United Nations Public Service Awards Case Studies

Chronic Tuberculosis (TB) is one of the legacies of apartheid, but since 1994, the ANC government failed to contain the spread of the disease. TB therefore persists as a significant public health problem and has increased from 774 per 100 000 in 1990 to 998 per 100 000 in 2006. This scenario was worsened by the 38 000 doctors and nurses posts being vacant in public hospitals and local clinics.

Because the Western Cape population is distributed unevenly, (partly due to the search for jobs and other economic opportunities), the TB burden in Cape Town (55%) is heavier than in other parts of the province. This has contributed to an increase of 68% in the number of reported TB cases in Cape Town over the last 10 years, with 27,017 TB cases reported in 2006. The demographic make-up and the socio-economic conditions of the sub-districts vary enormously and the increase has been disproportionally higher in geographic areas with poorer socio-economic conditions and high HIV prevalence rates, namely the Eastern, Khayelitsha and Klipfontein sub-districts. Due to dramatic increases in the number of registered TB clients at some TB clinics in these high burden sub-districts in Cape Town, clinics were faced with difficulties in organising services to effectively and efficiently monitor TB clients presenting on a daily basis for treatment. Various administrative tasks key to the success of the programme were neglected due to the increased demands made on staff due to the volume of patients. Budget constraints further limited the ability to recruit more staff. This ultimately impacted very negatively on programme performance and resulted in poor treatment outcomes. Poor patient treatment outcomes increased patient default rates and this not only meant that the treatment had to begin all over again, but consistently increased the risk of patients acquiring either Multi-Drug Resistant TB or worse still, the as yet untreatable Extreme Drug Resistant strain. The costs of treatment failure are high to both patient and health service and inevitably put pressure on already tight budgets. Urgent and innovative measures were needed to address the burgeoning crisis and provide support to staff.

The challenge was therefore two-fold, to provide support to clinic staff and to increase the TB cure rate.

What is the initiative about? (the solution)
The programme is located in 27 of the 93 TB clinics spread throughout the 8 sub-districts of the Cape Town City Health Department. It builds the capacity of the clinics to improve its cure rate by bringing a new layer of staff into the normal day-to-day operations of the clinics. The new staff is recruited from young unemployed high school graduates who live in the vicinity of the local clinics. They are trained in two highly specific roles. The first is as TB Assistants whose principal task is to carry out door-to-door follow-up visits to patients who have been diagnosed with TB and registered at the clinic. Each visit is recorded in a register and the data is collected, collated and analysed on a monthly basis. Defaults in visiting schedules are immediately apparent and remedial action is taken. Even though average home visits are set at 189 per month, in several cases however (in 2nd Quarter 2007) visits reached 300. The visits are scheduled at the clinic by the medical staff and the precise actions required are specified in the range of Assistants key role performances. The TB Clerks have a different set of roles and responsibilities which they carry out in the administrative centre at the clinic. They are primarily responsible for the intensive paper and computer registration and administration of the treatment of patients. This model has succeeded in reducing the treatment default rate from 11% in 2005 to 9% in 2006. Overall TB programme performance improved by 7% (from 69% to 76%) in 2006. In Khayelitsha where the cure rate in Quarter 3, 2004 was 24%, in Quarter 4, 2006 it has risen to 72%. In addition it has provided formal employment to 85 previously unemployed local community members.

