progress, which has been achieved from April 2002 – August 2004. The project
focussed on the goals and objectives of EU part B.
Duration of the support was initiated in April 2002 to August 2004. The support focussed
at the health district, sub districts, district Municipality and local councillors.
Partners for this project has been the National Technical advisor on PHC audit, the
University of Pretoria on DHER, Provincial HIV/AIDS/STI Department on developing the
HIV/AIDS plan and training of officers on HIV/AIDS, the Provincial DHS and devolution
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Department on the establishment of the district health councils, EU NPO project on the
establishment of the district task team, the DHIS coordinator on strategic planning
meetings and the National Technical Advisor on skills audit. HST facilitated Joint
meetings and avoidance of duplication was taken in to serious consideration.
3. AIM OF REPORT
The aim of this report is to inform the Bohlabela district, Provincial and National
Departments of health of the activities and progress of HST/ISDS in the Rural District
Health Systems Project (RDHSP). From The report will reflect on factors enabling and
constraining the delivery of the key objectives and highlight the lessons learnt.
4. PROJECT OBJECTIVES (focus areas)
A1: Help to build capacity to plan and manage PHC services and the District Health
Systems (DHS)
A2: Help to build up the knowledge, skills and capacity of local government councillors
A3: Help to strengthen, expand and improve PHC services
A4: Build the DHS by helping managers top develop appropriate strategic and
operational plans for PHC service delivery, and to build these into the integrated
Development Plans (IDPs) of local government
A5: Build service delivery capacity in identified districts
A7: Help to establish partnerships between government’s services and NGO’S, CBO’S
and other groups concerned with district development and PHC services
A8: Build the DHS by arranging or providing in-service training to build capacity in
financial planning and management
5. SOURCES OF INFORMATION
Information has been derived from the quarterly reports from April 2002 - August 2004.
In addition, information was derived from the situation analysis for Bohlabela district and
the indicators. See attached document on indicators at the back of this report.
6. DISTRICT HEALTH SYSTEMS AND HEALTH MANAGEMENT DEVELOPMENT
This section deals with the following objectives according to EU tender.
A1: Help to build capacity to plan and manage PHC services and the District Health
Systems (DHS)
A2: Help to build up the knowledge, skills and capacity of local government councillors
A3: Help to strengthen, expand and improve PHC services
A4: Build the DHS by helping managers to develop appropriate strategic and
operational plans for PHC service delivery, and to build these into the integrated
Development Plans (IDPs) of local government
A5: build service delivery capacity in identified districts
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A7: Help to establish partnerships between government’s services and NGO’S, CBO’S
and other groups concerned with district development and PHC services
6.1. A1: Help to build capacity to plan and manage PHC services and the District
Health Systems (DHS)
Situation analysis and functional integration.
o The purpose of the situation analysis was to establish baseline information on
health issues and indicators as a benchmark to measure health development and
progress. Use information to advocate for allocation of resources. Identify gaps
and develop plans to close the gaps.
Achievements.
Bohlabela district, in collaboration with the DHIS coordinator conducted the
situation analysis in September 2002 covering Bushbukridge and Maruleng Local
areas. A visit was undertaken by a joint team in 2003 i.e., the district manager,
ISDS facilitator, the National Technical Advisor and a member from KNP did
situation analysis in Kruger National Park on the 16 th – 18 th January 2004 and the
three regions of the Park i.e. Far North, North and central region were visited.
Completion of the last portion of the situation analysis in the Southern Region of
the Park was done in April 2003 on the 24 th and 25 th and this has been a joint
effort between the Health Systems Development Unit, the representative from
the district office and Kruger Park officer.
Findings of the situation analysis revealed amongst other things:-
o Work overloads, lack of training, and no Dr coverage in most clinics, lack of
Programme coordinators.
o Conditions of roads affecting the functionality of the mobiles.
o Shortage of skilled professionals e.g. community rehabilitation staff to provide
services for the disabled. Psychiatric and Oral health staff to cover the basket of
PHC services as adopted by the National Minister of Health and MEC’s of the
Provinces.
o Support services not fully equipped to provide effective and efficient service.
Copies of the situation analysis for both part A & B have been distributed to the
stakeholders i.e. the district management team, clinic supervisors, District Municipality
managers and Local Counsellors.
HST facilitated meetings between Bohlabela district and Kruger National Park as
Bohlabela district is supposed to run Primary Health Care services in Kruger
National Park (SAN PARKS) Managers of the Park were also involved in
devolution meetings and workshops. The participation by SAN PARKS
managers in these meetings have been very helpful as the Primary Health Care
Providers were anxious about their future and that they thought they even loose
their jobs.
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Constraining factors
o Shortage of personnel
o Office accommodation
o Communication problems: The clinic supervisor has to drive to the clinic to delver
messages.
o Correspondence is usually not typed, as the PHC section has no administrative
support.
o Effective communication between clinics and hospitals is a problem.
o Shortage of water subjects the community to a variety of other problems.
Enabling factors
o The Situation analysis has been a tool for the planning of the activities for
Bohlabela district.
6.2.Memorandum of Understanding between Mpumalanga and Limpopo Province.
