Final Report Clinic Management
Swaziland Primary Health Care Project USAlD Project No. 645-0220
Ministry of Health Kingdom of Swaziland
Management Sciences for Health Charles R. Drew University of Medicine and Science
Report prepared by: Dr. Marilyn A.E. Edmondson Clinic Management Associate
January 1991 Mbabane, Swaziland
BEST AVAILABLE COPY Paae ACKNOWLEDGEMENTS
EXECUTIVE SUMMARY
1. INTRODUCTION
2. BACKGROUND
2.1 Country Profile ...... 2 2.2 Health Sector ...... 4 2.3 Primary Health Care ...... 5
3. OVERVIEW OF CLINIC MANAGEMENT
4. CLINIC MANAGEHENT OUTPUTS
4.1 Improved Service Delivery and Output Approaches 4.1.1 Outreach Sites...... 9 4.1.2 Home Visits...... 12 4.1.3 Community Health Committees...... 22 4.1.4 Reference Manuals and Drug Management ....27 4.2 Improved Skills, Improved Conditions of Service, Improved Supervision
4.2.1 Training ...... 29 4.2.2 Upgrading of Nurses Accommodations...... 33 4.2.3 Clinic Supervision ...... 36 4.2.4 Supervisory Checklist...... @
5. DEBRIEFING
6 REFERENCES
BEST AVAILABLE COPY TABLE Page
1 . Regional Prolect-Assisted Outreach Sites...... 11
2 . TotaL and Fizr. 'ze 3f Home Visits by Reaion~...... 15 . 3 . Percent of (311~. ;zs Ehi:lng Home Vi~it~...... 16 4 . Active He&-:'. Zcm-ittees ...... 26 5 . Government. Klssion and Private Sector C1ir.l~~...... 37 6. Regional Clinics Supervisory Visits ...... 38 7. Frequency Distribution of Supervisory Visits ...... 39
BEST AVAILABLE COPY LIST OF FIGURES
Page
Home Vlsit~by Region
Hhzk,ho ...... 18 Manzini ...... 19 Shiseiweni ...... 20 Luhombo ...... 21
En-? Vi~lt~. Regional CompariEon ...... 22 8 23
S+~serv%seryVi~its by Region
Hhohho ...... 42 Ma-.-...,,..,...... - . 43 Shlselweni...... 44 Lubombo ...... 45
Supervisory Visits . Regional Comparison ...... 46 & 47
BEST AVAILABLE COPY APPENDICES
Xpp~nd:;: A Scope of Work
append;^ B Outreach Slteiz
Appendix C Lundzi Outreach Site-Speech and Newspaper Article
Appendlx D Survey Questionnaire
Ap?endlx E Clinlcs raking Home Visits
Appendlx F Active CI--2n:ty Health Committees
;rppendl>: G Clinls E~zel, -, r.aining-. Follow-up Form
Appendix H Treinee~- flir;c-Based Follow-up
Appendix I Nurses Accommodations Upgraded
Appendix J Supervisory Vi~its
Appendix K Supervisory Checklist
Appendix L Debriefing Agenda and Participant List
BEST AVAILABLE COPY ACKNOWLEDGEMENTS
Gratitude 1s expressed tc regionol public heslth matrons, clinic supervlsorE and nurses who acted a6 counterpart€ for the cllnic nanagemen: &ctivltie~. hppreilztion 1~ also extended to Robert Shongwe for his consultation on the renovation of nurse6 accommodation6; Erne~tMnisi for supplying home vls~tsand supervisory vi~itsdata and graphs: Fruit Phumie Llarn:~~icr typlng the report and Nozlpho Nxumalo for the report cover graphlcs.
-tr~try ;r.:c. tk.~. po~itionwas expedited by the lnvsluable as~istanceand cooperaylon of my colleagues on the Project: baniel Kraushaar, Vinz~r.: --c:-EI-:, Mary Kroeger and Albert Neill.
Speclal recognition is given to Jewel Bazilio and the rest of the staff at Drev dn:IJrrslty' International Health Institute for providing profes~ionaland personal field support.
Thanks is also extended to Dr. Margaret Price, my predecessor, for providing the brief, but thorough orientation to already implemented management interventions. Identified Clinic Hanagement documents and country resource personnel were helpful in establishing a baseline for continued project activities.
-v-
BESTAVAILABLE COPY EXECUTIVE SUMMARY
The Swaziland Primary Health Care Project (PHCP) was a cooperative agreement between the Government of Swaziland, Ministry of Health, ar.3 United States Agency for International Development. (USAID - Project No. 645-0220). Extending from April 1986 to June 30, 1991 the Project was implemented jointly by Management Sciences for Health (MSH) and Charles R. Drew University of Nedlcine and Sclence, (Drew) in support of Swaziland's National Health Policy (1983). The Project was dtis~~r.3~ to improve and expand the country's primary health care system emphasizing maternal child health and child spacing. The project's rldterm evaluation (September - October 1988) and subsequent Pro7ect Paper Amendment (May 1989), narrowed the project's original scope a?,= re-focused acitvities on the following regional and clinic level areas: Clinic-based and obtreach services; decentralization, ~L~?.SL-;, budgeting, financial management and health care financing; ar,d haaitr information system (HIS).
The clinic management associate was respon~iblefor the non-cl:nlczl aspects of clinic based services improvement, i.e. management s::ills, community development and outreach activities. (Project Paper Amendment, 1989). The current associate joined the project in its final year of implementation, therefore this report covers the ?cric? January 8 - December 31, 1990. The clinic management End of Project Status (EOPS) indicators are used to summarize the main accomplishments as presented below.
1. Improved Service Delivery and Outreach Approaches.
1.1 Outreach Sites
The outreach sites program was very successful in mobilizing communities to build structures for health activities. The intended project output of 49 sites was exceeded and a total of 84 structures received basic furnishings and equipment, such as salter scales/frames for weighing children and trunks for transporting supplies. Building materials for completing structures were also funded on a request basis.
1.2 Home Visits
Data from the Health Information System (HIS) show thzt 2,337 home visits were made nationwide in the ten month period January - October 1990. They were distributed regionally as follows: Hhohho - 855; Manzini - 556; Lubombo - 643 and Shiselweni - 253. Of the 90 clinics submitting data, 42 of them or 47% reported making home visits. It is not possible to tell whether or not this reaches the project's target cf a "40% increasew since no baseline was stated.
1.3 Community Health Committees
Community health committees are mechanisms for increasing grass-roots participation in planning, implementing and monitoring health acitvities. Results of a survey show that of 93 clinics reporting, 47 (51%) have active committees. On a regional or sub-regional basis, the percent of active committees ranged from 100% (Hhohho South) to 21% (Manzini Sub-Region).
BEST AVAILABLE COPY 1.4 Project - Produced Reference Hanual and Drug Management Systeu,.
The proportion of clinics maintaining the drug management system and using the Drug Formulary and Cllnical Reference Manual is cloee to 100 percent. Conversely, the Orientation Manual was available in 42 percent of cllnlcs and 1~ rareiy used. Relief nurses receive little, if any, formal orientatlzn to the clinic setting. According to c1lr.l~~upervisors, staff shortages 2reclude relea~ingnur~es for orientstlari prior to their clinic assignment.
2. Improved Skills, Conditions of Service and S~pervl~lon.
2.1 Improved Skills (Clinic - Based Trainins Follow-Up!
2.1.1 Workshop Traininq
Mo~tof the training in basic mar;agc?-.er.t ci:111~ including supervision, patient flcw, drug management and community outreach activitiec trsk place pricr tc the project's midterm evaluation. Approximately 700 participants attended 17 workshops ~n these areas. Clinic and community level interventions were systematically implemented followir,~the workshops. To review the sustainability of these previous inputs, visits were made to 17 clinics not yet involved in the clinic - based training. The clinics were effectively implementing innovations introduced by the project.
2.1.2 Clinic - Based Traininq Follow-Up
The training methodology shifted from workshops to the clinic based model after the midterm evaluation. The Clinic Management Associate's responsibility was to follow up the management aspects of the training. As the training is done in one region at a time, most activities were concentrated in the Lubombo Region where training took place February - June 1990. Fifty seven trainees (32 staff nurses, 25 nursing assistant from 26 clinics were visited with the clinlc supervisor or designate. Nurses spoke po~itivelyabout the training and in most cases were utilizing the newly acquired skills.
Although the Shiselweni Region training was completed before the Associate joined the project, visits vere made to eight clinics to observe the sustainability of project inputs. The reorganization of the physical set-up of clinics remained intact (ORT Corners, Salter Frames, Filing System) but nurses stated that they often did not have time to use the ORT Corner. Vi~its were made with the Public Health Medical Officer, as the Hatron was on study leave and the Clinic Supervisor position was vacant. Therefore, it was not possible to fully address some of the identified problems. The associate's involvement in the Hhohho Region Training was limited to assisting Clinic Supervisors make a plan for follow-up scheduled to start in January 1991.
BEST AVAILABLE COPY 2.2 Improved Conditions of Servlce (Upqradln~of Nurses Accommodations)
This project activity was intended to improve conditions of servlce for nurses vorking in rural areas, In cooperatlon with the Planning Unit, Ministry of Health, arid the four regione, a list of priority repair needs was establlches, Ba~lcrepairs were completed on 30 of the 52 houses for which reque~t~vere made. There are still critical housing problems relzte2 tc s:ru~turzl deterioration, lack of electricity, vater and plumbing whlch were beyond the scope of this project. The Kinlstry of Healtti, throuzt. the Planning Unit, has eetablist,ed goal€ for continuing the renovation and upgrading program.
2. 3 Improved Supervision
2.3.1 Monthly Supervisori r':_;: tc
Project output ind:=-r::-~ emphasized more frecuent L-.c positive supervisory VLE~~Sto cllnics. The target Gas stated as "at least 1;'. of rurkl cl~nics~ECE~V;T,~ monthly supervisory vltzlts from reglonal nurElng supervisorsn. Ava;latle lnformatlon show^ that thers are 149 government, rnlsslon and private sector clinics. Monthly vlslts to 119 of these cllnics wo~1d meet the project's target.
Health Information System reports were available for 89 (60%)of the 149 clinics January - October 1990. Only 5 (6%)of the 89 clinics vere visited each of the 10 months. However, some clinics received numerous visits in a given month and then were not visited for one or more months. For example one clinic's report showed the following visits by months: January -5; February -4; June and July -1; and no visits the other months. These 10 visits over the 10 months period average one visit per month, but the pattern E~OWEthat this would not present an accurate picture. Some clinics consistently receive more or less regularly scheduled visits, while others are seldom visited.
2.3.2 Su~ervisoryChecklist
The Supervisory Checklist served a number of purposes, including the monitoring of selected project indicators. Consequently, it was two lengthy and time consuming to be of practical use. The midterm project evaluation recommended that it be shortened and revised by the Ministry of Health with support from the project. An ad hoc group comprised of three clinic supervisors and the clinic Management Associate revised the checklist based on input from relevant personnel.
BESTAVAILABLE COPY 2.3.3 Obstacles to Supervision
The orlglnal project paper ~tatedthat one major difficulty in expanding prlmary health care services we6 a lack of effective supervision for cllnlc personnel. -yroject lnput l~areasedthe supervi~ory skill^ of nurses end improved clinic operational and rnanagemer,t support systems. Foremost among remaining proLlems 1s the lack of e~tebli~hedposts for clinic supervi=~rsas recommended in Health Manpower Hequlremento FY 1988 - 85 to FY 1992 - 93. Impleme-tzt:er, cf these recommendations would eliminate the need for a nursing sister in charge of a Public Health Gnlt TO also supervise clinic€ in the region. The V&T;O~E other demands made on those in supervisory poSit-r.rl-. rl!~r!ytimes takes prezeaence over clinic vi,c:+z.
BEST AVAILABLE COPY Regions use HIS data to monitor performance and set desired targets for home vlsltlng, outreach sltes actlvlty and ~upervlsoryvisits.
Matron& and Zllnlc Supervisors e~tahlisha reiillctlc orientation process for c:lnlc nurses based on policy guidelines. (Reqional Personnel MaTaqement Pollcles and Proceaur~,sectlon 6. Orlentation - Ministry of Health, Aprll 1987). The usefulness of the Orientation Manu=: tb,c~ldbe ascertained.
Ministry of Health, Plannlng Unit, Explore alternatives to using Public Works Department and community labor f~rmajor renovation or con6truct;cn cf staff houslng.
Hatrox~ari3 Supervisors revlew the 5uperc;~~ryCkleckll~t at least annuallv axd revlse as indicated.
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-..ne report of the Primary Health Care Project's Clinic Management
Ascaciate covers the perlod January 8 - December 31, 1990. The
~osition,supported by the sub-contractor, Charles R. Drew University
:i .':~Jicineand Science, ?rr.lv;dt=d clinic-focused inputs in the broad
-.-. -:_=..? _Ad of managenlent and c;ltre&zk~activities. Working collalorat~vell; vith designated counterparts, the major activities included:
(1) Clinic-based training ioll~w-upactivities related to management;
(2) Support/re-orientation of regional clinic supervisors and nurses to
project-initiated management strategies, such as increased use of
the supervisory checklist and project-produced manuals, maintenance
and improvement of the drug management system and reorganization of
clinics for more efficient operation;
(3) Expansion of outreach services; and
(4) Upgrading nurses' accommodations.
BEST AVAILABLE COPY 2. BACKGROUND
This sectlon describes the context in whlch the Project was set.
2.1 Cozntry Froflle
The F:ln;dorn zf Swaziland, the smallest country In Afrlca after the
Gambia, covers an area of 17, 364 square kilometers (km) (6,700
square -,leg . It has a maxlmum length oi 192 km from South to
North &r~d14; krn from East to West. The country hares ~ts
south~rr.,r.crrF~ern and western border^ with the Republic of South
Afrlca ar~dlts eastern border with Mozambique. The 1986 census
estlrnats2 tk'e population to be 712,131, with 31,072 of that number
employed as migrant workers in South Africa. In 1988, the
population was estimated to be 728,800 (Schneider, et. al. , 1989,
p.18). The majority of the population share a common language,
tradition and history.
