One of the challenges facing the healthcare sector in the Eastern Cape Province, South Africa, has been the lack of proper recording of Adverse Drug Reaction (ADR) cases which contributes to increased patient morbidity and mortality.
PEPFAR-supported partner Beyond Zero has identified gaps to adverse drug reaction reporting and pharmacovigilance – and has responded by providing training and mentoring as well as tools required to assist with voluntary reporting of ADRs. At the beginning of the organisation’s support, a challenge existed where no ADR forms were being completed. Normally, ADR reporting is voluntary and this is one of the main challenges in reporting. Together with the mentoring, training and tools provided by Beyond Zero, the organisation has since witnessed a surge in ADR reporting with 10 percent of facilities religiously undertaking this exercise.
Ansuya Naraindas, Pharmacy Advisor at Beyond Zero, says “whilst this may seem like a small number, it is a significant figure compared to previous years.” This has not gone unnoticed as the National Department of Health Pharmacovigilance has recognised Beyond Zero’s efforts made in this field.
“You cannot eat an elephant in one bite, but a little at a time. So for us, who have worked tirelessly on this programme have everything to celebrate this milestone because it shows that our work is impacting positively,” Ansuya said.
Notably, South Africa is currently witnessing growth in the pharmacovigilance arena. The antiretroviral and tuberculosis programmes recognise the importance of targeted monitoring of the safety of the medicines they use in patients and developing targeted pharmacovigilance systems to address particular problems with the medicines they commonly use.
The Minister of Health in South Africa, Dr Aaron Motsoaledi notes that currently there are over 3 million people on Antiretroviral Treatment (ART) in the country. However, with ART patients still facing numerous challenges, one of the key risks is Adverse Drug Reactions (ADRs) which can increase morbidity and mortality. It is therefore essential to monitor the adverse drug reactions linked to ART so that clinicians can make informed decisions regarding patient treatment and ensure that they do not default on their treatment.
To support the Department of Health and address the low rate of ADR reporting, Beyond Zero’s programme of support, aimed at encouraging
adverse drug reaction reporting entails:
Training 329 (and counting!) health care providers/workers including nurses, doctors, pharmacists, pharmacy assistants on pharmacovigilance, adverse drug reaction reporting and correctly and thoroughly completing ADR forms.
Mentoring staff at 321 primary health care facilities on how to
complete the adverse drug reaction form.
Providing ADR forms and written clinical tools and guidelines for the Prevention and Management of Side Effects and Drug Interactions in Adults and
Paediatrics to thes same facilities.
Locally, the challenge is the multi completion of ADR forms as this process demands that they be completed in triplicate. The lack of photocopy machines and unavailability of forms has also been reported as one of the challenges by facilities. To combat this, Beyond Zero has designed an innovative tool to improve adverse drug reaction reporting. The A4 booklet contains an adverse drug reaction form for the HIV and TB programme in triplicate form. This resource has been recognised and adopted for use by the National Department of Health Pharmacovigilance Department. The NDoH pharmacovigilance coordinator is set to continue rolling out the booklet in other provinces. Thus far, Beyond Zero has distributed this booklet to 430 supported facilities in the Eastern Cape
and Kwa Zulu Natal Provinces.
Clinical management of patients with adverse drug reactions is also important to ensure better patient outcomes. To that effect, Beyond Zero has printed and made available the management of Adverse Drug Reactions and Drug Interaction book for Adults and Paediatrics. The organisation has also been assisting the NDoH in rolling out their Decentralised Pharmacovigilance model in the Eastern Cape Province and Harry Gwala District in KwaZulu Natal Province, in South Africa. To date, hundreds of health care providers/workers have been trained on the various tools and approaches in this increasing more comprehensive ADR and pharmacovigilance model with plans to intensify this activity in underperforming clinics in need of further support.
The Eastern Cape Province is one of the poorest areas in South Africa and is faced with an avalanche of health challenges especially in the adolescent age group.