Achievements.
Health Systems Trust initiated discussions about the Memorandum of
Understanding between the two Provinces.
HST, Mpumalanga and Limpopo Province have developed MoU document
between the two Provinces jointly and a document is available. Several meetings
were held between HST and the two Provinces since October 2002 for the
development of the MoU document including the Joint management Forum. The
main aim of the MoU was to develop areas of collaboration and cooperation
between the two Provinces, strengthen reciprocal understanding, strengthen
relations in the field of Health by improving integrated service delivery using
existing resources, achieving functional integration and ensuring close
collaboration and joint management of services in the field of health.
Due to other commitments, there have been some delays in the signing of the
MoU.
There was change in the management of Mpumalanga Province before the signing
of the MoU, however, there has been the new management in Mpumalanga
Province and discussions are ongoing.
The MoU will be signed by signed by both MEC’s for Mpumalanga and Limpopo
Province.
SAN PARK (KNP) as a stakeholder has been briefed regularly about the
progress of the MoU.
6.3. Mapping of the district: Health Systems Trust facilitated the process to map
Bohlabela district. Local Councillors, health managers, District Municipality officers and
clinic supervisors and clinic nurses were engaged in the mapping process. The first
ISDS facilitator facilitated this.
6.4.Joint planning meetings
Regular Joint planning meetings between HST and Bohlabela health district and
the District Municipality were held.
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Meetings between HST, Bohlabela district manager and Limpopo Provincial DHS
and devolution manager were held to discuss progress and future plans pf the
RDHS project.
The identified gaps were discussed at the planning meetings.
On the 9 th of September 2003, a workshop on review of the RDHS project was
conducted and the Deputy manager for PHC gave an excellent presentation and
at this review meeting, there re was a recommendation that the Rural district
Health Sytems Project must continue.
A meeting was held on the 8 th December and another one on the 17 th December
2004, a meeting between Bohlabela district manager, and HST to discuss future
plans of the RDHS project as well as future role of the Health Systems
Development Unit. HST was satisfied with the implementation of the RDHS
project. The new line manager for RDHS initiatives was introduced to Bohlabela
district.
HST participated in the meeting with the Provincial managers in Polokwane in
February 2004 and the Provincial managers were briefed about the progress
made with the Implementation of the RDHS projects I Limpopo Province.
6.5.Devolution strategy
Achievements.
HSDU initiated the devolution strategy at district level and the first workshop was
conducted own in April 2003. Subsequent workshops were held between the
district manager and Programme managers, clinic supervisors, Municipal
manager and other managers, Executive mayor local counsellors.
Two work\shops were conducted on devolution strategy. Limpopo Provincial
office has been engaged in the district devolution workshops. In October 2003,
Bohlabela district participated in the Provincial devolution meeting and from this
meeting a task team for Bohlabela district was established and a plan of action
was drawn. HST has been driving the process. Subsequent devolution meetings
were held on monthly basic to discuss the transfer of Environmental health
services to the district Municipality and to clarify the role of the Department of
Health and Welfare as well as the role of the district Municipality.
A consultative workshop was for the Environmental health practitioners was
facilitated by Health System Trust on the 23 rd March 2004 and they were updated
about the current events about the devolution process The EHP’s were able to
raise their concerns and these concerns were addressed by the sub devolution
committee and presented to the bigger district devolution forum.
The devolution sub committee was established and the group consisted of the
finance managers for both health and the District Municipality and the Corporate
managers for health and the District Municipality. Deliberations by the
subcommittee were presented to the entire devolution committee.
The support by the Provincial DHS and Devolution manager, and the Provincial
Environmental health manager has been very crucial. Resolutions taken by the
Province with regard to devolution process was shared with the stakeholders on
the 9 th of September 2003.
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6.6.Provincial health and welfare Council and devolution task team initiatives
Achievements
HST has been participating in the above Provincial devolution task team meetings.
The Provincial office conducted two Provincial devolution task team meetings in
2003 and four Provincial meetings were conducted this year (2004)
Deliberations from the Provincial devolution meetings were shared at the district
devolution meetings.
6.7.Outputs
o
Comprehensive Situation analysis documents are available and this informs district
planning.
o MoU between the two Provinces document
o List of Assets for the Environmental health services have been documented and
this facilitated the planning for the transfer of Environmental health services.
o Devolution process has been completed.
o Established District health and Welfare Council and District Health and Welfare
Advisory committee.
o Joint health management team
6.8.Lessons learnt
o Unresolved political issues create tension amongst the beneficiaries of the cross
boundary area.
o Involvement of Unions, Councillors and other stakeholder’s inn district
development issues is essential.
6.9.Constraining factors
° Delay in the signing of the Memorandum of understanding between Mpumalanga
Province and Limpopo Province delayed the taking over the Primary health Care
services by Bohlabela district in the Kruger National Park.
° The signing of the MoU has been difficult because of changes in the
management of the Mpumalanga Province. Several meetings have been
postponed.
° For unknown reasons, meetings were postponed since May 2004.
° Not all the councillors attended the workshops .
° Tight schedules of councillors (majority being teachers).
