Health Policy Plan. 1996 DOHERTY 394 405

HEALTH POLICY AND PLANNING; 11(4): 394-405 © Oxford University Press 1996

Developing a plan for primary health care facilities inSoweto, South Africa. Part II: Applying locationalcriteriaJ DOHERTY, L RISPEL AND N WEBB

Centre for Health Policy, University of the Witswatersrand, Johannesburg, South Africa

This article is the second of a two-part series describing the development of a ten-year plan for primaryhealth care facility development in Soweto. The first article concentrated on the political problemsand general methodological approach of the project. This second article describes how the technicalproblem of planning in the context of scanty information was overcome. The reasoning behind thevarious assumptions and criteria which were used to assist the planning of the location of facilitiesis explained, as well as the process by which they were applied. The merits and limitations of thisplanning approach are discussed, and it is suggested that the approach may be useful to other facilityplanners, particularly in the developing world.

IntroductionPart I of this two-part series described the contextand general research approach of a project whichplanned the development of primary level healthfacilities in Soweto, Johannesburg, during 1992and 1993 (Rispel et al. 1996). The purpose of thisarticle,1 the second in the series, is to present thestep-by-step process by which the size, number andlocation of clinics were determined. The processseeks to integrate objective planning procedures withthe more subjective opinions of stakeholders.

The article is divided into three sections. The firstsection describes the assumptions and criteria whichwere employed by the research team to support deci-sions regarding the location and size of futurefacilities. The second section describes how theassumptions and criteria were systematically appliedin order to construct a prioritized list of facilitiesrequired over a ten-year period. The final sectiondiscusses the limitations and merits of this planningapproach.

In devising the plan, the research team was faced withthe problem of transforming the existing network ofover-burdened and unevenly distributed clinics intoa functional system. At the outset, the team developeda conceptual framework within which to plan future

facilities. This framework consisted of the followingelements:

• all primary health care services in Soweto shouldbe comprehensive;

• there should be equity in the distribution of healthcare facilities;

• physical access to facilities should be maximizedwithin the constraint of limited resources;

• planning should take account of the existingresource base of facilites in Soweto, which is con-siderable; and

• in terms of the development of facilities over 10years, priority should be given to communitiesmost in need.

The process described in this paper should beunderstood in terms of this framework.

Section 1: Assumptions and criteriaIn countries where accurate data is scanty, severalassumptions about the demographic and epidemio-logical characteristics of communities have to beaccommodated (Botha and Bradshaw 1985). Onlythen do criteria for the maximization of coverage,such as the optimum size and location of facilities,become useful. This section of the paper discussesthe various assumptions and criteria which were

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Primary health care in Soweto: Part II 395

applied in planning primary care facilities for theGreater Soweto area.

The research team chose to make conservative deci-sions wherever possible, with the understanding thatit is better to under-provide than to over-providephysical resources, particularly if it is understood thatthe option of expanding or otherwise adjusting afacility plan always remains open. In all casesassumptions and criteria were tested for consistency,and against the experience of health care workers forappropriateness.

The expected burden on clinic servicesThe first step in the development of a facility planwas to estimate the future patient load on clinic ser-vices. A major constraint was the absence of anydetailed and uncontroversial information on popula-tion size and health service utilization patterns,especially at the level of the individual townships andzones which make up Soweto. As discussed below,three major assumptions had to be made in order toovercome this otherwise crippling constraint.

The size of the Soweto populationFor political and practical reasons the Sowetanpopulation, which lives in a myriad of crowdedhouses, backyard rooms, shacks and hostels, hasnever been counted accurately. Population estimatesrange from as few as one million to as many as threemillion people. The research team settled on a popula-tion size for 1992 of approximately 1.2 million,an estimate which is relatively conservative butfor which the evidence is strongest (JohannesburgMetropolitan Planning Department 1992; Chris SteelArchitects, Centre for Health Policy and Rosmarinand Associates 1993). With the help of townshipmanagers this population was distributed between thetownships of Soweto and plotted by zone on a map.It was assumed that, provided low-income housingdevelopment continues in other areas surroundingGreater Johannesburg, it is unlikely that the Sowetopopulation will grow by more than 3% per annum(this percentage combines the effects of natural in-crease and migration). After 10 years (that is, in theyear 2002), the predicted population for Soweto willthus be close to 1.6 million.

