Haenertsburg/Tzaneen/Letsitele/Gravelotte Health and Welfare Situation Analysis of the District May 1998

Health and Welfare Situation Analysis of the
Haenertsburg/Tzaneen/Letsitele/Gravelotte
District
May 1998
Health and Welfare Analysis
of the
Haenertsburg/Tzaneen/
Letsitele/Gravelotte District
May 1998
Also available on the Internet
http://www.hst.org.za/isds
ISBN # 1-919743-39-1
Supported by a grant from the Department for
International Development (DFID)
Published by the
Health Systems Trust
401 Maritime House
Salmon Grove
Victoria Embankment
Durban
Tel: (031) 3072954
Fax: (031) 3040775
Email: [email protected]
Typeset and Printed by The Press Gang • Durban • (03 1) 3073240
Written by the health and welfare workers of the Haenertsburg/Letsitele/Gravelotte/Tzaneen
(Halegratz) district, and a facilitator of the Initiative for Sub-District Support (ISDS).
The health workers (Local Area Supervisors)
Matron P.M. Mahlatji
-
Nkowankowa Local Area
Matron M.A. Masungwini
-
Mugodeni-Grace Local Area
Matron S.C.P. Nimb
-
Tzaneen Local Area
Matron N.X. Mgimeti
-
Shiluvana Local Area
Matron E.Z. Mtebule
-
Julesburg Local Area
Matron. M.S. Mabitsela
-
Assistant Director, Nursing Services,
Dr C.N Phatudi Hospital
Welfare Officers
Ms. V. Machimana
Mrs. M. Nkuna (Mary)
Mrs K.M. Manyike
Mr. M.J. Mashele
Mr. C. Chuene
Health Systems Trust
Thulani Masilela - ISDS Facilitator
Department of Health and Welfare - Lowveld Regional Office
Mrs. M.O. Mdluli
Mrs. M. Nkuna (Mihloti)
Mrs. S. van der Westhuizen
Department of Health and Welfare - Provincial Office
Mrs. H. N. Manzini
Mrs. S.V. Mokoena
Non-governmental organisations (NGO’s)
Ithusheng Community Association
Mrs. M.J. Ramalepe
Department of Community Health, Medunsa, Pietersburg/
Polokwane Campus
Dr. J. Rawlinson
District Health Authority (DHA)
Mr N.S. Masila
Preface
This document is intended primarily for the incoming DH&WMT in the Halegratz district, the
Lowveld regional office and the provincial health department. This report presents the health
and welfare situation analysis that was conducted by health and welfare workers of the
Halegratz district between February and April 1998, with support from the Initiative for Subdistrict Support (ISDS), a project of the Health Systems Trust (HST). This document discusses
the health and welfare problems prevailing in the district.
The situation analysis of the Halegratz district was conducted before the DW&WMT was
appointed. The District Health and Welfare Plan described in this document is therefore
preliminary, and will need to be ratified by the DH&WMT. This preliminary plan does, however,
provide a foundation on which the DH&WMT can build. This it does by discussing the problems
that need to be addressed and the mechanisms of doing this. In the final analysis, it will be
the people of the Halegratz district, through their DH&WMT, and the District Health & Welfare
Authority (DHWA) who will decide on the best measures to deal with these difficulties. The
ISDS is committed to supporting this process, which should result in improvements in the
quality of care provided at the site of service delivery.
The ISDS
The ISDS aims to support improvements in quality of health care at the site of service delivery.
In the provinces where health and welfare are combined into a single department, the ISDS
addresses issues of quality of care in both the health and welfare services. The ISDS provides
support to selected districts across the country, with the aim of transferring the lessons learned
and successes achieved to other “knock-on” sites. The ISDS works together with the National
and Provincial Departments of Health (and Welfare in cases where the two are combined), to
ensure that ISDS activities are not stand alone interventions but that the lessons learned
ramify across various levels of health provision.
The ISDS started working in the Haenertsburg/Letsitele/Gravelotte/Tzaneen (Halegratz) district
in the Northern Province in February 1998. The implementation of the district health and
welfare system (DH&WS) in the Halegratz area was well under way before the ISDS became
involved. District boundaries had been clearly demarcated and the plan to implement the
DH&WS had been pit in motion. The district had been sub-divided into 5 local areas (i.e. subdistricts), and 5 supervisors were managing health facilities in the local areas. The process had
been thought through. The DH&WS was officially launched in the Halegratz district in March
1998 by the Superintendent-General of the Department of Health and Welfare in the Northern
Province. At that time, the appointment of a district health and welfare management team
(DH&WMT) was imminent. The Chief Executive Officers (CEO’s) or District Managers for the 24
districts of the Northern Province were formally appointed as of the 1st September 1998. The
ISDS continues to work in the Halegratz district, with the CEO and the DH&WMT.
Table of Contents
Chapter 1: Assessment of the health district
1.1.
1.2.
1.3.
Geography
Demography
Socio-economic profile
1
1
5
5
Chapter 2: Health Status and Health Problems
6
Chapter 3: The Health and Welfare Services
7
3.1.
Introduction
7
3.2
Progress with the implementation of District Health and
Welfare System (DH&WS)
7
Chapter 4: Assessment of Support Systems
12
4.1.
4.2.
4.3.
4.4.
4.5.
4.6.
Financial Management
Transport Management
Drug and Vaccine supply
Communication
Health Information
Human Resources
Chapter 5: The Public Health Sector
5.1.
5.2.
12
12
12
13
14
15
18
Facilities
18
5.1.1.
5.1.2.
18
21
Hospitals
Clinics and Community Health Centres
Referral System
22
Chapter 6: The Welfare Sector
6.1.
6.2.
6.3.
Organisation of Welfare Services in the Halegratz District
Welfare Status and Welfare Problems
6.2.1.
Social Development
6.2.2.
Resource Allocation to Community-initiated Creches
Key Programmes of the Social Security Sector
6.3.1.
Assessment of the Key Social Security Programmes
24
24
26
28
29
29
Chapter 7: Other Health and Welfare Service Providers
7.1.
7.2.
7.3.
Private Sector
Traditional Sector
NGO Sector
30
30
30
Chapter 8: Assessment of Key Health Programmes
8.1.
8.2.
8.3.
8.4.
Maternal Health Services
Child Health and E.P.I
School Health Services
Nutrition and Growth Monitoring
8.4.1
Personnel
8.4.2
Services Rendered
8.4.2.1 Health facility based nutrition programmes
8.4.2.2 Community based nutrition programmes
8.4.3
PEM Scheme
8.4.4
Nutrition Advocacy and Promotion
8.5. STDs and HIV
8.6. Tuberculosis
8.7.
Environmental Health
8.8. Oral Health
8.9. Mental Health
8.10. Rehabilitation and disability services
8.11. Chronic diseases
33
33
34
34
34
34
34
35
35
36
36
36
36
37
37
37
37
Chapter 9: Other Sectors which impact on health and welfare
9.1.
9.2.
9.3.
9.4.
9.5.
9.6.
Safety and Security
Education
Correctional Services
Agriculture
Water Affairs and Forestry
Home Affairs
Chapter 10: Summary of Key Health Problems and Conclusions
39
39
39
39
40
39
40
Chapter 11: Taking Action to Improve the Situation
11.1.
11.2.
11.3.
The District Health and Welfare Plan
Improving Communication
Lessons from other districts
42
42
44
Chapter 1
Assessment of the Health and Welfare district
1.1.
Geography
The Haenertsburg/Letsitele/Gravelotte/Tzaneen (Halegratz) health and welfare district is one
of the 5 districts of the Lowveld region in the Northern Province. It consists of services that
were in four previous administrations, Lebowa, Gazankulu, Venda, Transvaal Provincial
Administration (TPA), and the National Department of Health and Population Development.
The district is sub-divided into 5 local areas (sub-districts) namely, Tzaneen, Mugodeni Grace,
Nkowankowa, Shiluvana and Julesburg. The Halegratz district has a beautiful landscape,
graced by the Wolkberg and the Drakensberg mountains, and three main rivers namely,
Letaba, Letsitele and Thabina. The district has a tropical climate, and produces the majority of
South Africa’s mangos, avocados, and paw-paws. It has both urban and rural features, with
the latter being more pervasive.
A homestead in the rural part of the Halegratz district
1
Western
Region
Central
Region
Bushbuck Ridge
Lowveld Region
Northern Region
Region
Southern
Region
HEALTH and WELFARE REGIONS of the NORTHERN PROVINCE - July 1998
Bushveld Region
Prepared by Department of Community Health, PMHCo
2
Mooketsi/Bolobedu
Tzaneen Dam
Olifants River
Giyani
Haenertsburg/Letsitele/Gravelotte/Tzaneen
or
Ga-Selati River
Halegratz District
Greater Letaba River
The HALEGRATZ District and surrounding Health and Welfare Districts
Dikgale/
Soekmekaar
Ebenezer Dam
NokoTlou/
Fetakgomo
Hoedspruit/Makhutswi
Prepared by Non Vertical, Department of Community Health, PMHCo - September 1998
Phalaborwa
3
Van Velden Memorial (Tzaneen) Hospital
Mamitwa
Clinic
Mokgwathi Clinic
Ramotshinyadi Clinic
Ooghoek Clinic
Grace Mugodeni Health Centre
Mavele Clinic
Nyavana Clinic
(under construction)
Mookgo/Makgope Clinic
ROADS, VILLAGES and HEALTH FACILITIES of the HALEGRATZ DISTRICT
Spitzkop Clinic
Tzaneen PHC Clinic
Tzaneen LA Clinic
Tzaneen Busstop Clinic
Letaba Clinic
Mariveni Clinic
Letsitele PHC Clinic
Nkowankowa
Health Centre Dan Village Clinic
Zangoma Clinic
Khujwana Clinic
Muhlaba Clinic
Jamela Clinic
Lenyenye Clinic
Maime Clinic
Lephephane Clinic Carlotta Clinic
Mogoboyd Clinic
Dr CN Phatudi Hospital
Maake
Shiluvana Health Centre
Clinic
Julesburg Health Centre
Tours Clinic
Mogapeng Clinic
Prepared by Non Vertical, Department of Community Health, PMHCo - September 1998
4
1.2.
