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© 2002 American Public Health Association
COMMUNITY-ORIENTED PRIMARY CARE |
The authors are with the School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
Correspondence: Requests for reprints should be sent to Stephen M. Tollman, MMed, MPH, MA, Health and Population Division, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Parktown, 2193 Johannesburg, South Africa (e-mail: tollmansm{at}sph.wits.ac.za).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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Community-oriented primary care (COPC) originated in South Africa during the 1940s and 1950s, where it served to inform local church-based and nongovernmental organization–based initiatives during the apartheid years. During the 1990s, COPC played an inspirational role in the process of national health policy formulation.
Yet COPC’s contribution to current health practice remains more symbolic than substantive. Despite a policy framework that favors the widespread introduction of COPC, various political, structural, managerial, and human resource obstacles constrain its effective implementation.
Notwithstanding a rapidly changing health care environment and well-established health transition from infections and nutritional disorders to non-communicable diseases and injury, COPC and its variants remain abidingly relevant to South Africa’s—and Africa’s—health care reality. (Am J Public Health. 2002;92:1725–1728)
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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ALTHOUGH THE COMMUNITY-ORIENTED primary care (COPC) approach has been influential in informing health policy and practice in South Africa, this contribution remains more symbolic than substantive. Since South Africa’s first free election in 1994, a committed national health leadership has struggled to realize the promise contained within a decentralized, primary health care–centered policy framework—a framework that is unusually well suited to COPC practice. Community-based health practice in many parts of South Africa remains poorly developed, and this lack of development has seriously constrained local health development, including that necessary to the practice of COPC.
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EARLY YEARS |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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Previous work has detailed the key elements of COPC as these evolved through the work of Sidney and Emily Kark and their colleagues at the Pholela Health Center.1,2 Previous work has also described the Pholela center’s embrace by the pre-1948 South African Ministry of Health—through the Gluckman Commission—which envisioned a network of health centers as the basis for a national health service.3 The Institute for Family and Community Health was established in the late 1940s at Natal University as the key institution to provide the training and research necessary to support the rapid growth in health centers being planned.4 Through the Institute and its affiliated health centers, a robust body of practice knowledge was built up that reflected the effectiveness of a COPC approach in a range of geographically and culturally diverse settings.4–6
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THE APARTHEID YEARS |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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During the 1950s, the Institute came under increasing state-sponsored political and financial pressure that progressively undermined its work. Such pressure culminated, by 1960, in the demise of the COPC movement in South Africa after most of its leading proponents had left the country.7
The period from the 1950s to the late 1980s were high apartheid years. Urban health development was characterized by publicly funded hospital construction accompanied by an expanding private sector, both skewed toward a privileged White minority. Rural health care was largely provided—at times effectively8—by networks of mission-sponsored hospital and clinic systems.9 Services remained strictly segregated according to presumed racial origin, and no effective national health system development took place. During the 1970s, as apartheid-style "independence" was granted to Bantustans or "homelands," management and control over health and other public sector services was assumed by the homeland authorities. Although poorly organized and managed, these services tended to be less fragmented than their urban counterparts.
The 1970s and 1980s saw the widespread emergence of small-scale health development projects that were largely based in churches or nongovernmental organizations (e.g., the Alexandra Health Center near Johannesburg10). Most were premised on high levels of community participation. State involvement was negligible, although a few of the projects received support from more enlightened municipal or homeland health administrations (e.g., the "care groups" of the Gazankulu Bantustan, which focused on infectious disease prevention and local community development11).
Growing awareness of the World Health Organization–UNICEF Declaration on Primary Health Care12 gave a powerful boost to these efforts and contributed, in the early 1980s, to the founding of the National Progressive Primary Health Care Network (NPPHCN). Initially funded by the Henry J. Kaiser Family Foundation, the NPPHCN was broad-based and national in scope. Led as much by activists as by health professionals, and explicitly aligned with the political opposition, the NPPHCN gave weight to previously atomized efforts. It provided a vehicle capable of mounting a meaningful challenge to state policies and a forum within which to debate the shape of a future national health system.
However, and notwithstanding the contributions of COPC to the ideas captured in the Alma Ata Declaration,13 the Pholela legacy and its influence in many other settings—in industrialized as well as developing countries—was little noted within the NPPHCN. Oriented toward "the urgent business of challenging apartheid in health," the NPPHCN did not focus on advocating a measurement-based foundation for evaluating the impact of health services (Eric Buch, MSc, FFCH; oral communication; August 14, 2002).
