05 May 2010

The future of the role of workplace wellness programmes

in South Africa's changing healthcare landscape

Introduction• Introduction

• Vision for EH&W in the Public Service

• Functional Pillars (Current Objectives)

• Process Pillar for Implementation

• Structure/Levels of Implementation in the Public Service

• RBM and related indicators

• 12 Components of a functional M&E system

• Futures use of evidence and strengthened theoretical underpinnings of interventions, evidence for policy development and programme efficiency (HIV Example)

Presentation Outline

Introduction• EHW policy environment and programm es in the Public Service

have rapidly transformed and linked to part of 10 point health plan (HR for health, HIV&AIDS etc.)

• The EHWSF was launched in November 2008 and four related policies approved for implementation in the Public Service with effect form 1st April 2010.

• The four policies form the Specific areas of focus as key components (objectives) of EHW to be implemented uniformly across the entire public Service

• Strategic influence of the WHO Global Plan of Action on Workers Health 2008-2017, the ILO Decent Work Agenda in Africa 2007-2015, WHO Social Determinants of Health 2008, and Existing Legislation

Introduction

VISION CRAFTING FOR EH&W

§ AIDS free Public Service

§Assessment, Identification and

Management of Occupational Hazards

and Risks

§Comprehensive Wellness and its Healthy

impact on Service Delivery

§ Health Education, Promotion and

Management in the work place

§Meeting Government’s Developmental Agenda

Healthy and Productive Public Servants as

individuals and as a collective

Enhanced Productivity in the Public Service as

a sector of the SA Economy

Integrating EHW Vision in Plans and Activities

STRATEGIC FOCUS AREAS

STRATEGIC INTENT

VISION FOR

EH&W

ELEMENTS OF EH&W VISION

Vision for EH&W in Public Sector

*

VISION FOR EH&WA Healthy, Dedicated, Responsive and Productive Public

Service

Occupational Health Quality of Work LifeResearch, Monitoring andEvaluation

Occupational Health Education and Promotion

Occupational Health and Safety Management

Individual Wellness Physical

Work life Balance

Organizational Wellness

Individual Wellness Psycho-SocialHuman Rights and

Access to Justice

Treatment Care and Support

Prevention

Injury on Duty & Incapacity due to ILL Health

Mental Health /Psychosomatic Illnesses

Disease Management and Chronic Illnesses

Environmental Management

Risk and Quality Assurance

HIV and AIDS & TB MANAGEMENT

Pillar 1

HEALTH and PRODUCTIVITY MANAGEMENTPillar 2

SHERQ MANAGEMENT

Pillar 3

WELLNESS MANAGEMENT

Pillar 4

4 KEY INITIATIVES FOR HIGH PERFORMANCE IN THE PUBLIC SERVICE THROUGH HEALTH AND PRODUCTIVITY MANAGEMENT

CORE PRINCIPLES INFORMING IMPLEMENTATION OF EHW STRATEGY

LEGISLATIVE FRAMEWORK AS A FOUNDATION

• Capacity Development (Individual)

• Individual Employees• Managers (General, HR)• EH&W Practitioners (Entry level EH&W and Multi-skilled, non-professional)• OMPs, ONHPs, Occupational Hygienists, Specialists etc. (Professionals,

Specialists)• Centers of Excellence (Institutional Infrastructure, Schools of Public Health, WHO

Collaboration Centers)

• Organizational S ystems Support Initiatives (w ithin the department)

• Tools for implementation (Generic Implementation Guides, Systems Monitoring Tools)

• Integrated HIV&AIDS &TB Toolkit• HIV&AIDS Costing Tool• Guidelines on Child Care Facilities in work place• Return to work guidelines for temporary to permanently disabled persons • M&E Tools• OHASIS, IFMS, HR Connect

Process Pillars

• Governance Initiative s (Inter Departmental/ Other Stakeholders)

