District Health Team Research Articles

Leading change in the South African district health service

PurposeThe paper sets out to explore the leadership processes and dynamics of change management in a fragmented, and resource‐poor, health service in an impoverished rural region in South Africa.Design/methodology/approachThe paper outlines an action research process aimed at assisting the stakeholders of two rural clinics to integrate psychiatric care into the Primary Health Care service that they offer their respective communities. This involved the transformation of existing practices through a form of praxis that involved learning from action and acting on learning.FindingsThe findings of the paper relate to the role of leadership in the facilitation of transformational learning in team‐based social action. Four areas of leadership responsibility are highlighted: the transformation of inappropriate mental models; the development of strategic resilience; the shifting of the locus of control of stakeholders to a more internal position; and the creation of a social environment in which intangible capital resources are generated and leveraged in the collective interest.Research limitations/implicationsThis paper is subject to the limitations of potential bias and distortion in action research. Although the “objective” evidence of the integration of psychiatric services at Pelsrus and Kwanomzamo clinics exists, the portrayal of the learning processes through which this was achieved could have been influenced unwittingly by the authors' own knowledge and other interests.Practical implicationsThe paper endorses the educational importance of work‐based projects through which strong tacit leadership knowledge bases can be developed in health sector personnel.Originality/valueThis paper has attempted to share the effectiveness of work‐ and project‐based learning in district health teams in South Africa. In particular, it has outlined how the learning strategy of the module leverages the team structure of the district health management units in order to create and exploit the social and morale capital resources that are potentially available through such a structure and the covenantal culture that it spawns. Furthermore, an attempt has been made to show how these resources are leveraged in the generation of mission‐pertinent tacit knowledge that is then converted by project stakeholders into explicit knowledge forms that can be used more effectively in framing subsequent strategic action.

Measuring unmet obstetric need at district level: how an epidemiological tool can affect health service organization and delivery.

A national retrospective survey on the unmet need for major obstetric surgery using the Unmet Obstetric Need Approach was carried out in Mali in 1999. In Koutiala, the district health team decided to carry on the monitoring of the met need for several years in order to assess their progress over time. The first prospective study, for 1999, estimated that more than 100 women in need of obstetric care never reached the hospital and probably died as a consequence. This surprising result shocked the district health team and the resulting increased awareness of service deficits triggered operational measures to tackle the problem. The Unmet Obstetric Need study in Koutiala district was implemented without financial support and only limited external technical back-up. The appropriation of the study by the district team for solving local problems of access to obstetric care may have contributed to the success of the experience. Used as a health service management tool, the study and its results started a dialogue between the hospital staff and both health centre staff and community representatives. This had not only the effect of triggering consideration of coverage, but also of quality of obstetric care.

Evaluation of a home-care/counselling AIDS programme in Kgatleng district, Botswana.

In 1988 a programme for care and follow-up of HIV-positive persons and AIDS patients was implemented by the existing health facilities (district health team and hospital team) of Kgatleng District, Botswana. A survey study in 1991 tried to indicate the effectiveness and bottlenecks of the programme. All advisory nurses (AN) were interviewed via two questionnaires: one pertaining to case management of clients and one on their perceptions of their work. Seventy-two of 109 HIV-infected persons accepted and received counselling. Response of the 72 varied: 26 with a good, 34 with a moderate and 12 with a bad response. Prevention, contact tracing and home visiting were studied, as well as ANs' experiences and opinions of the programme. Some behavioural change by clients was indicated by the results though its extent remains questionable. Programme problems included client migration and refusal of counselling, and discontinuation of HIV-testing facilities. Once a relationship was established, confidentiality, questions and fear of stigmatization posed major problems. One-to-one support of ANs could help them cope better with these problems as well as discuss their own worries.

Working with Communities to Increase the Use of Health Services: An Experience from Togo, West Africa

A project in Togo, West Africa, demonstrated that motivated and skilled district health teams can increase community involvement in promoting positive health behavior. Village health committees, village volunteers, health workers, itinerant health agents, and school teachers collaborated with district health personnel in village-wide efforts to increase the use of health services targeted to children under five years of age. The project also demonstrated that in areas where health services are accessible, high levels of service utilization can be achieved by villages through a combination of strategies that rely on person-to-person and group methods of communication. Village-level educational programs, which included theater, storytelling, patient education at health facilities, and child-to-child activities in schools contributed to improvements in immunization coverage levels in children twelve to twenty-three months of age after less than one year following the educational intervention. The major factors responsible for the success of the project are summarized, and issues related to project replication and diffusion are discussed.

Organizational design and the district health team.

Organizational design and the district health team.

A health district as the operational unit for primary health care.