Despite attempts to achieve accuracy, the possibilityremains that the 1992 figure of 1.2 million is anunderestimate (but not, it is thought, by more than0.4 million). As described below, in several instances

generous criteria were developed to accommodate thisuncertainty.

Health service utilization patternsInformation on the pattern of use of health care ser-vices by a given population is critical in determiningthe need for health care facilities. Likewise, wherethe private sector is large, as is the case in SouthAfrica, it would be useful to know the proportion ofthe population dependent on the public sector.Although information for Soweto on these variableswas lacking, it was beyond the brief of the researchproject to measure the utilization patterns of theSowetan population. Instead, several assumptions hadto be made regarding utilization.

Utilization of clinic services

There is probably a high level of unmet need forhealth care in Soweto. It is certainly hoped that asadditional resources are made available by the newgovernment for disadvantaged populations, and as theemphasis in health care shifts towards the primarylevel, utilization of clinic services will increase con-siderably.2 Historical data on the annual number ofclinic visits in Soweto are therefore not useful predic-tors of the future utilization of health services. In theabsence of empirical information on the level of needfor health care, the research team assumed a futureutilization rate for Sowetans of 3.66 visits per personper year. This figure is proposed by the South AfricanCouncil for Scientific and Industrial Research (Abbott1992), takes into account child and adult utilizationrates for preventive and curative care which appearachievable in the next few years, and comparesfavourably with the utilization rate of 4 which hasbeen achieved by Botswana, another middle-incomecountry in Southern Africa (Centre for Health Policy1993; Mclntyre et al. 1995). The figure is higher thanthe national average utilization of public health ser-vices of 2.89 visits per capita per year (Mclntyre etal. 1995).

The proportion of the population using the publicsector

The next step was to determine what proportion ofthe Soweto population would be served by the publicsector over the ten-year period under consideration.It is currently estimated that 23 % of South Africans -(and even fewer black South Africans) have accessto private sector health care on a regular basis(Valentine and Mclntyre 1994). Little is known ofthe extent of the patronage of the private sector inSoweto. The research team decided to plan for a


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396 J Doherty et al.

public sector serving 100% of the conservativelyestimated 1992 population of 1.2 million. This isequivalent to planning for 80% of a population of 1.6million, the projected population in 2002 (and alsothe higher estimate for the 1992 population). Thisapproach both affirms the responsibility of the publicsector to serve the entire population (especially forpromotive and preventive care) and makes allowancefor a probable growth in the patient load on publicservices during the next 10 years due to escalatingmedical costs.

Locational criteria to maximize access toprimary care facilitiesThe literature abounds with evidence of the impactof distance on the accessibility and subsequent utiliza-tion of health care services (Shannon et al. 1973;Stimson 1981; Stock 1983; Joseph and Philips 1984;Habib and Vaughan 1986; Kloos et al. 1987; AndyTembon Chi 1990; Mulvihill 1991). Medical geo-graphers in particular have been concerned withspatial aspects of medical care and various theoreticalmodels for optimal spatial distribution of servicefacilities have been proposed (Shannon et al. 1973;Bennet 1981; Kemball-Cook and Vaughan 1983;Berghmans et al. 1984; Massam et al. 1986; Rushton1991). The various models have included variablessuch as distance and time travelled, the size and shapeof catchment areas, and the degree of dispersion offacilities. In general, these models have drawn on theprinciples of Central Place Theory which wasoriginally formulated to explain the size, number anddistribution of urban centres in a regional or nationalsetting, but has since been used to solve problemsin health care delivery (Gober and Gordon 1980;Mulvihill 1991).

In this research project, the main criteria used in theformulation of the health facility plan related to thedistance people live from clinics, the size of catch-ment populations, and the size and position of clinicsin the hierarchy of service functions.