Demography
The Halegratz district has an estimated population of 340 550 living in farms, urban areas and
villages. This represents 21% of the total population of the Lowveld region and 6,7% of the
province’s population. The languages used the most in the district are Sotho, Tsonga, Afrikaans
and English.
1.3
Socio-economic profile
The Northern Province has the unwelcome reputation of being the poorest province in the
country, and this description equally applies to the Lowveld region and the Halegratz district.
Halegratz is a place of contrasts, with the urban areas representing development and tourist
attractions, while the grim face of poverty is prominent in the rural areas. Sources of livelihood
in the district include agriculture, timber industries, and self-employment. Unemployment
rates are very high. Drought and uncertain rainfall negatively affect the situation for people
who subsist on agriculture. Illiteracy rates are high. Poor housing, scarcity of water and sanitation,
and lack of electricity highlight the difficulties prevailing in the district. Poor roads make
access to health facilities difficult, particularly in the rural parts of the district.
Agriculture is one of the main sources of livelihood in the Halegratz district
5
Chapter 2
Health Status and Health Problems
There is a shortage of reliable health indicators in the Halegratz district. The provincial
administration has initiated efforts to establish a district information system, and it is anticipated
that this will improve the data collection and provide better indicators. The health problems of
communities in the Mugodeni-Grace local area, as shown in Table 1, are characteristic of the
rest of the district.
Table 1:
Health Problems in the Mugodeni-Grace Local Area 1997
•
Diarrhoea
•
Skin diseases
•
Tuberculosis
•
Teenage Pregnancy
•
Backyard Abortion
•
STD’s and AIDS
•
Malnutrition
•
Diabetes
•
Hypertension
•
Asthma
•
Mental Illness
•
Disability
Source:
A community profile of the Mugodeni -Grace Sub-district, From Theory to Action, 1998.
The major causes of death in the Halegratz District include conditions such as diarrhoea, TB,
interpersonal violence and road accidents.
Table 2:
Diseases Notified in the Halegratz District in 1997
Condition
No. of cases notified
Measles
54
Tuberculosis
134
Neonatal Tetanus
1
Malaria
14
Source:
1996-97 Annual Report of the Lowveld Region
Not all of the notifiable diseases are managed at clinic or health centre level, but some are
referred to the district hospital where treatment and notification take place.
6
Chapter 3
Progress with the Implementation of the
district health and welfare system (DH&WS)
3.1.
The District Health and Welfare Management Team
(DH&WMT)
Efforts toward the implementation of the DH&WS in the Northern Province are advanced. The
Halegratz was the first district to be officially launched by the Superintendent General of the
Northern Province, Dr. N.Crisp, on the 18th March 1998. The organogram has been drawn up,
and negotiations with health and welfare workers to facilitate their migration into posts in the
district are underway.
The Chief Executive Officers (CEO’s) or District Managers of the 24 districts of the Northern
Province were appointed from 1 September 1998. The Halegratz district, together with the
Ngwcrits / Makhundu / Thamaga / Tubatse / Steelpoort Districts, which lie in the Southern
Region, have been declared the pilot sites for the implimentation of the District Health and
Welfare system by the Northern Province Government. The Grace Mugodeni Local Area has
been designated the pilot sub-district for the DH&WS in the Halegratz district (see case
study 1).
The CEO of the Halegratz district is Mrs. Soekie Van der Westhuizen. The main Halegratz
District Office is situated on the premises of Van Velden Hospital at Tzaneen. It is anticipated
that the district health and welfare management team (DH&WMT’s) will be fully functional by
the end of 1998. The initial tasks of the DH&WMT will be to develop district plans and to start
working on the 2000-2001 financial year budget.
Despite the complexity of integrating five
previous different administrations, significant
progress has been made by the provincial
administration towards creating a single
management structure for all health and welfare
services in the Halegratz district.
Mrs Soekie van der Westhuizen,
the Chief Executive Officer (District Manager) of
Halegratz, moving into the new district office
of Van Velden Hospital, Tzaneen.
7
Case Study 1 : Mogodeni Grace Local Area
The Mugodeni Grace Local Area is one of the 5 local areas of the Halegratz District. It is situated in the
jurisdiction of the Letsitele-Gravelotte TLC. This local area has a population of 119 000 residing in 34
villages. With regard to health facilities, Mugodeni Grace local area consists of 1 health centre, 7
clinics, 5 of which are functional, 2 mobile teams and 51 visiting points, 8 community health workers
and 1 youth information centre. Mugodeni Grace health centre plays a pivotal in the provision of
health and welfare services in the local area.
Mission
The mission of the health and welfare services in the Mugodeni Grace local area is to provide quality
integrated and comprehensive primary health and welfare services that are accessible to the people
of the area, with active community participation within the context of health and development
The DH&WS
The Mugodeni Grace Health Centre was identified by the interim District Health and Welfare System
(DHWS) Committee of the Northern Province as the initial site for the development of the DHWS in the
province. This initiative was launched by the then MEC for Health and Welfare, Dr. Joe Phaahla on the
07th February 1997.
Strengthening of Mugodeni Grace Health Centre
In line with WHO guidelines, which emphasize the strengthening of the health centre as a critical need
in the provision of efficient health care within the DHWS. In the strengthening of Mugodeni Grace
Health Centre, the following aspects were focused on:
Staffing
Staffing: The staff establishment was increased to include a medical officer (part-time), district health
and welfare facilitator, advanced mid-wife, and staff for the youth information centre, i.e., a director,
professional nurse, administrator, educator and cleaner.
Infrastructure: The premises of the health centre were upgraded, and a kitchen and laboratory were
erected.
Transport : An additional vehicle for the mobile team and a vehicle for medial officer were supplied
to the health centre
Equipment: Laboratory equipment and visual aids were acquired.
Community Participation : A local area health and welfare committee was formed, trained and sent
on exposure visits to other local areas to be empowered with regard to involvement in health and
welfare issues
Primary Health Care (PHC) Services
Services: To make PHC services rendered at the health centre fully
Mugodeni Grace Health Centre, the pilot subdistrict (local area) for the complementation
of the DH&WS in Halegratz district.
8
comprehensive, the following services were added: welfare, environmental health, psychiatric services,
ophthalmic services, dental health care, speech and hearing therapy and youth health information
centre
Successes of Mugodeni Grace Local Area
•
Mugodeni Grace was the first local area to compile a situation analysis that involved the
community
•
Community leaders participated at the National Health Systems Conference held in Durban in
March 1998.
•
Community leaders and local health and welfare providers were involved with the provincial
department of health in the 5-year strategic planning of the district health system
•
A local area organogram was established that involved placement of staff in local health facilities
•
On 08 th April 1998, the national Minister of Health, Dr. Nkosazana Zuma visited the local area
to evaluate progress with the implementation of the DH&WS and was appreciative of the efforts
made.
•
A Youth Information Centre was implemented as a pilot project in May 1997.
21 Five day workshops were conducted in which a total of 4000 youth
were trained in basic sexuality education and life skills
•
Extension of the distribution of condoms to taxi queue marshals, soccer teams, who were first
given training.
•
Exchange programmes between the local youth groups and the Netherlands youth
C hallenges of Mugodeni Grace Local Area
There are several impediments still hindering this local area from realizing its full potential.
Community leaders and health and welfare providers have attempted various measures to redress
the situation.
•
Communication: The means of communication are still limited to radiophones and manual
telephone exchange A request has been forwarded to Telkom for the replacement of this system
Telkom has undertaken to expedite this as a matter of priority.
•
Transport: Vehicles for the mobile teams are not sufficient, and there is no ambulance at the
health centre since emergency services are now run as a vertical programme. A request has
been forwarded to the provincial health and welfare department. The community is still awaiting
a response.
•
Shortage of Staff: At some facilities health facilities it is difficult to render a 24-hour service
due to inadequate staff. The local area is not attractive to outsiders due to its rural nature. The
local area health and welfare committee has taken it upon themselves to encourage local
matriculants to pursue nursing as a career, and to apply for admission to training colleges.
Furthermore, the need for more staff has been communicated to the provincial departments of
health and welfare
•
Attitudes: Impolite communication between the providers and the consumers of health and
welfare services was noticed to be a problem. A series of workshops were arranged in an effort
to rredress the situation, and consequently significant improvement has been observed.
The greatest challenge for the Mugodeni Grace Local Area is, however, to consolidate the gains that it
has made thus far, and to keep the momentum of improving the quality of health and welfare services.
It must also enhance its role as a leaning centre for the rest of the region, district and province, with
regard to the implementation of the DH&WS, from which lessons learned can be transferred to other
parts of the province.
Source : Courtesy of M.A. Masungwini, M. Nkuna, M. Nemo and D.C. Ngobeni, Mugodeni Grace Local
Area.