Swaziland is divided into four geographical regions referred to as
Highveld, Middleveld, Lowveld and Lubombo Plateau. Each has
markedly different altitudes, climates, scenery and economic base
activities.
The highveld, covering 29% of the country, is mountainous with an
average altitude of 1300 meters (3,500ft) above sea level. It
receives the greatest amount of rainfall of the four regions and
the climate is humid and near temperate. In winter, (Hay-August)
freezing temperatures and snow may occur. The major economic
activities of the highveld are forest and wood-pulp production and
asbestos mining. Swaziland's capital city, Mbabane, is the
commercial support center for this region.
BEST AVAILABLE COPY The middleveld covers 26% of the country and is the most developed an?
densely populated area. It is hilly with lar~evalleys and an altitucc.
of 700 meters. The climate is sutl-trapical, being warmer and drier
than the highveld. Good arable land makes it the most agricolturall>,
advanced with estate production of cltrus fruit and pineapple for
~xrart. Maize is the main crop but cther vegetables, bananas, cott~r.
-.,:zr - tobacco are also produced. Major manufacturing enterprises ei::~: arm.? :he second major town, Hanzini, and the airport at Hatsapha are lorztea in this region.
The lowveld i~ the largest, but least developed area, covering 37% of the country. It is hot and dry and in years of low rainfall, drought is a constant threat and crop failures are common. Yet with irrigation schemes, large capital - intensive estates produce sugar, citrus, rice and cotton. Non-irrigable areas are used for cattle ranching. A coal mine and three sugar mills are located in this region, and with soil management practices, it i~ considered to be the region with the greatest development potential.
The Lubombo Plateau, which borders on Mozambique, is the smallest region, covering only 8% of the country. Its altitude and climate are somewhat lower but similar to the middleveld. Subsistence agriculture and cattle ranching are the principle activities. The administrative center for this region is located at Siteki.
BESTAVAILABLE COPY page 4
Swaziland has a dualistic political structure which combines the
Western concept of government vith the traditional, Tlnkhundia system that administers Swazi Laws and Customs. The Head of State 1s Hls
Majesty, King Hswati 111, who is advised in the Governmsnt cf the country by Cabinet Ministers re~ponsibleto a bicameral Parilarnent.
The national development goals of economic growth, soclal ;:stlce, self-reliance and stability vere established after tt~c lu;c :'--I..A,.-
Sobhuza I1 led the country to independence from British Colcn~alism1r.
1968.
2.2 Health Sector Profile
Swaziland's National Health Policy (1983) was formulated to address what it described as the "unacceptable" health status of the Svazi
People. Cited among the major health problems were the high rates of infant, child and maternal mortality, an unfavourable incidence of preventable disease and nutritional deficiencies. These and other identified health problems were grouped into these three categories:
(1) Maternal-Child Health and Family Planning; (2)Communicable and
Environmental Disease; and (3) Nutrition. The policy statement endorsed Primary Health Care as the most effective strategy for providing accessible preventive and curative health servies in the targeted areas.
Under Swaziland's decentralization policy, authority for health sector activities is delegated to the four administrative regions: Hhohho,
Nanzini, Shiselweni and Lubombo. Regional Health Management Teams
(RHMTs) oversee a network of government, mission, private sector and traditional primary health care services.
BEST AVAILABLE COPY Nationwide there are nine hospitals; r.;ne healtti centers; E~X
public health units; 149 clinics; and :El cdtreash sites.
(Mini~tryof Health, Statl~tlcsUnit:. S=k.ne;der (1989) estimates
that there are some 10,000 traditlon~ltre~lers. p. 14 i .
Primary Health Care Project
The Swaziland Primary Health Care Frr:.rt FZ1CC (USA12 Prcject hc.
645-5220) was initiated April, 1986, ar.d szrtedcled to end December
31, 1990. The Project Assistance Ccrrletlon Date (PACD) was
extended by six months to accommodate ~artlclpanttraining
commitments and to continue the technical assistance of one team
member. The Project was implemented in cooperation with the
Government of Swaziland, (GOS) Ministry of Health, (MOH) through a contract with Management Sciences for Health (MSH) and a sub-contract with the Charles R. Drew University of Medicine and
Science (DREW).
The goal of the project was to improve the health status of children under five years of age and women of childbearing age.
The project's purpose was to improve and expand Swaziland's Primary
Health Care System. The goal and purpose were to be accomplished by improving service delivery (training and instituting interventions such as ORT, prenatal risk identificati'on and growth monitoring) and improving the management of health re,=ources.
BESTAVAILABLE COPY The original project deslgn had elght components whlch were reduced
in scope after the midterrr e--.aluatior.. The ~utsequ~ntF*rr~rct
Paper Amendment re-focus~5 actlv;t:es or, =hie following reg;an&; ~nd
clinic level areas;
(1) Clinic-Lased and outreach services;
(2) Decentralization;
(3) Plannir~g, Budget~ng,"~nar.z:~l Zznagement an2 Herltk. 1;:-E
Financing; and
(4) Health Information System Development.
3. Overview of Clinic Hanaqement
The Clinic Management Associate was one of the Project's five long
term advisors. This advisor was primarily responsible for the
non-clinical aspects of clinic based services improvement, i.e.
management skills, community development and outreach activities.
(Project Paper Amendment, 19893. Since the current AESOC~~~~
joined the Project in its final year of implementation, a brief
Eummary of prior accomplishments will be ~iven.
Prior to the midterm evaluation, workshops were used widely to
train personnel in Clinic Management topics. A record of workshop
activity shows that approximately 700 participants attended 17
workshops related to Supervision, Drug Kanagement and such
Community outreach areas as Home Vi~iting/Community Profiles,
Community Participation and Community Health Committee development.
BESTAVAlLABLE COPY -F I TIESE tr5lr;:f.z and f clic~w-or. ectl\71tlej pr=!c:=ed & rru~~er~f
susta~nat.leoutputs, irrciuding :he ftllowir~c,ar'car:ients: 1 Cllrrlc
Prug Form~l~r>- arid fiaridt~ook; '2' Ecper\vlcr,r~&rid Tr airrvrc Guide f cr
Implemer2ta: ::~fl. rial :,refIencE., !lonitor Ins 6'111 E\l?! uatlnn of the Druc
Hanogement Fvrten;; :) Zllnlcal Referenc~Plsr,ual fo-. Cii:rlcs orrd
,- . Hrblth rzr.:r*+s: 4. C~.r;~.r,t~tlor;Marlu~l 5z.r . ~-r.:zz, Health Centre=
arid F'a: -1 : i>~z.-ir,LJrilt~; ! 5) Refpy;-b; Fc':~~.. ; ; (t.: 3~1pervi~.3ry
Ctlc-ckl~rrL.r,~ Pc;ld~ llnes.
In aaditrcn tc doc~ments,cilr,ic level r; -r.sze-nr.: ;r.:erventions,
including the drug management system ar~d2sti~nt flow measures, were also initiated. Community developnient outputs included home visiting; working with Community Leaders, Rural Health Motivators and Community Health Committeec; and outreach sites expansion.
The workshop approach tc training was replaced by the clinic-based rn2del which ec?haci=ed 2 mare tas1:-epez~flc, =l:::L-~rzer.tec! approach. The Clir'ic Manaaement Assoclate'r rec-pon~ibilitsifi the
Clinic-bksed tr~lnlngand follow-up wac fzr slrtple mana~ement
Lnterveritlons. (Scope af Work - Append=>: hi. Foilow-up visits cf nurses who partlclpated in the trainlng were to be made with recional public health nurses [trainers] and supervisors, who according to the Kidterm Evaluation, were to do the placning and training. In addition t~ the reciirection of training, the Project
Paper Amendmerit (Ray 19E.S) act! tk:e Fievlsed Kork Flan (August 14.
1939) focused other C11z1~Xsnagen~~t actlv;t;es or. the prlority areas described below.
BESTAVAfLABLE COPY 3.1 Improved Service Delivery and Outreach Approaches
3.1. 1 Clinic Level ba~icmanagement interventions were almed at improving such clinic operations as: druglinventory management,use of project - related manuals and reorganization of clinic^ for efficiency.
1 Clinic/Community linkages were designed to increase access of underserved populations to health care and promote community participation in health care delivery. Major activltles included: constructing or upgrading outreach shelters, increasing home visits and strengthening community health committees.
3.2. Improved Skills, Corlditions of Service, and Supervision a:.= Kanagement Support.
Assumptions were made by the Project that training, (skills development) more s.;;;..;rtlve supervision and improved conditions of service, EUC~as better housing, would optimize staff productivity and motivation.
3.2.1 Improved Skillc
Clinic based training follow-up emphasizing basic management interventions.
3.2.2 Improved Conditions of service
Upgrading of nurses' accommodations; Supervisory Visits addressing conditions of service.
3.2.3 Imoroved Supervision and Manaaement Support
Monthly Supervisory Visits to clinics using supervisory checklist.
The specific EOPS related to the above areas along with relevant scope of work and work plan activities are used to organize the remainder of the report.
BEST AVAIL ABLE COPY 4. CLINIC MANAGEMENT OUTPUTS
4.1 IMPROVED SERVICE DELIVERY AND OUTREACH APPR3ACHES DEVELOPED
4.1.1 Outreach Sites
Esttbllsh 49 new uutr~azhsites, including provision of ba~icfurnishings and equipment.
Number of outreach sites operational
The outreach sites program was designed to increase accessibility and
utilization of MatErr.zl Ck-.ild Health service€ in rural areas. After
~uccescfulcornpl~?:>~ of seven pilot facilities in Mankayzne,
Sub-region cf Har.=inl (1987), the activity was extended to other
regions. The tarset of 49 operational sites was met in April 1990, at a cost below the budgeted El000 per site. In response to additional requests from nurses and communities, a total of 84 sites received assistance (Table 1) in the form of basic furniture (4 chairs, 4 benches, 2 tables and 1 examination couch); privacy and window curtains; trunks for transporting supplies; and salter frames/scales for weighing children. Building materialn for already started structures were ale0 funded on a request basis. (Appendix 6 - Project - Assisted Outreach Site€).
Structures are usually built of indigenous materials that can be hfforded by the community. The deslgn is simple, and the size varies from one room to several depending on community resources. Regional nursing staff from public health units or clinics visit designated sites on a scheduled monthly or in some cases, bimonthly basis. The annual schedule of visits is posted in respective clinics and a ccpy in given to a community leader.
BEST AVAILABLE COPY page 10
An outreach program has existed in Swaziland since the 1960's when Mrs.
N.E. Pludlu, the first Public Health Ratror! started the concept of
Mobile Cliriics. (Interview, Mrs. Aylllne Plamini, Public Health
Matron, 1972 - 79). Outreach sites are now an integral part of the
PZZ system and support the Kinistry cf Health's policy of providing
~ZZ~SEto heslth service within one hour's walking distance of users.
i L - 121:~j.
C;he o~treachsites concept is institutionzlized throughout the country. Data from the Health Information System (HIS) €how 161 government, mission and privatelindustry distributed regionally in the following way: Lubombo 50; Manzini 62; Hhohho 28 and Shiselweni 21. Of the 84 project - assi~ted~ites, 81 (96%) are reporting activity data on the HIS.
Other evidence of the sustainability of the project i~ the positive response of nurses and communities to the program. Many communities had officizl openings to dedicate their structures and express appreciation for the Project's support. (Appendix C-Speech and
Newspaper Article, Lund=i Outrezctr Dedication).
Constraints
Lack of transportation, shortage of clinic staff and impassable roads during rains led to cancellation of some visits. When the one vehicle was in for repairs or otherwise not available there was no backup system. In cne region, the transport was not available for three months during which time no visits were made.
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Table 1
Reqlonal Outreach Sites 'upported by Primarv Health Care Prn7ect
Region Health Care Facility Number or C;tc.,c
F~ggsPeak PHU Mbabane PHU
King Sobhuza I1 PHU Kankeyane PHU
- --- Lubombo Siteki PHU Good Shepherd Sithobela HC Ndzevane Refugee St Philips
Shiselveni Hlatikhulu PHU Nhlangano PHU
Total 84
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page 12
4. 1.2 HOME-
Proportion of rural cllnics from which nurses make regular home visits increased by 40% durlny project life.
Proportion of clinics ~z~r.2regular home visit€.
Home vlslts, like the oati-earrL s~tesprogram, expand K-=tr?~.l Zh;ld
Health and other Primary Zeal~hCare Servlces to rural ~c,nulatlons.
Where feasible, clinic nurses visit homesteads within thelr catchment area to identify health problems, give health education messages and follow-up specific clients, for example, defaulters. Prior to the midterm evaluation, the Primary Health Care Project sponsored workshops on home visiting/community profiles for nurses in all four regions.
These sessions included field experinces in conducting visits, developing community profiles and estimating and mapping clinic catchment areas. Participants were expected to initiate a home visiting program in their respective clinics using the Ministry of
Helath's Household Health Folder, which was revised during the training. On clinic visits made by the Clinic Management Associate, there was evidence that a number of clinics continue to make visits, maintain the record system and update and display their catchment area maps.
BEST AVAILABLE COPY page 13
Basellne data on the proportion of cllnlcc conducting home visits
before the inception of the Primarv Health Csre Pro3ect were not
available. It was not ~tatedhow many aadltlonu? clinics should make
home v:ci:s in order to reach the taraet ef a 40% increase by the end
of the prqrzt. i!owever, data obtalned i~,n2 survey of clinics in the
Lubon~: :;. -::cz ! Mrch 1?3L!) and reports frc-.: the 3ralth Information
Syster T:.:? the status of activitv I: -.-.-. a.The major findings
related to the project output indicators are presented below.
Home Visit Survey - Lubombo Reqion
The brief questionnaire shown in Appendix D was designed to collect
data on a number of indicators, including home visits. Of the 29
clinics surveyed in Lubombo, 11 or 38% of them reported making home
visits. Two of the eleven clinics stated that their visits were made
by Rural Health Motivators. The other 18 clinlcs, 62%, did not make vislts due to "shortage of staffu or "clinic 1s too busyu. Two additional clinics later reported making vislts, therefore, 45% of the clinics (13 of 29) in the Lubombo region made home visits.
