No Abstract.  South African Family Practice Vol. 47(6) 2005: 35-3

Gaede, B

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SA Fam Pract 2005;47(6) 35COPC analysis of intersectoralHIV AIDS work in OkhahlambaGaede B, MBChB, MMed(FamMed) MEDUNSACorrespondence to: besam@lantic.net(SA Fam Pract 2005;47(6): 35-37)IntroductionOver the past 2 years a non-governmental organisation has evolvedthat facilitates intersectoral work in theHIV/AIDS field in the OkhahlambaMunicipality. Okhahlamba Municipalityis situated along the Drakensbergmountain range in KwaZulu Natal andis home to approximately 150 000people. As in many rural areas of SouthAfrica, the community is characterisedby high levels of poverty and  illiteracyand subsequent poor health status.In trying to understand the processof setting up such an organisation, it hasbeen useful to reflect on CommunityOrientated Primary Care (COPC) as aconceptual framework. By reviewing thebeginnings of intersectoral work inrelation to the COPC model, importantlessons can be learnt for the future ofthe organisation.Background to COPCIn 1940 Sidney and Emily Kark initiatedan experiment at Pholela Health Centrein KwaZulu-Natal that led to thedevelopment of COPC (Tollman 1991;Tollman 1994). The process was basedon a concept of linking curative medicinewith a public health approach. Animportant aspect in the COPC processis that “local coopera-tion and communityresponsibility was to be developedwherever possible. The activities of thehealth centre were to be coordinatedwith those of other local agencies suchas the authorities responsible foragriculture and education.”(Kark 1951,p.665)In the description of the COPC, Karkemphasized the impor tance ofunderstanding the individual as anintegral part of his environment, as wellas recognition of the importance ofnutrition, psychology and social sciencesin the determination of health (Kark1951 ) .  Sens i t i v i t y  and  deepunderstanding of local culture andeconomic dynamics were importantaspects of how the Karks functioned inthe Pholela area. COPC has beensystemized into discrete steps, movingfrom a practice profile and individualpatient to making a ‘communitydiagnosis’ and planning interventions atcommunity level (Reid 2000). Repeatedsurveys to monitor the health anddisease of the community are integralto the process in the methodology(Tollman 1991).The key features of COPC are:• Linking the experience  of theindividual to the larger context offamily and community (includingcultural and economic issues)• Intervening at a clinical, family andcommunity level• Fostering a participatory approachbetween communities and relevantrole-players in the planning,implementing and evaluating ofprograms• Use of information (especiallysurveys) to assess health indicatorsand measure impact of interventionsCoordinating HIV AIDS work inOkhahlamba - Understanding theproblemOver the period of 2000 - 2002, the localAIDS Action Team of the health sectorwas coordinating the activities aroundHIV AIDS work in the catchmentpopulation of Emmaus Hospital. Box 1lists the participants of the Team. (Theauthor was the Medical Officer in theteam.)The team was meeting monthly andin the process attempted to improve therelationships between different levels ofcare (home-based care, PHC clinic,Hospital) as well as to improve thereferral system. From the surveys thathad been conducted in the communityby the Child Survival Project and theDepartment of Health, the followinginformat ion became apparent :• HBC is very acceptable andappreciated by the community(UThukela District Child SurvivalProject  2002)• There was a high level of knowledgeabout HIV, but poor behaviouralchange (UThukela District ChildDumo Baqwa AwardBox 1: Team members of the AIDS action TeamPHC coordinator HIV coordinatorHome-based care coordinator Child Survival Project (local NGO)Emmaus Hospital PHC sister VCT counselorsEmmaus Hospital Medical Officer PHC clinic sistersBox 2: Hlengiwe’s storyHlengiwe was weak and emaciated when she was brought to the hospital by a visitinguncle. He was shocked at her condition and ‘wanted to do something for her’. She wasadmitted to female ward where she was treated for chest infection and improved slightly,although remained weak and wasted. She ‘refused’ VCT while in hospital and was soondischarged. The doctor wrote a letter for home-based care, which she forgot at the hospitalwhen the sister who cared for her picked her up. However, a neighbour had referred herto the home-based carers already.Although the Doctor had filled in a form to try and apply for disability grant, she did notmanage to go the welfare offices to fill in all the forms as she has been too weak. Thereis little food at home and since she was ill she has not managed to work as a farm labourer.The sister has been looking after her has struggled to cope as he was becoming increasinglyill and she has her own family to care for. She had also taken Hlengiwe’s 3 children withher to her home.SA Fam Pract 2005;47(6)36Survival Project 2001)• The referral system between differentlevels of care in the department ofhealth as well as agencies outsideof the department of health was notworking well (evidenced by repeateddiscussions at the meetings)• Many needs outside of the healthsector (UThukela District ChildSurvival Project 2001)At a meeting in 2002, a review of thework to date took place. A number offrustrations had arisen also from a strongsense that the team was failing to meetthe needs of the patients. This wasillustrated by anecdotes of individualpatients shared by a number ofparticipants (e.g. PHC nurses, VCTcounsellors, HBC coordinator, doctor).Box 2 narrates one such storyThe ‘diagnosis’ that we came to afterreflecting on the information available tous (as well as the anecdotes such asthe story told above) included thefollowing:• People are suffering and we oftenfeel helpless• We do not understand all the aspectsof the care – what is going on athome and how decisions are made• Many aspects of care are ‘no-man-zone’ – no one is responsible forpulling the care together and lookingafter the person holist ical ly.