9
Assistant Director
Assistant Director
DIVISION: FINANCE &
ADMINISTRATIVE
SERVICES
PURPOSE:
TO HANDLE FINANCIAL
MANAGEMENT &
ADMINISTRATIVE
SERVICES
Assistant Director
DIVISION: HUMAN
RESOURCE SERVICES
PURPOSE:
TO RENDER HUMAN
RESOURCE SERVICES
FUNCTIONS
1. Provide personnel
management services.
2. Provide labour relations
services.
3. Administer
remuneration services.
4. Manage education and
training services.
5. Handle human
resource planning and
research.
PURPOSE:
TO RENDER TECHNICAL
SUPPORT & QUALITY
ASSURANCE SERVICES
DIVISION: TECHNICAL
SUPPORT & QUALITY
ASSURANCE SERVICES
Chief Commuity Liaison Officer
Assistant Director
ORGANOGRAM ofthe HALEGRATZ HEALTH & WELFARE DISTRICT
Assistant Director
Chief Executive Officer (District Manager)
Assistant Director
DIVISION: SOCIAL
SECURITY SERVICES
PURPOSE:
TO HANDLE SOCIAL
SECURITY SERVICES
DIVISION: WELFARE
SERVICES
PURPOSE:
TO RENDER WELFARE
SERVICES
FUNCTIONS
1. Render Social
Security services.
2. Manage payment
of grants and
pensions.
DIVISION: PRIMARY
HEALTH CARE
SERVICES
PURPOSE:
TO MANAGE PHC
SERVICES
FUNCTIONS
1. Provide
professional
welfare services.
2. Manage social
development
programmes.
FUNCTIONS
1. Render administrative
services.
2. Admister assets.
3. Manage allocation and
budget services.
4. Manage bookkeeping
and accounts services.
5. Render maintenance
services..
DISTRICT HOSPITALS
CCLO
SHILUVANA
LOCAL AREA
CCLO
PURPOSE:
TO MANAGE DISTRICT
HOSPITALS
CCLO
JULESBURG
LOCAL AREA
FUNCTIONS
1. Co-ordinate Aids & TB
services.
2. Render Epidemiology
services.
3. Handle computer
services.
4. Provide information
Services
5. Manage communication
services.
6. Carry out research &
epidemiology services.
CCLO
NKOWANKOWA
LOCAL AREA
FUNCTIONS
1. Render PHC
services in the
District,
2. Provide
Environmental
health services
3. Provide nutritional
services.
4. Render community
rehabilitation
services.
5. Provide
occupational health
safety services.
PRIMARY HEALTH CARE DIVISION
Chief Community Liaison Officer (CCLO)
MUGODENI GRACE
LOCAL AREA
District PHC Co-ordinator
(Assistant Director)
TZANEEN
LOCAL AREA
10
3.1.2
The District Health and Welfare Authority (DH&WA)
An interim District Health and Welfare Authority (DH&WA) has been established. It consists of
two members of each of the three Transitional Local Councils (TLC’s) in the Halegratz district,
that is, the Haenertsburg, Tzaneen and Letsitele - Gravelotte TLC’s. Mr. N.S. Masila of the
Haernertsburg TLC, has been appointed as the interim chairperson of the DH&WA.
The interim DH&WA will dissolve as soon as the Health and Welfare Bill of the Northern
Province is passed through parliament, and it will be replaced with a statutory DH&WA.
Mr N.S. Masila
Chairperson of the Halegratz District Health and Welfare Authority at a workshop
organised by Health and Welfare workers in August 1998
11
Chapter 4
Assessment of Support Systems
4.1.
Financial Management
The resources for primary health care services are provided by the provincial office through
the regional office as the district health and welfare system (DH&WS) is not yet operational.
Each health facility has its own budget allocation. Budgets for clinics and health centres are
currently administered by distruct hospitals.In all facilities, the bulk of the expenditure is
consumed by personnel expenditure. The finances of the welfare sector are managed by the
regional heath and welfare office. It is anticipated that this task will be decentralized to the
DH&WM in the financial year 2000-2001.
Case Study 2 : Resource Allocation in the Tzaneen Local Area
For the financial year 1998/1999, the Tzaneen local area has been allocated an amount of R280000
per clinic, excluding the salaries of the health personnel. The costs of running the mobile units are also
to be covered by this amount. This local area has six mobiles covering 314 points (see Table 4 in
chapter 5). Although the Tzaneen sub-district is relatively well resourced when compared to the other
areas, the budget allocation is reportedly inadequate. The following problems have been articulated
about the allocated amount:
(i) No money for the repair of equipment
(ii) Not enough money to pay the South African Institute for Medical Research (SAIMR)
(iii) Not enough money for cleaning material
(iv) Printing of record cards is very expensive
Health and welfare workers have also expressed concerns about the inadequacy of the budget
allocated to the other 4 local areas.
4.2.
Transport Management
The transport situation varies in the district. In the Shiluvana and Julesburg local areas, two
health centres, namely Shiluvana and Julesburg share vehicles. These vehicles are used for
different purposes such as rendering mobile services, transporting staff within the district and
for meetings. A transport officer is responsible for regulating the use of these vehicles. They
are regularly maintained and serviced. However, it is reported that these vehicles do not meet
the needs of the two local areas. At Nkowankowa local area the current number of vehicles
is seen as adequate. However, there are no vehicles designed as mobile clinics, and this
becomes a problem when health campaigns have to be conducted. The Tzaneen local areas
reportedly experiences transport difficulties, and is in need of 4 vehicles designed as mobile
clinics. A comprehensive audit of the transport situation, health and welfare services in Halegratz
is essential.
4.3.
Drug and Vaccine supply
Drugs are budgeted for by the provincial government and supplied by the two district hospitals,
C.N. Phatudi and Van Velden. The two district hospitals, assist in controlling the drug stocks in
different clinics and health centres. Health facilities are usually adequately supplied with drugs.
There is a vehicle especially allocated for transportation of medication to clinics and health
12
centres. In 1997 two professional nurses and an assistant pharmacist, were sent on a course
on prescribing practices in Hammanskraal (Pretoria). On their return they conducted workshops
throughout the district focusing on appropriate prescribing practices and drug management.
Occasionally some facilities do report drug shortages. A situation analysis of drug supply and
drug management in the district would yield useful information.
A pharmacist at CN Phatudi Hospital (centre) assisting two matrons with the selection
of appropriate medication.
4.4.
Communication
There are great disparities with regard to the means of communication in the district. In the
Tzaneen and Nkowankowa sub-districts, almost all functional facilities have telephones and
radiophones. In Mugodeni-Grace local area, the opposite is true, as most of the health facilities
do not have automatic telephones, and their radio phones are often out of order. These
facilities have submitted telephone applications forms to Telkom.
With regard to the processes of communication, it is felt that some work needs to be done to
improve communication between the provincial and regional offices, and the district based
health workers. (See Case Study 3) Notification about meetings and feedback about requests
submitted to senior officials are some of the areas that are seen as requiring improvement.
13
Case Study 3 : Shiluvana Sub-district
In the pre-election era, Shiluvana hospital, then under the Gazankulu administration, was situated 3
kilometers from the C.N. Phatudi hospital, which was under the Lebowa administration. During a
rationalisation process in 1997, the profile of Shiluvana hospital was changed to that of a health
centre. Five government clinics were placed under its supervision, and the Shiluvana sub-district
came into being. C. N. Phatudi became one of the district hospitals. A contract was entered into with
Life Care to provide Frail Care Services for patients at Shiluvana health centre.
These changes reportedly affected the motivation of staff members at Shiluvana negatively. They became demoralized and demotivated, and requested transfers to other hospitals in large numbers. It
was felt that the regional and provincial offices provided little support to the managers handling the
transition at Shiluvana. The process of communication was ineffective. Communication between health
workers at Shiluvana and regional and provincial officials apparently started improving when the
efforts to establish the district health system started.
Health workers at Shiluvana believe that in future it would be beneficial for all parties if regional and
provincial managers could communicate with staff at local level should there be any changes that
would affect them. In fact, they believe that more work still needs to be done to improve processes of
communication in general.
The profile of the former Shiluvana Hospital has been changed to that of a health centre
4.5.
Health and Welfare Information
The methods of capturing health and welfare information in the district require attention. A
standard flow of information does not exist in the district. There is no standerdised statistical
reporting formal in place. Some forms used by the different previous health authorities are
still being utilised. At some health facilities, health workers collect information and send it
directly to the epidemiology section of the district hospital, where it is analysed. At other
health facilities, health workers collect information and submit it to the local area supervisor
(community matron) who analyses and collates it into a single report that she sends to the
epidemiology section of the hospital.
14
Feedback from the regional health and welfare office is sent to the local area supervisors. This
feedback takes the form of the annual regional report, E.P.I coverage reports, notifications and
reports on surveys conducted. Feedback is received mainly by the health service managers,
but does not reach all relevant health and welfare workers in the periphery.
The current epidemiology personnel at C.N.Phatudi and Letaba hospitals will be accommodated
on the district staff establishment. A district information officer will be responsible for
consolidating, analysing and sending information to the district office and providing feedback
to all levels.
4.6.
Human Resources in the Health Sector
Diverse staff complements exist across the district with different implications for service provision.
In local areas such as Mugodeni Grace, where the staff establishment permits it, health
services are rendered on a 24 hours basis. In local areas such as Nkowankowa, staff shortages
have necessitated that service time be reduced to 8 hours a day, instead of 24 hours.
In terms of the recruitment of health personnel, a moratorium has been placed by the provincial
health and welfare department on the filling of vacant posts. The only posts that can be filled
are those vacated by virtue of death, transfers, resignations and retirement of health personnel.
