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Service delivery

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In any health system, good health services are those that deliver effective, safe, good-quality personal and non-personal care to those that need it, when needed, with minimum waste. Services – be they prevention, treatment or rehabilitation – may be delivered in the home, the community, the workplace or in health facilities.[1]

Although there are no universal models for good service delivery, there are some well-established requirements. Effective provision requires trained staff working with the right medicines and equipment, and with adequate financing. Success also requires an organizational environment that provides the right incentives to providers and users. The service delivery building block is concerned with how inputs and services are organized and managed, to ensure access, quality, safety and continuity of care across health conditions, across different locations and over time.

Primary care as a hub of coordination: networking within the community served and with outside partners[2]

Attention should be given to the following:

  • Demand for services. Raising demand, appropriately, requires understanding the user’s perspective, raising public knowledge and reducing barriers to care – cultural, social, financial or gender barriers.
  • Package of integrated services. This should be based on a picture of population health needs; of barriers to the equitable expansion of access to services; and available resources such as money, staff, medicines and supplies.
  • Organization of the provider network. This means considering the whole network of providers, private as well as public; the package of services (personal, non-personal); whether there is oversupply or undersupply; functioning referral systems; the responsibilities of and linkages between different levels and types of provider, including hospitals.
  • Management. Whatever the unit of management (programme, facility, district, etc.) any autonomy, which can encourage innovation, must be balanced by policy and programme consistency and accountability. Supervision and other performance incentives are also key.
  • Infrastructure and logistics. This includes buildings, their plant and equipment; utilities such as power and water supply; waste management; and transport and communication. It also involves investment decisions, with issues of specification, price and procurement and considering the implications of investment in facilities, transport or technologies for recurrent costs, staffing levels, skill needs and maintenance systems.


This section on Service delivery is structured as follows:

Contents

Analytical summary

The MoHSS is the main implementer and provider of public health services with a four tier system: outreach points (1150) clinics and health centres (309), district hospitals (29) and intermediate and referral hospitals (4). Faith-based organisations operate services for the MoHSS on an outsourcing basis. The private sector is sizeable, with 844 private health facilities registered with MOHSS.

These include 13 hospitals, 75 clinics and 8 health centres, mainly in urban areas of Erongo and Khomas regions. 72% of doctors in Namibia are in the private sector and a little less than 50% of registered nurses. The public sector cannot currently adequately respond to the needs for certain referral level specialised services so the MoHSS is looking into introducing new services and technology through the public-private partnership model. (MoHSS, July 2010)

The 13 regions have Regional Management Teams (RMTs), which are responsible for the translation, implementation and management of the public health system in the respective regions, including the hospitals. There has been some de-concentration of planning and management functions to the regions and the districts. The health district is coordinated by the DCC.

The Regional Director is a member of the Regional Development Committee assuring coordination between the Regional Council and the MoHSS. The Regional Council is responsible for environmental health in the regions although there is also MoHSS environmental health staff deployed in the regions. (MoHSS, July 2010)

Referral hospitals are not autonomous. This, in particular, has been identified as a problem in the two referral hospitals in Windhoek and in the intermediate hospitals in Oshakati. Windhoek Central Hospital (WCH) and Katutura Hospital are already teaching hospitals and it is envisaged for Oshakati Hospital to become a teaching hospital. (MoHSS, July 2010)

There is a varying level of service management skills at all levels and there is a clinical leadership vacuum, where there is no clear structure for clinical management and service quality assurance. (MoHSS, July 2010) Health in the community has been unsustainable due to a dependence on volunteer health workers. To address this problem, the MoHSS has developed the Strategy for Health Extension Workers (MoHSS, 2009) to facilitate the recruitment of Health Extension workers as public service employees and facilitate the implementation of Health Extension services.

A pilot programme is planned for 2010. (MoHSS, 13/10/2011) The National Policy on Community-Based Health Care (CHBC) and guidelines for its implementation (Directorate of Primary Health Care Services, MoHSS, February 2010) provide detailed roles and responsibilities at every level to facilitate stronger linkages from community to national level.

There is congestion in hospitals with primary care level patients due to perceptions that there are better quality services at hospital level. (MoHSS, July 2010) The PHC guidelines that are currently being drafted comprise a set of directions for implementation and selection of PHC service packages for: disease prevention and health promotion rehabilitation and curative services. Priority health problems, such as maternal and child health and nutrition, are integrated for accessibility and affordability at appropriate levels of care.

The World Health Organization (WHO) is also in the process of developing District Health Packages, which aim at better human and financial resources at service delivery levels. Health promotion is one PHC component that remains a challenge, partly due to the absence of health promotion strategies, capacity and resources. (WHO, 2010)

Hospitals play a critical role in the delivery of health services in Namibia. The 2008 HSSR found that hospitals in the country provide a full range of medical services including diagnostic, treatment, pharmaceutical, care, counselling, rehabilitation, and emergencies. They also serve as referral centres for the lower level facilities (health centres and clinics) and are available for 24 hours of the day. However, hospitals suffer from a general paucity of transport logistics for service delivery – to facilitate movement of drugs and supplies, and staff for outreach services and supervisory visits.