The maximum distance from a health care facilityAt present health care facilities are distributedunevenly across Soweto with a concentration in thecentral and eastern parts. As mentioned earlier, a keyprinciple adopted by the research team was that anyplan for primary care facilities should ensure anequitable distribution of health care facilities and thataccessibility to the population should be maximized.The first criterion chosen by the research team wasthus one which expressed equitable access in terms

of the maximum distance a patient could be expectedto travel to a health facility.3 A facility plan thatlimits this maximum distance will be more equitable(although obviously not everyone will live an equaldistance from a clinic) but it is the actual value ofthe limit which determines whether accessibility hasbeen optimized. If clinics are too distant, people whoneed care will not utilize them, especially for servicesthat appear less urgent (such as preventive care, thetreatment of mild illness or the collection of medica-tion for chronic disease). The neglect of mild andchronic conditions, and the avoidance of preventivecare, can have serious consequences (in terms of illhealth and the eventual cost of treatment) for bomthe individual and the community. As mentionedearlier, the international literature abounds withstudies which have looked at how increasing distancefrom a facility leads to decreased utilization of thatfacility, a phenomenon described as 'distance decay'.

Using international criteria and local experience asguidelines (Rispel et al. 1995), the project team chose2km as the maximum distance a patient should be ex-pected to walk to reach an urban health facility thatprovides a basic package of comprehensive primarycare (Centre for Health Policy 1993). It was as-sumed that this distance could be walked within halfan hour. The distance of 2km was translated into aradius of 1.5km around a clinic in order to take ac-count of the difference between actual walkingdistance and the straight line drawn on a map. Thus,when circles with a radius of 1.5km are drawn aroundexisting facilities in Soweto, the areas falling outsidethe circles represent populations living too far froma health facility. These areas correspond with popula-tions which staff and community members identifiedas being underserved through an extensive processof consultation (see Part I; Rispel et al. 19%), whichsuggests that the choice of a 1.5km radius was in-deed appropriate.

The size of the catchment populationThe maximum distance to a clinic that a society isprepared to accept does not depend entirely on con-venience. The affordability and functionality of afacility in terms of its size are also determiningfactors. The size of a facility depends largely on thesize of the population it is expected to serve. Theliterature suggests that a clinic which serves morethan 100 000 people becomes too complex andimpersonal to function adequately, while it is notcost-effective to build a fixed facility for fewer uhan10 000 people (Department of National Health and


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Primary health care in Soweto: Part 397

Population Development 1981; World HealthOrganization 1981; Orubuloye and Oyeneye 1982;Centre for Health Policy 1993). These upper andlower limits on clinic size were accepted by theresearch team. Soweto is a very dense settlement with100 000 people, on average, living within a radiusof 1.5km. Thus, the upper limit does not conflict withthe criterion for the maximum acceptable distancefrom a health facility.

The services provided by different sizes of primaryhealth facilityAn important next step was to define what constitutesa basic package of primary care services and whattypes of facility are involved in its delivery. Theresearch team applied some of the principles ofCentral Place Theory in the ordering of health facilityfunctions according to level of specialization and fre-quency of utilization. Facilities should be organizedin a hierarchy, with health centres supporting thesmaller clinics which surround them, and being sup-ported in turn by major health centres. Finally, clinicservices should be supported by a hospital. Thefollowing paragraphs describe in broad terms whatservices should be provided at each level of facility.This description serves only as a guideline, as theparticular circumstances of each community shoulddetermine services more precisely.

Small clinics

Where a catchment population for a facility is con-siderably less than 50 000 people, the research teamaccepted that the package of care should be limitedto those services for which people are unwilling totravel very far. These services include promotive andpreventive care, as well as treatment for chronic con-ditions which have already been diagnosed, and areprovided by nurses without postgraduate clinicaltraining (see Table 1) The research team called thefacility providing such services a small clinic,4

serving between 10 000 and 50 000 people. A smallclinic is open on some (or all) weekdays during officehours but not on weekends or at night. A small clinicwould be an ideal venue for other community activ-ities, such as after hours meetings, classes and recrea-tion. Other services, such as child care, could alsobe rendered from the site.

Health centres

In situations where the size of a catchment popula-tion (that is, the population within a 1.5km radius)justifies a larger facility, a broader package of careshould be delivered. This package includes general

acute care, diagnostic services and rehabilitationservices over and above the services delivered by asmall clinic. The research team called the mediumto large facility delivering this range of health carea health centre, serving between 50 000 and 80 000people (see Table 1).