° Postponement of the launching of the District health and welfare Council and
District Health and Welfare Advisory committee has been disturbing. This was
supposed to have been launched last year November 2003, due to Provincial
commitments, the launching event was postponed several times
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6.10.Recommendations
Engagement of SANPARK in MOU initiatives is crucial, as this would put both
managers and Primary Health Care Providers at ease.
Regular discussions between Bohlabela health manager, Municipal manager,
Executive Mayor and SANPARK need to take place.
7. DISTRICT MANAGEMENT TEAMS
The district management teams in Bohlabela district are as follows: -
Achievements
District management team. This team consists of the manager and programme
managers and the team meets once a month.
District task team: This team consists of the Local government managers, health
managers, local councillors and welfare manager.
District health and welfare council: This team consists of the Executive Mayor,
health manager, Municipal manager, Local Councillors and Union
representatives.
District health and Welfare Advisory committee: the Municipal Manager chairs
this team and the committee deals with administrative matters.
HST initiated workshops on the establishment of the committees including the
roles and responsibilities of the committees. Limpopo Provincial DHS manager
also played an important role in the clarifying the roles and functions of the
District Health and Welfare Council and the District Health & Welfare Advisory
Committee. Workshops and meetings have been ongoing since April 2003.
The Preparatory committee for the district health and Welfare launching was
established and the team has been holding preparatory meetings for the
launching. Regular feedback was given to the entire committee. This group
worked hard to discuss and make recommendations for the launching and these
deliberations assisted the entire committee to make decisions.
Steering committee: HST has been participating in the steering committee
initiatives. This team consists of the Executive Mayor, Municipal manager and
other managers, all heads of the Departments. The team is responsible for the
development and review of the IDP process.
Representative forum: HST has been participating in the representative forums.
The forum consists of the Local Councillors, Executive Mayor and managers of
other Departments.
Different stakeholders are represented in these meetings and there is strong
collaboration and cooperation between the district Municipality and other sector
Departments.
8.GOAL A1.3. Help to strengthen, expand and improve PHC services
Strategic plans
HST conducted two strategic planning meetings for Bohlabela district in March 2003
and February 2004.The district management team and other managers attended the
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workshops. This has been developed in line with the National and Provincial guidelines.
The facilitation of the workshops has been a joint effort between Part A and Part B EU
projects.
The strategic planning document has been shared with stakeholders.
Managers were assisted to draw both strategic and operational plans for each
programme and the operational plans and this is linked to the budget.
9.FINANCIAL MANAGEMENT SKILLS WORKSHOP
HST assisted Bohlabela district to conduct the financial management workshop on the
24 th February 2004, this facilitated the creation of commitment registers by each
programme manager.
10. GOAL A2 & A4: Help to build up the knowledge, skills and capacity of local
government councillors
A4: Build the DHS by helping managers top develop appropriate strategic and
operational plans for PHC service delivery, and to build these into the integrated
Development Plans ( IDPs) of local government
Workshops for Local councillors.
A.2.1. HST conducted workshops for Local councillors. In September 2002, Local
government councillors attended a workshop to introduce the National PHC package
and in the workshop they expressed the need for more health related information.
Participants also included the managers within the Municipality as also needed to learn
about health policies. Subsequent workshops for counsellors were conducted by HST
on HIV/AIDS, DHS&PHC, TB, 10 Point plan.
Local councillors have been deeply engaged in the DHER process.
Councillors were involved in activities such as the situation analysis, devolution process,
establishment of the District health and Welfare Council and District Health and Welfare
Advisory body.
11. A.3.
o The district manager was connected to DHSLG E mail
o Five programme managers were connected to E-mails.
o Four advanced midwives were supported by HST to attend a Midwifery
conference in Bloemfontein in 2002.
o Four managers attended the integrated management of Childhood illnesses
Conference in Durban in 2002.
o The district manager was supported by HST to attend the financial management
workshop in Pretoria .On her return she compiled a very useful report on the
lessons learnt and how she would apply the newly gained knowledge in her
management duties. Her approach lends some insight in to how training courses
can be utilised to strengthen managers to carry out their duties better.
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o Bohlabela district was supported by HST to conduct the financial skills
workshop. Programme managers and finance manager and officers attended the
workshop.
o The district manager attended the PHC ALMA ATA Conference in Pretoria in
2003 and she was assisted by HST to develop her poster for her presentation
and she won an award for having the best poster.
o Three officers were supported by HST to attend the District Health System
Conference in Gauteng in 2004 and lessons learnt from the Conference will be
applied to Bohlabela district.
12. A.4. IDP process.
HST participated in the initial development of the IDP document for the district and also
participated regular IDP meetings including the review meetings. Plans and success
stories of the RDHS project was discussed at these meetings.
HST also participated in the representative forum where all the councillors give their
inputs about the IDP process.
HST participated in the steering committee meetings. The heads of the all the Gov
Departments, the district Municipality managers attend these meetings.
In June 2003, HST participated in the infrastrure summit organised by the district
Municipality and IDP issues were discussed.
13. A5: Build service delivery capacity in identified districts
HST assisted Bohlabela district to develop the skills of clinic nurses regarding the
following aspects.