Health Information System(H1S)-Home Visit Data-January-October 1990
Home visit reporting is now integrated into the HIS. The graphs on pages 18 - 21 show the number of visits reported by each of the four regions in the 10 month perlod January - October 1923.
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The Hhohk.o Fieglon, for exapple, reported the fclllowing number of
\-IE~~E: 15 , lC, 92, 141, 105, 96, l38, lo?, 106, and 41, for a
:otal s' E"55, or ar, av~r;g~of EL. vizits per month.
-.I.+ Ilrle arid bar orap!is c,r ;sa~~-r22 and 25, respectively, compare
th~re5;ons witti eack, c,~~.ET.For example, in May, Manzln; reported
-. LC iswhile t!hoh:.c, Lstio.nto ar~d Shiselueni reported 135, ?6
1 27.5 22, re,rpect;v~-11.. -___i,,.,, ki;n,r visits srll range of visits t?.
:-eglori are ~t~uwrt1r1 Tii-t- 1. A. tothl of 2,305 vlsits were made
:k.roughclut the ccur1:r;: s~r-:.?trie period, or zri average of 221 v~s~tsper month. T~,E - 1 r.t-k.ly s7:ertge by region= is a follows:
Hhohho - 86; Kanzini - zt.;- - Lubombo - 64 and ~hiselweni- 21.
Ranae of Visits
Hhohho, Manzini and Lubombo made the lowest number of home ~lisits
1,6, and 0, respectively) in the months of January and February, while Shiselweni made the lowpet number, 7, in September. Regions made the most visits April - June as follovs: Hhohho (April) - 141; Nanzini (May)-142; Lubombo (Karch and April) - 130; and
Shiselweni (June) - 26. While it le beyond the scope of this report to present a detailed anzlysis and interpretation of data, regions could of use the HIS date to plan realistic targets and address factors related to change€ in home visit activity.
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Table 2
Tc!?,: Haale Vi~itsand Range of Vlsltz kt)' Ftegior~~ January - October 193a
I I I mhecicnal Total Visitc Fianqe i j Hhohho 855 1C - 141 Mar.zir.i 556 E. - 143 ' Lutombc 643 0 - 130 TL,2 ?C - 1 -1r.~Ef3~LifTii ,~3 l - 32 1 i I i Tct~l I 2,307 I !
F.anz~ - re~recentsa month when the lowest r~umberof ~l~it~ were 7,l;r ,:, :hat region and a month when h~ghestnumber of vlclts made. Example: Manzlni's lowe~trlumter of vie it^ waE 6 (Fe-ruaryr vhlle the highest number was 143 (May).
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In addition to regional data, individual clinic home visiting
performance can also be obtained from the HIS. Of the 90 clinics that submitted information, 42 (47%)of them reported making home vieit=.
The percent of clinics making vislts ~n each region/subregion is showri
~rrTable 3 and the complete list appears in Appendix E. The Table shovs that 75% of the clinics In Hhohho South make home vicitr, followed by Mankayane sub-region - 731; Shiselweni - 63%; Hhot~t~o nor^:.
- t,-.- .,.. ,uLombo: - 34% (Earlier Survey - 45::); and Hanzini ~ub-region-
--I -I .,. . It ~houldbe emphasized that th~:-esults are Lased on availtLlt ri- * - La-= for months of January - October 1990.
Table 2
Percent of Clinlcs Mak:~nq Home Vlsitc
January - October 1990
% Total Clinics No. Clinics of clinics Reporting Making Visits making Regions/Sub-Regions vizits
Hhohho
South 8 6 75%
North 7 4 4 577! j 4 i: i: 4. Manzini I la 4 21% I Kanzini
Mankayane 11 .. 8 73% a - *- +" 1 Lubombo 29 10 1 34% I i !L I P Shiselweni 16 10 63%
-
Not all the clinics reported (nationwide - 47% of clinics make visits
Data reported earlier on survey was 45%
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Summary
With 90 clinlcc reporting, 42 of them (47 %) are makine hcr;.~.:iclts.
Or, a regional/sub-regional basis, the percent of clini~si;~;,;:ir~g vicitc
ranges from 75% (Hhohho South) to 21% (Hanzini sub-reglor,,. The
Primary Health Care Project indicator of "a 40% increace i~.the number
of clinics during the llfe of the project," did not !~a\~rE zrareS
baseline. Therefore, ~t is not po~sitleto deterr,ine L-T~E~T.E.'; OF not
the target was reached. Shortage of ~taff,heavy pat-t:-:: IsaCc- arid
great distances between clinics and homesteads are among the deterrents to more frequent visits.
Sustainability
There is a system is place to sustain and support home visiting as an important outreach component of Primary Health Care. Where it is not practical for nurses to make visits, Rural Health Mctivators can supplement this activity. AE described by Dr. Makhubu in the booklet,
Nurses' Guidelines for Workino with Rural Health Motivators, the community-based workers "follow up defaulters when asked tc oc so by nurses in cases of T.B., Family Flanning, Immunization and other services that are provided in clinics" (~17).
BEST AVAILABLE COPY HOME VISITS - 1990 HHOHHO REGION
NO OF VISITS
------153 --
0 I I I JAN FEB MAR APR MAY JUK JUL AUC SE? OCT NOV DEC
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HOME VISITS - 1990 MANZlNl REGION
NO. OF VlSlTS 160 i - -- . ------A -- -.- -. . ------. I
JAN FEE MAR AFR RIAY JllN ?UL AUG SEP OCT NQV 2EC
BESTAVAILABLE COPY HOME VISITS - 1990 SHlSELWENi REGION
i I ! I I I I I I I 1 I 0 ' JAN FfS MP.F! A?!? MAY JUN JUL AUG SEP OCT NOV DEC
MOH iStsts unlt!
BEST AVAILABLE COPY HOME VISITS - 1990 LUBOMBO REGION
NO. OF VISITS :iC, - . ------.- -
MOH (Stats unlt)
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, "'if- \ ",,*.,, ;: i.\)j ,,jk \k, ll\d)l~. BqI &.I - qqf-7;* BY REGIONS
JAN FEE MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
REGIONS - HHOHHO MAN2lNl * LUBOMBO -+ SHlSELWENl
MOH (Stat6 unit)
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MOVIE VlE;iTS .Lf13 !QQlL BY REGIONS
NO.OF VISITS 760 r
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
MOH (Stat6 unit)
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4.1.7 COIHUNITY HEALTH COPtPtITTEES
Proportion of all cllnlcs with functioning commur~lty hesltt. c-rp::r~-c:
Increased by 40% durlng life of the Project.
Proportion of cllnics wlth functlonlng carnmur~lty heslth ~o:::-,-ttee.
(Document Only 1.
The community health committee 1s an advisory body which E~T.~~c-L2:- -
communication link betveen the community and the rural clin~czr.
health-related matters. In Swaziland, these committees are
well-established structure€ for mobilizing community participation in
Primary Health Care activities. The recommended Terms of Reference
established by the Ministry of Health, state that the main purpose of
such committees is "to educate the people on ~oundhealth practices and
motivate them to take actions which will improve the health of the
c~mmunity.~(Guidelines for the Future Operation of Health Services In
Swaziland 1986, p. 84 1.
While community health committees are an integrcl part of Swaziland's
.Primary Health Care System, their activity level varie~considerabLy.
At the time of the Second Annual Review of Primary Health Care (198?),
committees were functioning in only one-third of the 30 clusters
sampled. Of those committees sampled, 10% met weekly, 27% met monthly,
20% met as needed and 43% had never met.
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In the early stages of the Primary Health Care Prcject, sutstsntiol
support In the form or workshops was g~vento strenatrler.;:,c; ccjmmur,;ty developmerit actlv~tiec, lncludlr~g commlrni t y health. T- C'ir:~.: ttee~. Over
---.... - * .. 1, 000 person= attended 15 Cummur.lty F'~rtlc:pztlt~., lL,L.i88d,,, ,? H~ziltk,
. . Committee ar~dCommunity Leader workshops. A sur~e-7c: :.+el4-t, rarnrnl+-te~ furlct~onlng was alc~done at a Ba~lcHanagement ki.:-t:~.!~op13LE,,
. . .. February 7-'3) arid a list cf active 2nd ir,kctiv~rr- - _-.-.ec-;n;l=. obtained, but there was no evidence that the re~-L--::,..~:-E --~t.-lzt~;?LY used in any way. The same Same Survey Form wa~si - L :-c: r r --..;-.:.ttt~~ current function in^ cf health committees. Additlrr.zl ir.f~.rmztlor!wat obtained from Africa Hagongo, Health Education Ur.it, vhc zcjnducted a survey of committee functioning in the Lubombo South clinics.
Survey results are shown in Table 4 below and the list of active committees are included in Appendix F. The percent of active committees by region/subregion are as follows: Hhohho South - 100%;
Hhohho North - 782; Mankayane - 55%; Shiselweni - 50%; Lubomt~o - 45:! and Hanzini - 21%. Cf the 93 total clinics reporting, 47 :51::! cf them have active community health committee€.
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Table 4 ACTIVE COHHUNITY HEALTP Cf!',Y:TTF.FS 194il
I 1 .,., I I Totai El:r.;cs c Zl-n~cz, - jrf cLlnicr : Report lr~s 1~2thCommittees c*:th I Reg;ons/Sub-Regions I (~nrn~~ttees) I i I !-!tiOtlhO ! i 1 i South
M~r,zlnl
Yar,=-ni I Mankayane 5 P PCh Lubombo 29 13 I 1. 1 4"L I Shiselweni 16 E 50%
I n n Total all Regions 93 47
Overall Percentage of Clinics with Active Health Committees = 51%
The baseline that the Primary He~lthCare Project was uslng the measure a 40% increase in the functioning of health committees was not stated.
Therefore, it cannot be determined whether or not the target was met.
However, it is evident that health committees are institutlonaiized and functioning well in many of the clinics. Data such as presented here can as~istregion to set desired targets for this activity in their annual action plans.
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4.1.4 Reference Manuel& and Druq Flsnaqement System
Proportion of clinlcs at vn;ck, ~t~fflJ5~ ;rc,?ect-related manusls and
protocols to effectivelv d:a?r;c,,ce ar15 trest z~zrleritc :E % 5,::;;.
Proportion of clinics u~~ngmar,utic dc~+elctpedand lmplernented by
the Primary Health Z2r~Froject <[(rug cermolar\..7 Cllnlz~li:c-fererrce
Manual, Clinic (3rlcnt~t~anHanuali.
Number of clinics v:-.r. drug n:br;~?ernent~vstem cpera'_;or~sl.
The following manuals wcr~rrodu-ec with techr~lc~l~nd i~nanr,;~l
support from the Prlrnzrbf ?.e;ltr~ Care Project: Cllnlczl F.~-crer,ce
Manual (April, 1987); i 2: Srlerrtation Manual (April, 19E- ; ! S i 1 rsg
Formulary (February, 19651 and Supervi~orsand Trainers Sulde - Lrug
Management System (December 1989). The Clinical Reference Manual
provide= diagnosis and treatment protocols for the most common health
problems seen at rural clinics. The Drug Formulary accompanies the
Drug Management System and provides guidelines for safe practices in
ordering, storing, prescribing and dispensing essential drugs. The
Supervisors and Trainers Guide - Drug Management System, as the name
implies, is an instructor's manual for orientation, in-service cr
on-the-job training in drug mznagement. The manual was distributed in
September 1990 and there is no evidence of its use as yet.
The Orientation Manual was developed to assist newly as~ignedand
relief staff adjuct to work In the rural clinic setting. It is 6 tool
for addressing the problems cf high turnover and frequent rotation of clinic staff. (Kldterm Project Evaluation, 3ctober 198E!. The document was to be used in conjunction with a proposed two week orientation period for nurses being posted to rural clinics.
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Use of manual^
The prop5rt:~r. ef zI:r.:zs tisln.; t!,r I?llr;lc;l- F.eiero~ceManual, bruc
Formuleri. ar.3 n&;r.t;lnlna the Llruq Mar~aoemer.?.5yc:e~. 1~ close to :C)3:3.
only tw; ;f ;,r.+r =+JL~ ciinic~vl~~tea neeued asslstznce wlth proper
recordlnc cn the tally sheet and establiching rrinirr~um/maximum stock
levels. 1:czs-l;nal breakdowns ln the EVE+-E.? OCTET when rrew staff are
not pr:.: ;:- -.: r~r: er.*_ed tc the eycte-:. 7k.r- ou-k. t !,F ::f 2 1ce of the Senior
Public :-.,?z1:!. X:,:rcr~, 250 caplet eszh ci tk,? T,r>o Formulary and
Clinical Zeference Manual were reprinted.
The Orientation Manual was available in 4 of 29 clinics (14%) in the
Lubombo Region and 2 of 8 clinics (25%) in the Shiselweni Region. In the Hhohho South and Mankayane sub-regions 16 clinics (Hhohho South -5;
Mankayane -11) had copies of the manual. Nurses stated that they read
it on their own as there is no formal orientation program. Although about 42% of the clinics visited have orientation manuals, they were rarely used. (Clinics in Hhohho Korth and Nanzini Sub-regions were nct visited). There is no system in place for revievlnu and updating the orientation manual nor for absorbing the cost for reprinting.
Recommendation
Each Regional Health Management Team devise a strategy for orienting clinic nurses to their job respon~ibilitiesand work environment based on established policies. (Recional Personnel Hanaaement Policies and
Procedures - Section 6 Orientation (Ministry of Health, April, 1987,
P. 17).
Review the orientation manual's usefulness and revise accordingly.
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4.2 Improved Motivation of Health Workers Brought about by Improved
Skilis, Improved condition^ of Service and Improved Supervision.
4.2.1 Traininq
At least 80% of clinic nursing ~tafftrained in priority Primary Health
Care service areas, as well as in basic clinic management &kills.
::umber of nurses tra~:,od 15 Cl~nlcManagement including drug
management.
Workplan Activity: Provide clinic - based training to clinic nurse
in basic management skills including supervision, patient flow,
drug management, community profiles and outreach.
Prior to the midterm evaluation, the project used workshops to
train nurses in the above management topics. Project records show
that nearly 700 participants attended 17 workshops in the areas of
drug management, clinic management and outreach activities. These
workshops were followed by the systematic implementation of related
clinic and community level interventions. Monthly and quarterly
project reports indicate that the training target in terms of
absolute numbers was reached before the midterm evaluation.