The majority of staff at a health centre would benurses, including nurse clinicians, but medicalofficers would be available for patients referred bythe nurses. Patients would attend the clinic directlyif it were their closest clinic, or be referred from smallclinics. Wherever possible, communities should haveaccess to the services rendered by a health centre,as these services represent the full range of essentialservices at an accessible distance for the community.Only where the catchment population is too small,and where resources are scarce, should the morelimited services rendered by a small clinic be pro-vided to a community. Applied to the very denseurban population of Soweto, this principle yieldshealth centres and small clinics in approximatelyequal proportions, as will be described below. Inareas where populations are more scattered, the ratioof health centres to small clinics would be muchsmaller.

Major health centresIf small clinics and health centres are distributed sothat all people live within a 1.5km radius from at leastone of these facilities, the entire population wouldhave adequate access to 'a basic package of com-prehensive primary care'. Yet there are additionalprimary level services to which populations alsorequire access. These are services with a lower utiliz-ation rate, or which are more expensive or rare, andwhich therefore should not be provided at everyhealth facility (for example, X-ray services wouldneither be fully utilized nor affordable at every healthcentre). Facilities providing more complex serviceswere called major health centres by the project team,serving more than 80 000 people (see Table 1).

The scope of the project did not allow the researchteam to do costing studies in order to identify thenumber of facilities at which these more complexservices could be afforded. Instead, the principle ofequity was resorted to again in distributing theseservices across Soweto. Thus, in order to extendexisting patterns of access for better-off parts ofSoweto to other parts, the research team recom-mended that no clinics with labour wards should befurther than 4km apart from one another, and noclinics with X-ray services should be further than 5km


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Table 1. A summary of services to be provided by type of primary health facility

Type of facility Services

Small clinic Child immunization

Growth monitoringFamily planningAntenatal careChronic disease treatment (but not diagnosis), for example:

tuberculosissexually transmitted diseasespsychiatric illnesshypertensionasthmarheumatic heart disease

Some minor acute curative careOutreach servicesBasic rehabilitative services provided by community health rehabilitation workers

Health centre Services provided by small clinics plus:Acute curative careChronic disease diagnosisGeriatric servicesAdolescent/youth servicesOral health careMental health careSocial work

Major health centre Services provided by health centres plus any of the following:Maternity services24-hour emergency carePhototherapyX-ray servicesRehabilitation services provided by professional rehabilitation therapistsPsychiatric careShort-stay wardTheatre services for minor operations

Depending on a district's model, laboratory services, pharmaceutical depots,catering services and transport services could also be provided at major healthcentres.

apart. It was felt that, for these sorts of services,patients would be willing to travel further than forthe more routine components of primary health care.

The distribution patterns for labour wards and X-rayunits may be applied to other more complex (or rare)services such as 24-hour casualty units, rehabilita-tion services, psychiatric care and short-stay wards.As the decision to extend any of the more complexservices in reality depends on the availability ofresources and issues of feasibility (such as the abilityto attract skilled night staff to work deep in violence-torn Soweto), the project team did not attempt toallocate these additional services to individual healthcentres. Decision-makers will have to consider thepossibility of extending additional services to healthcentres on an individual basis as resources becomeavailable, while striving for the equitable distribu-tion of services as described above.

Section 2: The systematic application ofcriteria to determine the need for facilitiesThis section describes the application of criteria toa map of Soweto to ensure that maximum coverageof the population with facilities was achieved. Thisobjective planning process was at all times informedby the more subjective information which had beengathered through staff interviews and facility check-lists (see Part I; Rispel et al. 19%). The differentsteps are described in detail below, while the finallyrecommended distribution of clinics is illustrated inMap 2.

