A District Public Health Unit: experiences and lessons learnt from Ekurhuleni

The 2010 national mandate on the re-engineering of Primary Health Care (PHC) has identified the need for a more structured focus on maternal and child health challenges through District Clinical Specialist Teams and for more community engagement through PHC Outreach Teams and School Health services. (1)

The emphasis is on a preventative and population health based approach to the re-engineering of PHC, with a definite need to strengthen at district level the Community Health Diagnosis approach; Disease surveillance and control; Epidemiology and Health Research; Occupational and Environmental Medicine; support of specific health programmes which impact on the health of the community; evaluation of the social determinants of health; and a number of other related areas. Preventative/Community/Public Health Medicine (PHM) is recognized as a medical specialty that primarily strives to improve population health while also strengthening health system effectiveness and service delivery through its focus on Comprehensive PHC and Health Systems Management.

Therefore the inclusion in the 2011 national Human Resources for Health (HRH) Strategy (2) of district and provincial Public Health Units (PHUs) headed by PHM specialists and with other cadres of public health professionals in the health services seems to neatly dovetail into this perspective. (3) The strategy infers that the roles and job descriptions of PHM specialists have to be clearly identified and determined, with the roles of other cadres of public health professionals also alluded to, the challenge being of re-aligning the current training of these other diverse Public Health professionals  towards more competency based programmes that would respond to the health service needs of the country. The current PHM training programme is structured, competency based and nationally standardized through exit examinations by the College of Medicine, South Africa. The UK had a similar experience over a decade ago where they too had to review the training of all cadres of ‘public health’ workers and where the goal was to develop a multi-disciplinary public health workforce. (4)

So while South Africa trains and produces a range of Public Health professionals their role in the public health sector has yet to be clearly defined. This brief narrative explores the experiences of both authors over the last five years culminating in the current district PHU.

Establishing a district Public Health Unit

The Ekurhuleni Health district is one of three metropolitan areas in the Gauteng Province, South Africa. The district has about three million people who are mostly economic migrants from around the country and the African region. The district has two health authorities providing health services; the local government municipalities and the provincial health authorities.

Tuberculosis, Pneumonia, HIV and non-communicable conditions such as cardiovascular disease and diabetes mellitus are the most common causes of morbidity and mortality in Ekurhuleni. Ekurhuleni is one of the 25 priority districts in the country with high maternal mortality (5) and with many municipal wards categorized as poor.

In 2009, one of the authors (Ronel Kellerman) was appointed to the post of a district Community Health Specialist; this was the only district post in Gauteng at the time. The provincial head office had a medical advisor in the Public Health directorate, whose responsibility was to provide medical and technical advice in health promotion, control of communicable diseases, epidemiology, outbreak response, infection control, control of non-communicable diseases, including eye care, environmental health and port health.  The district job function as advertised included conducting epidemiological surveillance with community assessments; developing and co-ordinating the implementation of a comprehensive health information management system to be used for the planning, monitoring and evaluation (M&E) of health services; epidemiological analysis of disease data; promoting and conducting research in the district; assisting in outbreak investigations and disease control; and writing or drafting technical reports for the district management. It was evident that the need and roles identified at district and provincial level were quite different, although there was some overlap.

The various areas the author was expected to manage required integration with areas that were under other programmes, but more suited to the expertise and skills of a public health specialist. Disease surveillance was under the Health Programs manager and Health Information Systems (HIS) was under Corporate services. The district management together with the author determined that these two areas had to be brought under one unit, and a proposal to develop a district PHU incorporating all these sections was approved in 2010. The PHU therefore comprised of Disease surveillance, HIS, Research and M&E support activities, each with its own resources such as staff and equipment, though this was insufficient for a district the size of Ekurhuleni. Bringing all district data into one unit improved data verification and triangulation; increased access to data from different sources for M&E and assisted in developing a research agenda for the district and using district data for research projects of Master level students.

One of the inherent challenges in developing the district PHU at the time was that it did not fit into any existing district organogram and therefore allocating human and financial resources to the unit became problematic. The scope of public health specialists at district level is also quite broad and can be in any of the health systems areas such as drug supply management, procurement, M&E, strategic planning, health economics, policy development and the like. Therefore clearly defining the role and responsibilities of public health specialists at district level from the start is essential to minimize unrealistic expectations. 

When the Public health specialist arrived in the district, the expectations were that the incumbent would improve data quality and management of district health information; conduct community diagnosis with a view to finding solutions to the problems identified; review all the data from health programs and provide interventions to improve health service delivery.  District programme managers viewed the public health specialist more as an M&E advisor, presuming that they then could shift their M&E responsibility to the author. The difference between providing M&E support and responsibility for M&E became blurred. The author also had to manage the PHU; juggling managerial duties with supporting other health programs. Once more role clarification became essential.