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To reviev the sustainability of those workshop trainings and
management ~nputs,vlsits vere made to five clinics in Hhohho South
and twelve c:lnlcs In Hankayane. These 17 cllnlcs were found to be
effectively lmplementlng the drug management system as well a&
other lnnovatlons introduced by the project. The flve cllnlc~In
Hhohho South and elght of the twelve clinics In Mankayane also have
well functzcr,:ng GRT Corners established by the National ORT
pragra~.. L,k:cv:se, the ORT Unit at Hankayane Rospital was properly
malntaine:.
P-fter tk:~~lterm e~paluation, training methodology shifted from
~orkshopctz the clinic - based model. This strategy emphasized small, regional training with timely follow-up in the participant's
own work setting. The Clinic Management Advisor's responsibility was to assist the clinic supervisor in monitoring and reinforcing
the management aspects of the training by using the Supervisory
Checklist.
In the original plans for clinic-based training, 2 module cn clin~c management was to be included "to reinforce the knowledge and use of the supervisory checklist." (Paper-Clinic Level Trair.ing
Programme in Shiselweni, 29 August 1989). The program was to integrate training and supervision by mobilizing in one program the key figures or prlmary health care at the clinic level. Although a separate management module was not developed relevant content was integrated in the training and was the focus of the follow-up visits. k form (condensed version of ~upervisorychecklist) was developed (Appendix G) to record observations related to the following content covered during the tralnlng:
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1. Reorganization of clinic for efficiency.
a Proper positioning of the EPI refrigerator, ORT Corner,
growth monitoring equipment (Salter Scales/Framer) and
consulting room set-up
b Arranging paperwork according to the filing system
established by Dr. Joret (memo - V. Joret to M. Edmondsor; - March 10, 1990). The project supplied filer, filing
cabinets, where needed, arid t~ilt-shelvesfor more
efficient organization of record keeping materials. The
Clinic Hanagement Associate and clinic ~upervisorassisted
vith the implementation of the system and in some cases
(Lubombo Region) delivered files to clinics in the interval
when there vas no Training Backstop-for the project.
2. Hanagement of drugs and supplies to support selected patient
Care Areas
a. Immunization (EPI)
Adequate supplies of vaccines, needles and syringes,
properly functioning cold chain system.
b. Oral Rehydration Therapy (ORT)
Management of ORT Corner; maintenance of equipment and supplies; instruction& to caregivers; and record keeping - review of ksse~smentand Treatment Form where participants had attended
National ORT training.
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Most of the fcllow-up activities were concetrated in the L~bomboRegion
where participant training took place from February - Janu~ry1990.
Fifty seven trainees (32 staff nurses; 25 nursing assist~r,-~:frorr 26
clinics (Appendix H) were visited with the Clinic Supervi~~ror
designate. Some clinics were visited two or more times 2"~-t~ the late
arrival of ORT and weighing equipment which in some czser, z~lb>.e='the
implementation of skill€ learned in the training. Once e3,:;nent was
- .- - '= in place, clinics were re-visited to observe trainee 2i:;l-r, :. L'- L - teaching and re~pondto que~tionsor problems.
The clinic - based training and follow-up were cornp;~-:e5 :n the
Shiselweni Region before the Associate joined the prcj?=t.
However, visits were made to eight clinics with the Public Health
Medical Officer to observe the ~ustainability of project inputs.
The physical clinic innovations (ORT Corners, Filing System) were
in place, but it was not possible to ascertain the degree to which
skills were being implemented. Nurses did state that they often do
not have time to observe the ORT Corner. At the time, the Regional
Matron was on study leave and the Clinic Supervisor post was vacant
so it was possible only on a limited basis to redress problems
areas.
Involvement in Hhohho participant trainings which started in
October, was limited to orienting the Acting Regional Kztron and
Clinic Supervisors to follow-up activities for which a schedule was
made.
BESTAVAILABLE COPY 4.2.2 UPGRADING OF NURSES' ACCOMMODATIONS
Improved Conditions of Service for Rural C.llnlc Staff, includlrig
Provision of Limited Furnishings for Nurses' Acc~nmodations.
Number of Nurses Accommodations Upgraded.
The iack of adequate housing and facilltlez :r vr-l documented as a
ma~orconstraint to the posting and retcr:::;-. 5: r'-rzl cllnlc rtafi.
The cpgrad~ngof nurses' houses was the Fri-7ary Health Care project'^
effort to improve the conditions of serv~ceana uitlmately provlde sr.
incentive for nurses to work in rural areas. On reconnaissance visi~s
to clinics the overall housing situation was found to be less than
desirable except where there were newly built structures. Lack of
routine maintenance has led to serious structural deterioration of some
facilities well beyond the scope of this Project to address. Nor do
community groups, in most cases, have the skilled manpower to cope vj.th
the extensive renovation needs of some of the houses. Besides the
structural problems such as leaking roofs, falling ceilings and cracking walls, many houses are without stoves, refrigerators or an adequate water supply. In many instances, nurses are sharing a very small facility leading to extremely crowded conditions and lack of privacy.
The method of work used to approach this activ~tywas first to hold a series of meetings with the then Assistant Healrh Planner, Planning
Unit. Ministry of Health, to review the status of housing repairs occurring under the Rural Clinics Renovation Project (RCRP) and identify the best use of project funds. Page 34
Secondly, a detailed, prioritized list of basic rspalr requests
with cost estimates was cbtalned from the regions. Flr~ally ZA
planning meeting was held wit:. Prc2ect and P:znr,lng Unit representatives responc,tle f:r zct:*.-:ty tc esthtl~shL mechanism for implement~tio~.
The original plan for Frrjec: sscictance In rtaic Area was tz supply materials only with the. Icz~1zcrr;.sr,i:;ec proT::d;r.z t:.c l~~zr.
(Kidterm Project Evalu;t:: ;. . . -, C, w;~ later dec~clucthe-. tr;c e:::~:.: of the repairs and the z;L~c.:.,er~t -.~&;r;teniinceneeded, TC-.I;"i:-c-.2 &-;.;I-
=killed manpower of the ;~~hl~zNcrks Department ( Pk'D) . H~;v?i,er, attempts to coordinate this activity with FWD proved fut11e and Le'd to delays, except in the Shiselweni Region where the Regional
Health Administrator and the Public Health, Medical Officer spent considerable time working with PWD on this activity. The Project hired part-time carpenters and painters to do work in the other regions.
At the end of the Project, basic repairs have been completed on 30 of the 52 houses for which requests were made. (List of
Accommodation Upgraded - Appendix I). Basic renovations i~zluded repair of roofs, gutters, broken windows, doors, installation of locks and painting. The Project also provided: Curtain materials for about 20 houses; kitchen cupboards where nurses were sharing facilities; and a water tank for one clinic vhere the wzter shortage was criticel.
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In ~piteof the tremendous Project input into upgrading nurses'
acc~mmodatlonc, there are still ticute housing problems. It was
beyond the scope c~f the project to deal with plumbing, electrical
and appliance needs, which also need urgerat attention.
The Governn~ntis awsre of the housing situation at rural clinics
and ha= 2 ;I.-.:: icr ~tsimprovement. One oi the program priorities
designed to r:r~nz~!.er: rural clinlc Gervizes d~rlr.2the Fourth
National L --.<,rlc ;,r,ert Plan period ( 1983/€\4-1357<0P, was to con~truct
74 staff houses. More recer,tly, the tieslik. S~ztor- Development
Plan 1990/31 - 1992/93, reaffirmed the flinlstrj. c;f Health'€ commitment to continue its major clinic renovation and upgrading program. Priority will be given to "the renovation of rural clinics throughout the country" and "construction of ~taffhousing at clinics for nursing staff who are currently forced to &hare rooms or sleep or, clinic floorsn. (Health Sector - Development
Plan - 1990/91 - 1992/93, p. 88).
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b.5 leist eC?L of rural clinics receivirig ,zonthly supervisory visits fram
.-.-.-- -,--.. -- U1- nursing supsrvisors.
Fropsrtion of clir.ics rece~vln~ns--- . ' y supervisory visit from
..-,,v --ng-.. ~upervls3r !uslncj =~,e~):l;~t:.
. . . . . I .:. .~..--5:tive- - iaplem~r.:aticr. r i :t:s :::'.;rr.m.nent's National Health pol:^:;
- <- 2.~- :k:? Primary Health Care Pr;;~.:t's ir-rut are both dependent upon
z5equate clinic super~~;sion. -~. - A~iL-. - early project support included a number of workshops aimed at improving the
management/supervisory skills of matrons, clinic supervisors and nurses. In addition to training, the project supplied one supervisory vehicle for each of the four regions and sponsored driving instructions for three supervisors in order to alleviate transportation constraints. In most regions, clinic supervisors are functioning in a dual capacity. They are responsible for the supervision of a Health
Center or Public Health Unit as well as a number of widely dispersed clinics. To confound the problem, the Regional Public Health Matrons were on educational leave for the greater part of the year, adding more responsibilities to an already overburdened cadre.
There are eleven Kursing Sisters or Staff Nurses serving as clinic supervisors as follows: Hhohho - 5; Mazzini - 3; Lubombo - 2; and
Shiselweni - 1. All supervisors make sn annual schedule of their planned monthly clinic visits. However, other priority commitments often lead to cancellations.
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Accordi3~to the job description for Nursing Sister - Clinlc
Superviscr, vi~itsare to be made monthly to Government and Rissior,
c'ir.:cs and more often if there are special pr~blems. supervisor^ are
-,EL- 1 ex~e~fpdto vitjt ~,rjvste and industry facillties tc. provide EF'I
~ndFair.lly Xazr,r.inc; Su;lr;iies.?Ir~formatior~and tc follcw-up clr. health
statistics record keep~nc;.
There was nc dcz~~~~r-.z-.:c-.sr. the total number cf cl:r.:z: r.2:- the
percent reselv~r,~a,r.tr.-;; s~pervisoryvlr:ts at tkAe tlme the prc~ect'c
target cf La:: u;l; t.:r;L:;s!i~-.6. Therefore, the figure= ir: Tatle 5 will
be ilscd to dlsc~~;t!,r ~:z:uc ~f supervisory vlsits. The t~bleshows
that there are 52, 33 arid 64 Government, Mission and Private/Industry
Clinics, respectively, for a total of 149. Monthly supervisory visits
to 68 of the 85 (52 and 33) Government and Mission Clinics and 51 of
the 64 Private/Industry Clinics or a total of 119 clinics nationwide
would meet the project's target of 80%.
Table 5
Government, Mission and Private Seztor Clinics
Heqion Government Kission *Private Total
Hhohho 9 S 17 35 - Manzini 15 12 ;5 b~-
Lubombo A-13 9 12 33
Shiselweni -16 -3 -- -19
Total 52 33 64 149
Source: Kinistry of He~ltk,,St~tl~tics Unit and Regionzl clir,;c llsts.
Note: Public Health Units and Health Centres are e;:clzded.
*Private Sector includes all privste, ~zompany a:lll'
non-governmental organlz~tionclinics.
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Health Information System reports were available for 89 (60%)of the
149 cllnics, January-October 1990, as shown in Table 6. The clinics In
the LcSzvbc and Shiselweni Regions have the hlghest reporting rate
vklle lecc than half of the clinics ~n the @+-her two regions are
rg rsrt~~s.
Table i.
Re~ionalC1:nics Supervisory Vi~its
..K=.-. - -- - -.. .. Total Clinics .". ctal Reportinq Percent Reportlnq
E r! 3 r: k, c
Ha-zlr.:
Lubombo
Shiselweni
Total
Dsta Available for 89 of 149 Clinics = 60%
The graphs on pages 42 to 47 show the number of supervlscry visits by regions as well as a comparison among regions. A total of 623 visits were made during the 10 month period as follows: Hhohho - 176; Hanzini
- 263; Lubombo - 104 and Shiselweni 90. This averages about 62 vislts per month with each region contributing as follows: Ehohho -1e; Ranzinl
-26; Lubombo 10, and Shiselweni -8.
A review of the individual clinic data sheets showed that only 5 (6%) of the eS clinics were visited each of the 10 months Jsnuary - October.
However, a number at clinias received severs1 vi~ltsin a give:: month and then were not visited for one 3r ii.sr~mclriths. ( R~.pendl::-J
Individual clinic supervisary vis~ts:.
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Table 7 shows that supervisory visits ranged from 0-30, with 43% of the clinics being visited 1-5 times in the 10 month period. Clinics visited in the 21 - 25 and 25 - 30 categories represent the five clinics (6%) that were visited monthly.
Table 7
Supervlsorv ?isits - January - October 1990
Frequency Dlctr~tluticlrl of Supervisory Vilcitn
January - Qctoher 1990
No. of Times Visited No. of Clinics Percent
Total
BES JAVAILABLE COPY If cllnlc~recrlved 10 or 11 vialte In the 10 ncr:rhs F~Pi-iod,lt t-r,~~r,:
be assumed that this averages a visit per monrh over s 10 month
period. Thls 1s not the case, however, as ;:lustr~trc! ~ritkie foil~vlrig
example of one clinic's report; January - 5; February - 4; June and
July - 1 vislt each; and no vlsits the other mcnths. Conversely, clinics reporting 12 - 30 visits in the per;;;, Lzve received a numcei- of consecutive vlslts monthly (one clinic - 1 VIE~LBlfi one month) usually ~inceEarch.
The Primary Health Care Project has succeeded in increasing the supervisory skills of nurses and in improving the operational management of the supervisory support system. There are still a number of system factors, such as the lack of official posts, that must be addressed before the project's impact can be fully realized. The
Ministry of Health is aware of the problems related to clinic supervision and addressed some of them in the report, Health Manpower
Requirement FY 1988 - 89 to FY 1992 - 93. Clinic supervisors were recognized as "the critical element in the Ministry's plan to improve the management and productivity of the nationwide clinic network"
(p. 31). The report recommended a specific number of new supervisory posts per region based on workload, or the number of clinics to be visited, and other factors such as distances between clinics. The plan was designed to eliminate the need for a Nurcing Sister in charge of a facility to also supervise clinics in the region.