Health service managers must provide written motivations for the appointment of health
workers to these vacant posts. Another difficulty is the recruitment of staff to work in health
faculties situated in remote rural areas. This has resulted in several vacant posts in various
facilities remaining unfilled.
With regard to medical personnel, the primary health care facilities in two local areas, namely,
Nkowankowa and Tzaneen, are visited on a weekly basis by community doctors from the
C.N. Phatudi and Van Velden hospitals respectively. Primary health care facilities in the other
three local areas, Shiluvana, Julesburg and Mugodeni Grace, are not visited by community
doctors, but by final year medical students from the Department of Family Medicine at the
Medical University of Southern Africa (Medunsa). These students come to the Halegratz district
on a rotational basis, and stay for a period of 6 weeks. At any given point in time, there are
about 8 to12 medical students in the district, and they are evenly distributed amongst health
facilities in the three local areas. The family medicine students also take calls at the C.N.
Phatudi district hospital and the Letaba regional hospital.
15
Table 3:
Staff establishment in the Shiluvana Local Area as at April 1998
Shiluvana Sub-district
Category of
Health worker
Shiluvana H.C
Maake
clinic
Lenyenye
clinic
Mogoboya
clinic
Lephephane
clinic
Moime
clinic
Status of
posts
Status of
posts
Status of
posts
Status of
posts
Status of
posts
Status of
posts
Filled
Vacant
Filled
Vacant
Filled
Vacant
Filled
Vacant
Filled
Vacant
Filled
Vacant
Senior
Professional
nurse
3
2
0
1
1
0
0
1
1
0
0
1
Professional
Nurse
5
5
3
0
3
0
1
2
3
2
2
1
Senior
Enrolled
Nurse
2
0
0
0
2
0
0
0
0
0
0
0
Enrolled
Nurse
8
0
2
0
2
0
1
0
5
0
0
2
Enrolled
Nursing
Assistant
10
0
2
0
2
0
1
1
2
0
0
2
Total (n)
28
7
7
1
10
0
3
4
11
2
2
6
4.7.
Human Resource Development
In terms of human resource development, efforts are being made by the local area supervisors
to send enrolled nurses on bridging courses to upgrade their skills. Professional nurses are
also sent on various in-service training programmes (see table 4 overleaf). These efforts need
to be reinforced, and the skills of these workers further developed.
Courses should not be once off events but need to have built–in support mechanisms.
Furthermore, training courses should be evaluated to assess their impact on the practices of
the health workers.
16
Table 4:
Various courses attended by health workers in the Julesburg Sub-district
Course
No. of health workers undergoing training/attending course(s)
Julesburg
Health Centre
Carlota
Clinic
Jamela
Clinic
Tours
Clinic
Mogapeng
Clinic
Four Year Course
(General, Midwifery,
Psychiatry, Community)
1
2
2
2
0
Family Medicine
3
3
2
0
0
T.B. Course
2
2
1
0
0
Prescription
1
2
1
1
0
Neonatal Course
1
0
0
0
0
E.P.I In-service
0
1
1
1
1
Pediatrics Course
1
0
0
0
0
Advanced Midwifery
1
0
0
0
0
Orientation to T.O.P
0
0
0
0
0
Perceptor course
0
0
1
0
0
Genetics
1
0
0
0
0
11
10
8
4
1
Essential Drug
Total
Source:
Courtesy of Matron E.Z. Mtebule, Julesburg Sub-district supervisor
17
Chapter 5
The Public Health Sector
5.1.
Facilities
5.1.1
Hospitals
There are two district hospitals and one regional hospital in the Halegratz district. These are
Dr. C.N. Phatudi and Van Velden hospitals (district) and Letaba hospital (regional).
Dr. C.N. Phatudi Hospital
This hospital is situated on the northern-south of Tzaneen town, about +-20km from the
Letaba regional hospital. The hospital was activated on the 01 September 1990. Dr. C.N. Phatudi
hospital amalgamated with Shiluvana hospital in 1995.
Dr. C.N. Phatudi hospital is the “mother hospital” for three health centres, Nkowankowa,
Julesburg and Shiluvana. Furthermore, a total of 15 clinics in the Halegratz District fall under
this hospital (see Figure 2). The hospital also has four (4) mobile teams rendering health
services in remote areas.
Matron M.S. Mabitsela, Assistant Director, Nursing Services at CN Phatudi Hospital
outside the reception area of the hospital
18
Physical Layout
Dr. C.N. Phatudi hospital has a capacity of 200 acute beds, an out-patient department and an
operating theatre. The distribution of hospital beds is shown in table 5:
Table 5:
Distribution of hospital beds at Dr. C.N. Phatudi Hospital
Maternity Ward
40
Paediatric Ward
40
Male Surgical
40
Male Medical
40
Female Ward
40
Total
200
Human Resources
Table 6 below shows the distribution of human resources in the medical, nursing and
administration sections at Dr. C.N. Phatudi hospital. These are filled posts.
Table 6
Medical Section
Category
Medical Superintendent
Medical Officer Principal
Medical Officer
Part-time medical officer
Pharmacist
Medical Technologist
Radiographer
Dental Therapist
Speech Therapy and
Audioogy
Nursing Section
No.
1
1
2
5
1
1
1
1
1
Administration Section
Category
No.
Category
No.
Ass. Dir. Nurs. Services
Chief Prof. Nurse
Sen. Prof. Nurse
Prof. Nurses
Enrolled nurses
Enrolled Nursing
Assistants
General assistants
1
2
5
46
86
31
Sen. Admin. Officer
Admin. Officer
Chief Admin. Clerk
Admin. Clerk
Typist
Security
Porter
Housemother
Food Service Manager
Food Service Aid
Laundry Supervisor
Linen Supervisor
Seamstress
Artisans
Tradesman
Drivers
Operators
Messengers
SASO
Labour Sewerage
General Assistants
1
1
2
9
2
6
3
2
1
16
1
1
2
6
2
2
2
1
12
1
11
32
Constraints
Some of the problems articulated by the nursing service management are: inadequate staffing,
insufficient budget, and overcrowding in the female ward. It is seen as essential to upgrade
this facility to have another female ward.
19
Van Velden Hospital
Van Velden Hospital, also refered to as the Tzaneen hospital, is situated in the vicinity of the
centre of Tzaneen town. It is the older of the two district hospitals, having been established in
1966. In the previous political dispensation, Van Velden hospital was under the jurisdiction of
the Transvaal Provincial Administration (TPA).
Van Velden hospital is the “mother hospital” for two local areas, Tzaneen and lately Mugodeni
Grace. Two fixed clinics and 6 mobile teams from the Tzaneen local area refer patients to Van
Velden. A recent development is that the Mugodeni Grace health centre, the fixed clinics in
this local area and the mobile teams will now refer patients to Van Velden.
Van Velden hospital in turn refers patients to the Letaba Regional Hospital, and in cases of
emergency requiring ICU, referrals are made directly to the Mankweng/Pietersburg Complex
(provincial hospital) or to Garankuwa hospital.
Physical Layout
Van Velden has a capacity of 50 beds, an outpatient department, an operating theatre and a
laboratory of the South Institute for Medical Research (SAIMR). Table 8 below shows the
distribution of beds at Van Velden hospital.
Table 7:
Distribution of hospital beds at Van Velden hospital
Ward
No. of Beds
Maternity Ward
10
General Ward
40
(16 Female beds
16 Male beds
8 Paediatric beds)
Total
50
Human Resources
The table below shows the distribution of human resources in the medical, nursing and
administration sections at Van Velden hospital. These are filled posts
Medical Section
Nursing Section
Administration Section
Category
No.
Category
No.
Category
No.
Full time doctors
Private Practitioners
4
20
Ass.Dir.Nurs.Services
Sen. Prof. Nurses
1
11
Sen. Admin. Officer
Chief Admin. Clerk
Admin. Clerks
1
2
10
1
1
1
Prof. Nurses
Enrolled Nurses
Sen. Nurs. Assist
Nursing Assistants
26
10
5
7
Typist
Cleaners
Groundsmen
1
18
12
(who refer and admit
their patients at Van Velden
hospital)
Opthamologist
Orthopedic surgeon
General surgeon
20
Public-Private Mix
There are a total of 20 private practitioners who use the facilities of Van Velden hospital for
their private patients. Of these, 16 are general practitioners and two are specialists, a gynecologist
and a pediatrician. Their practitioners refer and admit their patients at Van Velden hospital.
Matron Valerie Risenga,
Assistant Director Nursing
Services, seen here at her
office at Van Velden Hospital
Table 8:
Basic hospital statistics for the two district hospitals
Basic annual hospital
statistics for Jan - Dec 1997
C.N. Phatudi Hospital
Van Velden Hospital
200
50
2953
(including emergency visits)
1000
Ave. bed occupancy rate
92%
88.9%
Total no. of in-patient
admissions in the previous year
6270
4915
4
4
170
26
160
incl. Caeserian Sections
112
No. of beds
Average no. of OPD
visits per month
Number of full-time doctors
Number of full-time
professional nurses
Number of theater
operations per month
Sources: Matron M.S. Mabitsela, Ass. Dir, Nurs.Serv, C.N. Phatudi hospital; and
Matron S.C.P Nimb, sub-district supervisor, Tzaneen Sub-district
5.1.2. Clinics and Community Health Centres
In four local areas of the Halegratz district, namely Nkowankowa, Mugodeni Grace, Shiluvana
and Julesburg, the health facilities consist of one health centre, five clinics, and numerous
mobile points.
