Peer learning in a patient's home
Healthcare requires practitioners to learn everyday. For them “content is a verb”. They have to take what they learn in practice, integrate it with their own prior learning and simultaneously relate it to formal rules, guidelines and the best available science — to formulate judgments so that they can act.
Learning from practice and transferring learning back into practice is the challenge that education and training has to address. This is why people who study to become healthcare practitioners need to try, test and improve their knowledge and skills throughout their student and professional lives.
In a system that is built around facilities, students get their apprenticeship in clinics and hospitals. But what happens when they have to learn to deliver services to people in their homes?
With COPC, for the first time since the 1960s, healthcare students have a learning platform that takes them into the streets, homes, créches and schools where people live, work and play. Beginning in 2008 undergraduate medical students at the University of Pretoria have participated in the Longitudinal Community Attachment Programme. From small beginnings, LCAS is now a routine part of every academic blok from the middle of their first year to the middle of their fifth year of study. Community-based learning is also a requirement for postgraduate students.
Community healthcare workers and team leaders are also expected to be involved in active learning. Often disadvantaged by the schooling system, UP’s Department of Family Medicine has also developed a COPC curriculum for CHWs. As it’s lead designer, Tessa Marcus says: “This curriculum is based on the services we expect to be delivered in communities by community healthcare workers and professionals. It covers the four epidemics and integrates substance use and mental health.It uses a practical and applied capability approach to learning that incorporates the best understanding of how learning happens.”
The capability approach to learning is designed for the 21st Century. It empowers people to take charge of their bodies and their health. It gives them skills to identify learning needs and to find out about things, when they do not know something or are uncertain.And it teaches them to think and to think about thinking.
CHWs and the whole team build skills and competencies in a continuous and ongoing way through the combination of practice and structured learning in the workplace.Marcus terms this “work-i-learn”.
Research
Research is an integral part of learning because it is about understanding our actions and the effects of what we do in a systematic way. As an academically supported model of service delivery model, research has been built into the development of COPC from the very beginning.
In 2015 the University of Pretoria’s Faculty of Health Sciences established the COPC Research Unit. Its purpose is “to explore and innovate the practices and processes of doing ICT-enabled community oriented primary care”.
As the head of the unit, Jannie Hugo, explains:“Our research efforts must contribute to quality health care delivery and healthcare capacity development within and beyond the sites where COPC is practiced.”
This is why we are involved in a wide range of research. Some of it focuses on implementation science to track the extent to which interventions are working. For this the team develops purposively designed studies using the data collected electronically on Aitahealthtm, or paper by healthcare service providers in the course of COPC and COSUP service implementation. They also use the COPC Planning toolkit to test ideas and assumptions. And they participant in a range of basic and applied studies working with local and international partners.
A Special Edition of the Department of Family Medicine’s work to support universal health care innovation is being prepared for publication in the peer reviewed African Journal of Primary Health and Family Medicine.
Partnerships and networking
Community oriented primary care is an approach and a set of practices that has guided thinking around universal health care for over a century. It is a story of a long and hard struggle to create a health system that serves the millions of people who are excluded, marginalized or poorly served by existing approaches to health care. It is an approach that challenges some of the conventions of how modern medicine is organized, distributed and delivered.
Tessa Marcus says that from very beginning, people have had to work together to struggle against very powerful economic, political and social interests to put Community Oriented Primary Care into practice.
There are many, many stories to tell about COPC in practice. They each tell us about what is possible and what can be done to improve the health of ordinary people. But they also tell us that “health for all” is a struggle that does not follow a predetermined, uninterrupted and clear pathway. Like all struggles, it is an “unsteady march[i]” that gains ground in some places for some time.
The seeds of COPC are to be found in China in the work of John B Grant, Jimmy Yen and CC Chen. In 1925 they worked together to provide clinical and public health services to the schools, workers and residents living in the Peking Municipality. Drs Sidney and Emily Kark togetherEdward and Amelia Jali pioneered COPC in Pholela, South Africa in the 1940s. For the first time in South African history, they created healthcare services for African people that extended from the clinic to homes and schools. Adapted to local conditions, they achieved a significant improvement in people’s health by working with individuals and families as partners.
In 2010 UP family medicine saw government’s primary care reengineering as an opportunity to implement 21st Century ICT enabled Community oriented primary care.
Sister Kate van den Berg says right at the beginning he got involved with the COPC. “I was running a small clinic on the outskirts of this city, near Salvokop. We were operating within the community without any partnerships. I was introduced by the university to COPC.
“Through a scientific approach of diagnosing the community, mapping the area and its needs and beliefs, the role of community health workers (CHWs) became key. We were able to also create a network of people to assist provide services.”
Information technology plays a central part in integrated COPC. According to Marcus, the UP Family Medicine team set about developing a device and web application with Mezzaninewaretm to support immediate electronic data capture and real time service support.
Through AitaHealthtm it is possible for the first time to link information and health care providers to people in their homes. Team Leaders and Community Health Workers (CHWs) use AitaHealthtmto register households and assess household members, capturing the information directly onto the device. Their work provides a comprehensive and live ongoing data set that the team can use to assess, manage and implement services.
Sister Kate comments that “we are from having an ICT integrated paperless system”. This is why there is still a need to use paper. The team developed the Link to Care booklet. This is a patient held record of people and services he or she has received. It records personal information and provides each service provider with information about the patient and their treatment history.
COPC is built on partnerships between people. Although some organisations share the same vision, the background and expertise brought forward by individual members. This diversity contributes to the partnership’s strength as complementary knowledge, skills, and experiences are brought to the table.
The main goal of the healthcare system is to get people healthy and to control and contain get diseases. There are many role players involved in patient care to achieve this. Partnerships are indispensable to achieving this. They work when there are clear goals, a shared vision and mutual respect. Through partnerships it is possible to mobilise human and other resources.