Who proposed the solution, who implemented it and who were the stakeholders?
During 2005, the City of Cape Town’s Health Department Judy Caldwell and Virginia Azevedo conceptualised the solution of adding a new layer of health worker to clinic staff, to increase the cure rate and to decrease the default rate at the City’s TB Clinics. A Memorandum of Agreement was signed with the Province’s Metro District Health Services and TB Care Association, a Non-Governmental Organisation, who has a long history in the sector. TB Care was responsible for the recruitment and selection of TB Assistants and Clerks from the local communities. TB Care signed contracts with each of the TB Assistants and TB Clerks and was responsible for all administration relating to pay, leave and disciplinary procedures. They were also responsible for giving regular feedback to City Health and reported on financial expenditure. Funding was provided by the Metro District Health Services (Provincial Government) and the City Health. The City Health provided training and was responsible for the daily line management of TB Clerks and TB Assistants, monitored performance and provided feedback to TB Care as required. The partnership has been critical to building the success of the project. The initial impetus from the City Health would not have been able to gain traction without the capacity of the TB Care to recruit and ‘house’ the assistants and clerks. On the basis of its community linkages it was possible for TB Care to recruit quickly and to establish salaries at the level well below that of qualified nursing staff (R1,500 per month for assistants and R2,000 for clerks). Thus holding down the overall costs and at the same time it could place the trainees within a stable and coherent organisation with clear HR rules and regulations. City Health’s contribution to the success of the programme is major. Job specification, definitions of roles and responsibilities, training and high energy line management have meant that the assistants and clerks have been rapidly embedded within the operational life of the clinics where they know that they are making a real contribution to the success of the treatment. In the process they are learning key skills for formal employment which will make it easier for them to find employment later.

Describe how and when the initiative was implemented by answering these questions
a. What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The programme’s primary objective was to reduce the pool of TB infection by improving treatment adherence and treatment outcomes, via improvements in the execution of key administrative tasks. A secondary objective was to offer training, employment and formal work experience to unemployed matriculated youth of the area. Strategies employed included TB Care and City Health identifying which clinics had the highest TB case loads; this was done by collating all the data from the TB clinics. Research was then conducted to establish what the optimal levels of caseload were and based on this information specific norms were developed to objectively determine which facilities were in greatest need of additional support. The criteria decided upon were the ratio of TB patients per staff of above 300 and a cure rate of below 80%. Based on these criteria, 27 facilities were selected to participate in the programme. TB Assistants were then employed to carry out door-to-door follow-up visits to patients who have been diagnosed with TB and registered at the clinic, while the TB Clerks were responsible for the paper, computer registration and administration of the treatment of patients.

b. What were the key development and implementation steps and the chronology? No more than 500 words
During 2005, the World Health Organisation had an Afro-Regional meeting in Maputo, where the TB crisis was on the agenda and in November, the National Health Management Council (NHMC) ratified the decision to declare TB an emergency in Southern Africa. The result was that the NHMC requested the development of a National TB Crisis Management Plan for South Africa. Due to the nature of the crisis in the Western Cape, the Provincial Department of Health provided additional funding for the TB Control Programme. Talks between the two levels of government acknowledged that they did not have the capacity to address the challenge. In July 2005, a Memorandum of Understanding was signed between TB Care Association, the City and Provincial Administration. TB Care agreed to implement and manage the programme. TB Care placed advertisements at clinics and notified health committees in the identified facilities, to recruit unemployed high school graduates. In August 2005, the first batch of 18 people were recruited, appointed and trained placed in facilities where the TB burden was more than 300 per year. Currently, 87 previously unemployed youth have received training and are employed at 27 facilities on a full-time basis.

c. What were the main obstacles encountered? How were they overcome? No more than 500 words
Generally, the NGO sector in South Africa is very suspicious of government and is hesitant to form partnerships due to past experiences. The staff of TB Care was no exception and had to be convinced that government was not going to exploit the staff and that this was a win-win situation for both parties. This was achieved by conducting ongoing meetings between the parties and highlighting the positive spin-offs. Another obstacle was that, due to budgetary constraints, government advocated for a cadre of volunteers to address the challenges faced at the local community level. But with the huge numbers of people being unemployed, people had very little option but to volunteer to gain practical work experience. While this has enhanced service delivery, people were unhappy and poverty levels had not improved. Government wanted to continue this modus operandi, but due to TB Care’s perseverance it was decided to pay the workers. High school graduates were targeted and given specific training so that the job would serve as a stepping stone to more lucrative employment. Due to the high levels of unemployment in the affected communities, the decision to target high school graduates was not without its obstacles, as facility staff became aggressive as they felt that their friends and family members should have been employed. This was resolved by always having open communication channels between the parties. An unintended consequence of having TB Care manage the programme off-site was that facility managers did not assume responsibility for the day-to-day management of the TB Clerks and Assistants. This issue was resolved by meeting regularly with the facility management and highlighting the increase in cure and defaulter rates and noting the TB Clerks and Assistants contribution in this regard.