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MOVING FORWARD, LOOKING BACK |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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The late 1980s and early 1990s witnessed the rediscovery of what was arguably a golden age in South Africa’s blighted public health history.5
Nkosazana Zuma, some 2 years prior to her appointment as the country’s first democratic-era minister of health, spent 3 days visiting and meeting with Sidney and Emily Kark during their 1992 visit to South Africa. The same visit saw the Karks host a high-level delegation of the South African Nursing Council led by its influential former president, the late Charlotte Searle, architect of the organization and of the role of the nursing profession during the apartheid years. Their agenda was to examine the role of community health nurses in South Africa in an era of primary health care. This discussion was more than symbolic, as Sidney Kark himself defined obstructionism by the Nursing Council, then led by Searle, as a critical factor in the failure to have—based on the Pholela model—community-level health workers formally incorporated into the health care team (Sidney Kark, MD; oral communication; February, 1992).
Throughout the Karks’ visit, meetings and discussions were held across the country with health officials, public sector leaders, academics, and university administrators.14 These meetings elicited high levels of participation but, lacking continuing endorsement by the health service leadership (themselves preoccupied with structural "transformation" of the health sector), had little sustained impact.
Various research, practice, and development initiatives were introduced at this time that drew, to varying extents, on the Pholela experience. The Mamre Community Health Project, started in 1987, is a Medical Research Council–University of Cape Town effort involving a defined community of some 4600 people.15 Health status surveys have supported several intervention research initiatives undertaken in partnership with the local community. By contrast with COPC practice, however, these initiatives were not accompanied by an extension to adjacent communities, and primary care clinicians played only a limited role in introducing and continuing the interventions.
The Agincourt project, an established university–provincial initiative, lies some 500 km northeast of Johannesburg. In 1992, in part motivated by COPC experience of continuous population monitoring, a comprehensive health and demographic information system was introduced to the Agincourt subdistrict as part of an effort to pilot decentralized rural health systems.16 An agenda of programmatic and systemsoriented work contributed to district and subdistrict health services development in the Northern and Mpumalanga provinces.17,18 (In recent years, responding to an inadequate evidence base informing public sector decentralization, Agincourt work has reflected a stronger research orientation, focusing on the dramatic health and social transitions under way in rural Southern Africa.19)
Of signal importance was the development of the national health plan of the African National Congress.20 Breaking fundamentally with apartheid health policy, this plan established primary health care and the decentralized organization of services within a single Ministry of Health as central tenets of future health practice. The plan was generated in close consultation with the World Health Organization’s Division of Strengthening Health Services. The director of the division (which led preparations for the Alma Ata conference on primary health care in 1978) openly acknowledged the seminal contributions of Sidney Kark to local health service thinking and practice (Eleuther Tarimo, MD; oral communication; 1995).
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POST-1994: HIGH IDEALS, HARD REALITIES |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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Policy and Practice
South Africa’s decentralized, primary health care–oriented health policy—in common with district-based systems in Zambia, Tanzania, Ghana, and elsewhere in Africa—lends itself to the large-scale introduction of COPC approaches and derivatives. The small-area census studies that underpin such approaches are well suited to describing population structure and its distribution, analyzing patterns of health service coverage and use, evaluating access of marginalized communities and vulnerable groups, and more effectively targeting preventive and promotive health programs.21 The country is struggling, however, to translate progressive national policy into effective provincial and local practice.
There are many obstacles to achieving this goal, of which lack of managerial capacity and limited community-based experience are only a part. Senior managers, many of whom held positions in the old apartheid health service, have been slow in adjusting to the new reality; district and provincial staff remain excessively concerned with accountability to their administrative seniors. This creates difficulties for local health teams and can lead to disregard for community concerns.
After 1994, the Health Ministry moved faster and further than other government departments to devolve authority and responsibility to the local level. Yet the health districts delineated have proved an uneven geographic and administrative fit with the recently demarcated local government boundaries. In addition, the South African Constitution of 1996 makes "primary health services" a local government responsibility, while comprehensive health service provision is designated a provincial responsibility—further confusing lines of accountability. As efforts to institutionalize local government (the "third tier") gain speed, a preoccupation with organizational structure and authority is deflecting attention away from health services development and delivery. These challenges to implementation, difficult under any circumstances, have undermined the best intentions of a motivated but administratively inexperienced health leadership.