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Recommendetlons
Review and update recommended posts fcr cl:n:c supervisors a= ~tsted13 Health Hanpover Requirements FY 198e - EF :s FY 1992 - 5:.
Examine EyStem factors (training, meet-- ss, clther duties) that interfere vith scheduled supervlzory vls;ts.
Analyze factors related to the inequitable pattern of supervisory visits, vhereby some clinics ars vi-cited -=re frequently than others.
BESTAVAILABLE COPY CLINIC SUPERVISION VISITS - 1990 HHOHHO REGION
V JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
MOH (Stats unit)
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E I C. .. . ! ! I 1 I p- -...... - .- .- ..
I
I i---- I JAN FEE? MAR JUL AUG NGV [jEC
BESTAVAILABLE COPY F-
JAN FES MAY LUN SEP
MOH ;Star unlt)
BEST AVAILABL E COPY CLINIC SUPERVISION - 1990 LUBOMBO REGION
NO. OF VISITS 20, I
V JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
MOH (Stat6 unit)
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CLINIC SUPERVISION VISITS - 1990 BY REGIONS
NO.OF VISITS 50 : . ! I I ...... 40 \. iF. \ . T. I :\, \ I
I 1. '<< i 30 k- F1.: '. ., '>. . .fl,, -t - , \. I 1 /I 1 i I .... I I .' I \\ 1-- .. r, -- '\ .--+' .* 9 / I '.., .,. \, -...... ' ...... " ...... 'f ." "" "... t'-'...... 20 r-, 4.: I . ; i '.. I \ */-v j . ,*.- \ ! -*' X,- 1- ' ...... ,* ...... \...... j 1 -2------%- --- ?/ -,=--- L -4.. !
'. '. ., 1 I I ! I I I I '.A I I 04 * L4 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
REGIONS
HHOHHO MANZlNl ?X- LUBOMBO -a- SHISELWENI
MOH (Stats unlt)
BEST AVAILABLE COPY EY REGIONS
- fE6 MAR APR MAY JUK JiJL AUG SEP OZT NDV DEC
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4.2.4. Su~ervisoryChecklist
Hld-Pr9ject Recommendation: Supervizsr:; fk.~-z\:l:~t k~ rev~sedLty
Minlctry of Heelth with project ~uppcrt.
The Cl~nlcSupervisory Checklist started as sn kctlon Plan at the firt:
supervisors meeting in January 1987. 1: vas preteeted at six clinics
in the Lubombo Region and updated at s Zcn~15E7 S~pervi~oryWorkshop.
E'ased sr, ~dent~fiedshortzomings, it -n;- - - z,s-.c. TF-,.lEed(J~.-.~~~~ 155s:
1. - and the accompanying guidelines were &-c-,:?eri. ik,e to31 was to 5~
used for evsluation, training needs asc~~ssrnentand supervision. It wzs
also to provide the basis for Annual General Meeting and Regional
Health Management Team reports and for awarding the RBemt
ClinicRtrophy. Additionally, it was the designated source of data for
a number of Project indicators.
These numerous intended uses resulted in an eleven page tool
accompanied by a nine page set of guidelines for completing the checklist. There were 24 areas with sub-areas related tc: (1) Pztient
Care Management MCH/?P, Child Welfare (Imrnur.i=ation, Growth
Eonitoring/Nutrition) child diseases - ARI Diarrhea (OFT) and communicaSle disease. Repetition= under each area related to patients seen in the previous month, record-keeping, patient-retained cards and equipment/commodities; (2)Outreach/collaborative activities - home visiting, RHM supervision, health committee functioning and relationships with various specialicts health care personnel; (3) cllnic environment - sanitation; (1) clznic organlzatior,/management - clinlc schedules, patlent flow, health education and (5) cllnic staff issues.
BEST AVAILABLE COPY page 49
Checklist Revision Process
1. Completed checklists from Lubombo, Shiselweni Region and the
Mankayane sub-region were reviewed. Dlscusslons were held with
supervisors to identify problem areas.
2. Input was obtained from matrons and other partlclpant-z zt:+r.cln~ a
management course at the Insxltute of Development ManaGdxer~t;
Clinic Supervisors; Program Coordinators; and FHC Frz:-z: LG.
members.
3. An ad hoc committee composed of three clinic supervisors and the
clinic management associate drafted, then finalized the revision
based on input.
The revised checklist (Appendix K) is five pages in length with an additional page for open-ended comments related to actions taken, strength and weaknesses and staff discussions. Six key indicators with sub areas address the following; Maternal Health/Family Planning; Child
Welfare; Childhood Disease; Health Education/Counselling;
Recording/Reporting; Inventory/Drug Management; and Inter-Intra
Professional/Community Activities. The checklist has been distributed and additional copies are obtainable from the office of the Senior
Public Health Matron.
Recommendation
Matrons and Supervisors periodicallly review and revise the checklist as indicated.
BEST AVAILABLE COPY page 50
Throughout the year, stctuc repcrtr on k~ycliillc marlagement activities
were given at the regularly scheduled meeting6 of already constituted groups such 2s: RHMTE in Shiselweni, Hk,chho ar~dLubombo; monthly meetings of E~:T Nursing Off :c-:.:-' c rs.:-~rterlyNatlunal meetin:: v: ..'. ?r:;n;strative nursing pe. = .~::: -~ : . Preparations far the end of project status rerc-+- (dcSrlefing) and handover actll~itiesstarted several months before the project completion date. A series of planning and orientation meetings were held with Sr. Harriet Kunene, Acting Matron, Hhohho, who also assumed specific tasks of Public Health Matron I since that position is vacant. In consultation with Dr. Lahla John Ngubeni, Public Health Medical Officer, Sr. Kunene and the Clinical Management Associate planned a national debriefing meeting which was held December 3, 1990, and attended by 25 participants. (Agenda and Participant List-Appendix L). Highlights of the meeting related to the continuation of specified project activities included the following: Sr. Hope Msibi, Cllnic Supervisor, Hhohho South, and Staff Nurse Matilda Jele assumed responsibility for following through on unfinished tasks related to distribution of outreach sites furniture and feedback on revised checklist, respectively. BEST AVAILABLE COPY Page Li Robert Shongwe's report given by the Clinic Management Associate related to setting up an on-going communication mechanism between the Pla~~ningUnit, Finistry of Health, and Regional nurses on housing r.eed5. Xatrnri E. Knzebele, Manrini Reglor., gave a report on the ~~shtrnor.th uanagement Course recently attended by matrons and it^ applicability to =:rengthenlng management and supervlclon ln Swaziland. rr. Harrl~tKunene and Hhohho Ncrt?. ;erssnr,el used thelr annual work rlan to illustrate how Prlmary S~~lthCare Project inputs could contlnue to be monitor by that d~cument. In addition to the above national debriefing meeting, final conferences vere held with Mr. Ephraim Hlophe, Undersecretary, Ministry of Health and Mr. Jay Anderson and Ms. Anita Henwood, Officer of Health/Population/Nutrition, USAID. BEST AVAILABLE COPY Page 52 REFERENCES Covernmezt cf Swa=iland, ministry af Health, !1983!, Natlcnal Health P~licv Gcvernment of E;waz-iznd, Yinistry of IIealtp,. ( 1386, 2anuar)-j Gcidellnec C,or Future 9peratic.~sf Hezlth Servicec in Svaziland, MhaSatic Svaziisna. Government 3f Swcl=ilar1d, x:n;stry of Health. (1997. March) Health Manpower Requirern~ntc - FY 1988-89 to FY 1992-93, Mbabane. Swazllsnd Pr;mary Heblt!. Care Project (USAID Pr~~eztNc. L45 - c229) Mbabane Swa=llzr,~. 5overzner.t rf Cu~z:lzr.d. Mlnlctry of Health/UNICEF. ( May). Guideline for the T:-i-:.l:-iz cf Rural Health Motivators. Kb~t~ane, =!w---- ' ---- C--IUrl.d. Government of Swzrllan5 Y~nlstryof Health/Swa=llarld Prlrnary Health -- - Care Frc~ect(Lz-- _ - .,- ... , ,3E7 ). Report on Eome Vlsitinq and Eommunity Prof :le and Druc K2r.z.-saer.t Workshop. Mbabane, Swaziland. Government of Swazilana/Primary Health Care Project. (19EL3, 17-22 July Report of Community Health Committee Workshop. Manzini Keglonal Health Management .. .. . Mbabane, Swaziland. Government of Swaziland/Department of Economic Planning and Statistics. (1990, January) Development Plan - 1990/91 - 1992/93. Mbabane, Swaziland. Green, Ted. (1983, September). Community Mobilization for Health and Development in Swaziland. Swaziland Ministry of Health, Health Education Unit, Mbabane, Swaziland. EakhuSu, M.P. (undated) Nurses'tuidplines for Worlcinc with Rural i4~a:tt~ Kotivstors. Mbabane, Swaziland. du,A. and Price, E. (i9e9, May) Fieport of E~7aluztioncf Referral . . rorss Pilot Project ??anz:n: Rezion. Prlmary Health Care Project/Plir,lstry of Heslth. Mbabane, Swaziland. Schneider, R., Kanagaratnam, . , and Ginindra T. (1989, March Swaziland Health Fopulation and Nutrition Sector Assessment. Eb~barie, Swaziland. Contract No. PDC - 1406-00-?144-03 Medical Service= Corporation International/USAID. Simelane Dora (1989, 19-12 April) Eankayane O~treachPrciect. Faper presented at Annual General K~eting. Kinistry of Health, Swa=ilznd. Testerink-Plaas E. f?. ( i985, February) E,:clzr,atorv Kntes on Pooulation D( D( 1985. Mbzbane, Svazilar,d. BEST AVAILABLE COPY APPENDIX A Pos ition Description Project Outputs C,L.;K!C; mGt;:;i.jENEbIT I;[)\.,.'I:GP Swzziiand Pri~,:+ Health Care I1ro~f.ct CLINIC MkNFil2EMENT iiSSOCIfiTE -' 1TCF:ITC0 CHIEF OF PQoTk ?., 7- rc: p, -.- -. +*ETC: T h~ Clinic r*~c?i-~s;rsni,rrrt~dviscr is ~:-:a~ctec!tr ;.._ ,- ,..-- CoUnt.€rF,&f't ;E 12: i ?n~,hir: with and through ti.:^ ' s ,; - 1 ! I.. - - ~... - H~a1f.h A~mini~tr-,t~r,rz.decign~tcd Clinic zd:,~,. :,LJ, ., and F'ublic He~ltt-1Yatrons in all aspects of her -:c - . With ceunterzarts where appropriate, under the scpet-vision of the Chief cf Party and technical direction of the MZH Physician the incumbent is responsible for carrying out the following activities: i. Assist in pianning, implementation and evaluation of clinic-based trzining together with the team's MCH Physician and Nurse Midc~ife. Responsibility in the training and follow-up would be for simple clinic management interventions. -. Follow-up of ciinic staff in facilities whet-% clinic based trainins has ta!:en place ernphzsizing clinic management i:~terv~.r~ticrrz.t~ src--.urs that a11 tr3inees &re fzllowed up &t aDpropriste intervals post training. 2- Fclls~tr up activiti~~at t5e clinic lev~lduring ~linic vi~itations and trair,ir>g including support 3f the referrs1 s),sterr;. drug management 2nd clinic super~~isionacti~,i ties. BEST AVAILABLE COPY - 8. Work with the Health Planning Unit - e F-eject's . -. Adminirtpatlve Assistant to u~gra.3~clinic nu1ses ~JL!EE~I r ,l;:t with the priorities of the RHMT's. h . . _ U'1 ng t>g :.c:~er~.i~oryCheck: i~t,moni t2: r 1cr12 -,- 5 :tc :;.- ,.",:- , k\.. - .. . rur ;l , estatlistInlent 2nd nlair,ter,jn=c 2' C 3,~;::~3!-~11.. . 5 L.> t, . . ~- & Cor~:n;itte~c_;niJ the f reqcerlcy of clir,ic ~LI:'F': ::Z-.~ :?:LC. LC La =k.+.I - ' fr.~::, t5~fhc=l.:ist VJZZ~~9~.cscz ;: ,r,jlc:.r;m.; i;,' :ric nlor,, tor-: nj trle PHC P:.c ject ss ~JC!! ;lf be uz.c= :. ::-!? ?:25. The incumbent is expected to work. toaether xlr- tn~:.-z~ezt 's tlCH . . F'hyslclsn and th~I\!u rse Mjrjwif e 25 a mler;~:.~r :' :.:- : -,? L,:Y~,L-Lcz~, -- - focuzing on clinic-based activities. Cjeccne;, :--.-.;,~C-.- dm .;; . . . - expected to coorci nate her activities with +'-'c.L..