d. What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Initially in 2005, Province funded the programme to the value of R211,883 and in the following financial year (2006/07) both the City and the Province provided R1,196,496 and this increased to R1,310,798 in 2007/08. Due to the success of the programme, funding has increased to R1,995,307 for the 2008/09 financial year. This funding for the intervention has been sourced through the specifically earmarked Policy Option and the TB Enhanced Response committed by the Province. The TB Care is responsible for the financial management of the programme and submits monthly and quarterly claims to both City Health and the Province, which release funds through the Metro District Health Services. TB Assistants and Clerks earn R18,000 and R24,000 respectively, per annum. Initially, only 18 TB Assistants and 13 TB Clerks were employed, but due to the success rate and additional funding, 87 previously unemployed youth were employed and have gained valuable work experience.

Is the initiative sustainable and transferable?
The programme is sustainable for a number of reasons. Firstly, its success rate is beyond reproach and the programme has committed funding from Provincial government. Another factor that enhances its sustainability is the experienced and committed professionals that manage the programme. It was originally conceptualised by Dr Virginia Azevedo the Director of South Peninsula Health and Ms Judy Caldwell, the TB Project Manager for City Health. The two other members of the project team are Ms Ria Grant the Director of TB Care and Ms Aspi Siyolo the TB/HIV/AIDS/STI co-ordinator for City Health. All are senior professionals with life careers in public health services. They have the confidence of both Provincial and local government and together they are setting new standards for TB care and treatment. Even though nursing staff turnover rates in the clinics are high as people search for better pay and easier conditions, project staff at the assistant and clerk levels are negligible due to the training and career pathing that opens up for them. Thus far only two assistants have been dismissed for not fulfilling their duties adequately. For the remainder, morale and commitment appear high. At the directorial and management level the programme is stable. The programme is transferable because the innovative model is powerful and inexpensive and its operational performance has demonstrated success. There is every reason to expect its replication as the project currently operates in less than half of the clinics of City Health.

What are the impact of your initiative and the lessons learned?
The principal lesson learnt from this programme is that it is possible to build a layer of non-professional, but trained staff to carry out routine tasks in order to free professionals to carry out the specialised work for which they are trained and qualified. This lesson has generic application as it tackles two issues simultaneously – the first being the intense pressure on high level services in poor regions and the second being the problem of schooled but unemployed youth in the same area. The creative innovation which the project institutes is to bring both problems into the same focus and to use one to address the other. Another key element of the programme is the partnership that was developed between government (City Health) and civil society (TB Care). This has resulted in improved and better services being delivered to the community, which has enabled government to deliver an efficient and effective health service as mandated by the South African Constitution.


Institution Name:		City Health Cape Town
Institution Type:		Government Agency
Contact Person:		Judy Caldwell
Title:		Project Manager
Telephone/ Fax:		+27 21 400 1869
Institution's / Project's Website:		+27 21 421 4894
E-mail:		judy.caldwell@capetown.gov.za
Address:		PO Box 2815, Cape Town
Postal Code:		8000
City:		Cape Town
State/Province:		Western Cape
Country:		South Africa

The Problem

Solution and Key Benefits

Actors and Stakeholders

(a) Strategies

(b) Implementation

(c) Overcoming Obstacles

(d) Use of Resources

Sustainability and Transferability

Lessons Learned

Contact Information