Can the re-engineering of PHC and/or the introduction of community paediatricians be the solution?

No abstract available.References 1-11 is part of correspondence titled: Improved management of patients with osteoporosishttp://www.samj.org.zaam2013ay201

Rural district hospitals – essential cogs in the district health system – and primary healthcare re-engineering

The article by Le Roux et al. raises the question why it is so difficult to re-engineer primary healthcare (PHC) and why the results so far have been disappointing. They highlight the critical role of the district hospital as the hub from which all activities in the rural districts should be co-ordinated.

Design of new cold rolled purlins by experimental testing and Direct Strength Method

New cold roll formed channel and zed sections for purlins, namely UltraBEAM™2 and UltraZED™2, have been developed by Hadley Industries plc using a combined approach of experimental testing, finite element modelling and optimisation techniques. The new sections have improved strength to weight ratio by increasing the section's strength through the use of stiffeners in the section webs. The European standard, Eurocode 3 [1], uses the traditional Effective Width Method to determine the strength of a cold formed steel member. However, the design of the new sections UltraBEAM™2 and UltraZED™2 using this method is very complicated in calculating the effective section properties as these sections contain complex folded-in stiffeners. In addition, the incorporation of competing buckling modes such as distortional buckling of these sections can be difficult to analyse. To overcome difficulties of using Eurocode 3 or such a standard with the Effective Width Method for determining the strength of these sections, the Direct Strength Method is adopted in this paper. Four-point beam bending tests were carried out to determine the buckling and ultimate bending capacities of the UltraBEAM™2 and UltraZED™2 sections. Results from both experimental testing and Finite Element analysis were initially used as validation for the design using the Direct Strength Method. The Direct Strength Method's results were then compared with the experimental test results for a broader data in which the UltraBEAM™2 and UltraZED™2 sections had a range of different width-to-thickness ratios. It showed an excellent agreement between test and Direct Strength design values suggesting that the Direct Strength Method is a powerful tool for the design and optimisation of the new cold roll formed channel and zed purlins.N/

Effects of cold roll dimpling process on mechanical properties of dimpled steel.

In this paper, the effect of a dimpling process on the mechanical properties of the steel material was studied experimentally and numerically. Nano-hardness and tensile tests of steel samples prior to and after the dimpling process were conducted to evaluate the effects of the process on the mechanical properties. Numerical simulations of the dimpling process and tensile tests were done by Finite Element Analysis; they were used to quantify the amount of non-uniform plastic strains and residual stresses introduced and the manner, in which this was distributed through the sheet. The cold roll dimpling process resulted in developing the plastic strain and residual stress which could correlate to the modifications in the strength and stiffness of the dimpled steel when compared to plain steel originating from the same coil material. The simulation of the dimpling process and tensile tests of the plain and dimpled specimens predicted similar behaviour to the experimental measurements and tests.N/

Rural district hospitals – essential cogs in the district health system – and primary healthcare re-engineering

To the Editor : The article by Le Roux et al. raises the question why it is so difficult to re-engineer primary healthcare (PHC) and why the results so far have been disappointing. They highlight the critical role of the district hospital as the hub from which all activities in the rural districts should be co-ordinated. Le Roux et al. write from their own experience at rural hospitals. We agree that there are many examples of well-run public district hospitals with excellent reputations, which have contributed towards improved patient care together with improved health status of the community. Hospitals that have built up reputations as providers of excellent rural healthcare services in the past decades are Elim, Donald Fraser, Gelukspan, Manguzi, Bethesda, Mosveld, Mseleni, Rietvlei, Zithulele, and many more.http://www.samj.org.zaam2016Family Medicin

Changing priorities in maternal and perinatal health in Gert Sibande District, South Africa

Gert Sibande District is a predominantly rural district in Mpumalanga Province, South Africa (SA), with a population of just over 1.1 million. It has a high prevalence of HIV infection and pregnancy-related hypertensive disease. In 2010 the district was one of the worst-performing health districts in SA, with a maternal mortality ratio of 328.0 per 100 000 births. Various programmes were introduced between 2010 and 2017 to address major causes of maternal and perinatal morbidity and mortality in the district. The focus has been on HIV-related morbidity, the direct obstetric causes of maternal and perinatal morbidity and mortality, and health systems strengthening. During the period 2010 - 2017, there was a steady decline in institutional maternal mortality with a drop of 71% in maternal deaths over a period of 6 years, from 328.0 per 100 000 births to 95.0. However, the ratio levelled off in 2016 and 2017, mainly as a result of a changing disease profile. The stillbirth rate showed a decline of 24.4% over a period of 8 years. With perseverance, rapid response and evidence-based strategies it was possible to more than halve the institutional maternal mortality ratio within 6 years. However, with the changing disease profile, conditions such as hypertensive disease in pregnancy should be prioritised and new strategies developed to further reduce maternal and perinatal mortality and morbidity.http://www.samj.org.zaam2020Family MedicineObstetrics and Gynaecolog

Cost effectiveness of clinical associates : a case study for the Mpumalanga province in South Africa