13.1. IMCI courses: HST initiated this in November 2002. To date 156 (65 %
saturation) clinic nurses have been trained in the management of childhood illnesses.
A scheduled continuing learning programme for clinic nurses was drawn in collaboration
with the clinic supervisors and programme managers and five workshops were
conducted as part of continuing learning programme.
13.2. Inpatient management of childhood illnesses.
Health workers from hospitals in Bohlabela district attended a five days training
workshop on appropriate management of children with severe Malnutrition in
Polokwane in October 2002 and this has been a joint effort between HST and Limpopo
Province- Community Health Department.
13.3. Mental health Course
Seven nurses were supported by HST to attend a one-week course in mental health in
2003.
13.4. IMCI facilitators
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Six clinic nurses were trained as IMCI facilitators at the Provincial office. HST has been
strengthening and supporting their practical skills and one facilitator was developed to
become a course director.
13.5. IMCI Household and community component
HST initiated the IMCI household and community component in Belfast Local area in
2003. Developments have been taking place in 2004 and steering committees were
established.
Workshops for the steering committee were conducted. This has been a joint effort with
Limpopo Province DoH. The community responsive programme (NGO) also joined
hands in this initiative.
13.6. IMCI Supervision
HST supported the supervision interventions in Bohlabela district. Trained IMCI nurses
are being supervised, guided and supported by the trained IMCI supervisors.
13.7. District health Information Systems.
As a joint venture with Part B EU tender, clinic records were checked in 2002 and plans
were made to close the gaps.
13.8. Workshops for clinic nurses
HST conducted five workshops for clinic nurses and nurses were trained on HIV/AIDS,
recent protocols ECT.
13.9. 30% of clinic nurses have been trained in Primary Health Care.
14. A.7. GOAL: Help to establish partnerships between Government services,
NGO’s and CBO’s and other groups concerned in district development.
14.1. Collaboration with NGO’s
o HST has been working closely with Non Governmental organisations and
Community based organisations within Bohlabela district since 2003. A workshop
for health committee chairpersons and secretaries was conducted in 2003.
o Involvement of NGO’s in Bohlabela district has been documented.
14.2. HIV/AIDS INITIATIVES
o Stakeholders have been involved in the development of the HIV/AIDS plan. The
Executive Mayor blessed this. An HIV/AIDS committee was established and this
is multidisciplinary.
o HIV Aids has been mainstreamed in Bohlabela IDP document. Two workshops
were conducted in June and July 2004. These workshops were organised by the
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district Municipality. Provincial HIV/AIDS (UNDP) also participated in the
workshops.
o There is close collaboration between the Department of Health and other
stakeholders such as NGO’s and CBO’s , traditional leaders and healers on
dealing with challenges that are health priorities such as HIV/AIDS.
14.3. Collaboration with Community Based Organisations
A workshop for Community based organisations were conducted in 2003 and their
involved in development aspects were documented.
15. EFFECTS AT DIFFERENT LEVELS.
Please note that Bohlabela district is the smaller district as compared to the other
districts within the Limpopo Province.Initiatives of both sub districts have been
combined.
Description Facility/Community District Province
Mapping of the
district
DHMT
DH& Welfare
Advisory
committee
DMT
DH&WC
Local Councillors and
the District Municipality
were engaged in the
mapping exercise.
Clinic Supervisors takes
part in decision making
Health committees,
NGO’s, Unions,
traditional healers and
traditional leaders are
engaged in the
committee
Health Counsellors,
participate in the
management team.
Health councillors
participate in decision
making
Done by the first ISDS
facilitator and District
managers and clinic
Supervisors.
District manager and
Programme manager’s
takes part in decision
making.
District manager, Deputy
manager PHC participates
in the DH&W Advisory
committee.
District Municipality, Health
and Heads of the
Departments and
Councillors form the district
management team.
Executive Mayor, Health
manager, Welfare manager,
Municipal manager, Unions,
and Health Councillors
make the political decisions.
DGS LG Emails - District manager is
connected. Five programme
managers have been
connected to E mail
A copy has been sent
to the Provincial office.
-
The Provincial Health
and Welfare Advisory
committee liase with
district committees.
-
Provincial Health and
Welfare Council makes
Provincial decisions
and liase with district
health & Welfare
council.
-
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Situation analysis
Skills
development
HIV/AIDS Plan
IMCI
IMCI household
and Community
component
Health Councillors
participate in data
collection for the
situation analysis.
Councillors were
engaged in the DHER
process, devolution
strategy.
Clinic nurses were work
shopped on recent
protocols and six
workshops were
conducted
Councillors received
training on health
policies.
Stakeholders i.e.
Traditional leaders,
Councillors, Traditional
healers, NGO’s, are
engaged in the
HIV/AIDS plan.
65% OF clinic nurses
have been trained in the
management of
childhood illnesses.
25 Community members
from Belfast Local area
have been trained in the
management of
childhood illnesses at
Community level.
District manager and other
programme managers were
involved in the situation
analysis.
SAN African Parks received
copies of the situation
analysis.
District manager,
programme managers and
clinic supervisors receive
training on writing skills.
Programme managers
received training on report
writing skills.