- -r\*C-n~tr&l ---. l=~ti 9n.' Transportation Azsociate (A1 Neill) at the RHMT l~,~~1. The incumbent, is expected to attend weekly team mestinzs an2 hole individual regular meetings with the COP. TRAVEL: The incumbent is expected to work at a minimum 50% of his/her time in the field outside Mbabane. MISCELLANEOUS Ezch team member is e::r\ected t; ~2nt;ibut~to th~tEstT1'5 MZTdtkllb bn5 qusrterlh reports ant: adrninis~r-ativeactivities 2s requesrsd L? the COP, 2nd USAIG. Eirezt overall su~ervisionin Swaziland is zsrri~kcut by. the COP with tezhr~ical guidance and direction given by the MI'JH Phyc,icisn. Gll team members will have per.formsn=E review and rlznning zs per M5H Guidelines each six months. BEST AVAILABLE COPY SWAZILAND PRIMARY HEALTH CARE F'R(3JEC CJ i rll c har~au~mentkssocci ate .elr$~tract clt F'r-r~ieztcjl-ttp~.?. Indl catot-s - March t.. IC''.l, 1 . Imprmved Servl ce Del i verb, ar~di~vt rc.~ =ti H;~~TC.ZC~~--ILJE.-,E? oped 1.a. Idumber o+ outreach sl te~crpet-at i onai . 1.b. 1 Clinic=. doing regu! s!- P,o,T~E <, i it^. 1. d. 1. Use ot manuals de;-cl Z>+~Q:1 rrt~l errfentea b.; F-,tiCF' Dr~cg Fat-mu1 dry. Cl i ni c Reference Han~ts1. Cl i nl c Orlentation Man~rs!. 1. d. 2 Drucj Management 5.y-stem operatlanal . 1. e functionins communi tv health cornmittec-. 2. lmraved c,l::i 115 and Mativatian @i Health Wot-l::ers. firaught about tlv Improved Transpmrt and Coi~lrnunica.ti01-15 and Improved Supervi~ion and Manajement support 2. a.5. Clinic re-organized, including privacy curtains. ii1 ing s~stems.patient flow measures. 2. b.4. Number of new health education materials developed. 2. d. Conditions of service i mpraved 2. d. 1 Nurses accornmodati on upgraded. 2.d. 4 Cl I nic Supervise!-r vi sits addt-ez.c,ing condi timn.: of servj !=e. 2.f.l. Use af Supervisury Check1is.t. 12 March 1??C! L,,: AYAILABLE COPY outputs Ihe clinic represents the front line of preventive, promotive bs a tear. V.Joret, n.lroeger and li.Price will maintain a (J) Ongoing rork on inproving the rcfcrral ~yslem and curative health services in Swariland. It reflects the clinic focus. Since training remains a priorily, training danc in total HOH policy towards health an4 thc comrunity on the one this area will primarily be clinic-base, and in-service (4) lvaluation of the rcfcrral syslea trial. hand, and the coanunily's response to those policies on the including devtlopnenl of skills of Regional Trainers. drug management program and regional olher . lor this clinic-level work lunds have becn allocttd here as $vpervisory me thcds well as in the clinic-level training sections of the rork plan. Clinic staff are faced with the impact of trtdilional beliefs focus and priorilies 41 this lime are: (5) Iraininq of regional traintrs to carry out clinic- and practices, limited knowledge and negative attitudes rhich based training can impede thrir effort!,. In many instances. the staff are (I) , Han8qemtnt skill$ including those relatcd to inv?ntcr., also faced with such environmental constraints as poor management, uork sch?duling, supervision. manq?inq 4~1g . @crtlopm*r~l of rrprnpri~t*clinic.fort1rr4 ranvalr housing, lack of potable rater, lack of basic ~anilation, and vaccine supply among others at the clinic IevpI absence 01 mcans of communication, inadequate or (I) rrr113~limit?? fund: lcr vpgradlng nursing housing non-functionin9 cquipnent and lack of es!,?ntial supplies. (2) Nursing skills in community outreach, h??lth ?!'!caiir'n, in thc re71rns Hany staff also lack the skills required lor thrr lo perlorm problem solving, and basic outreach serviccs to their basic lunclionr. be implemented at the clinic level - ...... --...... I IICI! ! !funds ! 1989 ! 1981 ! 1989 !! 1990 ! 1990 ! 1990 ! 1170 ! 1711 1711 'ir'41b ! 110. ! ! Cl lNlC HnNRStHf Ill PROtRbnnt !(t) ! QRI.7 ! QR1.3 ! QR1.4 !! OR1.1 ! PR1.2 ! PRI.3 ! 071.4 ! QR1.I '911.1 'I~ICIIC! fYPlPMOlOQY molt5 ! ...... 1___...... I I !?O !!raining regional trainers in clinic-based ! J,000 ! ! XXXXX~X!XXXXX~X~!~XXX~~~!X~X~XXX!~XXXXX~!XXXXX~X~ ':P, 18'19 be inn@\er-nlsd as pa11 nj Ihc rlinit tale4 training! ! !training including development of ! ! ! ! ! ! ! ! ! ! I ! !Lo be done in all regions -1arling *~lnjh~sclucni ! ! !nodules for clinic nanageaent. ! ! ! ! !! ! ! ! ! I ! ! t 2 !?I!Provide clinic-baced traininp to clinic nurse! 7,000 ! !xxxxxxx!xxxxxxx! !xxxxxxx!xxxxxxx!xxxx~xx!~~xxrrxr! I !2R !add'] fund5 available lser clinic-bared training) I ! !in basic management skills including ! ! ! I ! ! I ! ! ! I ! ! I ! !,upervision, patirnt Ilou, drug rgmt., ! ! I ! ! ! ! ! ! ! , I ! ! ! !coemuni ty pro1 iles and outreach ! ! ! ! ! ! ! ! ! ! I ! I ! L S !2? !Upgrade clinic nur~accomadations ! 44.000! !xxxxxxx! xxxxxrx! !xxxxxxx! ! ! I I !?o ! 4 !?5 !linalite and evaluls nursing orientaticn ! 500 ! ! !xxxxxxx!! ! xxx ! ! ! I 12r. 101 ! ! !mtnvals and procedares ! ! ! ! ! ! ! ! ! ! I ! I ! I 5 !24 !Implementation and evaluation of: ! 16.000! ! ! !! ! ! ! ! I !?C. lo! ! ! - referral system pilot ! ! !xxxrxxx! !! ! !xxxxxxx! ! I ! I ! , ! ! - drug manaqemrnt program . ! ! !xxxxxxx! ! ! ! !xxxxxxx! ! ! ! ! I I I I I ! ! - methods used for clinic supervision ! ! !XXXXXXX! ' !! ! !xxxxxxr! 6 !?5 !Generator maintenance and repair training ! 4.000 ! ! ! ! !xxxxrrx! ! I I I ';D ' I I I 'It, 10' ! 1 !?6 !coeplele 101 m~nurlsfor clinic management ! 500 ! ! !xxxxxxx! ! ! ! I , , '!C, I!!' I 8 !?1 !expand 6 eval clinic wpervisory checklist ! 932 ! !xxxxxxx! xxxvxxr! ! ! ! I I 9 !28 !Irainers alnual for drug management ! ZOO0 ! ! ! ! !xxxxxxx! ! ! I 110 ' I 10 !?9 !Oevelopment of nursing incentives ! IOOO! ! ! ! ! !xxxxxxx! I , I 110 ! ...... ! 1:.912 APPENDIX B Outreach Sites SWAZILAND PRIMARY HEALTH CARE PR0*7EC7 CLINIC MANAGEMENT ASSOCIATE OUTREACH SITES SHISELWENI REGION (11) S./N Alexia Masuku 1. buornintahq ,-r, . T,it?dze - I .EJkltsini\ 3 . T.ie3ze - 11 4. Mlindazwr; 5 . Zindwendweni 6. Ngololweni 7. Kholwane 8. Mf eny ane 9. Vulamehlo 10. Othandweni 11. Dudusini. BEST AVAILABLE COPY 1. .'+ . L,=,:1-.-.2 'c- r. -. !:&!::.:.. ..; 3. Id ci i a l,3 11 - 4. pj:,1 F.f--F,? 5. Lntl-~atldweni 6. Esiweni 7. Sitsatsaweni Church 8. Kashsba 9. Ngcina --SI TII::JEELA HEALTH CENTF;E c 5 i S 'I4 Elizabeth Langwenya N kon ,iwa c rooms ! Gucuka I class I Maloma c rcmm 1 Kukhanveni Ma1:wel:wet.i I sr;h~clI Mho~l c tree: started structure Mahi-10s he i tree J Mpiis~natj bunw PHILIPS ?I Sr. kaphael Ehartey Sr. F'auiina Mdziniso BEST AVAILABLE COPY HHOHHO (22) Sr. Harriet Runene J ubukweni Lundzi Makhwane Mantabeni I Mantabeni 11 Mlindazwe Siphocosini Luhlendlweni Bhikini Melete Maphalaleni Steendorp Kalamgabki Dlangeni Mbeka Near Sckroc~l Zandondcl School Nkomazi I Gushsde) Nkambeni School Ngcmane School Mavula School Ludlawini Mz imnene F'age - 3 BEST AVAILABLE COPY MANZINI 1. Mkhulamini 2. Ntabamhloshana 3. Mampemben i 4. Lesibovu 5. Mp111 ilz i 6. Bulunga I 7. Bulunga 11 8. Mhekelwsni 9. Lezi t.1-la 1. Thulwane Siyerldle I?*liahwini Luzelwini Mlindeini Dilini Maf utseni Ticantfwini Dzanyana Ciugwini Lunyaweni Mtini Total FHC Prcject. - Assist.ed Sites 84 10 July '9Cl rnargi~~utrsit-s Page - 4 BEST AVAILABLE COPY APPENDIX C Lundzi Outreach Site-Speech and Newspaper Article SPEECH - LrEr11CATION - LIltiT?Z 1 !-,r!TF.:EAI::H C I TE Dr. Marilyn Edmondson 10th August. 1390 To: Your Royal IIighnecs . I'r.int-.e Mt.hen,hl~. Indvuna Msgaguld, Headmaster Zwsnc. Regjfir~alI-Ie~qLti: .?cl~iiillictratipr. f-?ic.~I'lt.!~.ili. Sr . fiarriet. k;ul.;.r~e, Al:t in€ Matr.:~n. Est.een1cs.d Men1i~e.r:~c~r t nFj ill~nd..;i~::c:>rr~rnurli t,y Honoured Guezt? As a r~-preser1t.at.iver.f' t11~5',w9:,iland Primary Heslth Csre. F'r.:\.iect. and its Funding C!rganiz::?: i.-1; . t!-16: Ilr-lit ed States Ligcncy f..?. Irlt.erri:;ltion~l Development t USAlU ) . I wi .F ii t i: ,-.l:snilner~dt.115 r_.c.nmlur~it:; .-,r! 11IF. ci:impletic.n of this outreach siie . . . - The Swazilar~rJPrinlary !-i-:iitn tlzre f'r~>,iect.in ::c~~:~pc,~-:.- 2 .,I: ~:i1 !., the governn~entof the f:i;-;g .2,:#!r! Sc~a~iland . thrc~ugl~t.11~: I-! i f+Y:,' 0- f Flehlf.11. -. - is c~ommittedto streric:- iler,jllg ti-~edelivery ~f l?rin~z~~.;::4-:::.:7.!~ ['?!,? irl Rural hreas. One of :hc strat.egies to accomplish tiiir go;ll. iF:the ., . yrovi.aion of access LL-;.;. prry.?ent.ivehealth services : :.- 3%: i~~g communities to construct. outreach sites. In support ,s.f tilis essential c=c?mponent.of Primary Fiealtli Care, tlie Primary Health .731-e F.rr'jert provides basic furniture and limited materials for upgradir~gor completing st,ructures. To date. 75 sites throughout the country are receiving support at a total cost of approximately E50.000. The construction of outreach sites is a self-help. community-initiated activity with guidance being given by nursing personnel in the regions. The 1983, National Ilealth Policy of Swaziland states that improving health status of people requires a partnership between government and ccmmunity. The communit.y is not only the recipient of health care, DUT shares in the responsibility for developing health services. Communit~~ Participation is therefore an essential element in achieving the social goal of "Health for All by the year 2000". The Lundsi community servec as a model of what a highly motivated community can achieve with limited financial support from government and international dcnors. MI* task is t.o present to -the community. the furniture for the cutreach site and share in tl-15 celebratinn of this important c)cra.e,inn. The sum nf E750 was alsc contributed. TCJ assist with bulding materials i_1ShID/Swasiland and F'rimarp Health Care Project encourage your strong, well functioning health committee to continue its active role in assisting His Majesty's Government. through the Ministry of Health, to provide basic health care to all. MY God bless your effcrts and give you strength to continue the upgrading of your community. Sisw2t.i 1nt.arpreter Mr. W.M. Jele BESTAVAILABLE COPY The Times of Swaziland Tliursd:~~,August 16, 1W0 Comlnunities nust also take part in health projects UY hlIlLEN(;I Swaziland s;~~;iares hfOATHA that the irr~r.rovcn~c~l! ~RI~~ARYhc.llll of tl~cIlcnl~L .ra::s r\f a,ld USAJ~) the nab011 cLs lor a deputy director in part~~ersl~ipbclwccl~ D~hl.ullyn goveriltne11~and con\- Edrnondson has told mu".iljes8 a XlCp. .~hc the Lun&.i cconlmunity LullrhJ ConmluNr).has they are not only tden by budhlp ~tsclf recipients of Iiedtl~.but a healtl~outreach arc also expected to IUre. share in tlii rcapon- "The Swaziland sibility for its improve- Primary Health Cue ment. . Pm'act. in coopention Spe.