Handbook for Clinic/CHC Managers

October 1999

Table of Contents

Introduction: Purpose and use of the handbook
Section 1: Clinic and CHC Manager's Checklist
Section 2: Best Practices - some examples
Section 3: References and Resource List

ACKNOWLEDGEMENTS

Many people contributed to the publication of this handbook. The editors wish to thank the following persons in particular: Dr Jon Rohde; Ms Joan Littlefield; Dr Rudi Thetard; Mr JP Sallet; Dr Helen Schneider; Dr Umi Sanker and her team; Dr Noddy Jinabhai and the reference group.

Yogan Pillay and Bennett Asia

INTRODUCTION: PURPOSE AND USE OF THE HANDBOOK

A fair amount of attention has been paid to the establishment of the District Health System, the building and upgrading of clinics and the strengthening of management at certain hospitals. However, not much attention has been paid to strengthening the management of clinics and community health centres in the past five years.

The emphasis on improving quality of care, restated most recently by the President in his address to the first sitting of Parliament after the June 1999 elections and by the Minister of Health when she launched the National Patient's Rights Charter in November 1999, implies that we must seek ways to increase the efficiency and effectiveness of the health service at all levels of care. Communities and health service users must be convinced that primary health care is appropriate care and not cheap second-class care. Unless we improve service delivery at this level our patients will continue to believe that hospital care is always appropriate and the best care they can get for all conditions and continue to bypass primary health care services.

In an attempt to help managers of clinics and community health centres, the national Department of Health, with the assistance of the Department of Community Health, University of Natal and the Equity Project, has produced this management tool. We hope that this tool will be easy to use and via its use and feedback that it can be revised to ensure that it is user-friendly and useful to clinic and community health centre managers.

This tool is in two sections: the first section contains a checklist which managers can use to ensure that the vital aspects of management are taken care of on a monthly basis (some items are less frequently monitored and others more often). The second section contains examples of what needs to be done and how it can be done. This section is provided to help those managers who need to develop their capacity in certain areas of management. In drafting this section we tried to include 'best practice' strategies that have been tried in facilities similar to yours. We hope to collect other examples for inclusion in revisions of this publication. So please send us examples of strategies that you have tried and that work.

SECTION 1
CLINIC AND CHC MANAGER'S CHECKLIST

This checklist is designed to be easy to use and refers to the most important areas that need to be managed. How should you use this checklist? We recommend that the manager review the items in the list below and tick all those that are in place once a month (unless indicated to the contrary below).

A. GENERAL LEADERSHIP AND PLANNING

B. STAFF

C. FINANCE

D. TRANSPORT / COMMUNICATION

E. VISITS TO CLINIC BY SUPERVISOR

F. COMMUNITY

G. ORGANISATION OF SERVICES / QUALITY / CLIENT SATISFACTION

G1. Client Consideration:

G2. Service Organisation:

G3. Clinical Standards:

H. EQUIPMENT and FACILITY

I. DRUGS and SUPPLIES

J. INFORMATION AND DOCUMENTATION

J1. References and resources

J2. Recording and reporting of data/information

The mission statement developed by the Hershel Clinic in the Aliwal North District of the Eastern Cape reads as follows: “Provision of comprehensive holistic health care service regardless of race, colour or creed at the preventive, promotive, curative and rehabilitative levels accomplished by putting health services within the reach of communities, i.e., PHC therapeutic environment for both the consumer and the caregiver. To ensure consumer driven service delivery”.

J3. Managing with information

SECTION 2
BEST PRACTICES: SOME EXAMPLES OF HOW TO ACHIEVE A WELL-MANAGED AND EFFICIENT CLINIC OR COMMUNITY HEALTH CENTRE

This section provides details on each of the items in the checklist and also provides some ways of improving management in these areas. These examples may be useful in assisting you to improve your management skills and strategies.

Look through the following descriptions of interventions with your team and identify ideas that may be useful. You should adapt these ideas to meet the needs of your situation.