Most of the clinics in the Halegratz district do have basic infrastructure such as piped water,
electricity, Not all clinics have security fences. There is not an alternative source of power, and
in case of power failure candles are used. The clinics provide the core P.H.C. package consisting
of : Ante-natal care (ANC), Family Planning, STD and HIV programmes, Immunization
programmes, Psychiatric Services, Chronic Ailments, geriatric, School Services, Postnatal Care
and treatment of minor ailments.
21
In the Tzaneen sub-district, there is no health centre, and there are only three clinics. However,
there are far more mobile visiting points in this sub-district than in other sub-districts. This is
due to the fact that the catchment population of this sub-district are farm workers, who have
to be visited on their farms.
The Chief Community Liason Officers of local areas in Halegratz District.
From L - R, Matron NX Mgimeti of the Shiluvana local area, Matron P.M. Mahlatji of the
Nkowankowe local area, Matron E.Z Mtebule of the Julesburg local area, Matron S.C.P. Nimb of the Tzaneen
local area and Matron M.A. Masungwini (front) of the Mugodeni Grace local area.
5.2.
Referral System
There are clear guidelines for the referral systems. These state that patients that patients who
need observation are to be referred from the clinic to the health centre, while acute patients
are to be referred from both the clinics and health centres to the district hospitals. However,
these guidelines cannot always be strictly followed, and patients are at times referred directly
from the clinics or health centres to the Letaba regional hospital. Reasons for this include
patients’ wishes to be transferred to their preferred hospital, geographical access, that is,
some health facilities are situated closer to the regional hospital than to the district hospital.
The Nkowankowa health centre, for instance, is located only 7 kilometers from Letaba hospital,
and about 20 kilometers from C.N. Phatudi hospital.
Referral to the provincial hospitals is only through the regional hospital. Other difficulties
arising from the referral system is that there is often no feedback to the local facilities about
patients referred to the district and regional hospitals.
The mobile teams in Halegratz district provide comprehensive PHC services daily
22
Figure 2: Organization of Public Health Facilities in the Halegratz district
District Hospital
(C.N. Phatudi)
Regional Hospital
(Letaba)*
District Hospital
(Van Velden)
Julesburg health centre
Khujwane clinic
Nkowankowa health centre
Nyavana clinic
Mamitwa clinic
Mugodeni Grace health centre
6 mobiles covering 314 points
Spitzkop
Bus stop
Tzaneeen clinic
Tzaneen
Sub-district
Shiluvana health centre
Jamela clinic
Letsitele clinic
Ramotshinyadi clinic
Mugodeni Grace
Local Area
Lephephane
Carlota clinic
Dan clinic
Mokgwathi clinic
Nkowankowa
Local Area
Mogoboya clinic
Mogapeng clinic
Mariveni clinic
Julesburg
Local Area
Lenyenye clinic
Tours clinic
Shivuvana
Local Area
Maake clinic
Population: 80 000
Tzaneen local authority clinic
Ooghoek clinic
Population: 119 000
Mookgo/Makgope clinic
Mavelel clinic
Muhlava clinic
Population: 50 684
Zangoma Clinic (new)
Population: 93 699
Moime clinic
Population: 68 363
* Letaba Regional Hospital is not part of the Halegratz district, but is a referral hospital for the 2 district hospitals, CN Phatudi and Van Velden
23
Chapter 6
The Welfare Sector
6.1.
Organisation of Welfare Services in the Halegratz
district
Health and Welfare are two integral components of the same department in the Northern
Province. There are 16 welfare officers (social workers) for the entire district with a population
of 340 550 (see table 9). This gives a ratio of 1 social worker per 21 284 people. The problem
of an inadequate supply of social workers is common throughout the country, particularly in
provinces with large population sizes and limited resources. As one welfare officer puts it:
”The case load is high but the incentives are low”.
Table 9:
Human resources in the welfare sector in the Halegratz district
Haenertsbug/Letsitele/Gravelotte/Tzaneen (Halegratz) District
Local Areas
Resources
Human resources
(welfare fficers)
Mugodeni
Grace
4
Nkowankowa
Julesburg
4
Shiluvana
3
3
Source :
Courtesy of Mrs. Vicky Machimana and the Welfare Team
6.2.
Welfare Status and Welfare Problems
Tzaneen
2
Total
16
Due to the poor socio-economic status of the majority of the people of the Halegratz district,
welfare workers in the district spend a large proportion of their time implementing measures
to address poverty and the effects thereof. The welfare problems that are dealt with in the
Mugodeni-Grace sub-district, shown in Table 10, are also are characteristic of the rest of the
district.
24
Table 10: Welfare Problems in the Mugodeni-Grace Local Area – April 1998
Unemployment
Malnutrition
Backyard abortion
Teenage Pregnancy
Family disputes
Non-maintenance of children by legal or biological parents
Child Abuse
Mental illness
HIV and AIDS (e.g. AIDS orphans, etc.)
Various disabilities
Services to the aged
Source :
Courtesy of Mrs. Mary Nkuna, Chief Social Worker, Ritavi DCO
A variety of strategies and techniques are used by welfare officers to address these difficulties.
A brief selection of these measures is discussed in Case study 4.
Case Study 4: A Brief look at Measures used to Address a Selection of Welfare Problems
Poverty
Communities are encouraged to start self-help projects. These projects receive support from the
social development
Component of welfare (see Table 8), a care support grant of R100-00 per month has also been introduced to assist families that cannot make ends meet. Children from such families, who are under the
age of 7 years qualify for this grant.
Teenage Pregnancy
Teenagers who fall pregnant often face various difficulties of unplanned motherhood. With this concern in mind, a social worker based in the Shiluvana and Julesburg local areas initiated a youth group
at the Julesburg health centre. The aim of this was to provide a forum where youth issues would be
openly discussed and the youth empowered with life skills including the ability to resist peer pressure.
The Ithusheng Community Association, in conjunction with the Health Systems Development Unit (HSDU)
based at Tintswalo hospital, have reinforced these efforts by launching a fully fledged youth project at
the Julesburg health centre in April 1998.
Family Breakdown
This consumes most of the social workers’ time, and calls for the application of family therapy skills.
There is generally a caseload of 6 families per day for a social worker, which limits the amount of time
spent on other aspects of social work. Family breakdown leads to other problems such as non-payment of maintenance. A need has been identified to utilize other human resources available in the
community, e.g. ministers of religion in providing counselling to families. Another strategy being explored is to recruit volunteers to be trained by the Family and Marriage Association of South Africa
(FAMSA) and equipped with skills to save families at risk of breaking down.
25
Abused Children
On average, 14 abused children are seen by social workers every month. This includes sexually abused,
physically abused and neglected children. A common problem encountered by social worker is that
mothers of girls who have been sexually abused by their fathers are reluctant to be supportive to these
children. Due to the stigma attached to sexual abuse, and the fear of destabilizing the family, relatives
discourage most mothers from reporting cases. More services are needed in this area. The yearly
Child Protection Week, which aims to empower children to protect themselves against abusers, is
inadequate. Another problem has been the lack of a Child Protection Unit (CPU) in the South African
Police Services (SAPS) in the district. However, a CPU has been launched in the Tzaneen station of
SAPS as of August 1998.
Street Children
The problem of children roaming the streets, clad in rugs and begging was first noticed by the community of Tzaneen local area in 1993. The health and welfare department in the Tzaneen local area
was informed and it responded by launching a project that aimed to identify the children and bring
them together, investigate their problems and home circumstances through personal views, attend to
their health and social problems and rehabilitate and place them in their respective homes. It was
discovered that these children deserted their families for various reasons such as delinquency, desire
to escape from poverty and orphanhood, amongst others. The project that takes care of these children now has a total of 80 children ranging for 9 up to 18 years of age. While the department of health
and welfare makes efforts to meet the objectives set at the beginning of the project, lack of community
support has limited the success of the programme.
Source :
Courtesy of Mrs. K.M. Manyike , Professional Welfare Officer, Julesburg and Shiluvana Local
Areas; and Mr. C. Chuene, Professional Welfare Officers, Tzaneen Local Area.
It is noteworthy that these problems are very similar to the difficulties facing the health sector,
for instance, malnutrition stemming from poverty, teenage pregnancy, mental illness, abused
children, and this accentuates the need for collaboration between the health and welfare
sectors of the department.
6.2.1 Social Development
The social development component of the welfare sector seeks to strengthen the capacity of
communities to face the challenge of alleviating poverty. The social development initiative
provides capacity building to organizations, individuals and groups. The development of
infrastructure and income generation programmes is the other focus areas of the social
development initiative. Table 11 shows the various projects that receive support in terms of
the social development initiative.
26
Table 11: Resource allocation to various projects in the Halegratz District as at May 1998
Tzaneen TLC
Project
Greater Haenertsburg TLC
Letsitele/GravelotteTLC
Purpose
Purpose
Amount
Amount
Project
Project
Life Skills Training
in Ghavaza and
Burghersdorp
Purpose
R86 000
Brick making,
juice making,
hair salon
Amount
R35 000
Completion of
premises
R50 000
Young Women
Educational Group
R45 000
R5000
Mangweni
Training Centre
Thushanang
Community
Brickmaking
Money not used
according to
stipulated purpose
R50 000
Setting up of
communal garden
R70 000
R5000
To start a sewing
project and later
a creche
Sedan Communal
Garden
Bonn Communal
Garden
R5000
To start a
communal garden
Communal
Garden
Msiphani Crechee
R5000
To sustain the
Production of
fresh vegetables
reasonable
prices
Sewing Project
Hluvukani
Communal Garden
R6000
Setting up of
communal garden
R35 000
from the National
Department of
Welfare and
Population
Development
R10 000
Hitekani
Communal Garden
R10 000
Setting up of
communal garden
27
Unemployment
Development Forum
Tinghitsi Development Project
Ipopeng Sewing Club
Titireleni
R5000
Tsakani
Communal Garden
Courtesy of Mr. M.J. Mashele, Welfare Officer, Halegratz district
Source :
6.2.2. Resource Allocation to community-initiated creches
Table 12 (below) shows the allocation of resources by the welfare sector amongst different
crèches initiated by community members. Resource constraints make it difficult to subsidize
all registered crèches.