According to Statistics SA, the province has the highest teenage pregnancy rate, the highest fertility rate in the country and an HIV/AIDS prevalence of 29.9% in adolescents and youth. This is a bleak picture which has motivated the PEPFAR-supported NGO called Beyond Zero to develop a programme aimed at mitigating the challenges faced by the province. In support of and in partnership with the Department of Health, Beyond Zero has started rolling out its Adolescent and Youth Friendly Services (AYFS) programme.
At its core is the promotion of adolescent and youth friendly services by ensuring access and utilisation of health facilities, the improvement of optimal health status of adolescents and youth in South Africa by addressing key youth health policy priorities, building capacity of healthcare providers to improve service performance for the delivery of (adolescent and youth) services, including the promotion of services for HIV infected and exposed adolescent and youth for effective prevention, management, care and support. Another component of AYFS is the FPE concept, which aims to reduce teenage pregnancy by empowering boys and girls. Its emphasis is on the preparedness of an individual on whether he or she is Financially, Physically and Emotionally (FPE) ready to have a child.
For instance, a public high school serving a very disadvantaged community was among the schools with the highest teenage pregnancy in East London last year, with reportedly 74 cases. By the age of 19, roughly one third of girls in South Africa has been pregnant, or has a child. Falling pregnant under the age of 19 carries a 2 to 5 times higher risk of suffering complications or dying while giving birth as compared to older women. The socio-economic consequences of adolescent pregnancy are also enormous as schooling is interrupted and early parenthood is likely to adversely affect educational achievement with significant employment and socio-economic ramifications.
Two passionate nurses working as part of the Beyond Zero team in the Eastern Cape Province, South Africa, are turning the tide against the high level of teenage pregnancy among students; and HIV/AIDS prevalence in adolescents and youth through an innovative programme designed to mitigate these challenges.
Awonke Gaqana, a Nurse Mentor and Mandisa Mona a Technical Advisor Specialist have rolled up their sleeves and are working with various key stakeholders in the targeted districts in Amathole and Buffalo, East London, to ensure that public clinics create an enabling environment for adolescents and youth where they could easily access health services through a well-resourced and effective facility. An enabling environment is being created through the training and mentoring of clinical staff at clinics that Awonke and Mandisa are providing.
Over the years, public health facility practitioners have earned themselves a reputation of being uncooperative and dismissive amongst teens, an element which has contributed to the targeted age group refusing to utilise these facilities. As a response to this, the AYFS team has been training and mentoring clinical staff at clinics by empowering them with both clinical and psychosocial skills and knowledge to effectively dialogue with youth as equals and work together with these vulnerable clients to try and better address their needs.
The team has also been busy with educational campaigns at schools around the area where they educate students about matters relating to teenage pregnancy and HIV/AIDS; and prevention thereof. This has helped create an enabling platform for students to ask questions around these subjects and are subsequently encouraged to sign a pledge to reserve themselves from irresponsible and
risky sexual behaviour.
Beyond Zero Nurse Mentor Awonke Gaqana highlights that the AYFS programme is but one component of an arsenal that they are using to mitigate the current challenges facing the youth in South Africa. She says whenever the team conducts AYFS trainings, nurses are always encouraged to change their approach in how they deal with the youth. “We focus our energies on creating an enabling environment for both clinical staff at facilities and the targeted youth and adolescents to ensure maximised service provision and accessibility. We are adjusting our approach to suit the current challenges facing our children as they need to be fully educated about health risks and irresponsible behaviour,” she said.
Awonke further offers that the keys to the success of AYFS at public health facilities is the emphasis on the positive service approaches that at its core necessarily includes an attitude of Respect, Dignity, and Non-judgement – the implementation of which has a direct impact on the increase of clinic utilisation by the youth.