• There are many failures within thehealth sector to work closely together• Families are often not involved wheninteracting with the formal healthservices• Other sectors should be involved toaddress the needs of people withHIV AIDSAttempts at solving the problemOut of the review, one of the aspectsthat became obvious was that othersectors would need to be involved inorder to provide more integrated careto people affected by HIV AIDS. Abrainstorm about the stakeholders inthe support and treatment of peopleaffected by HIV AIDS identified a longlist of organisations. Two participantsfrom the team (including the author) wereasked to take the lead in contactingthe organisations and inviting themto a meeting to explore workingtogether.At the first meeting approximately 40people attended from a wide range ofgovernmental depar tments andcommunity organisations. At the initialmeeting, current activities and serviceoffered by each of the organisations wasshared. This generated a lot ofenthusiasm and immediately contactswere made and phone numbersexchanged. Participants expressedsurprise about the number and extentof resources available in the area.Due to the success of the firstmeeting, it was resolved to meet on aregular basis. The initiators of the firstmeeting took the responsibility tocoordinate future meetings and involvedas many organisations as possible. Thepurpose was to support coordinationand potent iate what individualorganisations were doing already byplacing them in a wider network ofservices. A number of organisations onlystarted to attend once it became moreobvious that the meetings were usefulfor a wide range of groups. (Box 3 showsthe list of organisations that participatedin the meetings over the past 18 months.)The meetings took place 1 to 3monthly, depending on the situation inthe area and workloads of theparticipating organisations. The numberof participating organisations also variedand to some degree depended on thecommitment and vision of the individualsthat were part of the meetings. Out ofthe meetings, it became evident that theregular meetings were playing animportant part in the service provisionas many organisations had little contactwith each other outside of this forum. Itwas therefore decided to form an NGO(called Philakahle/Wellbeing) tocoordinate the HIV AIDS work andparticularly to support community-basedorganisations in the area.Intersectoral work – analysis ofcurrent situationIn order to assess the success of theintersectoral work that has been initiatedand to provide direction for the future, a‘SWOT analysis’ (analysis of strengths,weaknesses, opportunities and threats)was done to explore the current situation.In this SWOT analysis the key aspectsof the COPC model discussed aboveare used as a guide to assess ourinitiative.Strengths• A lot of information regarding thesituation is available and is beingshared at the intersectoral meetings• Contacts have been made betweenorganisations• It seems obvious to work together –the whole is greater than the sum ofthe parts.• Many government departments andcommunity- and fai th-basedorganisation are involved and havepledged continued engagement• The focus is beyond the medicalaspects of the patient; it includescommunity-level initiatives andeconomic supportWeaknesses• There is poor coordination of servicesdespite meetings• It is difficult to achieve joint planningas accountability of individuals is totheir parent organisations and thereare different systems operating indifferent organisations• Intersectoral work is no-bodies(?nobody’s) work – no one is account-able for whether it works or not• Not everyone ‘found a place’; somesectors (especially that are close topatients, e.g. traditional healers) arenot central in the approach• When focussing on organisationalaspects of the intersectoral work itis easy to forget the person and theBox 3: List of organisations participating in the intersectoral meetingsDept of Health Churches (4 denominations)Dept of Welfare Traditional Healer OrganisationDept of Education Wellbeing center (support for HIV + people)SAPS Home-based care organisationDept of Agriculture Ekuphileni (orphan care)Dept of Correctional Services Local Youth groupLocal Government Mathew 25 (church-based welfare org)Dept of Tourism Lovelife youth center (Gugulethu)Government Communication and Information SystemCOUNT (Literacy NGO) Christian Listeners (supporting HBC)Farmers Support Group Ubuntu partners (faith-based welfare org)HIVAN (HIV research org)Dumo Baqwa Awardfamilies at the centre of our work.