NHI: Doing things differently in KZN

District Clinical Specialist Teams have reduced deaths due to malnutrition among young children by 75 percent.
District Clinical Specialist Teams have reduced deaths due to malnutrition among young children by 75 percent.

When Thandi’s* teacher noticed that the seven-year-old wet herself continually, she reported this to nurses who had started to visit schools in Umzinyathi district.

Nurse Hloniphile Sikhakhane went to the girl’s home in search of answers and discovered from her granny that a neighbour had been raping the Grade One child.

“We reported the case to the social worker. The man has been arrested and the child was taken to hospital to have an operation. She is much better now,” Sikhakhane tells Health-e News.

Umzinyathi is one of the poorest districts in the country. Malnutrition, pneumonia and tuberculosis are the biggest killers of children in this largely rural district stretched between Dundee and Greytown in central KwaZulu-Natal.

But slowly the fortunes of the district are improving after an infusion of resources since it was chosen to be a National Health Insurance (NHI) pilot site.

Many of the improvements involve doing things differently rather than a cash injection, according to Abdus Cassim, who is the district’s NHI co-ordinator.

Leadership is also key, with one healthworker after another talking about the good example set by Jabulani Mndebele, the bullet-shaped district manager who works long hours and leads by example.

The NHI’s long-term aim is to ensure all people have access to decent healthcare by harnessing public and private health resources, but this cannot be done unless the care in public facilities is vastly improved.

Ten districts in the country – the NHI pilots – are experimenting with how best to improve public health, and how to shift our health system from one that cures to one that aims to prevent sickness.

In the North West, Community Healthcare Worker Fikile Mokabane tests a pensioner's blood sugar in the NHI pilot site.
In the North West, Community Healthcare Worker Fikile Mokabane tests a pensioner’s blood sugar in the NHI pilot site.

New teams focus on community health

This transformation, which Health Minister Dr. Aaron Motsoaledi calls the “primary healthcare revolution”, is based on three teams.

Umzinyathi’s 23 school teams have brought nurses into schools, concentrating on the poorest areas. They ensure kids are vaccinated and dewormed, check eyes, ears and teeth, identify those with health problems and educate the older ones about family planning and HIV, among other things.

Family Health Teams (also called ward-based outreach teams) visit people in their homes to offer basic treatment and teach people how to be healthier.

There are 15 Family Health Teams in Umzinyathi. Each team is headed by a professional nurse and an enrolled nurse, and staffed with up to 12 community care-givers.

The care-givers are the “eyes and ears” of the nurses, according to district co-ordinator Thembelihle Dlodlo. They are responsible for up to 80 households in their immediate neighbourhood, and visit different households every day. Their priorities are to ensure that pregnant women and small children to get regular check-ups at their clinics, and to do basic health promotion.

The nurses in the team oversee the care-givers and also do house visits. Nurse Nobuhle Phakathi admits that it has been hard for many nurses to trade comfortable clinics for driving around every day, often in rough terrain, to visit people in their homes.

“It was hard and very different to have no office, have to deal with dogs and people who are resistant to us,” said Phakathi. “Some people are clueless about health. There are so many myths. But now many people are coming to the clinic for immunisations and pap smears, so we can see that we are making a difference.”

Although doctors are not strictly part of the family teams, Cuban-trained Dr Sanele Madela joins them when he can. Prevention is the cornerstone of the Cuban health system, and Madela is most comfortable visiting patients at home.

“Many patients get swallowed by the system if they try to go to hospitals,” says Madela, a small and passionate man. “It is far better if patients can be treated at clinics because most don’t have money for transport to hospital. But there have been skills shortages in the past.”

Mfowethu Zungu, the NHI KwaZulu-Natal provincial co-ordinator, says Umzinyathi’s Family Health Teams have the advantage of being able to draw on other government departments though a provincial initiative called Sukuma Sakhe.

Launched in 2011 to address developmental problems, Sukuma Sakhe ensures that different government departments work together to address problems – so, for example, the Department of Agriculture assists families faced with malnutrition to grow their own food.

District Clinical Specialist Teams slash some child deaths by 75 percent

The final team is the District Clinical Specialist Team (DCST), made up of specialists – in theory, at least – to support healthworkers to improve their clinical care.[quote float= right]”The team was able to get a woman in obstructed labour airlifted from her clinic to hospital after a service-delivery protest had blocked all the roads – saving both her life and that of her baby”

Unfortunately, rural Umzinyathi has not been able to attract a single specialist, so its DCST is made up of three nurses specialising in primary healthcare, paediatrics and midwifery. Despite the lack of specialists, the DCST has been able to implement important changes, in part by identifying skills- and equipment shortages and plans to address these.

District manager Mndebele tells Health-e News the “fatality rate of children hospitalized with malnutrition was alarming”.

Over 30 malnourished children per 1000 hospitalised a year ago were dying, but this had been reduced to 7,5 deaths per 1000 by the start of this year thanks to better training.

Paediatric nurse Zandile Ntuli reports that the district’s high death rate for newborns is also being reduced thanks to new ventilation machines to help premature babies to breathe, daily ward rounds by doctors and the non-rotation of staff.

The DCST has also worked on setting up a smooth referral system from clinics to hospitals.

Midwife Philisiwe Mbatha says the best example of this was how the team was able to get a woman in obstructed labour airlifted from her clinic to hospital after a service-delivery protest had blocked all the roads – saving both her life and that of her baby.

Twelve private doctors have also been contracted to work in clinics, and this has resulted in fewer patients going directly to hospitals for treatment.

Unlike all other provinces that have one NHI pilot each, KwaZulu-Natal has two official pilots – Umzinyathi, Umgungundlovu – and has added Amajuba as a third, paid for by the province itself, while the others get a national grant.

Zungu, the NHI KwaZulu-Natal provincial co-ordinator, says one of the biggest challenges in the pilots is to bring about a mindset change amongst healthworkers.

“Healthworkers have been taught to think we must get the sick to come to us and we will give them medicine. But we want to change the mindset from curative to preventative health,” says Zungu. – Health-e News.

*Name withheld to protect the child

An edited version of this story was first published in the Sunday Tribune newspaper


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