Commentary is provided on the usefulness of the health district as the organizational hub for implementation of primary health care (PHC) objectives. The recommendation is based on experiences in developing countries, and the awareness that PHC has been constrained by political, economic, social, and bureaucratic factors. A district government area is defined as a clearly defined administrative unit under the aegis of the central government and is responsible for local management. At the district level, the geographic and demographic area is small enough for managing problems and solutions and large enough to have professionally qualified staff. Community participation, intersectoral action, affordable appropriate technology, equity and social justice, and major components of PHC can all be implemented at the district level. Community initiatives can be incorporated into district programs. District health teams have access to District Health Officers, who encourage and support directly and indirectly health-related community initiatives. External cooperation agencies have been active in developing and strengthening local and district government. The 8 basic components of the Alma Ata Declaration on PHC can be realized at the district level. The district level also provides the ideal opportunity to encourage cooperation between people, their governments, and external agencies and to develop a strong national health system.

Achieving health for all: a proposal from the African Region of WHO

The Director of WHOs Regional Office for Africa presents a health development framework based on the primary health care (PHC) concept. the government should review national health policies national health strategies and national heath services to resolve basic issues. Then it should define the framework for health development by breaking down the goal into operational target-oriented subgoals for individuals families and communities by creating health districts as operational units and by organizing support for community health. Once this framework has been decided the government should use it to restructure the national health systems. At the district level health and development committees helped by community health workers and district health teams would be responsible for community health education and activities. The provincial health offices would oversee district activities select and adapt technologies and provide technical support to communities. A board would manage the provincial hospitals (public private and voluntary). These hospitals would work together to organize secondary medical care programs. A public health office wold link them with the provincial health centers. Other sectors would also be involved e.g. departments of education and water. The national health ministry would set national policies plans and strategies. A suprasectoral health council would coordinate cooperation between universities and other sectors and external agencies. National capacity building would involve establishing management cycles of health development using national specialists as health advisors and placing health as a priority in development. To implement this framework however the government needs to surmount considerable structural economic and social obstacles by at least decentralizing and integrating health and related programs at the local level fostering a national dialogue and promoting social mobilization.

Integrating health services: the experience of NGOs in Ethiopia

Many non-governmental organizations (NGO) remained in the Wollo region of Ethiopia following famine relief and emergency medical service efforts of 1984-85. Since then these organizations have helped identify strategies and processes needed to implement Ministry of Health (MOH) policies especially in the area of integrated maternal-child/curative health services. This paper discusses the strengths and weaknesses of 4 broad approaches to health development adopted by the NGOs over the post-famine relief period of 1986-88 and considers further strategic adaptation in later years. Under the themes of direct management clinic adoption impact area and air-drop resources earlier NGO approaches largely suffered poor sustainability non-replicability and inefficient use of resources. Moreover these approaches distracted the MOH from pursuing its own viable approaches effectively stymieing the development of district and regional health systems. Later NGO approaches support improvements in the MOHs priority health programs through the provision of technical and material assistance for analyzing developing and implementing improved systems of district health management and care. NGOs wishing to adapt their existing programs into a comparable health systems approach should build upon existing relationships with the MOH in support of district and regional health services foster skill development among indigenous health personnel seek avenues to improve efficiency and promote activity-based training and regional and district health team management.

Economic adjustment and current trends in child survival: the case of Zimbabwe

The relationship between health and welfare policies and economic performance and the efficacy of economic adjustment measures in Zimbabwe since independence are examined along with the accompanying changes in infant and young child health. As a result of the successful struggle for independence certain economic measures and social reforms have been instituted and these have had a positive influence on health. The most important include the setting of minimum wages for all categories of labor food subsidies the land resettlement program expanded education water development and drought relief programs. The management and delivery of health care; in line with the new primary health care (PHC) approach has been transformed slowly. The curative and preventive services have been integrated in provincial and district health team structures accountable both to higher levels of the health structure and to the local government structures at the level of service. Active steps have been taken to reform medical education to make the training of physicians more relevant to the needs of Zimbabwe. Some of the changes introduced since independence include: free health care; hospital and rural health center building program; the Zimbabwe expanded program on immunization (ZEPI); diarrheal disease control program (DDCP); a national nutrition program; a program of child spacing; and a national village health worker program. All these and other programs call for expansion of government expenditures. A table shows how the vote allocations and the actual expenditure of the Ministry of Health changed over the period. Due to the scarcity of data it is difficult to be anything but speculative regarding the impact of the health sector interventions on infant and child mortality and morbidity. Yet it is likely that certain programs -- particularly ZEPI and DDCP - have had and continue to have a rapid positive impact on child survival. Any significant impact on deaths resulting from respiratory infections low birth weight and other neonatal causes as well as deaths resulting either directly or indirectly from malnutrition would require improvements in nutritional status of both children and mothers as well as reductions in levels of crowding and further improvement in access to health care. The primary effect on the health sector of the recession period has been to restrict the Ministry of Healths ability to finance services.