A. General Leadership and Planning

  1. Vision / Mission Statement

A vision is a mental representation of a possible and desirable future state of an organisation.
An example of a vision for a clinic may be: “To be the best provider of primary health care in the district and province”.
A mission is an organisation's purpose and scope of operations.
An example of a mission is: “To provide efficient and effective primary health care in collaboration with the community we serve”.

  1. Core values for team

The core values of the team working in the facility should be defined by the team. Examples of core values are:

Writing these core values down and displaying them is useful because:

  1. the team can be reminded of them; and
  2. they can be communicated to patients who use the service who in turn will know what to expect from the personnel (this is clearly related to the Patient's Rights Charter and Batho Pele).
  1. Annual operational plan or business plans

An operational plan sets out what services the clinic or CHC will deliver during the financial year, who will deliver the services, when the services will be delivered and how the services will be monitored (include here supervisory visits) and evaluated to see if the objectives of service delivery are met. This implies that indicators and targets will have to be determined for each activity. The plan should be completed well before the beginning of the financial year and discussed with the clinic supervisor. Supervisors may use the plan to monitor progress in service delivery on a quarterly basis. More information on the process of developing such a plan can be found in a publication by the national Department of Health called 'Health Planning for District Management Teams: Some simple planning frameworks and tools'.

B. STAFF

  1. Orienting new personnel

New personnel should be oriented during their first day and informed about: the vision and mission of the clinic/CHC; the business plan of the facility; how the facility is managed; their roles and responsibilities (including supervisory issues); where supplies are kept and how to access and restock them; how the transport and communication system works; how to arrange for vacation and sick leave, etc (this is not an exhaustive list). It would be useful to develop a standards of operation manual for the facility which is a record of these issues so that new staff can be given copies of the operating manual.

  1. Staff establishment for all staff categories. Is it known? Are vacancies discussed with supervisor?

It is useful to get (from the district office) the clinic/CHC's staff establishment. The staff establishment/organogram must be displayed for all to see and used for the planning of service delivery. As this may change from time to time it is important that this is updated regularly. In developing the business plan and in discussion with the supervisor and district or sub-district management the need for more staff and what to do with excess staff should be raised.

  1. Job descriptions

In order for roles and responsibilities to be clear and known to all and to ensure that there is no duplication or gaps it is important for each staff member to have a job description. It is also important that the job description of all personnel relates to the mission and vision of the facility, the district and the province.

A job description should have approximately five or six objectives and ranked in order of priority. Management and supervisory responsibilities should also be reflected. Each objective should then be described in terms of outputs and competencies. Output descriptions should include: the end result of the tasks or duties necessary to achieve the objective; how the job can contribute to the service delivery programme; and performance standards required. Outputs may be structured in the following manner:

Besides the outputs the job description should include a competency profile which lists the inherent requirements for the job. This profile may include the following: (a) job knowledge and skills description; (b) description of personal attributes (attitude, understanding, behaviour); and (c) work area in which learning is required with indicators (qualifications, training, experience) including statutory requirements were applicable.

  1. Task list

Are staff sharing non-specialised, uninteresting tasks?
Are staff getting opportunities to share interesting duties, tasks?

  1. Workload estimation and use of information

Crude workload can be estimated by dividing the head count (total number) seen at the clinic or community health centre) by the person hours worked (total number of hours worked by all personnel for a day or week). For example, if a clinic with 4 nurses saw 80 patients a day and other clinic with 2 nurses say 60 patients a day the workload for each will be 20 and 30 respectively. Note that this is a crude workload because the real contribution per nurse may vary.