&i~ig when she wid the government of presented fumirurc to Swaziland tiirough I+ the Lu~~dziClinic Health Ministr . Is rccently. Dr Ed- committed to en{-- n~ondsontold the com- ing Ihe discharging nf mul~ityit is for this pnmvy health care in reason that community ~rdwens. p,dcipaion UI he ini- "A stratagem in provcment of health achieving. this od is services is deemed an Ule mvlslon otacces- imporIan1 clement in sibilly md ~vcntive anainin the tocial o;ll health services by rc- *.H~%~For AIFB~ sisting cmrnunihes lo The Yur 2000." construct outreach 'The Lundzi com- sites. To sup munity serves as a component o PS":nipor- lhiS model of what a hiplily tance to the Primary motivated community Health Can (PHC), tk can at& with meapt PHC project maker rmancid support fm provu~onsof basic fur- the government and niture and limited donors." Dr Ed- materials forupgdng mondson said. or completing struc- tures. The Lundzi com- munity bud1 the clinic 'Todate. them uc75 themselves. The hrmi- riter thro~~qhoutthe lure wiu dcmated b the country ruavmg sup Prim., Health Eare port as 8 total cost of Pro'ect m collabor~tion annroximatelv ESO witk its Cundin or 000. 'Ihc concOnSLNCSLNCdon anidon. the $nit2 of ouvuch nter IS a hates Agenc for Jn- self-hel . community ternational develop- initiate rognmmc ment (USAID). and unier strict Dr Edmondson said guidance of nursing the 1983 National personnel JO the Hcalth Policv nf ~gion." BEST AVAILABLE COPY APPENDIX D Survey Questionnaire If the ~iini,: has nst, m5de hl?me vlcits. 5t3te tl~erl;as3r*rlcz * WLl-r' t Example: Nc. 1-ransyclrtati~r~,clinic t.nc8 busy. etc. I a. hrug Formulary Manual t.. i:'lini c Iief rrence Planual c. Clinic C~rientationManual Freq1:~rncy cpf use of each Manual a. Drug Fc>rn~ularyManuai I. Clinic Ref ergnce Manual c. Clinic Cwientati.cn Manual 4. List- the Clinic Nurses accorr~~~~odationsinanle of site in mcbst. need cbf repair. 1.131;.;,. a list. c.i tl-le tJ3~i~rephirs t.hat wctuld t~pgrad~:t.he accc~mmoci~i:.i .F Hew c.ft.sn did the superviscsr visit yc,~clirlic in 1$'8$: ------lduniter i,t visits in 3 9gi1 . ------, 3~~~t.5it.l BEST AVAILABLE COPY SWAZILAND PRIMARY HEALTH CARE PROJECT Home Visits - Lubombc Req~on M. Edmondson March 19, 1990 Clinics Making Home Visits (Clinic Staff1 Freauency (week1y Clinic Record Once I Twice I (Three times) Yes 1 No LZ-.shasna X ?.:;ar,a Ra1 1 way X hzzevane X S : ZSr, i flazarene X Sitek~PHL' X S ?nof anen I X St. Philips X Tambuti X Simunye X X Mpolonjeni Not stated Not stated Tambankul u Bhol i Ubombo Ranches Clinics Not Makinq Home Visits 1. Tikhuba 2. Tshaneni Health Centre 3. Mhlume 4. Mpaka Refugee 5. Manyeveni 6. Shewula 7. Sigcaweni 8. Sithobela Health Centre The above nine clinics stated reasons for not making home visits as either too busy or shortage of staff. 9. Ebenezer 10. Gilgal 11. Good Shepherd Hospital 12. Ikhwezi Joy 13. Langa Bricks 14. Lubuli 15. Sinceni 16. Vuvulane * Fol 1ow-up: Additions: Making visits - Bholi and Ubombo Ranches, thus 45% (13 of 29) of clinics in the Lubombo Region report mak~nghome visits. BEST AVAILABLE COPY The eight clinics numbered 9-16 did not give reasons for not making home visits. Summary : Thirteen of twenty - nine c1;nics are making home visits fcr E total of 45% The other sixteen clinics (55%) do not make v~s-ts. eight of the clinics is the latter groups cited shortage of staff or too busy as reasons for not making visits. The other eight clinics did not give reasons. BEST AVAILABLE COPY APPENDIX E Clinics Making Home Visits Append ix Individual Clinics Makinq Home vlslts {Total - 42) and Number of 'bi?slts Nade January - --3cto~er '93:' South - 6 of 8 = 75% North - 4 of *7 = (data Incomolete) 1. Salvation Army 65 I. Herefords 43 2. Mctshane 32 2. Ndzingeni 33 5. iobamba 30 3. Mshingisningini 17 4. Slgangeni 10 i. Horo 9 5. St. Mary's 5 6. Nkaba 4 Manzini Manzini Sub-reqion - 4 of 19 = 21% Mankayane Sub-resion - E of il 73X 1. St. Florence 37 Geben i 2. Mafutseni 19 Sigcineni 3. Bhekinkosi 18 Mus i 4. Engculwini 7 Ncabanen i Mahlangatsha Cana Luyengo Mangcongco Lubornbo - 10 of 29 = 34% St Phi 1ips 84 Si munye 46 Siteki Nazarene 34 Tambuti 26 Ngomane 16 Sigtaweni 9 I kwezi 5 Shewul a 4 Sinceni 2 Bhol i 2 (Home visits reported by Refugee clinics where not included) Shiselweni - 10 of 16 = 63% 1. Mashobeni 66 2. J.C.1 64 3. Our Lady of Sorrows 40 4. Lavumisa 20 5. Zombodze 15 6. Nkwene 6 7. Phunga 6 6. Mahlandle 4 9. Ntshanini 4 10. Dwaleni 2 'Vr~ly7 uf the clinics in Hhohho North reported. RCCT d\/d I1 An1 C mDV APPENDIX F Active Community Health Committees Append ix Active Clinic Health Committees Hhohho South - 9 of 9 = 109% 1. Sigangeni 2. Nkaba 3. iobamSa c. Motshane 5. Ekuphileni 6. Florence (on HIS - Listed Manzinl 7. St. Mary's 8. Malandzela 9. Salvation Army North - 7 of 9 = 78% 1. Bulandzeni 2. Herefords 3. Mangweni 4. Ntonjeni 5. Horo 6. Endzingeni 7. Balegane Manzini Manzini Sub-Region - 4 of 19 (Gov't, Mission, NGO's) = 21% 1. Bhekinkosi (Nazarene) 2. Mliba (Nazarene) 3. Sigcineni (Gov't) 4. Sigombeni (Red Cross) BEST AVAILABLE COPY Mankayane Sub-Reqion - 6 of 11 (Gov't, Mission = 55% 1. Mahlengatsha 2. GeSeni 3. Ncabaneni 4. Musi 5. Mangcongco 6. Cana Lubombo - 13 of 25 (Gok't, Kission, Industry) = 45X 1. Sithobeia Rural ~ealtnCentre 11 . Vuvu 1 ane 2. St. Philips 12. Lomahasha 3. Sinceni 13. Gilgal 4. Ikwezi 5. Lubuli 6. Mpol onjeni 7. Siphofaneni 8. Shewula Nazarene 9. Bholi 10. Tabankulu Shiselweni - 8 of 16 = 50% 1. Gege 2. Zombodze 3. Ntshanini 4. Dwaleni 5. Matsanjeni 6. J.C.I. 7. Nkweni 8. Phunga Total Number of Clinics - 93 Percent of Clinics Total Number with Active With Active Community Health Committees - 47 Committees - 51 % BEST AVAILABLE COPY Summary - Active Health Committees by Region Region 1. Hhohho South - 9 of 9 = 100% North - 7 of 9 = 78X Manzini - 4 of 19 = 21% Mankayane - 6 of 11 = 55% Lubombo - 13 of 29 = 45% 4. Shiselweni Shiselweni - 8 of 16 = 50% BESTAVAILABLE COPY APPENDIX G Clinic Based Training Follow-up Form 1 CLINIC FGLLOW-[JT' VISIT - CLINIC MANAGE!-IENT ASSOCIATE (-'1inic - --- Visited t.: Clinic staff /dat.ez At.t,ended Traininp Follow-Up Activities Clinic Organizatjon a. Filing system b. Patient flow c. Consulting room set-up d. Position of refrigerator for vaccines (11 Vaccines corr2ctly planed (2)Gas supply (cylinders.1 e. F'ri-~acycurtains 2. Irnmunization/Growth Monitoring a. kct.ivit.ies placed f c~ravcid Ctongestion-separate sick from well children h. Immunization schedule . Use of disposable/reusable syringes disposal methods d. Use nf salter scale e. Road tro health card BESTAVAllABLE COPY 3. Oral Rehydration Therapy (ORT) a. Corner functioning/frequency of use . Equipment maintained - table. twc benches, ORT Chart. plastic rur1=. spoons, buckets. measuring cup:. 4. Mani~als a. Ilrug Formulary h. Clinical Reference c . Clin1.c Orientation 5. Drug Management System 6. Community level activities a. Supervision of RHMs b. Home visits c. Community health education d. Community health committee 7. Supervisory Visits a. Supervisory Checklist used or1 visits b. Visits addressing conditions cbf service 8. Nurses' accommodation 9. Other Comments/Actions - Page 2 - BEST AVAILABLE COPY APPENDIX H Trainees Clinic Based Follow-up SWAZILAND PRIMARY HEALTH CARE PROJECT LUBOMBO REGION - CLINICS/TRAINEES FOLLOW-UP CLINIC MANAGEMENT ASSOCIATE Hazel Sembe S/N Nomsa Magagula Laurene Klamo2 S/N Thandie Ndabandaba Durn1s;ie Mavtiso :reiief nurse Tikhuba) 7 r- IS~E:ir,?aSats~ - tdursing Assistant (S:.'N relief from S~tekiPHU) Anna Dlamini Elizabeth Simelane 4. Gi1 sal Venancia Dlamini Lillian Shongwe 5. Lomahasha Nelisiwe Mamba Dudu Masilela Ruth Nyoni 6. St Philips Priscilla Gina Sr. Raphael Sharkey Janet Yeboah 7. Sithobela Health Centre Beauty Dlamini Trainer - Thembie Dlamini Mildred Dlamini (transferred Sinceni Clinic) Fortunate Magagula Netty Fakudze Khetsiwe Thwala BEST AVAILABLE COPY 8. Siteki Nazarene Sibongile Mdlalose June Stewart 9. Sinceni Sindile Gamedze Trainer - Thembie Dlamini (now Staff Nurse at clinic) 10. Vuvulane Tobhie Mndzebele Phephile Nsibandze Otilia Mlotsa Dinah Gele Veronica Vilakati Elizabeth Nxumalo Dudu Ndz imandze 13. Good Shepherd Trainers Sibongile Vilakati Sr. Eunice Hlalaza Maureen Mayenge S/N Flavia Katuramu Rose Matsenjwa ( PHU 14. Bholi Trainer Happiness Maziya Patricia Gina Mildred Zwane 15. Shewel a Nazarene Beauty Magagula Ruth Ns ibandze 1 6. Ndzevane Refuqee Eli zabeth Matsebula Pedro Fumo Lydia Gumedze Pauline Mdziniso BEST AVAILABLE COPY 17. Ikhwezi Joy Gertrude Gamedze ( SIN - working a1 one) IS. Manyeveni (Malindza/Mpaka Nazarene) Busisiwe Dlamini Irma Lukhele Minah Mathabel a A1 bertina Matse7,jwa 20. Simunve Khosi Mhlonga Sizake 1 e P:agagu i a 21 . Simunye/Ngomane (separate clinic - administered by Simunye) Emma Nhlapho 22. Tambankul u Angeline Simelane Sr. Julia Ndlangamandla 23. Ebenezer Phyllis Mamba/Nursing Assistant 24. Siocaweni Sellina Magagula Gugu Maarja 25. Ubombo Ranches El izabeth Lukhele S/N Maggie Dlamini S/N 26. M~aka(Malindza) Refusee Christine Mutube S/N Jenny March S/N BEST AVAILABLE COPY No Trainees 1. Mpaka Coll ieries (Emaswati Coal 1 2. Mh 1 ume 3. Tshaneni 4. Big Bend Sugar 5. Si tsatsa~eni Did Nst Complete Trainina 1. S. S~melane (H.I. Bholi) .-.3 N. Mtsetfwa (Malar~aAss't - St. Phlllps) -.- 12-es Dlamlni (H.I. Malaria - Ubombo Ranches) BEST AVAILABLE COPY Clinic Yanagement Associate Clinic l'isits - January - December 19- January 15 Or.ientation field \-isit5 - !!: . !-. Jcret, PHC !lCII Physician. Lubombo Reqion iubuli Clinic - Clinic based training site Good Shepherd Scho~la: Nursing - Planning for Training of Trainers. Orientation Fields Visits - Dr i. Joret and Firs Joyce ?ltirrr;'. ..- r , !-.SFPA. Hlatikhulu PHU Nhlangano HC Znmbodze - Clinic-based Training Site Hhohho South - Sister Hope Msibi, Clinic Supervisor Nkaba blotshane Lobamba St. Mary's Salvation Army 51ar.ch 27 and 29 Shiselweni - Dr. T. Braeken, PH Medical Officer Nhlangano Cege Zombodze Matsan.jeni ?lahlandle Lavumisa J.C.I. Hluti August 7 Sister E. Nyoni Joyce Mtimavalye UNFPA Project Lubombo S imunye Tshaneni Yhlume Shevula Nazarene Lomahasha Tabankulu l'uvulane BEST AVAILABLE COPY August 8 K. Nkabindze, Community Health Nurse Siteki PHU, J. Mtimavalye Lubombo Ubombo Ranches Bis Bend Sugar Estate Bhol i Ndzevane Refugee Lubul i Sithobela Siphofaneni Gilgal September 5 - Dr. V. Joret Hhohho Xorth Emkhuzweni HC - Reconnaissance visit - Hhc!.!lc ReClon clinic based training' site. September 19-21 Sister Dora Simelane Mrs Joyce ?ltimavalge, UKFPA Project Manzini Region - Mankayane Mahlangatsha Luyengo Bethlehem Ncabaneni Musi Gebeni - Proposed site for ganzini clinic based training Cana Sigcineni Dwalile Mankayane PHU Usutu Pulp-Mill HC Mankayane Hospital - OPD, ORT and Maternity Unit BEST AVAILABLE COPY APRIL - JUNE 1990 Til-rhuha Ebenszer i;c,od Shepherd Siteki PHI! -14 -- ~irtd 15 May Accompanied by S . !; ;q.l,ni~ix I..l3gag1-116, Trainer. Siteki F'HI.; Mpc~lnn.isni 2it.ek.i Nazarene A - Good Shepherd ivisi ted 14 +, : :' I Tikhuba Ebenezer 12 - 15 June Accompanied by S,!1.i Elizabeth Langwenya, Sit.hGbels Health Centre. Bholi St. Philips Ikhwezi Joy Siphofaneni Sithobela Health Centre Sinceni Gilgal 19 - 21 June Accompanied by Mr. A. Nyoni, PHC Project Tabankulu Shewula Nazarene Lomahasha Ubombo Ranches Mpaka Railway Malindza iMpakai Refugee Simunye INgornane Vuvulane Ndzevane Refugee Sigcaweni Manyeveni BEST AVAILABLE COPY 2 clinics, Tikhuba and Ebenezer - visited twice Good Shepherd - visited three time: Visit.ed. but no traineec Mpaka Collieries tEmaswhti Coal1 Tshaneni Mhlume Eig Bend Sugar 11 July '90 l7rptref BEST AVAILABLE COPY APPENDIX I Nurses Accommodations Upgraded 7 -. >;Ig511g.