Step 1: Identification of existing viable clinicsAs mentioned earlier, a key principle of the researchteam was that the facility plan should make optimaluse of the existing infrastructure. Soweto has a com-plex network of 24 existing facilities (see Map 1)


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KEY

Local authority boundariesExisting clinics (T.P.A)Existing dinks (city health)

* Mobile clinics--- Theoretical catchments

(1.5km radii)

Map 1. Soweto health plan: existing facilities and theoretical catchments

KEY

• ixistkigcintes(TP.A)• jdsttng dHcs (dry health)• 'itoMa cHnfcs

• M ^ B 'robftble catchments of proposed hearth centres/ " ^ :>robabto caJchments of proposed imaD cBracs

B H Area covered by snal cDrac. rhabrtedHHjm' Area covered by smal cfWc, uninhabitedB t f Veas outside catchments[ O Proposed new health centre';'&' ExisUng dnic - proposed health centreWf: "roposed new smtS cWcs

i:^;il Ensbng cinic - proposed smal dnicj ^ = j PeripheraVunderdeviloped area* n

theoretical catchments

Map 2. Soweto health plan: distribution and probable catchments of proposed clinics


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which, for a number of historical reasons, distortsan ideal planning model dramatically. For example,the siting of one clinic next to Baragwanath Hospitalon the outskirts of Soweto has more to do with thereality of delivering care in a strife-torn township thanwith the ideal of bringing care close to the people.In addition, approximately half of the clinics are runby local authorities and provide mainly preventivecare, while the other half are run by the provincialauthority and provide mainly curative care. Some ofthe preventive and curative clinics stand side by sideon the same site, while others lie several kilometresapart. The clinic buildings vary in age, size and stateof disrepair, and some are inappropriately situated.

The first step was thus to identify which of theexisting facilities have the potential to become func-tional, comprehensive health centres. Considerationsincluded the location and physical condition of thefacility, and the range of services offered, especiallywhether both preventive and curative care are alreadybeing provided on the same site. Interviews withhealth service personnel and communities, as well asanalyses of the physical and functional suitability ofbuildings were crucial in informing the decisions (seePart I; Rispel et al. 1996).

Step 2: Definition of catchment areas andpopulationsA circle with a 1.5km radius was then drawn aroundeach of the identified health centres. The circles weresubsequently distorted by taking into account geo-graphical barriers (such as hills and railway lines orrivers without bridges) which impede access to thefacility. Where the circles of neighbouring facilitiesoverlapped, this area was bisected, causing a furtherdistortion of the catchment circles.

The population inside each catchment circle was thencalculated by estimating the proportion of the popula-tion of each township administrative zone that fallsinside this area. The size of communities falling out-side the catchment areas was estimated in a similarmanner.

Step 3: Identification of new or expanded facilitiesto serve the catchment populationsIf the population inside the catchment areas of exist-ing facilities is smaller than 80 000 it was assumedthat the existing clinic will suffice as the facilityserving the area (although it might need to be up-graded). If the population is larger than 80 000 theoption of building another clinic (either a health centre

or a small clinic) in the catchment area was inves-tigated. If the size of the population falling outsidethe catchment area of an existing facility is largeenough (that is, above 10 000 people), the option ofbuilding a small clinic or sometimes a health centrein this underserved area was considered. In the fewinstances where the outside population is smaller than10 000 people, it was regretfully acknowledged thatthese people will have to travel further than most tothe nearest facility.

In this way facilities were located across Soweto sothat they achieve maximum coverage and the largemajority of the population live within a 1.5km radiusfrom a small clinic (at least) or a health centre (atbest).

Step 4: Modification of the catchment areas andpopulationsThe introduction of new clinics distorted the catch-ment circles of existing clinics because of new areasof overlap. The researchers again chose to bisectoverlapping circles in the case of health centres.However, where catchment areas of small clinicsoverlapped those of health centres, catchment circleswere not distorted. This is because small clinics donot provide the full range of services available athealth centres, and therefore cannot substitute fullyfor health centre care.

The final population within the catchment area of eachfacility (both existing and needed) was then calcu-lated. At this stage the researchers checked whetherthe emerging plan was realistic and reasonable basedon the information gathered through interviews withhealth service staff and tours through Soweto (see PartI; Rispel et al. 19%). This comparison of objectivewith more subjective information was an invaluabletool when choices had to be made between differentoptions.