Table 12: Resource Allocation to different community crèches
Halegratz District
Sub-districts
Resource
allocation
MugodeniGrace
Nkowankowa
Julesburg
Shiluvana
Tzaneen
Total
Subsidized Creches
8
23
7
15
44
93
Registered Creches
Not subsidized
1
26
0
0
1
28
Source:
Courtesy of Mrs. Vicky Machimana and the Welfare Team
Itireleng Educare Day Centre, situated in Halegratz district, is one of the
creches not subsidized by the welfare sector
28
6.3.
Key programmes of the Social Security Sector
The Social Security sector has six key programmes namely:
1)
Old Age Pension
2)
War Veteran
3)
Disability Grants
4)
Maintenance Grants
5)
Foster Care Grants
6)
Care Dependency
7)
Child Care Grant
6.3.1 Assessment of the key social security programmes
T able 13 shows the allocation of resources to eligible people applying for grants in the 6 key
areas. According to the ReHMIS report of 1995, there are 48 495 people who are 65 years of
age and above in the Lowveld region. A total of 15508 pensioners received old age grants in
the Halegratz district in the financial year 1996-97. This constitutes 32% of the pensioners who
live in the Lowveld region. Without closely scrutinizing the criteria for the granting of pensions,
for instance, whether the lower age limit is 60 or 65 years, it appears that most pensioners in
the Halegratz are receiving old age grants. Children, however, who constitute the majority of
the district population, are not receiving much support in terms of maintenance, foster care
and care dependency grants (see table 13).
Table 13:
Allocation of social security grants
Halegratz District
Local Areas
Programme
Mugodeni-Grace
and Nkowankowa
Local Area
Shiluvana and
Julesburg
Local Area
Tzaneen
Local Area
Total
No. of recipients
No. of recipients
No. of recipients
No. of recipients
6145
8262
1101
15508
25
15
1
41
Disability Grant
281
663
717
1661
Maintenance
270
206
68
544
Foster Care
61
6
8
75
Care Dependency
9
2
5
16
6791
9154
1900
17845
Old Age
War Veteran
Total
Source:
Courtesy of Mrs. Vicky Machimana and the Welfare Team
29
Chapter 7
Other Health and Welfare Providers
7.1.
Private Sector
There are about 7 industrial and 2 private clinics in the Halegratz district, most of which are
based in the Tzaneen local area i.e. Tzaneen local area. Some of the industrial clinics are
Mondi Timbers, Northern Timbers, Letaba Estates, Sapekoei, Middelkop, and Grenskop. The
employers carry the medical costs for patients using industrial clinics, while private clinics
cater mainly for patients who are on medical aid. There are also about 33 general practitioners
in this district. Like the private and industrial clinics, most of them are located in the Tzaneen
area, and few in the townships and villages. The average rate of consultation is R70-00, with
medication.
7.2.
Traditional Sector
In Nkowankowa sub-district alone, there are 190 traditional healers registered with the NorthEastern Traditional Healers Association (NETTHA). In the Shiluvana and Julesburg sub-districts
combined, there are a total of 204 traditional healers, belonging to an organization known as
the African National Traditional Healers Association (ANATHA). It is believed that most community
members consult traditional healers. However, a community survey conducted by the Ithusheng
Community Association (ICA ) in 1998 found that people were generally reticent to divulge
whether they were consulting traditional healers and, or faith healers.
7.3.
NGO Sector
There are numerous NGO’s working in the Halegratz district. Two NGO’s, Lesedi and Bulamahlo,
based in Shiluvana sub-district, provide literacy and child care programmes. Golang-Kulani,
located in Tzaneen sub-district, provides training for child-care workers. Thushanang, also
situated in Tzaneen focuses on self-help skills and income generation projects. Hlanganani,
based in Nkowankowa sub-district, facilitates community development projects.
Another important NGO in the Halegratz district is CHOICE, situated near Letsitele Valley. This
Organisation offers a wide range of health services such as : Childbirth Preparation Classes,
Childbirth Exercise Classes, Post-natal Services, Breastfeeding Counseling, Sibling Sessions,
Introductory Prenatal Sessions, Fatherhood Classes, Follow-up visits, Immunizations, Well-baby
Clinic, Domestic Workers Courses, First Aid Training and AIDS Education.
One of the oldest NGO’s in the district is the Ithusheng Community Association (ICA) which
provides a variety of community services in the areas of health care and community
development (see Case Study 5).
30
Case Study 5 : Ithusheng Community Association (ICA)
Ithusheng Community Association (ICA), situated in Lenyenye in the Shiluvana sub-district, is one of
the oldest and prominent NGO’s in the Halegratz district. Dr. Mamphele Ramphele, now Vice-Chancellor
at the University of Cape Town, originally founded it in 1979. The focus of the ICA has always been on
health and community development, viewing the two as intricately linked and inseparable. Ithusheng
has grown and expanded over the years, and currently has the following programmes: health services,
facilitation of the establishment of child care centres, training of child care workers, adult literacy
programmes, and self-help projects. The ICA is an important interface between the health services and
the community. Health services are rendered in a down-to-earth and flexible manner, in a homely
environment. It is well positioned to facilitate community involvement in health care.
A village health worker (VHW) programme has been conducted at ICA since 1983. A total of 134 VHW’s
have been trained to date. They are rendering health and community development services in the
Halegratz district, such as home visits, designing of VIP toilets and mudstoves. The critical role of
community-based health workers, VHW’s or community health workers (CHW) is widely acknowledged
in the district. As one community matron puts it, “they are still a link between the clinics and our
communities as they communicate whatever problems they encounter (in the community) and refer
where necessary”.
The recognition of the ICA extends beyond the borders of South Africa. In 1995, the current director of
health services at Ithusheng, Mrs. Mankuba Ramalepe, won the Nelson Mandela Award for Health and
Human Rights, endowed by the USA-based Kaiser Family foundation, for her unwavering commitment
to uplifting the health status and social development of her community. In 1997, the literacy programme
at ICA won the Provincial ABET award for being the best literacy programme.
In 1998, the ICA was commissioned by the Initiative for sub-district Support (ISDS) of the Health Systems Trust to conduct a community survey in the Halegratz district, looking at the community’s perception of the health and welfare services provided in the district. This was part of the situation analysis being conducted by health and welfare workers and the ISDS in the district. The findings of this
survey are discussed in a document entitled Community Perceptions of Health and Welfare Services
rendered in the Halegratz District, compiled by Mankuba Ramalepe and Jakes Rawlinson.
A fieldworker interviewing a community member during the survey of community
perception of health & welfare services in Halegratz district
31
Table 14: Summary of health services rendered at the Ithusheng Health Centre
(a project of the ICA) in the period 1992-97
1992
1993
1994
1995
1996
1997
Immunization
3 769
4 010
6 753
2 182
5 090
3 379
Family Planning
5 978
7 423
8 648
2 049
6 643
4 955
Minor Ailments
4 310
4 644
8 854
3 792
2 502
2389
Health Education
4299
4673
5073
5213
5404
6601
Referral to other
health services
-
57
294
34
256
184
18 356
20 807
29 622
13 270
19 895
17 508
Total
Source:
Courtesy of Mrs. M. Ramalepe, Director of Health Services, Ithusheng Community Association
32
Chapter 8
Assessment of Key Health Programmes
8.1.
Maternal and Reproductive Health Services
According to the 1996-97 Annual Report for the Lowveld region, there were 2408 deliveries
conducted at C.N. Phatudi hospital, 1266 deliveries at Van Velden hospital, 1441 deliveries at
Shiluvana hospital (before its conversion to a health centre in 1997). Thus a total of 5115
deliveries took place at the hospital. Very few deliveries, by contrasts, were conducted in the
primary health facilities in the local areas. For instance, only 162 deliveries were conducted in
the 5 health facilities in the Shiluvana sub-district in 1997. No deliveries were conducted in the
primary health facilities in the Tzaneen local areas, with 3 clinics and 314 mobile points.
According to the 1996-97 Annual Report of the Lowveld region, information about the maternal
mortality rate at the C.N. Phatudi hospital is not available. At Van Velden hospital, a maternal
mortality of 0:1000 was recorded in the period 1996-97. At Shiluvana hospital, a maternal
mortality rate of 1.3:100 000 was recorded for the same period. It is assumed that 20% of the
deliveries take place at home, conducted by traditional birth attendants.
There is limited data of stillbirths, Caesarian sections, and early neonatal deaths in the district.
A situation analysis of maternal and reproductive health services in Halegratz is essential as it
could shed light on the performance of these services.
8.2.
Child Health and E.P. I.
The 1996 ReHMis report states that the data on immunization were not reliable enough to
facilitate analysis. However, the 1996-97 Annual Report of the Lowveld region presents the
following coverage figures for immunization campaigns conducted in the Halegratz district
(see Table 15).