• Many aspects of care are not wellunders tood and addressed• The link between clinical care andbroader support and follow-up is stillweakOpportunities• A new organisation has been formedwith a mandate to coordinate HIVAIDS work• There is little precedent which allowsfor innovation and new ideas to beimplemented• Many organisations are participatingwith a wide scope of interests andskills, with the possibility of greaterinvolvementThreats• Some smaller organisations fearbeing ‘taken over’• A new bureaucracy may beestablished that perpetuates theinaccessibility of service• There may be a loss of focus onindividual patients’ needs• There may be divergence ofexpectations amongst role-playersWay forwardFrom the SWOT analysis, it is evidentthat while a lot of work has been donealready and real success has beenachieved, there are a number ofweaknesses in the approach. Theinvolvement of the client and linking theexperience of the client and their familiesto the broader intervention is animportant area that needs to be exploredand developed. From the health caresector’s perspective, linking the clinicalcare with the larger intersectoral work,is a further challenge.The challenge for the new organisationis to develop clear relationships witheach of the participating organisationsand identify the ‘merged agenda’.Important in the process is to maintainthe focus on the client and his/her familythat we want to assist, rather than to beobsessed with the organisational aspectsof the work. Strong leadership thatencourages the community and ‘client-voice’ will be a prerequisite to achievingthe goal of integrated care for peopleaffected by HIV / AIDS in the community.Dr Bernhard Gaede is currently workingas a medical officer at Emmaus Hospitaland is a director in the NGO, Philakahle/ Wellbeing, coordinating HIV AIDS workin the Okhahlamba Municipality inKwaZulu-Natal.References1. Kark SL. Health Center Service – A SouthAfrican Experiment in Family Health andMedical Care, In: Social Medicine, Cluver EH(ed.), Johannesburg, Central News Agency,661-700. 19512. Reid S. Community Orientated Primary Care.In Handbook of Family Medicine.  Ed. R Mash.Cape Town, Oxford University Press, 2000.  pp223-2433. Tollman SM. Community-orientated primarycare: origin, evolution, application, SocialScience Medicine, vol.32, 633-642, 19914. Tollman SM. The Pholela Health Center – theorigins of community-orientated primary healthcare (COPC), S Afr Med J, vol.84, no.10, pp.653-658, 19945. UThukela District Child Survival Project. Home-based care Evaluation. Bergville, 2002.6. UThukela District Child Survival Project. Mid-term Evaluation – Lot Quality AssuranceSampling Survey of the uThukela Community.Bergville, 2001.SA Fam Pract 2005;47(6) 37Industry NewsFIRST DUMO BAQWA AWARDThe first Dumo Baqwa awardwas awarded at the annualconference of the Rural DoctorsAssociation of Southern Africa(Rudasa) in September 2004 toDr Bernhard Gaede for hisarticle about the establishmento f  a  communi ty  basedorganisation, Philakahle, doingHIV AIDS care in Okhahlamba.The Dumo Baqwa Award is dedicated to the memory of ProfDumo Baqwa who died in 2001. Dumo was the Head of PrimaryHealth Care at the University of Cape Town at the time of hisdeath.This award is the brainchild of Prof. Jan De Maeseneer fromGhent, Belgium. Jan and Dumo met in London in 1995. Theirmeeting was that of 2 people with a lot in common in theirpersonal history and their commitment to action for more justiceand equity world wide. Dumo invited Jan to Cape Town wherehe showed him the  situation in the townships and the need forCommunity Oriented Primary Care. They were instrumental inthe formation of the Family Medicine Education Consortium(FaMEC).As Dumo Baqwa passed away in 2001, he could not be partof the further development of co-operation between Belgiumand South Africa. So it was decided, in memory of this mostinspiring person, to create the Dumo Baqwa Award.The Award consists of an amount of 1000 Euro and is financedby the Flemish Departments of Family Medicine. It is given ona yearly basis to a post graduate student who completed his/hertraining in family medicine in South Africa. The candidates arerequired to submit a draft journal paper on a topic that is relevantfor the demonstration of the importance of community orientationin family medicine and the link between family medicine andcommunity health development. The paper must be based onwork done with the significant involvement of the author andshould focus on the community orientation in family medicine.During the first three years the VLIR-project "Own initiatives" EI-SEL 2003-14 will participate in the financing. Prof Baqwa’sdaughter, Nosizwe Baqwa, presented the award in Tshilidzinito Bernhard. She spoke about her father and his passion forthe needs of people in townships.Bernhard is currently working at Emmaus Hospital. Since hisstudent years he has been involved in community activitiesand, as a medical student, he was very involved in theMuldersdrift Clinic. He has been a facilitator in districtdevelopment, medical manager of Emmaus hospital, butnowadays he is back to mostly clinical medicine at EmmausHospital. Bernhard is an active member of Rudasa and is alsoan honorary lecturer at both the Universities of Pretoria andKwaZulu Natal.The article describes the process of mobilising differentorganisations in the rural KZN community to collaborate inimproving care to people suffering from HIV and AIDS.Recognising the contribution made by the community to hisreceiving the award, Bernhard requested that the 1000 Euroaward be donated to Philakahle, the organisation formed in theproject.Prof Jannie HugoDumo Baqwa Award

COPC analysis of intersectoral HIV AIDS work in Okhahlamba

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COPC analysis of intersectoral HIV AIDS work in Okhahlamba

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