BACKGROUND : The National Department of Health of South Africa decided to start a programme to train mid-level healthcare workers, called clinical associates, as one of the measures to increase healthcare workers at district level in rural areas. Unfortunately, very little is known about the cost effectiveness of clinical associates. AIMS : To determine, on a provincial level, the cost effectiveness of training and employing clinical associates and medical practitioners compared to the standard strategy of training and employing only more medical practitioners. METHODS : A literature study was performed to answer several sub questions regarding the costs and effectiveness of clinical associates. The results were used to present a case study. RESULTS : The total cost for a province to pay for the full training of a clinical associate is R 300 850. The average employment cost per year is R196 329 and for medical practitioners these costs are R 730 985 and R 559 397, respectively. EFFECTIVENESS : Clinical associates are likely to free up the time of a medical practitioner by 50–76%. They can provide the same quality of care as higher level workers, provided that they receive adequate training, support and supervision. Furthermore, they seem more willing to work in rural areas compared to medical practitioners. CONCLUSIONS : The case study showed that training and employing clinical associates is potentially a cost-effective strategy for a province to meet the increasing demand for rural healthcare workers. This strategy will only succeed when clinical associates receive adequate training, support and supervision and if the province keeps investing in them.http://www.phcfm.orgam2017Family Medicin

Education médicale et amélioration de sa qualité: une étude de cas au Mpumalanga, Afrique du Sud.

BACKGROUND : The short timeframe of medical students’ rotations is not always conducive to successful, in-depth quality-improvement projects requiring a more longitudinal approach. AIM : To describe the process of inducting students into a longitudinal quality-improvement project, using the topic of the Mother- and Baby-Friendly Initiative as a case study; and to explore the possible contribution of a quality-improvement project to the development of student competencies. SETTING : Mpumalanga clinical learning centres, where University of Pretoria medical students did their district health rotations. METHOD : Consecutive student groups had to engage with a hospital’s compliance with specific steps of the Ten Steps to Successful Breastfeeding that form the standards for the Mother- and Baby-Friendly Initiative. Primary data sources included an on-site PowerPoint group presentation (n = 42), a written group report (n = 42) and notes of individual interviews in an end-of-rotation objectively structured clinical examination station (n = 139). RESULTS : Activities in each rotation varied according to the needs identified through the application of the quality-improvement cycle in consultation with the local health team. The development of student competencies is described according to the roles of a medical expert in the CanMEDS framework: collaborator, health advocate, scholar, communicator, manager and professional. The exposure to the real-life situation in South African public hospitals had a great influence on many students, who also acted as catalysts for transforming practice. CONCLUSION : Service learning and quality-improvement projects can be successfully integrated in one rotation and can contribute to the development of the different roles of a medical expert. More studies could provide insight into the potential of this approach in transforming institutions and student learning.CONTEXTE: La courte durée des roulements des étudiants médicaux ne favorise pas la réussite des projets approfondis d’amélioration de la qualité qui nécessitent une approche plus longitudinale. OBJECTIF : Décrire le processus d’intronisation des étudiants dans un projet longitudinal d’amélioration de la qualité, au moyen du thème de l’Initiative des Hôpitaux amis de la Mère et des Bébés comme étude de cas; et examiner la contribution possible d’un projet d’amélioration de la qualité au développement des compétences des étudiants. LIEU : Les centres de formation clinique du Mpumalanga où les étudiants médicaux de l’Université de Pretoria ont fait leurs roulements dans les districts sanitaires. METHODE : Des groupes consécutifs d’étudiants ont dû, avec l’autorisation de l’hôpital, s’engager à suivre les mesures spécifiques des Dix Conditions pour le Succès de l’Allaitement maternel qui est la norme de l’Initiative des Hôpitaux amis de la Mère et des Bébés. Les sources de données primaires comprenaient une présentation PowerPoint du groupe sur le terrain (n = 42), un rapport écrit du groupe (n = 42) et les notes des entrevues individuelles dans une station d’examen Clinique structuré objectivement à la fin du roulement (n = 139). RESULTATS : Les activités de chaque roulement changeaient selon les besoins identifiés par l’application du cycle d’amélioration de la qualité en consultation avec l’équipe de santé locale. Le développement des compétences des étudiants est décrit selon les rôles d’un expert médical dans le cadre du CanMEDS: collaborateur, promoteur de la santé, érudit, communicateur, gérant et professionnel. L’exposition à la situation réelle dans les hôpitaux publics sud-africains a eu une grande influence sur beaucoup d’étudiants, qui ont aussi été les catalyseurs du changement de pratique. CONCLUSION : L’apprentissage par le service et les projets d’amélioration de la qualité peuvent être intégrés avec succès dans un roulement et peuvent contribuer au développement des différents rôles d’un expert médical. Un plus grand nombre d’études pourra donner un aperçu des possibilités de cette approche et transformer les institutions et l’apprentissage des étudiants.http://www.phcfm.org/am201

“Making a difference” – Medical students’ opportunities for transformational change in health care and learning through quality improvement projects

Background Quality improvement is increasingly becoming an essential aspect of the medical curriculum, with the intention of improving the health care system to provide better health care. The aim of this study was to explore undergraduate medical students’ experiences of their involvement in quality improvement projects during a district health rotation. Methods Student group reports from rotations in learning centres of the University of Pretoria in Mpumalanga Province, South Africa were analysed for the period 2012 to 2015. Interviews were conducted with health care providers at four learning centres in 2013. Results Three main themes were identified: (1) ‘Situated learning’, describing students’ exposure to the discrepancies between ideal and reality in a real-life situation and how they learned to deal with complex situations, individually and as student group; (2) ‘Facing dilemmas’, describing how students were challenged about the non-ideal reality; (3) ‘Making a difference’, describing the impact of the students’ projects, with greater understanding of themselves and others through working in teams but also making a change in the health care system. Conclusion Quality improvement projects can provide an opportunity for both the transformation of health care and for transformative learning, with individual and ‘collective’ self-authorship