-.,-, . -A Mi5sirr.n i 2 I LJgr:iJ we111 7. L. I4k.?,ts.3 HI. ikjh I.igf;tll1.1r1i ..)*' . l,.-~t~a~nl-~r~ Maf utsrni 4 . E.lalan~:l.;la I ril.1~1~~l-krl,:lii r Marlk,;lv arle SuI->-Fze...~jit:] i 4 ! EQ. Motshan.. **I. Ijwslile 5. M~azi r) . Mahlangatsl~a 6. Luysrlg(2 3. Mangcongc~ 7. Gebeni 4. Sigcineni 8. Ncabaneni 8 completed North ! 9 ! ** Nurse & Nursing Assistant. r, 1 . Man,-eni I. Mshingishingini expected tcb share very small 2. tlorc 6. Endzingeni house. Health inspecter's . . Entf ~n.ieni 6. Eal egane house currently being used by 4. Hereford5 nurse. but must vacate soon. 5. Rulandzeni 1 i_.c\m~let.ed 6. House No. 12151 ?'cr,tai acsomnic~?at.i.~;r~~t.~he upgraded - - 30 cc~mplet.ecl (:;+ge - New tjc:use but. - Pr13t:lem wit.h water - Collecting water fram river - Nc, water t'ank. I 4 stari houses I . Jerichl: - New hcuse - Electricity connected to cne hcuse net the other. FI.la.r:h(:,tcleni 1 Nurses houses n.:~t_. ccnrie,:ted t.3 gener,ator. Electricity Ka-Fhunga ! Eioard appiicatiori submit,t.ed by flara Hsnsc>n ('Fiep.>rted Hlut i 1 9th Msrcfl 1991:1 I. Eij11u:ation t.r.. share cost?; - schcacslc t;ege .t near cnuld share s&me line BEST AVAILABLE COPY APPENDIX J Supervisory Visits cLi..!?..l.c(...L4..). r!s2. ~ .~..C.f...... Y i.~..&L.5. Lobamba 24 ( Visited Monthl$j) Sigangeni 27 i Visited Monthly r Bulandzeni 1s N kaba 1s Ndzingeni 1s Horo 11 Herefords 11 Mangweni 9 Mo tshane 8 Mshingishingini 7 Salvation Army 6 Ekupheleni 5 Ndvwangeni 5 Malandzela 4 Mbabane Family Life - 7 St. Mary's L * Individual data sheets not available for all Clinics in Hhohho Region. *x Summary Report list - 176 visits. BEST AVAILABLE COPY Region Man= i nl Engculwini 21 i.Visi ted monthly Eihekinkosi 16 Nafutseni 14 Mliba 13 M;lkerns Family Life 10 Family Life C!ssociation 10 E kuazeni - Swazican d St. Juliana's -r, St. Florence 4 Kwaluseni 4- Emoyeni 2- Kabudla -' r Cic~lwirii L Swszilznd Railway L-, St. Tneresa's 1 Nonhlanhla 1 Erigombeni 1 Sub- total Summary Report Lists 265 BESTAVAILABLE COPY Individual-- - - Clinic -. -- -Supervisory- .. .. - .--- ..-...... V.1-s..~...t.s Luyengo 30 ( Visited Monthly ) musi 26 i Visited Monthly 1 GeSeni 16 Ncabaneni 13 Mangcongco 9 Cana 8 Sigcineni 8 Mahlanga tsha b Dwalile J-C Bethlehem 3 BEST AVAILABLE COPY Recjlorl Lubombc PI2.l I -id;a h!a?ve~eni Sinceni GiA-, yG-- 1 Ubombo Ranches Lorna hasha Siteki Nazarene Bholi Mpoionjeni Vuvulane Lubuli I kwez i Simunye Shewula Tikhuba Malindza Refugee Ndzevane Refugee Siphofaneni Tarrlbuti Ngomane St. Philips Ebenerer Sithathsweni * Summary Sheet :04 Mpaka Colliers Tambankulu Mill Clinic Mhlume Manangz College Cr. Martin's Flame BEST AVAILABLE COPY Hlclti Zombodze Nashobeni hatsanjeni Lavumisa Mhlosheni Bethany Our Lady of Sorrows Nkwene Gege Ntshanini P hu nga Mahlandle J.C.I. Dwaleni b!hletsheni .1- Su~imarySheet = *80 BEST AVAILABLE COPY APPENDIX K Supervisory Checklist SWAZI LANU SUPERVISORS CHECKLIST FOR CLINICS REGION ...... CLINIC: ...... CLINIC CODE: ...... NO.: ...... NURSE-IN-CHARGE: ...... SUPERVISOR: ...... RATING SCALE 1 . E:xcel lerlt all items p~-*~s-=nt 2. Satisfact t-91-y - absence of item 3. Needs Inip~.o~~emerit- Mcrp tllat~ 1 area ~~nsat,isis~::tory- bleeds Improvement 4. N/'A blot Applicatlle I I I I I I I I I I I I DATE I I DATE I I DATE I AREAS I RATING I REMARKS/ACTION : RAT ItlG I RF:PlARKS/ACTIc:N : HAT I tlG : R.Et?ARY,S/ACT ION ] ------I I I I I I I I I I 1 I I 1 . PATIENT CARE MANAGEMENT I I I I I ------I I I I I I ...... I I I I I I I. I I I I Maternal fIealth/Family Planning I I I f I I I I I I I I I (MH/FP) I I I I ------I 1 I I I I I I I I I I , I 1.1 Complete Medical and obstetric I I , I I I 8 I and/or FP history and physical I I I I I I I I I examination I I I I I I I I I I, I I I 1.2 Risk identification and referral ! I I 1.3 Tetanus Toxoid status I I 1.4 Sexually transmitted Disease (STD)I screening/protocol I I 1.5 Neonatal immunization 1I I 1.6 Relevant FP interview examination,: counselling I I 1.7 Annual PAP SHEAR I I I 1.8 Required data correctly entered I 1 on antenatal, delivery and FP I I Cards/registers I I 2. Child Welfare ------Immunization 2.1 Adequate supply of vaccines/ dilutents 2.2 Current, immunization schedule 2.3 Stari1.e syringe/needle for each injection I 2.4 P~.operinjection technjq~~e I I I : DATE I : ~A'T'F: I : DATE I AREAS I RATING : REMARKS/ACTION I HAT 1 11G I Rl;I.lAI{.KS/A(7'r ION : RATING : REMARKS; ACTION i I I 1 2.5 Operation/maintenance of Cold I I Chain Ia I 2.5.1 Temperature I 2.5.2 Vaccine Placement/rotation I I I 2.6 Prompt diagnosis, tracing and aI reporting of communicable disease ! outbreaks. I Growth Monitoring/Nutrition I I ------I I I I I I I I I I I 2.7 Proper weighing equipment, I I I I procedure and plotting. I I I I I I I I I I I I 1 I I I 2.8 Interpreting growth chart to I I I I Caregivers I I I I I I I I I I I I I I 1 2.9 Diagnosis and nutrition counse- I I I I 1 I I lling for growth faltering I I I I f I I I I I I I 2.10 Breast feeding promotion I I I I I I I I I I I I I I 2.11 Storage/distribution of World I I I I I I I I Food Supply I I I I I I I I I I I I I I I Childhood Diseases I 0 I ------I I I I I I I I I I I I I I I I I I I 2.12 Dehydration assessment and Oral I I I I I Rehydration Therapy (ORT) for I I I I I I I children with diarrhea I I I I 1 I I I . I I I I I I I DATE I i)A'i3I~: I : DATE 8 AREAS :RATING:REMARKS/ACTION ~HA'TU~~:: lil~il~lih.~ h:,l 2.13 ORT Corner functional I 2.14 Ilome use of ORS/SSS demonstrated I to Caregiver I I 2.15 Diagnosis of Acute Respiratory I Infections (ARI) on basis of I breathing rate JI I I I I 2.16 Current Management protocol to I I treat/refer coughing children I I I., 3. HEALTH EDOCATION/COUNSELLING ------ I 3.1 Health messages and counselling intergrated in all health I activities I I I I 3.2 Individual and group health I I education and counselline sessions: I provided I I I I 3.3 Written educational plan reflects I tI priority topics and target groups : I I I I I 3.4 Appropriate teaching sl.rategies I I I I involve clients (songs, drama, I I I I return demonstrations) I I 1 I I I 4. RECORDING AND REPORTING I I ------I I ------I I I I 1 I 4.1 Ledgers/registers maintained I I I I 4.2 Patient Cards contain required I I I I data I I I I I , I I 4.2.1 Risk factors and action I I I I taken recorded in red I I I I I I 4.3 tlaalth Information Systenl (HIS) I I tally sheets completed accurately I I I I and sub~nittedon time. I I I I I 4.4 Data feedback used to improve I I services I I I 1 I 1 4.5 Graphs posted and up to date I I I I I I I I A Fi 1 i rip Sv~1,r:rn ~r~anizerl 4 I I : DATE I l DATE I DATE I AREAS j RATING : REMARKS/ACTION i RATING :REMARKS/ACTION I RATING :REMKS/ACTION I 5. INVENTORY/DRUG MANAGEMENT I I 5.1 Equipment, supplies and drugs I I adequate to support priority aI aI services, I I I I 5.2 Timely ordering and procurement I I 5.3 Inventory list available/curront 5.4 Preventive maintenance/repair of equipment 5.5 Authorized Minimum/Maximum Stock of essential drugs 5.6 Ordering. Storing, Dispensing and control ling drugs by established procedrlrss 5.7 Prescribing by national protocols 5.8 Safety precautions - Drugs 5.8.1 Shelved and labelled 5.8.2 Unit doses 5.8.3 Proper disposal of syringes needles 5.9 Appropriate instructions/advise patients 5.10 Follow-up on patient compliance with prescribed medication INTER-INTRA PROFESSIONAL/COMMUNITY AC'I'IVITlES ------I I I I I 6.1 S~lpervisionand' support of Rural I I I I Health Motivators ( RtlHs ) I I I I I I I , I I I I I I I I ' I I : DATE I : DATE I l DATE I AREAS IRATINGIREHARKS/ACTION :RATINGIREHARKS/ACTION :RATING:REMARKS/ACTION : ------~~~~~~~~~~~~~~~~l~~~~~~l~~~~~~~~~~~~~~~~l-~-~~~l-~~~~-~~~~~~~~~~l~~~~~~~~~~~~~~~~~~~~~~~l I I I I 6.2 Home visits where feasible I I I I I I 6.3 Functioning of comml~nity health I committee I I I I 1 I 6.4 Cooperation with Tradj.tiona1 I I Health Workers, community leaders,! I women' s group I I I I I I 6.5 Monitoring of Outreach Site I I activity, as applicable 6I t1 1.1 I I 6.6 Collaboration with national I I I I programs and other sectors to I I I I address community needs I I I I I I I I I I I 1 I r Summary of Findings / Action Takeh: Suggestions for Improvement: Clinic / Staff Strengths: Other: Revisions: Oct-L)t:f.: 19811 0ctot)er 1900 - C:l i rlic S~~p,cr.risr)r.c,a11d Date(s) of Discussio~lswit11 Staff: Cl j t,ic t-lan.~cernrr~tAs50cia+,? Swazi 1 and PHC F'rojact APPENDIX L Debriefing Agenda and Participant List SWAZILAND PRIMARY HEALTH CARE PROJECT NATIONAL MEETING OF PUBLIC HEALTH MATRON & SUPERVISOR HANDOVER ACTIVITIES OF C3 MARILYN EDMONDSON CLINIC MANAGEMENT ASSOCIATE - PFIMLRY HEALTH CARE PROJECT DATE: Monday 3rd December. 1990 TIME: 9:30am- 12:30pm VENUE: Mbabane Public Hea!:h Csnference Room AGENDA 9 : 30am Devotion - Sr Mabi 1 isa Opening Remarks - Dr. John Ngubeni, Medical Officer for Public Health. Overview of major clinic management associate handover activities - M. Edrnonason. Status Reports (tea break - 10:15) 1. Outreach sites - Sr. M. Jele 2. Nurses accommodations - M. Edrnondson and Robert Shongwe, Planning Unit. 3. Supervisory checklist revision - Ad hoc Committee Report - Sr. H. Msibi. 4. Follow - up of clinic based training - M. Edmondson and Sr. Kunene. C3NTINUED M0N;TORING OF PRIMARY HEALTH CARE PROJECT INPUTS IN REGIONAL WORKPLANS - HHOHHO PRESENTATION: 10:iS-11 :00am H~ghlightsof I.D.M. course(sl for Matrons and usefulness in improving Management skills - Matron E. Mndzebele. Evaluation of Hhohho Reg~onalWorkplan - Sr. H. Kunene Lunch SWAZITAANL, PRIMARY HlZECI Dr. M. Edmondson Clinic Management Associate ., . -, fi~\lI:~r~~-li Hit. 1.1; Plt13t13r~e, E't4r-1 F. 7\' ,4...... ,:,t.lli cia C7ist.-1- MI-)oL)ane. FHU I-.1,; Z.inl-lane l~/~,iitt.~~.Mankayarle. PHU . !. . 1!!3 l'13tr8:)n, SFiF'bJ SIliselweni -- . --,.., 1--,.:i-,tr.th Magagllia 5 /N I-'utlic Health Mlati : l!i~~'i+l7sliab~)alala S :'N Il-11.angano P . [I. Subcentre F: . N . Mkhonta S IN Mbabane. PHlJ G.S. Magagula N/Sister P. Peak. EHU Mary Magaguls N/Sister Hhohho North Clinics J. Vilakati 1,4/Sister Hhohho North Clinics Thokozile Mncil-la S iN Peak PHL! Thandie Mndzebele S /N Mbabhne. PHU H. Msibi S iN Mhabanz. Gov' t. Hospital L. Ij. Dlamini ,;'N Mbabane. PHU H . kiunerie N/Eist,er Mbabane. PEIO Mari l:r-r~Edmondson Clinic Management Associate PHC Project Msvis fJ>;umslo S;N Mbabane. PHrJ E. T. Mndzebele Matron. MRPE King Sobhuza I1 Page - 1 BEST AVAILABLE COPY C', krisca S. Khumslcl ..,1 d t.5 r King Sc~bhuza 1: M~ryL. Magwazs si z,t.-;r ILing SG~~IUZE~I i Ann3 Mdluli Sister Ii. F'. 1' Ilespit.ii Mat ilcia Jele S J Id Mbabane. FFlrl Tliarrdie i4:.;um~lc7 Matron LFLFII j t+?bi. I,i;l! 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