District manager, HIV/AIDS
programme manager,
District Municipality
managers and officers, HIV
coordinators from different
Departments participate in
the HIV/AIDS plan.
District manager, Deputy
managers for PHC &
Mother and child have been
supplied with documented
list of IMCI trained nurses.
Clinic Supervisors have
been active in decision
making about the IMCI
household and Community
component.
- -
Provincial office
received a copy
-
Provincial HIV/AIDS
Department works
closely with Bohlabela
district HIV/AIDS
committee and HIV
task team.
Documented list of
IMCI trained nurses
have been sent to the
Provincial office.
Provincial office is
furnished with the
number of community
members trained
including the progress.
16. HEALTH PROGRAMMES AND QUALITY OF CARE
Goal 6. Help to develop and implement appropriate strategies to deliver
comprehensive PHC package.
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Planned activities and actual inputs.
16.1. TB review
A TB review was conducted in all facilities.
Managers were engaged in TB review. The first meeting was organised with the DoH
managers and Programme coordinators where it was decided that the TB services
coordinator, together with HST to look at the format and decide how the questionnaires
will be handled. A second meeting was arranged with the PHC coordinator where it was
agreed upon that the questionnaires will be distributed in the workshop being organised.
Copies were made for health facilities in Bohlabela District and this was distributed to
the facilities for them to complete.
The questionnaire needed the following: -
o Information from 2000 to date.
o Population of the catchment area.
o Information on teaching materials e.g. guidelines, protocols, Policy manuals, New
EDL book in each facility, calculation of % for different facilities, Drugs used to
manage both adults and children, management of MDR ect.
o Training in HIV/AIDS to manage co infections.
In addition, the researcher had to check clinic records, observe how they manage, ask
for documents, test knowledge on how to use protocols ect, and to assess if the service
is available.
Identified gaps
o Clinic nurses had difficulties in completing the Questionnaires.
o Some of the professional nurses felt they needed a TB nurse to complete the
questionnaire.
o Others did not know their population.
o There is generally shortage of manpower.
o It has been difficult to locate the questionnaires.
Following the review. TB courses were conducted to close the gaps. 3 workshops were
conducted last in 2003..
24% of clinic nurses have been trained in TB management.
Lessons learnt.
o Facility staff is key important figures at community level.
o Orientation regarding the tool to be held regarding its usage, importance and
meaning.
o Assess the existing tools before the new ones.
14

Constraining factors
Lack of supervision TB implementation by the facilities was identified as a
serious problem.
Despite training in TB implementation, the impact on health services has been
minimum.
Clinic nurses did not have knowledge to complete the TB questionnaire
especially the calculation of percentages.
o Some of the clinic nurses did not respond to the questionnaires.
16.2 PHC Audit
The PHC audit was conducted in collaboration with the Technical adviser from the
National Health Department (Mrs Emma Mabidilala) several meetings were held and the
district managers and clinic supervisors were engaged in all the processes. This
process was completed in August 2003.
The objectives of the audit was to assess performance of facilities, sub districts and
districts on the implementation of the PHC package and to identify gaps per service
component and services so as to develop plans to close them.
The Audit revealed areas of good practice and a number of gaps. The information
gathered assisted the district in future planning.
16.3. Client satisfaction survey.
This was conducted in all health facilities and facility staff participated in the
process.
Key findings
Age of the participants ranged between 20 – 45 years. 51.35percent were females and
19% were men.
o The results revealed that 46 % of the respondents are satisfied with the hours
that the clinic is opened.43 % were not satisfied as they mentioned that some of
the clinics do not provide 24 hrs service.
o With regard to the working hours
o 72.97% indicated that the clinic is not too far from their houses and the clinics
were within reach.
o High percentage of respondents 83.8 % mentioned that they stay for a long time
at the clinics without being registered. As clinics are overcrowded. Respondents
were satisfied with the services provided by the clerks as 67.6 % mentioned that
the clerks were helplful.2.7% disagreed.
o The respondents 83.8 % were satisfied with the cleanliness of the clinics.
o Waiting areas seems to be inadequate (46 %) and that some of the mobile points
do not have waiting areas.
15

o The respondents 89.2% were satisfied about the clinic nurses who listened to
their problems.
o 73% of the respondents were satisfied the way they were examined by the clinic
nurses and 67.6 % mentioned that the sisters were able to explain what was
wrong with them. 75.7% were satisfied with the skills of the clinic nurses and 0 %
disagreed. 97.3% were satisfied about the explanation on how to take
medications and 73 % of the respondents indicated that they did not wait long to
get medications. 83.78 % of the respondents were satisfied about the service
rendered at the clinics.
o High percentage 83.4 % was not sure where the clinic committees are active,
only 10.8% had an idea.
o The major concern n raised by the clients 86.5 % was the they are not always
seen by the preferred nurse
The results showed improvement in accessibility of clinics. Nurses were said to be rude
to patients but looking at the results of the report there is great improvement in attitudes
of the nurses. The community chooses clinic committees and they act as a link between
the clinic and the community. It is surprising that the communities are not aware of
these committees. Strategies to involve the communities have to be identified.