  1. List of PHC services (PHC checklist) and required skills - how to use the list to determine skills gaps in clinic to ensure that the clinic can offer services. The national Department of Health has developed a package of services to be rendered at community, clinic and CHC level. In addition, the Equity Project has developed a checklist which may be used to determine the gap between currently provided services and the full package.
  2. On-call roster. These are mandatory for the planning of services that are rendered after hours and over weekends. It is important to develop these in a transparent manner thus avoiding complaints of favouritism. It is also important to be even-handed and ensure that all staff have the opportunity to indicate their choices and to accommodate these whenever possible. Such an approach is more likely to ensure a happy and productive workforce.
  3. Absentee register. A recent survey conducted by the national Department of Health revealed that absenteeism is a big problem in the public health system.

Managers must ensure that they have a register to record absenteeism and ensure that steps are taken to identify personnel who are chronically absent. Discuss the reasons for absenteeism with the staff member concerned. If you feel that you need assistance bring this to the notice of the clinic supervisor and the person in the district responsible for human resources.

  1. For each staff member

Keep a record of meetings, workshops, training sessions attended; Is the balance of opportunity among staff reviewed and is it equitable?

  1. Staff meetings (Are they held regularly and what should they cover?)

The contents of staff meetings depend on need but all staff should be encouraged to add items to the agenda. Typically agenda items include: welcome & introductions especially of new staff; apologies; confirmation of the agenda; corrections to minutes of last meeting; matters arising from last meeting; new matters (which may include: service delivery issues; staffing issues like leave, training issues, the roster; finances; drugs and supplies; issues from the meeting with community structures like the clinic committee; maintenance of building and equipment; transport, etc).

  1. In-service training at clinic/CHC level

Discuss this with clinic supervisor and develop plan for training. Establish the training needs from the job descriptions prepared (see above) and ensure that trainers and materials for training are available. Ask the supervisor for a list of resources available in the province.

  1. Contents of a staff file

All personnel should have their own staff file in which the following information could be recorded:

C. Finance (note: not all clinics may be responsible for finances as yet):

  1. Is the budget for year known for main categories?
  1. Monthly recording of expenditure in each category
  1. Transfer of funds between line items

D. Transport / Communication / Supervisor's visits

  1. Transport
  1. Telephone/radio
  1. Supervisor Visits
  1. Written record of supervisor's visit

E. Community

  1. Does a clinic committee or community health committee exist?

Do staff members attend these meeting? Do staff present clinic issues e.g., disease patterns, problems with defaulters that community members may be able to assist with etc? Does the committee have formal minutes?

  1. Community involved in helping with facility needs:

Communities can be encouraged/supported to assist in various ways, e.g., as volunteer health workers responsible for the DOTS programme; peer-to-peer HIV/AIDS education; patient case finding, referral of preventive care clients (immunisation, etc); caring for the elderly; maintenance; clinic gardens etc. This should not be seen as burdening the community but may be mechanisms through which community ownership of the health facility may be encouraged.

F. Organisation of Services / Quality / Client Satisfaction

F1. Client Satisfaction (refer to the Patient's Rights Charter as well)

  1. Waiting times:

Is the time clients wait to be seen by the nurse/doctor reasonable?
Is the total time spent in clinic/CHC reasonable?

We need to ensure that clients/patients do not wait for long periods of time at any point during their visit to the clinic/CHC. Short waiting times are important as they signify: (a) that we respect the time of our patients/clients; (b) that we take them and their concerns seriously; and (c) that we are part of an organisation that is efficient.

Waiting time can be tracked by following a few patients at random and assessing how long after they arrive at the facility they are seen by a nurse/doctor. In addition, it is important to calculate how long it takes a patient from entering the facility to leaving after having received treatment. This may assist you to figure out where the blockages are so that you may be able to reorganise the services to ensure better throughput (time taken from entry to exist).

It is important for the clinic/CHC to set benchmarks for waiting times after discussion with the community through the clinic or community health committee.

  1. Privacy: the Patient Rights Charter has a series of rights that health providers are obliged to provide, one of these is the right to privacy. Ensure that you do all within your means to ensure that patients have privacy. Discuss this with your supervisor if necessary.

