PHM-Exch> Why, despite good policies, money and skilled workers, PHC performs so poorly

[Claudio Schuftan]

from EQUINET

HOW GOLDEN POLICIES LEAD TO MUD DELIVERY – AND HOW SILVER SHOULD BECOME THE
NEW GOLD
Dr. Karl Le Roux, Zithulele Hospital, Eastern Cape, South Africa

There is a general perception amongst academics, government officials,
non-governmental organisations (NGOs) and the South African public at large
that as a country we have good policies, but that we implement these
policies poorly. In fact, one of the fundamental issues that we need to
address as a country is to try to understand why, despite good policies,
adequate amounts of money and more skilled workers than in most parts of
Africa, South Africa performs so badly (especially in health and education)
when compared to other African countries. The tendency of policy makers is
to blame downstream factors, such as general lack of capacity , “lazy
managers” or “obstructive clinicians”, which to some extent is reflected in
the research.

But my job today is to describe to you what it is like being at the rural
coalface. Though I have loved working in a rural hospital for the past six
years, it has also been one of the toughest periods in my life. Working in
rural medicine is a bit like sitting on a rollercoaster: a combination of
enormous challenge and reward, feeling exhausted and exasperated and then
inspired and invigorated, seeing dignity and strength in patients, but also
sadness and unnecessary suffering and death. One always feels stretched and
one often feels as if one is hanging on by one’s fingertips. The rural
idyll is something that might be experienced on weekends off, but the
reality of the working week is that on the whole one is extremely busy and
constantly rationing care and doing the best one can with the resources
available.

It therefore might come as no surprise to the reader that at the coalface
“policies” are more often seen as a hindrance than a help to the delivery
of health care. Policies or programmes are often imposed from above, with
no consultation and with little understanding of realities on the ground.
There is usually poor data collection and feedback, lots of time-consuming
and unnecessary paperwork and a focus on irrelevant aspects of care with
the neglect of critical aspects. I need to make clear that good, realistic
and helpful policies are greatly appreciated by most clinicians working at
primary care level, as they improve care and the health of our patients
(for example the new antiretroviral treatment guidelines).

But there are also many examples of policies and programmes that aim for an
unrealistic gold standard (with its unnecessary and unhelpful complexity)
and which, as a result, undermine the provision of good healthcare to as
large a population as possible.


The first example of this is the new Road to Health Booklet. Although an
extremely well-intentioned document, it is completely unrealistic to expect
a busy primary care nurse to use this tool properly. It appears as if the
designers of the document have never set foot in a packed rural (or
township) immunization clinic, or tried to fill in the booklet with 60
screaming babies requiring injections in the waiting room outside. A year
after it was introduced in our area, we still find that critical data such
as mother’s HIV status and type of prevention-of-mother to child
transmission (PMTCT) treatment provided is left out, whilst on the old,
much simpler Road to Health Card, this was filled out really well.

Another example of where aiming for gold results in mud delivery is the
District Health Information System (DHIS), a tool with so many parameters
and different indicators that it is not actually possible to fill it out
correctly unless each clinic has several dedicated data capturers with
computers and technical support. As a result, much of the data is literally
made up (I have seen it happen with my own eyes) and results in very poor
quality data. At a recent meeting in my district, for example, several
clinics had a higher than 120% coverage for measles vaccination. Yet
managers and health planners scratch their heads and wonder why we get such
poor quality data and complain that overloaded nurses at the coalface must
just fill the data sheets out correctly. The DHIS needs to be simplified
drastically, and nurses on the ground must get regular feedback on certain
critical indicators that truly reflect improved care.

Many people balk at the idea of not aiming for a “gold standard” at a
policy level – surely we must at least aim for the stars even if this isn’t
really achievable?

Firstly, I would like to argue that we have ample evidence of how aiming
for gold actually undermines the provision of care at grassroots level, and
that we instead need to focus on simplicity and doing the basics really
well. This would result in the biggest health impact on the greatest number
of people.
Secondly, I think that we need to be cognisant of our limitations in terms
of both human and financial resources in South Africa and recognise that we
do not have the capacity to achieve gold right now, although it may be
possible to aim for gold 20-30 years from now.

In the health sector we should be working within a framework of clear,
straightforward priorities, aiming for what is achievable (silver?) and
doing the basics extremely well, with simple monitoring and clear feedback
to all healthcare workers.

I would like to argue that a policy cannot be labelled as “good” unless it
is implementable. We need to recognise that putting policy together is the
beginning of a long process. Policymakers need to be involved in drawing up
implementation strategies, and government must support policy
implementation through adequate finances and capacitating and empowering
managers to manage the changes that will be required when policy is
implemented.

Let me end with a final plea from the coalface that those of you who write
policy use the following as your guiding principle: good health policies
make things better and easier on the ground and result in improved patient
care.

Please send feedback or queries on the issues raised in this briefing to
the EQUINET secretariat: admin at equinetafrica.org. This oped was featured in
a paper for the Public Health Association of Southern Africa newsletter at
le Roux K. How golden policies lead to mud delivery – and how silver should
become the new gold. Newsletter of the Public Health Association of South
Africa. November 15, 2012. ). The views expressed are those of the author
and do not necessarily represent the views of PHASA.
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