• Inter Departmental/Steering Committees• Network for Technical Expertise (NIOH, DoHE, Schools of Public Health)• Public Sector Summit agreements on Improvement of Working Conditions

(PSCBC Endorsement)• NEDLAC (National HIV&AIDS Work Place Plan)• Inspectorate/ PSC (DoL, PSC)

• Economic and Devel opment Initiatives ( AU, SADC, Bi-National, UN, ILO, WHO)

• Country Reports (UNGASS, SADC Prevention Report, ILO Recommendation on HIV&AIDS and World of Work)

• WHO Modules on Occupational Health (NIOH, University of Illinois)• Piloting of OHASIS In DoH and DoE (University of British Columbia, DOH)• AU (Africa Peer Review Mechanisms)• SADC (Simultaneous Mainstreaming of HIV&AIDS) Gender, Disability, Youth

Development into Public Service and Administration)

Process Pillars

HIV&AIDS

MANAGEMENT

Reduce Burden of Disease Enhance Productivity

inPublic Service

Provincial Coordination of Programme Implementation, M&E and Province specific

Impact assessments.Provincial Capacity Building

(HRA) anticipating, recognizing, evaluating and Controlling

health hazards in the Public Service toprotect employee

health and well-being and safeguard

the community at large

Implementation of HRA by an approved

Entity and Implementation of Controls(engineering, administrative &personal protective equipment

HEALTH & PRODUCTIVITYMANAGEMENT

SHERQWELLNESS

MANAGEMENT

Comprehensive identification of

psychosocial health risk, and use of evidence based

practices to ensure individual and

organizational wellness

Reduce Number of Infections

Reduce impact on Individual Employees, families, communities

and Society

•Macro level Governance

•National Institutions

•Meso level Governance

•Provincial Institutions

•Micro level Governance

•Depts & Institutions

•Policy, Implementation Guide, M&E and Impact Assessment Framework .Mainstreamed Public Sector Response to NSP 2007-2011. National Steering Committee& SANAC coordination

•Frameworks for Estimation of Disease Burden, Policy Implementation M&E, ImpAs. National Steering Committee Coordination. Coordination of National Flue Pandemic Preparedness Plan

•National Policy Framework and OHS Standards guided by legislation and SABS

•Coordination by Steering Committee

•Comprehensive Policy covering (EAP and WLB & Wellness)

•Coordination by National Steering Committee

National Frameworks for delivery

Provincial Frameworks for delivery adapted for Prov. customs & trends

Departmental Framework& Processes

•Provincial Coordination of Programme Implementation, M&E and Province specific Impact assessments.

•Provincial Capacity Building

Provincial Coordination of Programme Implementation, M&E

and Province specific Impact assessments.

Provincial Capacity Building

•Implementation of Costed, Mainstreamed, Comprehensive, HIV&AIDS dept. specific Programs. As part of EHW Committee and Plan

Provincial Coordination of Programme Implementation, M&E and Province specific

Impact assessments.Provincial Capacity Building

•Departmental Surveys Registries of Exposure to Risks, Injuries and Diseases. Early Detection and reporting diseases within legal framework Health Education, Promotion Treatment Support

•Wellness (EAP+WLB) Program Planning and Implementations Based on Id of risk for individual and organizational wellness

PILLAR 1 PILLAR 2 PILLAR 3 PILLAR 4

Levels of Implementation-Possible SPS Implications

Project / Program LevelPopulation

Level

Resourcese.g.

FinanceStaff

Drugs, Supplies

Equipment

Functions,Activities

e.g.TrainingLogistics

IEC

Servicese.g. Facilities offering

ServiceTrained staffUtilization:New clients

Return clients

Intermediate

e.g.HIV+ on ART

ART Adherence

Inputs Processes/Activities Outputs Outcomes Impact

Long-terme.g.