F2. Service Organisation:

F3. Clinical Standards:

  1. Infection control
  1. Drug Dispensing and Labelling
  1. Waste disposal procedures:

The following waste disposal for medical waste has been developed by the Health Department of the City Council of Durban and may be used with the necessary adaptation to local conditions:

  1. Sharps containers

Uses: (a) needles and syringes note: do not re-sheath needles or separate needle from syringe; (b) scalpel blades, blood lancets, and stitch cutters; and (c) broken glass, ampoules and other dangerous sharp objects.

Management of Sharps:

  • Ensure that container is properly assembled before use
  • Keep container in an easily accessible place on work table but out of reach of children
  • Have one container for each work area where sharps are being used to limit moving the container
  • When moving the container, close the lid without sealing
  • Rotate containers if one area of the clinic is less busy, e.g., between family planning and immunisation
  • Once used, immediately place the needle and syringe into the sharps container (the needle must not be recapped or detached from the syringe)
  • When the container is three-quarters full, seal and place in a safe storage area until collected
  • Ensure that the clinic has an adequate stock of empty sharps containers to replace the used ones
  1. Medical soft wasteboxes

Uses: (a) used swabs preptic and cotton wool; (b) all used dressings; (c) haemolysing sticks, pregnancy, urine and blood testing strips; (d) empty vials e.g, Depo Provera, Vaccine, etc.

Management of Soft Waste

  1. Post-HIV exposure prophylaxis (PEP) for employees:
  1. For all exposures, immediately clean the affected area with an antiseptic agent and water. Mucus membrane and eye exposures should be rinsed and flushed extensively with water.
  2. Evaluate the exposure

2.1 The following are potential exposures that should be considered for PEP

  • A blood contaminated needle stick injury
  • An injury with a blood contaminated sharp instrument or similar instruments contaminated with semen, CSF, pleural or other serous fluid (excluding urine and faeces).
  • An exposure to the mucous membranes (eye, mouth) with the above fluids.
  • A blood contamination of compromised or diseased skin (such as a weeping eczema).
  • Prolonged exposure to a large volume of blood on normal skin
  1. Determine the HIV status of the exposure source

3.1 If there is no record of the HIV status of the source patient, then an attempt should be made to obtain blood from the patient for this purpose. This should be done according to existing guidelines for HIV testing and include pre and post-test counseling. An approved rapid HIV test could be performed and later confirmed by routine HIV testing procedures.

3.2 If the patient refuses HIV testing, if there is no record of a recent HIV test result, or if HIV testing is not possible or available, then a doctor caring for the patient should be consulted as to the likelihood of the patient being HIV positive. Clinical signs indicating possible HIV infection include: TB infection, signs of immune deficiency such as oral thrush (candidiasis) and/or oral hairy cell leukoplakia on the tongue, recent herpes zoster or molluscum contagiosum infection, Kaposi sarcoma, recurrent infectious conditions such as diarrhoeal diseases, pneumonia, meningitis, skin sepsis; or unexplained weight loss, seborrhoeic dermatitis or persistent glandular lymphadenopathy. Using these clinical parameters in the absence of an HIV test is far from ideal as many HIV positive persons will be asymptomatic.

[In situations where there is a high suspicion that the patient may be in the window period, then an HIV PCR or HIV p24 antigen test could be considered.]

  1. Recommendations for PEP

4.1 PEP is recommended for any high-risk exposure .

4.2 Zidovudine (ZVD) in combination with Lamivudine is recommended for high risk exposures. Single therapy with ZVD may be effective and is preferable to no PEP but is likely to be less effective than therapy with more than one drug. Single ZVD PEP therapy is not recommended by any recognized international authority.

4.3 Indinavir can be added for very high risk exposures. Very high risk exposures include: 1) large volume of blood; 2) deep injury; and, 3) if the source patient has been on ZVD for more than 6 months.

