Summary Bulletin 8 - DHS-LG Discussion List

"MINOR AILMENTS"

Definition of "minor ailments"

Understanding and defining what is a "minor ailment" can be difficult. The very term "minor" trivialises the conditions – and yet they are the major reason for patients attending clinics. There is a perception that if a complaint is "minor" it can be treated by someone with very little knowledge and does not require specially trained people. However, many of these complaints may be related to non-biomedical issues, such as psychosocial, work-related, traditional or spiritual. Also, what appears to be a minor problem can be a symptom of something much more serious. For example a headache can be a minor ailment, but it can be associated with such things as hypertension or a brain tumour or severe stress. The question is, when does a headache become a "major illness"? The care-seeking behaviour of people needs to be understood and for health care providers to treat people and not merely the disease.

It was suggested that the use of terms such as "curative care" or "curative services" may be better, as nurses are dealing with more serious problems and working more as a family physician. The term "minor ailment" is misleading and could be an insult to those providing the service. Signage indicating that "minor ailments" are treated in a clinic may be adding to the confusion. Community members may perceive that anything "major" must go to hospital, thus adding to the hospitals’ workload.

In the Free State a "minor ailment" is defined as "Any illness considered minor and that is not covered through one of the major PHC programmes". Some provinces are using a proxy for "minor ailments", such as head counts, which may include some major illnesses that are not captured elsewhere on the District Health Information System, such as opportunistic diseases related to HIV/AIDS. The new minimum data set is expected to address some of these problems.

Other definitions for "minor ailments" offered by doctors were: -

• Treatment that is within the scope of practice of a nurse
• Conditions that can be treated in an outpatients department and the patient can go home
• Flu, cold, diarrhoea, pain complaints with no major pathological underlying condition
• Condition that is acute and that will resolve quickly with the right essential drug list treatment

No consensus was achieved as how to define a "minor ailment" and further investigation may be required. It was suggested, for example, that an analysis of the conditions categorised as "minor ailments" should be done. This could be done in a number of randomly selected clinics so as to determine the resources required to handle them. This needs medical input and assessment as to appropriate level of care for each "minor ailment".

Work overload

The complaints of too many "minor ailments" to be treated are arising from a perception of being overloaded with work at the clinics. "Minor ailments" account for 60-70% of clinic visits and the pressure of increasing workload with decreasing staff numbers tend to crowd out the more serious conditions. Staffing norms should be applied and additional appropriate posts created. Trends over time must be monitored. But a practical problem is that there are no staff available to fill the posts that are created.

There is a curative bias in the clinics that has been exaggerated by the "one-stop-shop" approach. Health education and simple home remedies for commonly occurring problems are required. Money needs to be put into these and to support the PHC approach.

The optimal deployment and skill mix of staff within a clinic is essential. Highly trained professional nurses must not be diverted to doing tasks that can be adequately done by lower cadre of staff or even non-professional staff. A study of the role of community health workers in treating minor ailments at some clinics was inconclusive as to their effectiveness – but it did show that they play a very important role in promoting gardens, health education and distribution of food parcels.

Dealing with a ever increasing workload does lead to compromising clinical care. However, the feeling of being overworked and under-resourced is often a matter of perception rather than reality. A review of what and where services are delivered is required, not through further research, but looking at using our resources better. The answer is not to add still another level of health care worker to the system e.g. someone between the nurse and the doctor. This will lead to further over-expenditure and is likely to increase the problems.

Effective health education and promotion is required to decrease the demand for treatment of minor and major diseases. But these require resources and most importantly, time. The increasing number of "minor ailments" being treated means there is less time for preventative and promotive health.

The possibility that increase in "minor ailments" at clinics is due to patients "shopping around" for drugs requires consideration. Could a small levy for drugs prevent this?

There is an understanding that Primary Health Care Clinics are there to treat "minor ailments". If the clinics want to treat other things, then they probably are acting beyond their level of competency and therefore resources may not being used optimally. But consideration must also be given to the process of rationalising hospital services. Through this process the more stable chronic ailments (hypertension, diabetes etc) are being referred to clinics for follow-up. However additional staff numbers have not been provided at the clinics, despite advanced planning. There is an ongoing struggle to implement all priority programmes due to lack of resources and the tension is more between the priority programmes than with the "minor ailments". There is in fact an increase in number of "major ailments" being treated or followed-up at the clinics.

In addition there is a belief that clinics are over spending because the staff are required to work beyond their scope of practice. This is an incorrect conclusion. There may well be over-spending on "minor ailments", but this is more likely to be because: -

• The sheer load of patients forces the approach of a ‘pill for every ill’, which is expensive
• An approach to care that is propagated through the Essential Drug List and Standard Treatment Guidelines that are more hospital based with a biomedical approach
• Nurses being trained in this approach which is easier than having to deal with issues that are psychological, social, environmental etc.
• Problems being treated symptomatically without getting to the root cause, and therefore the patients keep coming back.

However there are PHC nurses treating many conditions, such as in the Gateway Clinics (Eastern Cape) and referring those they cannot manage to doctors in the hospital outpatients. This works well where there are standard treatment guidelines and therefore a standardised approach to many conditions.

The focus of care needs to be on the majority of patients and not the one in a thousand presenting to a hospital. Primary care is the foundation of the health services and these require specialised resources, including human resources. Specialists in primary care and family medicine are needed to deal with these "minor ailments". For example, relegation of clinic visits to the junior doctors to give support to nurses, who are often experienced, is wrong. The most experienced doctors are needed to give clinic nurses advice and support on how to deal with these "minor ailments", which are non-specific and difficult to define.

A possible way of decongesting the clinics could be through private-public partnerships (PPPs) or interactions (PPIs) with general practitioners and the private sector. PPPs and PPIs are used for non-clinical services, so why not extend these to clinical services? The White Paper on Transformation of Health Services provides for accredited providers, but no further policy has been developed. Private doctors doing sessions in public facilities have replaced the previous district surgeoncies. The Western Cape is providing drugs to general practitioners for sexually transmitted infections (STIs), but there is no policy on this. The national department of health is working with general practitioners to improve their skills in HIV/AIDS, TB and STIs.

Staffing norms

An in-depth discussion on staffing norms for clinics was included and has continued on the list. These discussions will be summarised separately, but are closely related to understanding work overload at clinics and management of "minor ailments".

Summary prepared by Wendy Hall (hstwendy@sai.co.za)
Health Systems Trust,
April 2003

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