Infection rateMortalityFertility

Results Based Management Approach Int RBM(2)

• Objectives are implemented through 4 Policies

• Each Policy has strategic objectives of its own (e.g. Prevention of HIV&AIDS)

• Each Objective has pol icy measures (e.g. reduce vulnerabil ity to HIV infection - Evidence based )

• All Policies have Implementation guide with RBM Modelwith indicators of input, process, output, outcome and impact.

Indicators and Measures

*Step 1:Conduct stake holder review

Implementing Cycle for EHW

Step 2:Design Conceptual Framework

Step 3:Design StrategicFramework

Step 10:Annual PerformanceReview Reports

Step 4:Design guidelines toImplement Step by step

Step 5:Annual PerformancePlans

Step 6:Monitoring and Evaluation Tools

Step 9:Annual INDABAConference

Step 8:EHW Steering Committee

Step 7:

Quarterly Reviews

Legal and Political mandate

Implementat ion Cycle

12 Components of an Effective M&E System

• Programmes

• People reached with services

• Behaviours change

• Fewer new infections/injuries/ diseases

Theory of change (traditional)Future: Towards Better use of evidence and

understanding of disease and health promotion -HIV&AIDS Example

Theory of Change (traditional)

• HIV is an infectious disease• Basic measure of spread is the

number of secondary infectio ns from one primary infection (index case)

• R0 = βcD– β probability of transmission per contact

– c number of contacts with infected persons per time unit

– D duration of time infected

Theory of change (suggested new)Theory of Change (suggested new)

• Reduce β, c, or D– Cannot reduce D (in fact, ART increases survival time and thus

increase the number of years an individual lives with HIV, and thus increase the duration of infection (D))

• Therefore, we need to reduce β (transmission rate) or c ()in order to reduce Ro

• HOW?– Reduced contacts with inf ected persons– Reduced risk of infecti on, if contact has taken place

THEREFORE….….

To reduce new infections from an index case (i.e. to reduce Ro), we need to ei ther

Theory of change (traditional)New Prevention Paradigm

Better use of evidence for policy consideration

• What constitutes ‘what works’ in prevention ?

• Different levels of evidence – at the individual, research setting and population levels, ranging from…

– Randomized control trials – higher incidence in control arm than in intervention arm: can estimate infections averted

– Modeling of number of infections averted by specific programmes – e.g. male circumcision and PMTCT

– Estimation of infections averted by comparing with results from unlinked prevalence surveys

– Move away from traditional theory of change, with ‘guesses’ that the one will lead to the other

– Quasi-experimental designs– Laboratory testing (e.g. condoms)

• What may be effective at the individual level, may not be efficacious at the population level

Better use of evidence of interventions that work

– At individual level: 60% efficacy at individual level (research data, empirical data)

– At population level: 4 circumcisions needed to avert one new infection (modeling data – see next slide)

– At population level: Evidence based Communication to avert risk compensation, and to encourage multiple interventions

Better use of evidenc e of interventions that work- Male circumcision example

51.2

25.6

12.8

6.4

3.2

1.6

0.8

0.4

0.2

0.1

Number of circumcisions needed to avert one HIV infection

Source:Williams et al, 2006

SwazilandBotswanaZimbabweZambia

Malawi

South AfricaLesotho

TanzaniaMozambique

Better use of evidenc e of interventions that work- Male circumcision example

• Cost-effectiveness (the choice of the mix of interventions – averting the most infections) – are we doing the right things?

• Technical efficiency (the delivery of prevention services at least cost) – are we doing them right?

• Targeting (the choice of the mix of target populations) - are we doing them to large enough scale focusing on the most appropriate populations?

Source: Bertozzi, et al. 2008; and Rugg et al, 2005

Future consideration of other dimensions of Programme Efficiency

• EH&WSF and Policies approved ad currently being implemented across all departments

• Implemented as part of HRMD

• 4 Priorities based on current evidence of what are the major pri orities

• Results based methodology guides implementation

In Conclusion