The Chiawelo Community Practice (CCP), led by Family Physician at Wits University, Dr Shabir Moosa, is reengineering the delivery of primary healthcare services in Soweto through a community-based care modelled for National Health Insurance (NHI).

Dr Moosa developed the CCP as an experiment in developing community-oriented primary care (COPC) for GP-led teams contracted to the NHI.

His team includes a family medicine registrar, a clinical associate, an enrolled nurse as team leader and 21 community healthcare workers (CHWs) who care for over 15,000 residents from the community of Ward 11.

The CCP provides comprehensive clinical services, from immunisations to ARVs on an appointment basis in order to reduce waiting times often associated with public health facilities, and includes high quality care and regular home visits by clinicians.

Under the model, trained CHWs, equipped with basic health education, go from door-to-door to do household assessments, gathering information about the family’s medical history and registers them into the CCP, developing a community profile or diagnosis of Ward 11.

The data collected is used to create a health profile of every resident and keeping track of their medical history.

“Having a strong record-keeping system at the clinic helps the patient-care crew. Viewing records from the community and engagement with the community helps the CHWs to do more focused health promotions that are relevant to the community,” said Dr Moosa.

Commenting on the success of the CCP model during  Gauteng’s annual Health Budget Vote, Gauteng Health MEC, Qedani Mahlangu said: “Primary healthcare, as we champion it today, integrates ward-based care, clinics, community health centres and district hospitals and focuses on the holistic care of each person in the household as well as the health and wellbeing of the broader community.”

“Through this, the Department will ensure that community members receive appropriate care; there is a monthly follow up plan in place and most importantly the CHWs have been able to gain confidence of and build trust with the community they serve,” continued Mahlangu.

Since March 2014, CCP has mapped the community and registered 3,571 families using the National Department of Health’s tool from the PHC Outreach Team Toolkit.

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