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SAMJ: South African Medical Journal
versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.105 no.9 Pretoria Set. 2015
http://dx.doi.org/10.7196/SAMJNEW.8379
CORRESPONDENCE
Rural district hospitals - essential cogs in the district health system - and primary healthcare re-engineering
To the Editor: The article by Le Roux et al.[1] raises the question why it is so difficult to re-engineer primary healthcare (PHC) and why the results so far have been disappointing. They highlight the critical role of the district hospital as the hub from which all activities in the rural districts should be co-ordinated.
Le Roux et al. write from their own experience at rural hospitals. We agree that there are many examples of well-run public district hospitals with excellent reputations, which have contributed towards improved patient care together with improved health status of the community. Hospitals that have built up reputations as providers of excellent rural healthcare services in the past decades are Elim, Donald Fraser, Gelukspan, Manguzi, Bethesda, Mosveld, Mseleni, Rietvlei, Zithulele, and many more.
Some of the following aspects will have played an important role:
• Integration of hospital and district services. The doctors and allied healthcare workers (HCWs) working in the hospital went out to visit the clinics in the district, saw patients with the clinic nurses, and did on-the-job training of clinic staff.
• Strong leadership in the form of committed champions who had built up good-quality programmes to address the major health problems diagnosed by assessment of the community ('community diagnoses').
• A co-ordinated team approach to the major health problems in the district, e.g. a mental health programme run by a community psychiatric nurse who also saw the admitted patients in the ward and followed them up after discharge at their homes and nearby clinics. The same applied to programmes to control malnutrition, tuberculosis, measles, maternal health and diarrhoeal diseases. These and other common public health challenges are addressed by integrated programmes such as GOBI-FFF (growth monitoring, breastfeeding, immunisation, family planning, female education and food supplementation), diarrhoeal disease control including safe water supply and sanitation, tuberculosis control with active case-finding and contact tracing, and school visits by the dentist and school nurse.
• Optimal use of the available resources in the district such as manpower, scarce skills (doctors and allied HCWs) and transport, and efficient supply of drugs, stationery and other necessities to the clinics from the district hospital.
• Optimal communication, because the HCWs in the district and the hospital knew each other well. A continuous rotation of staff through the hospital and clinics ensured good understanding of the community's health needs.
• Joint planning and evaluation by the district health team, or what Le Roux et al.[1] call 'primary care management teams'. This structured and intensive co-operation between district health teams of clinics, mobile teams and the hospital made significant progress possible despite limited resources and other adverse conditions such as apartheid and homeland policies.
The presence of primary care management teams in properly supported and well-run district hospitals, as called for by Le Roux et al., is vitally important in the delivery of PHC. District clinical specialist teams can get involved by adding their expertise and monitoring the impact on the health status of the community in the catchment area.
The establishment of the monitoring and response units in the Waterberg, Gert Sibande and OR Tambo districts to accelerate the decline in infant, child and maternal mortality is an example of how the divide between the district hospital and the district health services can be healed and a united response to the unacceptable high mortality rates among infants and mothers created. The whole district healthcare team will take responsibility for the health of the population in the district and be accountable for performance.
The development of ward-based outreach teams makes it possible to integrate care from the home to the clinic and the hospital through a community-orientated primary care approach. The district hospital is an integral part of such integrated care.
Common sense and the experience of many HCWs in rural districts support the call for re-establishment of the district hospital as the 'hub of expertise, training, supervision and support for its feeder clinics and [to] be the guardian of the health of each member of the community it serves'.
Martin Bac, Jannie Hugo
Department of Family Medicine, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa
References
1. Le Roux KWDP, Couper I. Rural district hospitals - essential cogs in the district health system - and primary healthcare re-engineering. S Afr Med J 2015;105(6):440-441. [http://dx.doi.org/10.7196/SAMJ.9284] [ Links ]