Table 15: Immunization coverage in the Halegratz district : May-June 1997 Campaign
District
Haenertsbug/
Polio
Measles
First Round
Second Round
Measles
9/12-5 years
Measles
5-15 years
84%
67%
83%
82%
Tzaneen/
Letsitele/
Gravelotte
Source:
Courtesy of Mrs Soekie van der Westhuizen, Lowveld regional Office
33
8.3.
School Health Services
School health services are rendered by clinic nurses from the health facilities situated in close
proximity to the school. The nurses visit those schools, and involve teachers as much as
possible, for instance, in the weighing of children. In most of the local areas of Halegratz, the
school health services are integrated into the mobile health services, and are rendered
throughout the year. Transport problems and shortage of personnel impact negatively on the
delivery of these services.
8.4.
Nutrition and Growth Monitoring
Malnutrition is one of the leading problems in the Halegratz district. This is mainly related to
the adverse socio-economic situation. Nutrition thus falls within the top priority list of the
Reconstruction and Development Pogrammes in the province
8.4.1. Personnel
In terms of personnel for nutrition services, one (1) dietitian post exists at Van Velden District
Hospital. Another dietitian is employed at Letaba hospital. Although this is a regional hospital,
the dietitian still serves the Halegratz district. A total of 10 Specialized Auxillary Service Officers
(SASO’s) have been redeployed to the local service areas. They are evenly spread across the
district, as each of the 5 local areas of the district has two SASO’s.
8.4.2. Services Rendered
8.4.2.1 Health Facility Based Nutrition Programmes
These consist of two components. The first component falls within the Primary Health Care
System and it addresses the following problems:
(i)
Undernutrition and Obesity
(ii)
Macronutrient deficiencies
-
Vitamin A Supplementation
-
Iron and folate supplementation iodine
-
Addressing iodine deficiency disorders through
fortification of salt
The second component is therapeutic dietetics based mainly within the hospitals but also in
the community. This also includes food services to patients and staff in the hospitals.
34
The problems that are commonly seen are :
Undernutrition
Overnutrition
Hypertension
Diabetes
Constipation
Gastritis
Peptic Ulcers
Iron deficiency anemia
TB
8.4.2.2.Community Based Nutrition Programmes
These consist of :
(i) Projects aimed at alleviating hunger and poverty through income
generation and food distribution. Presently 23 villages are funded
(ii) Primary School Nutrition Programmes. Currently 173 schools in the
Lowveld region are participating in the programme and this benefits
75 871 children.
8.4.3. PEM Scheme
This is a food supplementation programme operating through clinics and health centres. It is
aimed at vulnerable groups. Growth monitoring for children under six accompanies this scheme.
This intention is that supplementation should be accompanied by nutrition education. This
should also be consolidated into an Integrated Nutrition Programme.
A nutritionist giving nutrition education to women at Tzaneen Clinic
35
8.4.4. Nutrition Advocacy and Promotion
Advocacy and promotion activities are undertaken during Nutrition Awareness Week.
These entail :
•
Breastfeeding awareness campaigns
•
Diabetes Awareness Week
•
World Food Day is observed in conjunction with the Department of Agriculture
•
Radio talks aimed at providing reliable information on nutrition issues
•
Talks to groups and individuals on nutrition issues
8.5.
STD’s/HIV
STD’s and HIV are increasingly becoming a major threat to the community of the Halegratz
district. For instance, in 1997, a total of 2576 patients were treated for these conditions in the
Shiluvana sub-district, with a total of 68 363 residents, representing 3, 8% of the total
population, and an even higher proportion of young people. It is not known how many of
the patients with STD are successfully treated. Diagnosis of these conditions is done through
history taking and sending samples to the laboratory for testing. People with HIV/AIDS receive
counseling.
Management of these conditions is by means of a standard protocol for the treatment of
STD’s, including health education. HIV/AIDS awareness programmes are conducted every
year, and condoms are distributed.
8.6.
Tuberculosis
TB is one of the major health problems facing communities in the Halegratz district. Efforts are
also underway to address this problem. The Halegratz district has been declared a pilot
Demonstration and Training District (DTD) for the management of TB by the provincial
government. Ms. Colleen Jackson has been assigned the task of ‘district TB coordinator’.
Courses have been conducted with clinic nurses, who are now able to diagnose patients,
notify accordingly and treat effectively. After each new diagnosis, a notification form is completed.
On a monthly basis, notification forms are sent to the epidemiology and information section
of the district hospital. In order to enhance compliance, each TB patient is allowed to choose
a supervisor, who may be a nurse or a community member. The chosen supervisor closely
monitors and ensures that the patient takes the treatment. This treatment method needs to
be formally evaluated.
The South African Institute for Medical Research (SAIMR) runs laboratory services at Van Velden
Hospital. This institute has proven very helpful to the health facilities in the Tzaneen local
area with regard to the diagnosis of TB. For instance, when TB sputa are sent to the SAIMR,
results become available within 1-2 days.
8.7.
Environmental Health
Environmental officers are not evenly distributed throughout the Halegratz district, and access
to them is difficult. The local areas have on average two malaria teams. The Tzaneen local
area has a relatively easy access to the National Institute for Tropical Diseases, based in
36
Tzaneen. This institute provides free malaria smears to the community and training to health
workers. In general, there is a healthy working relationship and collaboration between the
environmental health officers and health workers in the local areas.
The ReHMIS report for 1996 points out that the numbers of environmental health officers and
their support staff in the Northern Province is severely inadequate and limits their capacity to
carry out their responsibilities in this area where basic infrastructure related to water and
sanitation is lacking. This holds true for the Halegratz district. The ReHMIS report recommends
that suitable and objective indicators for human resource planning in environmental health
be developed. It also recommends that suitable objective indicators and surveillance for of
environmental health in general should be developed.
8.8.
Oral Health
These services are not rendered at the local health facilities at sub-district level, but are provided
at the district hospitals. This is due to the limitations in human resources, in this instance the
absence of dentists, dental therapists or oral hygienists, nurses often take it upon themselves
to teach communities about oral health
8.9.
Mental Health
In most of the clinics and health centres across the district, there are nurses trained in
Psychiatry. Clinics and health centres see patients discharged from the hospital. The treatment
of these patients still involves repeating and adjusting medication. In a few clinics, psychiatric
services are integrated into primary health care, and patients receive their treatment throughout
the month. In most situations, a group of psychiatric patients visits the health facility on the
same day to receive their treatment. There is only one clinical psychologist available at Letaba
regional hospital.
8.10. Rehabilitation and Disability Services
Occupational therapy and Physiotherapy services are still hospital based. Patients in need of
these services are referred to the hospital.
8.11. Chronic Diseases
Chronic diseases are monitored at primary level on a monthly basis, particularly asthma and
hypertension. These conditions are referred to the secondary level of treatment every three
months to examine them, or in case of emergency. Diabetic patients are seen and examine
at primary level every month, and may visit the clinic as the need arises.
37
Table 16: Community Services Rendered in primary health facilities across the Halegratz district in
the financial year 1996-97*
Services Rendered
No. of patients seen
Ante-natal
12 261
Deliveries done
2023
(excludes deliveries at hospitals)
Post-natal services done
1520
Immunization done
63772
Condoms distributed
253992
Injections given (F/P)
80634
Oral contraception given (F/P)
20355
Minor Ailments done
204510
Chronic disease
8020
Geriatric patients seen
4342
Psychiatric patients seen
612
Tuberculosis
134
Genetics
-
Laboratory samples
2205
Occupational/Physiotherapy
Source:
·
60
Opthalmic
897
Home visits done
8011
Health Education
3043
Mrs Soekie van der Westhuizen, Lowveld Regional Office
This data has not been analyzed in terms of local areas (sub-districts). Variations between local areas
are bound to occur. For instance, facilities that expressed concern about their staff establishment, and
facilities that do not have community health workers, must have contributed very little to the figure of
8011 home visits for 1996-97.
38
Chapter 9
Other Sectors which impact on health and welfare
Sectors that impact on health and welfare in the Halegratz district are Safety and Security,
Education, Correctional Services, Agriculture, Water Affairs and Forestry and Home Affairs.
9.1.
Safety and Security
The South African Police Services (SAPS) are also actively involved in health issues. At Lephephane
Clinic, in the Shiluvana sub-district, there is a satellite station of SAPS on the premises of the
clinic. It is known as Ritavi police station. Members of SAPS assist health workers a great deal.
They assist by providing security, providing transport during emergencies, and by assisting
when the means of communication at the clinic is malfunctioning. At Nkowankowa local
area, members of SAPS assist with, among others, the handling of violent psychiatric patients
9.2.
Education
As already pointed out, the main area of collaboration between the health and education
sectors is the school health services. Another point of convergence of the two sectors is the
immunization campaigns conducted at the schools.
9.3.
Correctional Services
Health workers from Shiluvana local area visit the Maake Police Station, situated in the same
local area, at least twice a month. The purpose of these visits is to screen prisoners with
health problems or physical complains and offers them the relevant treatment.
9.4.
Agriculture
Agricultural officers are involved to varying degrees in the sub-districts. Their roles range form
non-existent to very active. In the local area, for instance, negotiations are underway for
agricultural officers to play an important role in the establishment of communal gardens. In
Nkowankowa sub-district, they are anonymous.
9.5.
Water Affairs and Forestry
At provincial level, the Department of Water Affairs and Forestry in the Northern Province is
currently conducting a water supply and sanitation study which is aimed at planning water
supply and sanitation to all communities in the province. This initiative is a joint with the
National department of Water Affairs and Forestry as part of the Reconstruction and
Development Programme (RDP).
When completed, this initiative will have a significant impact on health and welfare status in
the province, including the Halegratz district.
