Can the re-engineering of PHC and/ or the introduction of community paediatricians be the solution?
Article Type: Letter to the editor
Subject: Primary health care (Forecasts and trends)
Community health services (Forecasts and trends)
Pediatricians (Services)
Author: Bac, Martin
Pub Date: 11/01/2012
Publication: Name: South African Medical Journal Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 South African Medical Association ISSN: 0256-9574
Issue: Date: Nov, 2012 Source Volume: 102 Source Issue: 11
Topic: Event Code: 010 Forecasts, trends, outlooks; 360 Services information Computer Subject: Market trend/market analysis
Product: SIC Code: 8399 Social services, not elsewhere classified
Geographic: Geographic Scope: South Africa Geographic Code: 6SOUT South Africa
Accession Number: 308294354
Full Text: To the Editor: The recent article about the new paediatric sub-specialty to improve child health in South Africa quotes grim child health statistics to illustrate the need to look for new strategies to improve child health. (1) Can the re-engineering of primary healthcare (PHC) and/or the introduction of community paediatricians be the solution?

I would like to share my experience. We were also confronted with bad child health conditions and statistics, but achieved great improvement in one decade (Table 1). (2-4)

The improvement in maternal and child health was achieved by the vigorous implementation of PHC in the whole catchment area of the Gelukspan Community Hospital. The factors contributing to this achievement included a change from curative hospital-based medicine to PHC; a determined effort to reach every child and pregnant woman in the community; comprehensive and integrated approach by the health services as a whole and no fragmentation; building a health team with strong reliance on nurses and allied health workers; and re-allocation of staff and resources to community-based services so that all villages had a clinic or visits by a mobile clinic.

During this time a visit to the hospital by the late Professor John Hansen during his sabbatical had a profound impact on the development of the services as a result of his enthusiasm and encouragement. However, the work was done by the PHC team without any specialist doctors or nurses, and with involvement of the mothers as 'the most important health workers'.

A similar remarkable improvement in maternal and child health recently reported from India was achieved by a nurse-driven programme and strong focus on community involvement. (5) Maternal mortality decreased by 75% and infant mortality by nearly 50% to 43/1 000 within a few years.

The potential impact of the re-discovery and implementation of PHC is considerable, and there is no reason to delay starting. The involvement of (community) paediatricians can contribute to the process, but cannot substitute for a focused approach by the whole health team and the involvement of the community.

Martin Bac

Department of Family Medicine

University of Pretoria

(12.) Swingler G, Hendricks M, Hall D, et al. Can a new paediatric sub-speciality improve child health in South Africa? S Afr Med J 2012;102:738-739.

(13.) Bac M. Evaluation of child health services at the Gelukspan Community Hospital, Radithuso, Bophuthatswana, 1976-1084. S Afr Med J 1986;70:277-280.

(14.) Bac M. Progress towards Health for All in the Gelukspan Health Ward--1985. MD thesis, Medical University of Southern Africa, 1987.

(15.) Van Oord DJ. Fertility transition in a rural African community. MD thesis, Medical University of Southern Africa, 1996.

(16.) Alehagen SA, Finnstrom O, Hermansson GV, et al. Nurse-based antenatal and child health care in rural India, implementation and effects--an Indian-Swedish collaboration. Rural and Remote Health 2012;12:2140. (accessed 8 October 2012).

S Afr Med J 2012;102(11):815. DOI:10.7196/SAMJ.6368
Table 1. Health status indicators, Gelukspan Health Ward

Indicator                     1978         1985          1989

No. of children <5 years      9 000        13 500

Perinatal mortality rate      60/1 000     78/1 000      39/1 000

Infant mortality rate         >200/1 000   41/1 000      24/1 000

<5 mortality rate             105/1 000    17/1 000      6/1 000

No. of paediatric deaths in   144 *        63            33

No. of visits to UFC/child    <1/year      7/year

Total No. of visits to UFC    3 000        95 000        76 709

Home deliveries               75%          29%           15%

ANC visits                    2 077        15 375        19 679

Supervised deliveries         684          2 554         2 981

Maternal mortality rate       ?            180/100 000   50/100 000

Family planning visits        1 000                      17 746

Health care worker/           1/7 000      1/1 000

Doctor/population             1/30 000     1/10 000

Midwife/population            1/12 000     1/2 500

* In 1979.

UFC = under-5 clinic; ANC = antenatal clinic.
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