The frequent breakdown of some critical equipment and machines, coupled with the absence of equipment replacement plans were identified as a constraint to the delivery of quality services. (MoHSS, 2008)

Long term and chronic health care services are partly the mandate of CBHC at the household level, which is managed by a variety of organisations. About 5,000 community based health care providers have been trained in provision community health services (such as hygiene, home based care, prevention of diarrhoea, etc).

Oral and dental services are being rendered in fifteen (44%) out of the 34 health district hospitals across the country. The other areas are served by an outreach programme on a rotational basis. Oral health was included in the guidelines for the Health Promoting School Initiative and the Smiling School Project was initiated to help Namibian school children achieve and maintain optimal oral health. Oral health modules were included in training of nurses and teachers and IEC material was developed.

Major constraints facing dental health services include the lack of adequate dental instruments and material, lack of transport and failure to include dental staff in HIV/AIDS workshops. There is only one dentist and dental therapist per region except Khomas, Oshana and Otjozondjupa regions. (MoHSS, 2008)

The social welfare sector provides treatment and rehabilitation to abusers of drugs and alcohol. The treatment is provided at treatment centres and is followed by after-care services, which are essential in minimising relapses. The Ministry runs outreach programmes to sensitise communities and promote responsible lifestyle and behaviours. The Coalition on Responsible Drinking (CORD) is an alcohol and drugs campaign that disseminates information against the use and abuse of alcohol and other drugs, and promotes sober lifestyle and responsible drinking. Regional and constituency CORD Committees were established in Erongo, Oshikoto, Omusati, Kavango, Karas and Otjozondjupa. (MoHSS, 2008)

Mental illness is a major cause of morbidity as well as some mortality amongst the population of Namibia. Major constraints include lack of adequate skilled labour and mental health facilities and equipment, and inaccessibility of services for the majority of the population, particularly in rural areas.

The MoHSS is currently addressing shortcomings in the staffing, use and management of ambulance services in partnership with the Motor Vehicle Accident Fund. It also needs to build a national long-term pre-hospital emergency management service that includes infrastructure development and procurement of an emergency fleet. (MoHSS, July 2010)

The provision of family welfare services by the Ministry has decreased following the transfer of key functions, such as child welfare and social assistance to other ministries. Five homes for older people are registered at the MOHSS. The directorate Social Welfare Services provides quality assurance through inspection and investigations of complaints. The Ministry also provides services for people with disability (4.7 % of the total population in 2001). (MoHSS, 2008)

The CBHC Programme objectives include several that are explicitly people-centred. (Directorate of Primary Health Care Services, MoHSS, February 2010) At facility level in the public health sector, there are still concerns about the people-centredness of care. The 2008 HSSR found that there were issues with friendliness of staff. Complaints of nurses being rude and not paying attention to the clients were reported.

It was also found that there were language barriers (and lack of communication for the blind and the deaf) as well as lack of physical structures to facilitate access by people with physical disabilities. Studies point to the existence of stigma and discrimination against PLHIV in Namibia’s clinics and hospitals (Lush, Samaria, & Petrus, 2003; Lush & Ashby, 2005; Buskens, 2008).

Traditional medicine is widely used in the country and is often the first port of call. However, there is no regulation of the practice and more can be done to appreciate the contribution of traditional medicine. In the health district, a range of PHC programme services are delivered at outreach, clinic, health centre level and to some extent at hospital level. General outpatient screening is a feature of the services with treatment of common ailments and referral of more complicated cases. The referral system is weak, and as a result there is no continuity of care, largely due to lack of transport.

Outreach and mobile services are not functioning optimally for the same reason. (WHO, 2010) Consumer perception about quality of services is very favourable, except for dissatisfaction over the closure of health facilities during weekends and holidays.

Priority areas for improvement include: efficiency in service delivery (in particular, increased capacity to deliver PHC services at health centres and clinics); coverage of services (especially maternal and child health, ambulance, dental, laboratory and welfare services); management of service delivery; technical and clinical capacity; planning; quality assurance and supportive supervision; health promotion (especially in maternal and child health, TB and HIV/AIDS prevention); and monitoring (e.g. of multi-drug resistant TB).


Organization and management of health services

Package of services

Public and private health care providers

Person-centredness and characteristics of primary health care services

Shadow practices

Quality of health services

Priorities and ways forward

Others

Endnotes: References, sources, methods, abbreviations, etc.

  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. Framework and standards for country health information systems, 2nd ed (pdf 1.87Mb). Geneva, World Health Organization and Health Metrics Network, 2008