16.4. Clinic supervision
Initially, the workshop, which was planned by HST on clinic supervision, collided with
the clinic supervision workshop organised by the Province and as an end result, the
PHC manager and clinic supervisors attended the Provincial supervision workshop.
However, the Supervisors manual has been adapted for local use.
Supervisory system is in place.
Enabling factors
Bohlabela manager, Programme managers and Clinic supervisors have subsidised
vehicles and this eliminates transport problems.
Constraining factors
I
There are still limited clinic supervision and support visits.
Frequent Provincial meetings seem to limit supervision visits, as the officers must
comply with the officers must comply with the Provincial demand.
16.5. DISCA
DISCA was conducted at the clinics.
The results were shared with the district manager and programme managers.
As an action plan, STI courses were conducted in order to equip clinic nurses with
the necessary skills.
16

16.6. Skills Audit
The objective of the Skills audit was to assist managers with planning and prioritising
staffing and training for PHC service delivery and to identify staffing gaps.
Workshops were held in collaboration with the National Advisor, Evol Drennen. The
District manager, Programme managers, DIO and Clinic Supervisors were involved in
the skills audit intervention.
Feedback about skills gap was discussed in the meeting in collaboration with the
National technical Advisor.
The information on skills audit assisted the district to plan for the future.
A Document has been distributed to the manager and Programme managers.
Key findings
o Findings revealed that Health facility staff is evenly distributed and their skills are
being updated.
o The skills mix of staff in the district is guite evenly balanced when compared to
other districts and this is important as it assists the smooth running of the clinics
generally.
o The four-year Diploma nurses are being retained in Bohlabela district, which is
encouraging and this needs to be sustained to ensure PHC nurses for future
PHC services in the district.
o There is large proportion of Enrolled Nurses who have completed bridging
training to RN level.
Recommendations
o More nurses need to complete Advanced midwifery as soon as possible as this is
a gap in being able to provide maternity services at twenty four hour CHC’s and
clinics.
o 38 Professional nurses have to be pursued to do Midwifery training especially in
PHC where this expertise is mandatory as there are routine maternity patients
needing attention at PHC level in the community.
o Increase Doctor support for PHC clinics will be needed in the future especially
with the management of HIV/AIDS patients on treatment.
o More training for managers need to be undertaken.
o A team of relief staff to assist at clinics when nurses are away.
o On the site training by mentors is essential as this would allow for more contact
with learners and thus increases the support.
o Regular updates and raining to all nurses in order to sharpen their skills.
o Additional support of newly trained nurses.
o Bohlabela district to improve conditions of service and to look at career paths for
nurses.
16.7. EPI
A series of EPI workshops has been organised jointly by Bohlabela District
management team, HST and Limpopo Department of Health and Welfare. These
17

workshops focussed on factors such as maintenance of cold chain, ECT. The main aim
was to improve the immunisation rates in the district. Clinic nurses were trained in this
regard.
16.8. Nutrition surveillance
Bohlabela district conducted a workshop on nutrition surveillance with ISDS support in
September 2002 and 30 clinic nurses attended the workshop.
16.9. Effects at different levels.
Description of activities Facility/Community District Provincial
TB review
Facility staff attended
TB courses
Managers and clinic
Supervisors were
-
DISCA
PHC Audit
Clinic staff participated
in the survey
Facility staff was
engaged in all the
processes.
engaged in the review
Clinic supervisors and
Deputy managers
participated in the
planning of the DISCA
intervention
District manager, Deputy
managers and clinic
Supervisors participated in
the PHC Audit from the
beginning up to the end.
Action plans were drawn
to address the gaps.
Copies of the reports were
distributed to all the
managers.
Clinic Supervision - Clinic Supervisors were
trained in clinic
Supervision.
Client satisfaction
Skills audit
Facility staff
participated in the client
satisfaction survey
Facility nurses were
involved
District programme
managers and Clinic
Supervisors were
involved.
Programme managers
and clinic Supervisors
were involved
A copy of this
report was sent to
the Provincial
office.
Provincial office
coordinated the
training.
-
A copy has been
submitted to the
Provincial
Training section.
18

17. HEALTH SERVICE SUPPORT SYSTEMS
Goal A.8. Assist with the development of cost centres.
17.1. DHER Process
The DHER process was initiated in August 2002.Facilitatorts contracted by HST was
Prof Eric Buch and Mr Jan Van Rensburg from the University of Pretoria .Mr Jan Van
Rensburg has subsequently carried forward the DHER process. A district DHER task
team was established and this team worked closely with Mr Jan Van Rensburg in
identifying source of financial data for the DHER. Skills in capturing, analysing, verifying
and cleaning up of financial data were imparted to the district personnel during the
process of completing the DHER.
Local Government councillors from both Bohlabela local Municipalities i.e.
Bushbuckridge and Maruleng satisfactory attended the meeting. At this meeting the
Executive Mayor welcomed the DHER process. This process has been very helpful to
Bohlabela district as it informed the allocation of resources within the district.
A four days workshop was conducted to in November 2002 to prepare the DHER task
team for intensive data collection.
In October 2003, HST organised a feedback session and this was held at Mthunzi
Lodge and feedback was given by the University of Pretoria to Bohlabela district.