Public Health Clinics in the Eastern Cape Province in South Africa, have long been faced with numerous challenges that have largely contributed to a lack of inefficiency in the area of service delivery. One such crucial area has been in effective patient filing and record keeping systems. Beyond Zero recently responded to the call of the provincial Department of Health (DoH) by developing and rolling out a patient medical record system that the Department has lauded as a key time saver that has greatly improved the quality of patient care and effectively unblocked bottlenecks created as a result of proper record keeping.
Beyond Zero, a PEPFAR funded NGO in East London, South Africa, provided its expertise and took on the task of creating an efficient Public Health Record system which has benefitted 60 clinics this far. Added to this has been the donation of 248 steel cabinets to house 24,000 files from PEPFAR to ensure seamlessness in the programme’s implementation. This has ensured that proper record keeping is maintained at clinics and has positively impacted on the turnaround time as clinical staff are able to attend to patients within a short time.
Previously, patients had to contend with long queues, frustrated clinic staff and patients alike, and serious lack of resources as the Department of Health battled with addressing these challenges. Even more frustrating was the fact that patients were made to buy note books which served as their clinic consultation records containing their health history. The disadvantage this presented was the continued loss of these note books and the clinics were left with no file for easy reference. This also caused problems for the Auditor General (AG) as it could not be provided with files for auditing purposes, a clear lack of operational systems at these facilities.
Beyond Zero Monitoring and Evaluation Assistant, Ndilinde Mlakalaka, said: “The turnaround strategy that we have deployed has managed to swiftly impact positive change in the targeted clinics and this has largely been achieved through the willingness of the clinic staff to adopt new tools and techniques, as well as, prioritise service deliver in the communities they serve. The core of Beyond Zero’s mandate was to improve systems internally at the clinics and we have delivered on this – communities now receive improved and better service”.
Currently, all the clinics that have benefitted from Beyond Zero’s intervention have been equipped with training of staff on effective record keeping. They now boast of Primary Healthcare Facility Health Record (PHFHR) files containing each patient’s health background. During consultations, the patient and a staff member are required to sign the file as an acknowledgement of the consultation and the observations carried out thereof. A smaller version of the PHFHR is kept with the patient and contains the same information for when the patient approaches another facility for assistance.
At the clinic, each patient’s file is kept in one box for simplified reference and is backed up with an electronic system. For access to a patient’s file, one needs the latter’s identity document or surname. It is a seamless process that has managed to simply the consultation time, including auditing activities.
This has been achieved largely through a clinical staff training provided by Beyond Zero at the clinics on the new filing system in preparation for its full roll out. It has improved the quality of data records at PHC level in line with Beyond Zero’s strategy. As part of the filing system, Beyond Zero has also introduced visitor’s card for patients outside of the catchment area – a new aspect to service provision in these communities. It allows for the patient to use the same card for hospital visits as it contains his/her health background. This bears testimony to Beyond Zero’s expertise in the area of health systems strengthening and the rollout of this programme continues to impact positively in the area as it has improved healthcare services in the affected communities.
Beyond Zero and its provincial Department of Health partner has been approached by other NGOs and the South Africa National Department of Health to utilise this record system and approach as an emerging gold standard for the country.
Beyond Zero has made remarkable progress in efficiently rolling out Antiretroviral Therapy (ART) at all 430 facilities it manages in the Eastern Cape and KwaZulu Natal.
This has been achieved through the establishment of the highly successful Nurse Initiated Management of Antiretroviral Treatment (NIMART) mentoring programme which has seen 200 nurses certificated in the Buffalo City Municipality and Amathole District this far.
Decentralisation of services to Primary Health Centres (PHCs) has strengthened retention of patients on ART and reduced the burden of managing uncomplicated cases at referral hospitals. It has increased ART uptake and reduce workload at referral facilities, enabling them to concentrate on complicated cases. In redefining our role, the Institute for Youth Development South Africa (IYDSA) has now changed to Beyond Zero, a change that represents a renewed commitment to the founding core principles and operational approach for which IYDSA has earned its reputation as a hardworking, solidly reliable NGO partner in South Africa.