4.4 PEP should be initiated promptly, preferably within 1-2 hours after the exposure. The interval after which there is no benefit from using PEP is not yet defined, however most experts recommend PEP within 24 hours after exposure. Some experts may still consider PEP 7-14 days after the exposure in cases where there is highest risk exposure. To avoid delays in starting PEP, starter packs of recommended drugs should be available in all health care settings.

4.5 PEP should be continued for 4 weeks. PEP should be discontinued if there are serious toxicities or intolerance and should be continued even in the presence of mild side effects.

4.6 Exposures such as small blood volumes or other body fluid contact on normal healthy skin are considered very low risk. PEP is not recommended in these cases but can be assessed on a case by case basis. For exposures to urine or faeces, PEP is not recommended unless these are contaminated with blood.

4.7 If the source patient's HIV status is not known, initiating PEP should be decided upon on a case by case basis, and based on circumstances including the likelihood of HIV infection in the source patient.

4.8 PEP is recommended if: 1) the source patient is HIV positive; 2) the rapid HIV test is positive; or, 3) or if there is a high index of suspicion that the source patient is HIV positive.

4.9 An Elisa HIV test should be done and documented on the exposed health care worker at baseline (i.e. within 24 hours of the injury), at 6 weeks, 12 weeks and at 6 months. In rare instances sero-conversion can take place over a period longer than 6 months.

4.10 Tests for occupational exposure to Hepatitis B and C, syphilis, malaria etc should also be considered if deemed appropriate.

4.11 Supportive counselling should be available to the health care worker. The health care worker should consider using a barrier method for safer sex. Avoidance of pregnancy in female health care workers is also recommended until sero-conversion is excluded. Pregnancy in health care workers should not preclude the use of PEP.

4.11 If HIV sero-conversion occurs the health care worker should be referred for appropriate counselling and treatment and informed about compensation claims.

4.13 An appropriate and confidential reporting system should exist within health facilities to document all occupational exposures and details on the source patient, for medico-legal purposes and for possible compensation and insurance claims. All HIV related occupational exposures, irrespective of whether PEP is recommended, should be reported.

4.14 Health care facilities should delegate responsible officials to oversee the reporting and recording of occupational HIV exposures.

4.15 If the HIV test on the source patient is negative, it can be assumed that there is a low risk of exposure to HIV unless there is reasonable information to suggest that the source patient is in the window period. In these cases PEP is not recommended.

G. Equipment and Facility

  1. Essential equipment for PHC in place

E.g. oxygen, equipment for pelvic exams, BP machines, scales, etc. Needed equipment can be determined through the PHC package of services and the norms and standards being developed. Equipment that is in place but not functioning should be noted. Note which services cannot be rendered due to lack of specific equipment.

The national Department of Health suggests the following essential equipment list (a final list is expected shortly):

  1. Consulting Room
  1. Procedure Room
  1. Staff Room
  1. Dispensary
  1. Utility/Dirty Store
  1. Instruments
  1. Inventory of clinic equipment

Should be updated every 3 months, and include new equipment as it comes in.

  1. Broken equipment

List of broken equipment should be up-to-date, with the problem stated, the date that someone was informed (stating the date and who). Also, a label on the piece of equipment should state that it is broken and what is wrong.

  1. Routine maintenance of equipment

Note each piece of equipment on the inventory that requires routine maintenance, including each type of maintenance, how often, and when it is next due.

  1. Facility clean, tidy

Is activity of cleaning staff monitored? Is corrective action taken to ensure facilities are kept clean and tidy?

  1. Facility Repairs Needed

Keep a list of repairs needed in the clinic (for repairs to such items as doors, windows, toilets, etc.) Discuss the repair needs with the supervisor, clinic committee, or other potential resource for resolving these problems.

  1. Vaccine Refrigerator

Is the temperature recorded daily? If not, why?
Are only vaccines kept in the refrigerator (i.e. no lunches, shopping, veggies from the garden)?