A training plan was developed in Bohlabela district based on the results of the skills
audit and PHC audit.
Findings of the DHER (District health Expenditure review 2001/2002.
The main objective of the DHER was to look at whether we are getting to the best for
the value of money we have got i.e. sustainability, resource allocation, equity and good
value to the community. Sources of information were obtained from the demarcation
board, Department of Health and Welfare, and Managers from Bohlabela district.
Key findings
o Malaria death as well as HIV/ADIS was not included. This was a bit difficult
because of HIV/AIDS is shaded in other conditions.
o The results revealed that bed occupancy and length of stay in the indicates that
patients stay longer (10.58%) at Tintswalo hospital as compared to Mapulaneng
Hospital which is 7.76% and Sekororo hospital 4.71 %
o Budget allocation showed disparities. Tintswalo hospital received 24 %, Sekororo
hospital 14 %, Mapulaneng 29% and clinics and
o Health centres combined 13 %. PHC services received the lowest budget.
Professional services received 13.72 % whilst support services received 72.85 %
o Allocation of staff: 20% is the administrative staff, 28% Mapulananeng hospital,
19 % Sekororo hospital, 3% Community health centres, 5% mobile clinics. High
percentage is allocated for administrative staff vs. Professional staff members.
This result reflects inequitable distribution of resources.
19

o 24% work in the clinics, 42% work in the district hospitals, i.e Tintswalo and
Sekororo.
17.2. Drug supply and management
Bohlabela district was faced with serious drug shortages in the clinics. Drug delivery system
was inadequate as the delivery was once a month instead of twice a month.
Discussions have been carried out with the district manager and other managers
including clinic supervisors. Two meetings were held in 2003 to discuss this. Another
meeting was held with the Provincial manager for Pharmaceuticals to further discuss
drug shortages in Bohlabela district. A document outlining the roles and responsibilities
of hospital personnel, PHC personnel and district office personnel in DSM has been
compiled.
This has been resolved as there is an amalgamated company, which delivers drugs
from the depot directly to the clinic.
It was difficult for the clinic nurses to implement the skills and knowledge gained from
the courses due to insufficient drugs. There is great improvement with drug delivery
system since the Amalgamated company took over and drugs are delivered directly to
the health facilities.
17.3. Effects at different levels
Description of activities Facility/Community District Province
DHER
Councillors were
involved in the
DHER process
They attended the
workshops where
the DHER was
introduced and the
subsequent
meetings.
District managers,
Programme managers
and Clinic Supervisors
were engaged from the
initial stages of the
development of DHER
including data
collection.
The above managers
were engaged in the
feedback about the
DHER results and were
acknowledged by the
University of Pretoria.
A copy of the DHER
has been submitted
to Limpopo Province
Department of
Health and Welfare.
Lessons learnt
o Involvement of district officers in district development is crucial. The district will
be able to conduct its won future DHER.
o Recommendations from the DHER inform financial planning.
20

Challenges
o Tight schedules of the district managers and supervisors.
o Clash of activities, Provincial initiatives and HST initiatives at the same time.
o Delayed signing of the Memorandum of Understanding.
o Political leadership change in Mpumalanga
o Limited finances.
o Lack of offices for the district staff members.
18. CONCLUSION AND RECOMMENDATIONS.
The district will still need support with regard to DHER, as it should conduct the
DHER on its own.
There is still a need to tap at the University of Pretoria as a backup system.
The district needs to conduct the district health plan using the National guidelines.
Clinic Supervision needs serious consideration, as there is still limited supervision &
support to the health facilities.
DHS & district meetings should continue
The relationship between the Provincial offices needs to continue.
There is a need to strengthen collaboration between community services and
hospital services. Regular meetings and workshops should be held jointly.
Limpopo Provincial health Department needs to take the recommendations of DHER
and to seriously consider this in the allocation of funds.
Referral system needs to be strengthened. Need for gateway clinic at Mapulanang
hospital.
Feedback mechanism from the Institutions needs to be strengthened.
Matikwane hospital to also offer Primary Health Care services.
Clinic supervision to be strengthened.
Need for coordinated programs.
19. Acknowledgements
° HSDU appreciates the support and guidance provided by Health Systems Trust.
° Special thanks to Bohlabela District Health manager, Programme managers, and
supervisors for their participation in the RDHS project despite their tight schedules.
° With heartfelt l thanks to Limpopo Province DHS, PHC, and Environmental Health
Departments, Provincial Population & Development for their wonderful support.
° The support provided by Bohlabela District Executive Mayor, Municipal manager and
Institutional support and community development manager, and other managers is
greatly valued.
° Thanks to CBOs / NGO and other EU partnership projects (Part B and EU NPO and
Partnership project) for their wonderful support.
° The Involvement of HSDU by HST in the RDHS facilitation in Bohlabela district has
been a good move as it has future impact to maintain sustainability within Bohlabela
district and links with Health Departments, District Municipality, and NGOs internal &
external will grow further.
