1. Strengthening district leadership, clinical governance and ward based outreach teams

2. Output 1: Districts are able to oversee improvement in reproductive, maternal and child health services.
Output 2b: Strengthened delivery of Ward Based Outreach Teams

3. Presentation overview
“Health Systems Trust’s role in the programme is to lead activities under Output 1 of the programme to Enable Districts to Oversee Improvement of RMCH Services and provide technical input under components in Output 2 of the programme for Strengthening Ward-Based PHC and Obstetric Neonatal Emergency Care Services”
National Coordination and Induction and Orientation Training of DCSTs - Ms Fiorenza Monticelli (HST)
The RMCH Technical Advisory (TA) Package - Ms Susan Naude (HST)

4. National DCST coordination and functionality
National RMCH Steercom Meeting, Pretoria
29 January 2015

5. Legacy of the national coordination
Recruitment (58.8%), updated national database
Stakeholder engagements (Universities, professional organisations)
DCST reporting framework
Case studies for best practices in districts
Strengthened link between levels of management (district, province and national)
DCST representation in strategic planning committees.
A DCST handbook (continued orientation of new DCST members and clarifies the roles of DCSTs to the new district managers). tm
The national coordinating post strengthened the functionality of the DCSTs and complemented the I&O training of DCSTS which enhanced leadership and clinical governance skills to perform their roles and responsibilities.

6. What should be carried on into the future
Mentoring plan for DCSTs and by DCSTs
System refinement of DCST role and functionality (performance management) to suit the new cadre of employee who is neither direct clinician or manager.
Full engagement of universities/ roles to explore additional resources available in the academic field.

7. National Induction and Orientation Training of DCSTs
Fiorenza Monticelli (HST)
National RMCH Steercom Meeting,Pretoria
29 January 2015

8. Objectives and background
Main Objective
To conduct the national DCST Induction and Orientation Training
minutes of the special Steering Committee meeting on the DCST Orientation and Induction programme, held 24 August 2012 confirmed that the RMCH project would train DCSTs nationally (excl. KZN),
the MTT guidelines* provided a broad framework for the induction and orientation training of the DCSTs,
the national training would link in to what was being done in KZN.
*National Department of Health. District Clinical Specialist Teams in South Africa. Ministerial Task Team Report to the Honourable Minister of Health, Dr Aaron Motsoaledi. October

9. Legacy
5 DCST Induction and Orientation Training modules, resources and DCST toolkit. Also available on HST and RMCH websites.
Tailor-made training videos on Post-Partum Haemorrhage and difficult Caesarean sections (YouTube)
A moderated online e-discussion list for DCSTs
A Clinical Governance handbook for DCSTs and other clinical leaders
A national DCST database
A DCST steering committee
Training materials and SOPs on family planning for WBOTs, facility staff in maternity units and PHC facilities
External review of the DCST stream.

10. Impact - Was the training successful?
An objective external evaluation of the DCSTs is in process and guided by a national Steercom. Results and recommendations will advise on sustainability, challenges and way forward.
Feedback obtained through the workshop evaluation process transformed from ambivalence and negativity in earlier workshops to overall positive responses and appreciation.
A Focus group discussion with consultant developers and trainers, facilitators and district specialists who participated throughout, considered the I&O training as having achieved its overall objectives.
Improvement in national impact indicators is premature to assess, however improvements in outcome and impact indicators are evident in a number of facilities and some districts as a result of DCST efforts.

11. Theme
Discussion
Context specific training
DCST function is understood and applied differently in various provinces and districts, thus training and content is adapted to speak directly to the needs of the province whilst still covering the required content overall.
Provincial MNCWH forum
Establishing a forum which is resourced at provincial level and supported by an academic institution is essential for peer learning.
Replication of training
The National Induction and Orientation training approach, methodology and content can be adapted for national training of MNCWH coordinators and managers and other PHC streams such as contracted GPs, School health management teams and WBOT leaders.

12. Lessons learnt Theme Discussion
Content development
Involving local experts in content development increases the relevance and practical application of contents and promotes local buy-in.
Sufficient time should be made available to make allowance for several consultative meetings at province and district level with relevant stakeholders and to identify and meet with local experts before training and orientating of a new cadre is done.

13. Recommendations
Continued professional development and training of DCSTs
DCSTs require on-going clinical and leadership training
The I&O training focused on leadership, health systems, M&E, management and strengthening of MCH. (no clinical training).
Through the DCST SteerCom, the NDOH can guide provincial specialists to ensure provincial oversight by coordinating provincial RTC structures and academic institutions in providing consistent clinical training for DCSTs.
This equally applies to training to optimise the leadership role of the DCSTs. (their leadership is constrained by lack of direct line management and financial control). This can be coordinated through linking up with existing leadership courses offered by NGOs (MSH, HST, FPD) in provinces/districts.
Continuous on-site accompaniment, mentoring and coaching is required, to achieve sustained skill development. To this end dedicated work by the provincial specialists for mentoring and coaching activities is required as is currently being done in in KZN and Free State districts.

14. Recommendations
2. Central coordination and monitoring for sustainability
The RMCH project has aptly demonstrated the worth of a national DCST coordinator:
facilitated and guided the functionality of DCSTs,
supported and guided appointment of DCSTs,
liaised with provincial coordinators in order to create an enabling environment for the DCSTs
created guidelines for the monitoring and evaluation of DCST activities
The formal post for a national DCST coordinator needs to be created and filled as a matter of urgency to ensure sustainability of the work done by the RMCH national DCST coordinator. .