H. Drugs and Supplies

  1. Stocks secure:
  1. Stock cards

Used and up-to-date? A manual for training drug inventory management is available (obtain copies from the supervisor).

  1. Orders placed regularly and on time
  2. Verify drugs received against order placed

Discuss discrepancies with supervisor and identify the point at which problems occur.

  1. Monthly stock-outs recorded

What drugs have been out of stock this past month? Discuss each stockout with supervisor, noting how and when orders were placed, increased usage, etc.

  1. Organisation of stock

Keep drug stocks tidy and organisation patterns to make work easier and to prevent accidents (ie keep oral suspensions away from parenteral preparations)

For each drug, follow “FEFO” (first expiry, first out). This can be supported by placing drugs that will expire later behind the drugs that were already there. Don't be caught unawares - sometimes a newly arrived stock expires sooner. Be sure to check dates!

No expired stock should be on shelves. An example of a storage procedures checklist can be found in the following table:

  1. Drug ordering to save costs

Following Essential Drug List (EDL)?
Cost-effectiveness of drugs used analysed:

Some formulae to use in calculating stock levels:

Total used for period A (issue units)/period A (months) - number of months out of stock

Stock on hand (issue units)/average monthly consumption (issue units)

Average monthly consumption X maximum stock factor

Average monthly consumption X reorder factor - stock balance

Other factors that influence the quantity to order are: campaigns; outbreaks; promotion; stock out periods; storage capacity; statistics; seasonal factor; budget available.

If stock on hand is greater or equal to maximum stock level do not order

  1. Rational prescribing

The supervisor can support the clinic/CHC in analysing the number of items per prescription as compared with the Standard Treatment Guidelines. Conditions such as TB and STDs should not be included in such an analysis as they require more drugs than normally recommended for other ailments (on average).

  1. Lab test supplies

Supplies for lab tests conducted in clinic/CHC or for taking specimens to send out should be in supply and not expired. For example, for sputa collection for TB smears, blood tests, pregnancy tests, etc. Make a list of lab tests that are conducted in the clinic/CHC and specimens that are taken in the clinic/CHC as a tool.

J. Information and Documentation

J1. References and resources

  1. Material on each national programme

Policies, protocols, treatment guidelines, technical updates, etc. All latest programme information that guides the clinic's/CHC work should be available to staff (ask supervisor for copies).

  1. Norms / standards for clinical services

Written norms and standards for various clinical services have been developed by the national Directorate for Quality of Care. Service providers are guided regarding approaches, expectations regarding client interaction, and resources that should be in place (ask supervisor for latest documentation).

  1. Other resource materials / references

Informational materials such as periodic publications from health NGOs or DOH, texts on primary health care, etc. can provide on-going additional information on patient care and services management. Should you have access to the internet the following websites may provide useful information: www.who.ch (the WHO website); www.doh.gov.za (national Dept of Health); www.msh.org (Management Sciences for Health); www.hst.org.za (Health Systems Trust).

  1. Flow charts

Flow charts for the wall or desk top are available for STD Syndromic Management, TB, IMCI and other patient conditions. When available, these resources should be in every relevant patient consulting area to guide clinicians during consultations (please ask your supervisor for copies).

  1. List of circulars, documents received

A simple list of all official documents received will help to ensure that the clinic/CHC is not missing any information that is important to managing services or as employees. The clinic/CHC list can be compared with the list the supervisor maintains.

J2. Reporting, recording

  1. Patient records

Patient held records are used in a number of districts. If used in your area, are new cards available for new clients or to replace lost cards?

If clinic/CHC held records used, delays in retrieving patient records contribute to long waiting times and overall patient dissatisfaction. Lost records (including those misfiled) cause even longer delays while staff search for the file before giving up, and important continuity information is lost as well.

Clinics/CHC can periodically measure the average time it takes to retrieve patient records. Strategies to improve the retrieval process can be developed by the clinic/CHC team and progress noted over time. Analysing the percentage of files lost can also provide a baseline for staff to use as a starting point while implementing improvement strategies.