21

APPENDIX ONE
Key health indicators
This is a sample of some indicators that will give an idea of the district profile and
performance. They are probably not directly linked to the performance of the HST
facilitator but do give a perspective of what remain the focus areas for intervention and it
is therefore useful to compare figures over the past two years. The selection of
indictors is largely from the DHIS, comparing data from the Situation Analysis (SA) 2002
with the most recent available data
35.9 24.0 34.4
Priority
programme
Indicator
Child Health
Immunisation
coverage (%)
Drop-out rate
DPT-Hib1-3
(%)
Maternal
Health
Low birth
weight rate
ANC
coverage
1 st ANC visit
before 20
weeks rate
Peri-natal
mortality rate
STI’s/HIV/AI
DS
STI partner
tracing rate
%
% correct
treatment
(acc. to
DISCA)
VCT
coverage per
1000
District Municipality
SA
2001
Target
for 2004
2003 SA
2001
Bushbuckridg
e
2003 SA
2001
Maruleng
2003
80 72.4 71.3 77.8
7.4 7.9 4.5
12.3 9.3 15.7
100.4 104.9 77.4
50 34.4 35.9 24
2.4 1.6 3.3
?? 40 41.5 41.4 41.5
11 11.6 8.3
22

population 15
yrs and older
2004 20.5 20.6 19.9
VCT testing
80 40.5 40.9 37.1
rate %
2004 44.3 46.7 32.5
HIV
prevalence
(% antenatal)
National TB
Control
Programme
Incidence (all
TB) per
100,000 pop
Proportion
PTB %
New smear
+ve
conversion
rate
317.5 356.8 121.5
88.3 88.3 88.2
73.3 73.2 73.8
Cure rate* 63.3 61.7 84.6
Interruption
8.3 8.4 7.7
rate
Sputum turnaround
Not collected in DHIS
time
Drugs
% Essential
drugs with
stock outs
Not collected in Bohlabela
Low birth weight rate
This data is obtained only from the deliveries that occur in the clinics and CHC. Hospital
maternal health data has not been collected in the PHC data set, only in the Hospital
dataset which does not collect low birth weight. Therefore this is not representative of
the entire district and should be treated with caution.
Perniatal mortality rate – the same comment as above
VCT coverage per 1000 population 15 yrs and older
2004
Numerator: Clients counselled for HIV
Denominator: Population 15 yrs and older
I am providing the figures until May 2004 to show that there has been a substantial
improvement
23

VCT testing rate – I have included this indicator
Cure rate – this refers to NEW smear Positives
This is based on 2 quarters of data for 2002
Interruption rate – also new smear positives
See comment as above
1 st ANC visit before 20 weeks rate – added this indicator for you
Target for 2004
I have added this column so that you can demonstrate that the district has understood that they
need to improve various services
24

APPENDIX TWO
FEEDBACK FROM THE MANAGERS ARISING FROM THE QUESTIONNAIRES
Summary
1. What HST has contributed in Bohlabela district
o HST has contributed in developing strategic indicators.
o Drawing up strategic document.
o Drawing up district Expenditure review.
o PHC Audit for service delivery.
o DHER process
o PHC skills audit.
o District situation analysis.
o Financial support for finance course.
o Devolution process.
o Support TB and STI management.
o IMCI courses, DHS conferences, Maternal health Conferences
o IMCI coverage has improved.
o PHCN coverage has improved.
o Health workers are able to use information collected at facility level.
o Report writing skills.
o Team building skills.
o Drug supply has improved with the implementation of the Clara System under
Amalgamated.
o Project review was conducted.
2.Most useful aspects
o District Health and Welfare Council and Advisory committee.
o Devolution process completed.
o Staff capacity building – IMCI training, PHCN training, Skills Audit, PHC Audit.
Less effective
o Little involvement of the hospitals
o Workshops not done for other categories e.g. allied workers, paramedics.
3.What HST has contributed to professional and personal development.
o Financial management skills
o Conflict management skills and team building.
o Understanding work about DHS.
o Presentation skills- papers and posters.
o Better informed managers.
o PHC benefited from the project.
o Capacity building of the PHC staff.
o Development of DHIS
o Every clinic knows the indicators.
25

o Managers feel they have capacity to go forward.
o They know themselves where they have worked.
o They need to develop a forum for Seminars to share skills.
4.What HST could have done better.
o Limit staff turn over (HST & National Health)
o Limited time, short period for implementation.
o Accessing finances and project implementation.
o Allocation of budget to be transparent.
5.Recommendations for future involvement.
o Few activities still outstanding.
o Capacitate health managers on research.
o Culture of documentation and presentation skills to middle and junior managers.
6. Any other comments
o It was exciting to be part of membership that interacted with the project.
o Managers have been capacitated and strengthened form both personal and
professional perspective.
o If funds were available, they would recommend that the project be extended.
o HST to be binded by commitments made at the beginning of the project and
continue funding committed activities.
o District to improve on report giving amongst each other.
o Need for annual analysis of package gaps.
o The Department to evaluate the staff establishment as it affects provision of
Comprehensive Primary Health Care.
o Financial support regarding workshops and Courses.
o Serious need for District management meetings.
o Signing of MoU between Mpumalanga and Limpopo Province to be pursued.
26