15. Technical Assistance (TA) Package and ward based outreach teams
Susan Naude (HST)
National RMCH Steercom Meeting, Pretoria
29 January 2015

16. Objectives
Development of a tailored TA package for each district to address coverage gaps
Assist RMCH teams to report on MNCWH mortality audits and support teams to use data for planning and implementing RMCH strategies
Improve routine health information use for quality data and monitoring of key health indicators.

17. Technical assistance approach
Advocacy and capacity building of DMTs and DCSTs through
training and technical assistance along the continuum of care
Support data utilisation to plan intervention and conduct mortality
and morbidity audits
Improve service delivery through support and Technical
Assistance package to DM, DCST and MNCWH coordinators.

18. Technical assistance package
Sexual reproductive health (SRH)
Family Planning
SRH Policy rollout and dissemination of Primary Health Care and Maternity operating units Standard Operating Procedures
Increase Uptake of FP Services
Capacity Building for Health Care Workers
Antenatal care
Early antenatal care
Basic antenatal care

19. Intra-partum care
Monitoring of intra-partum care (ESMOE and Fire Drills)
Partogram implementation (interpretation and action)
Postpartum care (maternal): prevent and manage PPH
Postnatal and newborn care
Essential new born care
Maternal-New born care: visit within 6 days (creating demand through CSO grantees work and strengthening client friendly services)
Childhood
Infant and Child care: prevent case fatality from and management of diarrhoea, pneumonia and malnutrition

20. Impact of TA interventions
1.Support to the District Management Team
Improved data usage and interpretation - M&E dashboards with maternal
neonatal and child health indicators have been created and are being used by
districts to monitor progress.
2.Support implementation of CARMMA
The District Health Plans of 25 RMCH priority districts, which in previous years
had none or little mention of CARMMA activities or indicators, included
CARMMA indicators in the 2014/15 plans. This indicates that the districts have
begun planning the monitoring of the implementation of CARMMA
In eThekwini (KZN), Capricorn (Limpopo), and Ekurhuleni South (Gauteng),
Kangaroo Mother Care is now practised in all birthing facilities thus reducing
the early neonatal death rates in these facilities

21. Impact of TA interventions
3. Key interventions along the continuum of care
An active roving team on Family Planning for post training mentorship and on-site training was created in Ekurhuleni District (Gauteng), resulting in observable increase in demand for MNCWH services such as uptake of family planning, antenatal care and post-natal visits.
DCST are taking the lead in mortality and morbidity reviews in many districts. Northern Cape DCSTs completed protocols on clinical guidelines for referral of newborns.
Intrapartum care focused on plotting and interpretation of partograms to promote care and appropriate referral (with DCST)

22. WBOT impact
Ward Based Outreach Team leaders (WBOT’s) and other relevant managers were trained in the 9 provinces including the 25 RMCH districts on family planning and MNCWH messages.
Awareness was created of their worth, impact that they could have, need for a dedicated team leader and linkage to a PHC facility and school health teams.
WBOT linkages were created for postpartum follow-up in households, e.g. Thusanong hospital has WBOT teams attached to it to assist in post-partum follow-up.
In some districts where WBOTs activities were combined with the work of civil society organisations, this led to early observable demand for MNCWH services, especially the uptake of family planning, antenatal care and post-natal visits.

23. Legacy
DHPs changed to include CARMMA and MNCWH indicators and related activites.
Improved interrogation and utilisation of data to plan interventions and monitor progress (dashboards and district reporting tool).
Auditing of partogram and other cards (BANC & child records) to address with DCSTs
Family planning flipchart for WBOTs (also being used in clinics)

24. Recommendations
Provide leadership development for provincial managers, DMTs, hospital and PHC managers through leadership programmes offered by universities, business schools and NGOs (MSH, HST and FPD).
Human resource departments should have a recruitment and retention strategy in place for critical posts (MNCWH coordinators, doctors, anaethetist, advanced midwives etc.) to render quality care at district level
Clinical mentors need to be appointed by Province as part of the RTC to mentor and evaluate health care workers post-training to ensure skills have been acquired and applied.

25. Recommendations
MNCWH directorate at NDOH should put a communication strategy in place to make sure that policies and information reach facilities.(utilising DCSTs and academic institutions).
District and/or facility management should consult with community leaders to ensure community participation to foster ownership and commitment for support and sustainability of interventions.(e.g. Zithulele hospital).

26. Recommendations
DCST should be an integral part of quality assurance committee and other clinical governance structures.
District/sub district Primary Health Care Coordinator should link each WBOT to a PHC facility to improve continuity of care for women and children, referral from and back to community and track cases that are lost to follow up.

27. Conclusion: Requirements for sustainability
A dedicated national DCST coordinator.
Provide leadership development for DCSTs, provincial managers, DMTs, hospital and PHC managers through engagement with universities business schools and NGOs (MSH, HST and FPD).
Ensure a provincial recruitment and retention strategy to fill critical posts (DCSTs, MNCWH coordinators, doctors, anaesthetists, advanced midwives etc.) at provincial and district level as a priority to render quality care.

28. THANK YOU