Before 2010, only doctors were allowed to initiate ART until the government announced its decision to give accreditation to nurses as well. The programme entails adequately capacitating frontline workers in managing HIV/TB co-infections, initiating paediatrics – it also assists in building good programmes in facilities. NIMART is a three-day training programme followed by five to six months of mentoring before a compiled portfolio of evidence can be submitted to the Regional Training Centre (RTC) for assessment.
Through the programme, Beyond Zero has seen a surge in people that have been initiated on ART and one of the key benefits is the fact that it has brought the service closer to people. As an appreciation and recognition of the work done by nurses under various trying circumstances, Beyond Zero committed themselves in acknowledging and honouring the work done by frontline workers on an annual basis. Last year, a NIMART certification ceremony was hosted by Beyond Zero, the first of its kind in the country, which was the culmination of the process whereby the nurses that were trained by RTC, FPD, ANOVA and mentored by Beyond Zero, Africare and Khethimpilo were certified as NIMART competent nurses. One of the programme’s positive spin-offs has been the rise in children that have been initiated in ART facilities, a significant shift compared to previous years.
Currently, 80% of the Beyond Zero managed facilities have children, which previously were referred to tertiary hospitals. The buy-in from the ECDOH in rolling out NIMART has been crucial in increasing outputs as well as for sustainability of the NIMART programme.
Beyond Zero’s technical support to Primary Health Care (PHC) facilities in Peddie, a rural village situated a few kilometers from East London in the Eastern Cape Province, has injected much needed confidence to mentored NIMART nurses who are now confidently initiating paediatrics on ART.
Our new name, Beyond Zero, is highly representative of who we are, what we do, and where we aim to be – a respected friend and valued partner who transforms its knowledge, strength, and passion into actions that help lead the healthcare system and communities beyond the zero new HIV infection target to a higher state of good health and well-being for all.
Since the inception of Beyond Zero’s ART Scale Up in April 2010, PHC facilities were assessed and have NIMART nurses that are spread across 27 facilities where they initiate both adults and paediatrics.
Previously, NIMART trained nurses that were confidently initiating adults on ART were not initiating children on ART. The technical know-how provided by Beyond Zero has gradually built staff confidence to deal with paediatrics initiation. In the past, nurses used to refer children on ART initiation to district and tertiary hospitals, and have now stopped because of their level of training.
To date, facilities in Peddie have 170 children on ART that are initiated and managed by NIMART nurses with the support of Beyond Zero’s Nurse Mentors. The standard of care offered by these facilities has gained the respect and trust of the district hospital in the area which now easily transfer paediatrics to the surrounding PHC facilities as it has faith in the Beyond Zero’s mentoring and mentors.
Results delivered. Lives saved. The power of PEPFAR partnership at work.
Three years ago the Nelson Mandela Metropolitan University (NMMU) in Port Elizabeth was confronted by one of the biggest challenges when a large number of patients on ARVs could not be assisted at its Campus Health Centres.
The Eastern Cape Department of Health (ECDOH) concluded that it would provide patients with medication for all other primary health conditions but would not allow the site to be accredited as an ARV site.
Beyond Zero, a name change from the Institute for Youth Development South Africa (IYDSA); a change representative of a renewed commitment to the founding core principles and operational approach for which IYDSA has earned its reputation as a hardworking, solidly reliable NGO partner in South Africa, adopted a successful intervention model by offering support to the university through the provision of technical assistance. Beyond Zero and NMMU then presented a unified strategic plan to the health department detailing how it would support the clinic.
After successful negotiations, NMMU was given the nod to commence with initiating ARVs in 2010. NMMU thus became the first institute of higher learning in South Africa to be accredited to provide ARVs. This proved to be a major milestone as other universities came to benchmark against the NMMU.
Currently, the university has Zero lost to follow ups and a viral suppression rate of over 90% and boasts a unit of clinical excellence which has been fostered through Beyond Zero’s initiatives.
Results delivered. Lives saved. The power of PEPFAR partnership at work.