The prevailing policy environment has been heavily influenced by World Bank efforts to promote primary care packages and encourage public–private partnerships.22 Such approaches, while favoring narrowly focused disease-oriented programs, are nevertheless compatible with COPC practice, which emphasizes community-sensitive, cost-effective interventions to address established health priorities. An excessive focus on specific diseases could, however, distract attention from broader social priorities, such as adolescent health, domestic violence, and mental health problems.
Initiative for Subdistrict Support
Responding to sluggish and uneven implementation of policy, the Initiative for Subdistrict Support is a creative attempt to strengthen the heart of the district system, namely subdistricts and the health centers and clinic networks within them. The initiative was introduced in 1995–1996 as a nongovernmental organization–government partnership, strongly supported by the Kaiser Family Foundation and involving the Health Systems Trust. The initiative works with demonstration sites in all provinces to strengthen and accelerate their decentralization efforts. Being concerned with service delivery to geographically defined populations, the initiative holds elements in common with COPC practice. It nevertheless lacks a comparable concern with developing the populationwide information base that is necessary to inform interventions and evaluate program impacts.
Human Resources
South Africa’s nurse-based health system offers an unusual opportunity to evolve forms of nurse-led COPC practice. To date, however, it has proved difficult to combine well-tried, populationoriented approaches with traditional and persisting curative, individually oriented, facility-based practice. Partly in response to this difficulty, the National Committee on Health Human Resources has motivated the introduction of "midlevel workers" to extend the reach of predominantly nurse-based teams. It may be feasible for these midlevel workers, who are more qualified than community health workers, to take on the information gathering and health promotion roles previously played by "health recorders" in Pholela.2
In 1995, senior faculty of the Hebrew University–Hadassah School of Public Health were invited to present COPC workshops to local and provincial health staff as well as to academics of several universities. In 1999, with support from George Washington University and the Hebrew University, the National School of Public Health near Pretoria became the first South African school to formally introduce a "COPC track" into its master of public health program. While several course participants are local and regional public health managers, gauging their impact on service delivery is at this point premature.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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While the general influence of COPC on national health policy can be cogently argued, its translation into practice has been limited and patchy at best. The policy framework created has not, as yet, enabled the emergence of a functioning district health system able to draw effectively on health center practice as pioneered in Pholela and the Institute of Family and Community Health.
The health care environment in South and sub-Saharan Africa is undergoing rapid change. An evolving market orientation in public policy (reflected in an emphasis on cost-effectiveness, user fees, packages of care, and public–private partnerships) poses critical challenges to the public health sector; private-sector practitioners are increasingly evident (and competitive) in all settings, reinforcing the need for more effective functioning of the public sector; health transitions are well established, with noncommunicable diseases, accidents, and injuries juxtaposed against malnutrition and infectious disease.19 Critically, many of the medical and social consequences of HIV/AIDS will increasingly be apparent—and require response—at local and district levels.
There remains an abiding need to establish high-functioning research and development partnerships between government and universities and nongovernmental organizations. Their potential to inform good practice is, however, consistently undervalued. Local and district health development, informed by COPC experience, is well suited to such partnerships, which should be structured to maximize public-sector learning and to facilitate upscaling and extension. Experience elsewhere4 suggests that the "pure" form of COPC, with full expression of 5 "essential" elements,23 is unlikely to emerge and be maintained in the South African public sector. Nevertheless, core elements of COPC—the integrated application of clinical and public health practice, informed by local epidemiology and focused on defined communities—are abidingly relevant to the health care reality of South Africa and Africa as a whole.
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Footnotes |
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Peer Reviewed
Accepted for publication August 28, 2002.
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References |
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TOPABSTRACTINTRODUCTIONEARLY YEARSTHE APARTHEID YEARSMOVING FORWARD, LOOKING BACKPOST-1994: HIGH IDEALS, HARD...CONCLUSIONReferences |
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23. Abramson JH, Kark SL. Community oriented primary care: meaning and scope. In: Connor E, Mullan F, eds. Community Oriented Primary Care. Washington, DC: National Academy Press; 1982.
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