In 2011, the other author (Leena Thomas) moved to the district and was involved, primarily, in establishing ward based PHC Outreach Teams in the district. As a PHM specialist and a joint medical staff with the Department of Public Health Medicine, School of Public Health, University of Witwatersrand, there was also an opportunity for this author to establish the district as a site for training PHM registrars. This was in line with a national mandate to train health professionals at all levels of care in the health system, and increase the number of PHM specialists. (2)

As with the experience of her colleague, the author also had to go through the process of determining where the district management of ward based PHC Outreach teams should be located, since the district already had a PHC program and a Family Medicine program. The district management together with the authors felt that the expertise required to establish ward based PHC Outreach teams rested with public health specialists in the PHU, in collaboration with the other relevant programs. In 2011 and 2012, the author managed to implement more than the planned number of PHC Outreach teams for the year, together with support from PHM registrars and district staff. These outreach teams are currently providing community based health services to almost 80 000 people. However, establishing the teams and monitoring their daily operational activities were two different processes. Facility managers and sub-district PHC managers also had roles in this regard which they were not necessarily exercising. Again the need for role clarification and responsibilities of other health programmes supporting ward based PHC Outreach teams was evident.

Functions of the district Public Health Unit

As a result and within the contexts introduced earlier, both authors, decided to review their existing roles as public health specialists and how this could be aligned to a more structured district PHU as expected in the National HRH strategy. The thinking was that the district PHU would continue to be a key component of the District Management Team. The following was envisaged as the functions of the district PHU:

Strengthening health systems by supporting the District Management with: Supporting Health Services and Population Health (together with District Specialist Teams) through: Education, training and research
Strategic and Operational planning within the district in terms of developing District Health Plans and the like The Re-engineering of PHC: implementing and supporting school health services and ward based PHC Outreach teams together with the HAST and PHC programs in the sub-districts. Expansion of the formal teaching and learning platform to the district for training of PHM registrars and undergraduate medical students; MPH and MSc students
Monitoring and Evaluation of the impact of health services and programs, including supporting and managing Health Information systems Disease surveillance: working closely with the sub-programmes HAST, Health Programs and Specialized services in the Control of communicable and non-communicable diseases through clinical preventative medicine (screening, immunization); Health Promotion and Health Education

Establishing and strengthening District research activities

Health economics: including planning for the implementation of the National Health Insurance Maternal & Child Health: working with the District Clinical Specialist teams and sub-programmes in evaluating morbidity & mortality trends, health services and overall impact on maternal and child health. Support in-service Training and Development of health workers at district level
HRH planning and workforce analysis in line with Service Transformation Plans, District Strategic Plans, and Integrated Development Plans Occupational Health: supporting the provision of Occupational Health services to employees of the district health services  
Intra and Inter-sectoral collaboration within government as well as with other stakeholders Environmental Health: working with the sub-programme in ensuring a reduced health impact from poor water, sanitation, refuse removal, pest control and other environmental factors.  

The three main areas were: strengthening health systems; improving health services and population health; and education, training and research.  Recognizing that these areas were also broad, prioritizing critical areas each year would also be key in achieving planned outcomes.  In order to ensure that the full scope of such a PHU could be realized, both authors determined the resource implications, mainly human, and developed an organogram which was presented to the district management in 2012. It is hoped that over the next few years sufficient resources will be obtained to capacitate this unit. However, given the current financial constraints in the province, other strategies are also being explored. Through an arrangement with the Department of Public Health Medicine (or Community Medicine) at the academic hospital supported by the University of Witwatersrand, PHM registrars are already rotating through the district. There are also plans for another PHM specialist employed in the hospital to provide additional support to the district in the current financial year mainly in the area of disease surveillance and control. Opportunities are also available for masters’ and doctoral Public Health students to pursue experiential learning in the district while at the same time providing a much needed service. Integrating HIS staff across provincial and municipal facilities has also taken place to optimise existing staff.

This district PHU is one of two in the Gauteng Department of Health; and although it still requires additional resources to function optimally, it is a significant achievement for Gauteng and has been alluded to by the Minister of Health in one of his presentations on the progress of the HRH strategy earlier this year. (6)

The benefit of an optimal district PHU still has to be clearly understood by provincial and district health services in the province and around the country where the onus has primarily been on responding to clinical service delivery needs with short term gains. While patient care is still relevant in a high disease burden setting such as in South Africa, a paradigm shift is required towards a more population health based and preventive approach to health care in the country and where the investment and gains are much more in the longer term. Such is the thinking of the current Minister of Health, and within that, PHUs both at district and provincial level, but especially at district level are increasingly becoming more relevant for South Africa.

Note that the views expressed in this article are those of the author(s) and do not necessarily represent the views of PHASA.

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