  1. Patient visit recorded and services recorded

One example of a recording system could be a simple tick register.

  1. Continuity records

Registers and other follow-up systems of clients requiring follow-up care can be easily developed. Clients who do not return for essential repeat visits must be followed up. This is important for those cases where not completing treatment can result in the development of resistance to treatment/medication, e.g. MDR-TB.

Other examples for which continuity of care is essential are: FP, EPI, ANC, STD, chronic diseases like diabetes, hypertension and epilepsy)

Any system supporting continuity should be kept up-to-date with follow-up done for “defaulters”.

  1. Lab specimen register kept? Missing results followed up?

Keep is book in which all specimen collected are reflected by name, patient number, date on which specimen sent to lab, date on which results received.

  1. Medico-legal forms available (notifications, statutory responsibilities)

Examples include: births and deaths forms; forms for occupational health reporting

  1. Notifiable diseases

New cases must be reported immediately. Are there time lags in reporting? Explore with staff the causes of lags in reporting, and make plans to resolve them.

“Nil” reports should be submitted weekly. By reporting that no cases of each notifiable disease have been treated by the clinic/CHC, the surveillance system can be confident that low numbers of cases reflect low incidence, rather than poor reporting.

  1. Births and deaths forms

The new birth notification form (BI 24) was promulgated in August 1999. The death notification form (BI 1663) was promulgated in July 1998. To ensure that all births and deaths are registered please ensure that the forms are filled in accurately.

  1. Monthly PHC statistics report - accurate, on time, filed/sent according to district and provincial requirements

J3. Managing with information

  1. Monthly data checked, discussed, graphed with/by clinic staff - action? Shared with clinic committee?
  2. Data displayed and updated regularly?
  3. Annual data verified, discussed and used for developing annual plans etc
  4. Operational plan (business plan) developed

Note:This is not a monthly activity list, but plans can be reviewed and updated often). Check if your plan is in line with the district, provincial and national plans? Ensure that the plan is informed by statistics that you collected?

  1. Catchment area map

Including location of mobile stops, DOTS supporters, CHWs and other outreach activity (for more information consult the MSH's publication called 'Mapping for PHC' which should be available from your supervisor)

SECTION 3
ADDITIONAL REFERENCES

Often even the information provided in the section above will not be sufficient to assist one to change one's practice or may not work very well. This section provides examples of other resources that you may wish to consult if you get stuck.

The various issues of Kwik-Skwiz published by the Health Systems Trust and available on their website (www.hst.org.za) or through your district office. The issues produced over the last few years have focussed on areas like how to conduct a rapid situation analysis, budgetting, rational drug use, strengthening community participation, administration, how to set up a registry etc.

The Centre for Health Policy at WITS has developed a model for quality improvement called 'problem based approach to clinic management'. Please contact them directly or via the district office for copies of their model. Contact the Centre by calling 011-489 9931; fax 011-489 9900.

A district in the North West Province has produced a document on Batho Pele service standards for use at clinics. Contact the Mafikeng District Office and ask for Mr MC Malaka (tel:018-3845918).

The Equity Project has produced a document on how to map the catchment area of a district or facility based on their experiences in the Eastern Cape. The publication is called ‘Mapping for PHC’ and can be obtained from the Bisho offices of the Equity Project (tel: 040-635 1310; fax: 040-635 1330).

JP Sallet of the Equity Project has produced a manual entitled 'Managing Drug Supply for Health Institutions'. Much of the material relating to stock cards and ordering were supplied by Jean-Pierre. Please contact him via the Equity Project offices at the number provided above.

The national department of Health has produced a synopsis of national policies. Please ensure that your staff are fully conversant with all the relevant policies of the national, provincial and municipal health departments. Copies of the synopsis of health policies and legislation may be obtained from the national Department of Health's communication unit (012-3120713).

DESIGN & LAYOUT
Cathleen Fourie
The EQUITY Project