9.6.
Home Affairs
The national Department of Home Affairs and Welfare have started an initiative to improve
the registration of births and deaths at health facility level. Personnel at clinics, health centres,
and hospitals complete the “notice of birth” forms which are collected by officials from the
Department of Home Affairs. These officials then return to the health facilities at a later stage
to deliver the birth certificates. The health personnel then deliver the birth certificates to the
mothers of the newly born babies.
39
Chapter 10
Summary of Key Health and Welfare Problems
and Conclusions
From the perspective of the health workers, the key health problems facing the Halegratz
district are : Diarrhoea related conditions, Teenage Pregnancy, Backyard Abortion, STD’s and
AIDS, Malnutrition, Mental Illness and Disability. Table 17 presents a summary of the efforts
that have been undertaken to address these challenges, and interventions that are still
required.
From the perspective of welfare workers, Poverty, Family Breakdown, Child Abuse and nonmaintenance of children are major difficulties facing the welfare sector. In the long-term,
however, the socio-economic status of the people of the district holds the key to their health
and welfare. The disease profile and social well being of the Halegratz district will change
fundamentally when the living conditions of the people are improved. All sectors thus have
to contribute to community development and social upliftment.
Factors that impact on the delivery of health and welfare services in the district are poor
information, and poor communication between health and welfare workers and managers
of services at various levels. There is a lack of information, for instance, about key health
indicators for maternal child health such as stillbirths, Caesarian sections, and neonatal deaths.
The development of the District Information System is essential. In the welfare sector,, limited
resources still affect the capacity of the sector to provide support to all eligible individuals and
organizations. Not all registered creches are subsidized by the government. Not all eligible
income generation projects are being funded.
Another consequence of the previous separate administrations is inter alia, the lack of a
standard policy for the training of health and welfare workers. The criteria for the selection of
applications for various training courses and programmes must be developed.
Logistical problems still encountered in both the health and welfare sectors are staff shortages,
few vehicles, and lack of alternative sources of electricity, amongst others.
In the light of the fact that the health and welfare workers of Halegratz district emarate from
different previous administration, it is important that a common identity and a sense of
identity is developed.
These are the challenges facing the incoming district health and welfare management team,
health workers, welfare workers, sub-district supervisors, the community and the ISDS in the
Halegratz district.
40
Table 17: Summary of major health problems in the Halegratz district and efforts to address them
Health Problem
Identified
Lack of accurate health information
Malnutrition
Training and placement at each
clinic of a nurse with skills in
TB diagnosis and management
Short term P.E.M Scheme
district health information system
(DHIS) commission
Measures undertaken
to address it
Improvements in patients
compliance
Early diagnosis and treatment of
TB cases
Intervention still being monitored
Implementation
of a DHIS
Outcome
Improvement of family
planning services
Health education aimed at
reinforcing compliance
Health education aimed at
prevention of TB
Integrated nutrition Programme (INP)
Recommendations of the commission
will inform the setting up of DHIS
Further Interventions
required
Close supervision of TB
treatment by health workers
e.g. VHW
No major Improvement
No major improvement
More workshops to try to reach a
compromise with health workers
opposed to TOPs
Difficult. Legislation says health
workers have a right to refuse to
perform TOPs.
Health Education
Health Education
No improvement. Resistance on
the part of some health workers and
fear on the part of most health workers
On return, the two professional
nurses conducted workshops with
nurses in clinics and health centres
focusing on appropriate prescribing
practices
Health workers made aware that
legislation allows performance of
TOP=s. A course was started to
teach health workers the procedure
Two professional nurses and assistant
pharmacists sent by the regional office
to a course on effective drug
management in Hamanskraal in 1997
Improvements in prescribing
practicies and drug management
41
TB
Teenage Pregnancy
STDs
Back yard Abortions
Prescribing practices
Introduction of the Essential Drugs
List in the health facilities
* Measures implemented by the Regional and Provincial Offices of the Department of Health and Welfare
Northern Province
Chapter 11
Taking Action to Improve the situation
Following the completion of the situation analysis of the Halegratz district, the district health
and welfare workers came together to formulate ways of addressing the problems identified
during the situation analysis. Several workshops were held in which crucial steps were taken
such as developing a District Health and Welfare Plan and a Communication Strategy for the
district.
11.1.
Developing a District Health and Welfare Plan
Strategies
❖
Conduct a situation analysis of the health and welfare district
❖
Identify key areas for priority intervention
❖
Design appropriate interventions
Action Taken
❖
Documentation of the health and welfare profile of the district
❖
Workshop held on 05-06 August 1998 to identify priority health and welfare needs and
to formulate appropriate strategies for intervention.
Successes/Achievements
❖
Publication of a situation analysis
❖
Identification of certain health and welfare priorities in the district
❖
Compilation of a guiding document entitled :”Developing a District Health and Welfare
Plan and a Communication Strategy for the Halegratz District”
Looking Ahead
The appointment of the District Health and Welfare Management Team (DH&WMT)of the
Halegratz district is imminent. Future activities will include strengthening the DH&WMT as it
assumes its management responsibilities, and formation of tasks teams by the DH&WMT to
seek ways of addressing the key priority areas of the district
The key challenge for the DH&WMT is the reality of the limited resources for health and
welfare in the Northern Province and the understanding that this situation is not about to be
immediately redressed. The issue is how best to use limited resources at the district’s disposal
and unearthing creative ways of mobilizing support from other sources.
42
11.2.
Improving Communication
Poor communication, both in terms of the means and processes of communication, was
identified as a key problem in the Halegratz district. The lack of the means of communication
(e.g. lack of telephones and malfunctioning radio phones) and a one-way top-down process
of communication have necessitated that more attention be paid to communication.
Strategies
❖
Develop an appropriate protocol for the district management team and
other role players.
❖
Help improve the means of telecommunication of the district
Action Taken
❖
Workshop held on 05-06 August 1998 to develop a communication policy for the district
❖
Presentation by Telkom representatives at the workshop and introduction of relevant
Telkom contact people (local area and district managers) to the district health and welfare
workers
Achievements
❖
Draft communication protocol developed
❖
Channels of communication opened between Telkom and local health and welfare
workers
❖
Compilation of a guiding document entitled :”Developing a District Health and Welfare
Plan and a Communication Strategy for the Halegratz District”
Looking Ahead
Future activities will include: continuous situation analysis of the means of communication in
the district, continuing the negotiations with Telkom to ensure speedy installation of telephones
in the district health facilities, installation of e-mail in the district office and training of local
health and welfare personnel to support the use of computers and e-mail.
Health and Welfare workers of Halegratz district, Lowveld region and Provincial Department of Health,
with members of the DHWA during the “Communication and District Health and Welfare Plan”
Workshop at Eiland Resort Northern Province
43
11.3.
Lessons from other districts?
The implementation of the district health system (DHS) is a learning process for all those
involved in it, as this system never existed in South Africa before. If district health and welfare
management’s teams are to be involved in making this novelty a reality, they need to be
exposed to developments towards the DH&WS in other parts of the country, particularly where
tangible progress has been made. This would be an enlightening experience of the DHS at
work, and would provide them with the inspiration and motivation to render services differently,
within the DHS framework.
Strategies
❖
Encourage exchange visits between district management team from different ISDS sites
❖
Focus the visits on practical problems experienced in both districts, rather than on general
discussions about the DHS
❖
Identify participants in the exchange visits very carefully, and include only strategic and
influential people who will use their experience of the visits to effect positive changes
in their districts on their return
Actions taken to date
❖
Exposure visit organized by key health and welfare workers (local area supervisors) and
members of the transitional local councils (TLC’s) in the Halegratz district and the ISDS
facilitator to the Impendle/Pholela/Underberg District, KwaZulu-Natal in May 1998.
Achievements
❖
Documentation by the Halegratz health and welfare workers of their experiences of
the visit to the IPU, detailing in practical terms the gains made from such visits and
recommendations for both districts.
Health and Welfare workers and members of the DH&WA of the Halegratz district and health workers
from IPU district at Gomane Clinic in IPU KwaZulu-Natal during the visit by the Halegratz team.
44
❖
Maintenance of the links between the Halegratz health and welfare workers and the
IPU health workers
Looking ahead
The gains made from such exchange visits should be reviewed from time to time, and if
tangible evidence of their positive impact is found, they should be encouraged. Different
ISDS sites have been declared best practice sites sites for various areas of intervention. If the
exchange visits provide evidence that health and welfare workers do learn from one another,
and do implement the lessons learnt, then more visits to these best practice sites should be
undertaken.
45
References
Health Care in the Northern Province : Implications for Planning, ReHMIS Report,
Published jointly by the Health Systems Trust and Department of Health in 1996
Introducing the Initiative for Sub-district Support : 1996
Published by the Health Systems Trust, 1996
McCoy, D (Ed) (1997) :
A Health and Health Care in Mount Frere, Technical Report 2C
Initiative for Sub- District Support,
Health Systems Trust
McCoy, D and Bamford, L (1998) :
How to conduct a rapid situation analysis - A guide for health districts in South Africa,
Initiative for Sub-District Support, Health Systems Trust
Nxumalo, Z and Donohue, S (1997) :
Action for Health in Tonga-Shongwe, Technical Report No 2E,
Initiative for Sub- district Support, Health Systems Trust
Report on an exposure visit to the Impendle/Pholela/Underberg (IPU) district,
compiled by the Health and Welfare Workers of the District
Van Der Westhuizen, S (1997)
Lowveld Region : Annual Report, For the Financial Year : 01 April 1996-31March 1997
46