Step 5: Estimation of the size of facilitiesThe next step was to convert the catchment popula-tion of a clinic into an estimate of the size of the clinicneeded. This estimate had to be more precise thanthat suggested by the terms 'small clinic' and 'healthcentre'. The conversion was effected by means of aformula developed by the South African Council forScientific and Industrial Research (CSIR) (Abbott1992). The formula calculates the number of 'func-tional units' required to serve a population of a givensize, a functional unit (FU) being a consulting roomor treatment area used for the provision of core


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services. The formula does not predict spatialrequirements for X-ray, physiotherapy and dentalservices, or obstetric beds, which would have to becalculated using different norms.5

The formula for the calculation of the number of FUsneeded to create the core of a clinic is:

Size of catchment population XNo. of visits per person per year

No. of consulting days per year XNo. of patients seen per treatment room

The CSIR applies a number of assumptions to theformula:

the average number of visits per person per year= 3.66

the average number of patients seen per day perconsulting/treatment room (or per clinician) = 35

the number of consulting days per year = 250

For example, in the case of a catchment populationof 60 000 people, the FUs required would be:

60 000 x 3.66

250 x 35= 25

It was beyond the scope of the research team to testthe assumptions employed in the CSIR formula,assumptions which decide the size of the facility thatis needed by a community. If anything, the assump-tions probably err on the side of generosity, resultingin facility calculations which are larger rather thansmaller. For example, fewer FUs would be estimatedif the number of working days were increased (forexample, if clinics remained open over weekends) andif more patients could pass through each functionalunit (for example, if the clinic stayed open for morehours each day). Likewise, a smaller building wouldbe required if fewer visits were made per patient peryear, which is the situation at present (Mclntyre etal. 1995). Although the accuracy of FU calculationsis not known (not least because the population figureson which they are based may be incorrect), they arenevertheless very useful in indicating the relative needof communities for services, and the relative size offacilities to meet this need. The research team there-fore felt comfortable in making use of the CSERformula in developing a facility plan, with the under-standing that, while health authorities might wish toscale down the size of facilities to conserve resources,the relative size of facilities should always remain thesame.

Step 6: Prioritization of facilitiesThe sequence of steps described above yielded a listof small clinics, health centres and major healthcentres which need to be expanded or built on newsites. The general location of these facilities wasknown in terms of their central position within adefined catchment area, and their general size wasknown in terms of FUs. The final step was then toprioritize the order in which these facilities shouldbe developed over a ten-year period. For this pur-pose, the project team developed a set of criteria forrating the priority of health centres and small clinics.As the weighting of different characteristics impliedby the ratings had to be determined subjectively bythe researchers, the prioritized list yielded by therating process was checked for its rationality againstthe opinions of the health workers, researchers andcommunity members. The criteria and ratings arepresented in Tables 2 and 3.

Step 7: The final facility planThe facility plan which emerged from the processdescribed above recommended that 31 clinics shouldbe developed in Soweto over the 10 years followingthe study (see Map 2). Wherever possible existingresources were utilized, even where this meant a lessthan ideal situation. For example, if the buildings forthe preventive and curative services for an area werelocated several blocks apart but were in good condi-tion, it was recommended that the staff be integratedbut that they should continue to operate, at least inthe short term, from the two different sites. Wherebuildings were deemed unsuitable for the provisionof health care, it was suggested that they be convertedfor other uses, such as extra office space. In theend, 19 of the 23 existing clinics were retained forupgrading.

Sixteen of the clinics in the final plan were health cen-tres and 15 were small clinics. It was suggested that11 to 13 of the health centres should have maternityservices and four should also provide more expen-sive or specialized care, such as X-ray services. Thelocation of the new facilities was indicated roughlyas the centre of a catchment area outlined on a mapbut it was left to the health authorities to identify theexact sites. An estimate of the final size of all theclinics was provided in terms of the number of func-tional units but it was again left to the healthauthorities to decide on the design of each facility.The health authorities were encouraged to apply theconcept of flexibility in their future planning. For


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Table 2. Criteria and ratings for the prioritization of health centres

Criteria Rating

Physical condition of existing facility

Functional suitability

Additional functional units (FUs) required

Presence of geographic barriers

Presence of high-density residential areas (e.g. informal set-tlements, hostels) or areas considered to be very poor

Priority accorded to clinic by the health authorities (e.gtheir assessment of need for repairs)*

Whether money had already been set aside fordevelopment of the clinic

1 Facility in good repair and no immediate maintenance required2 Facility in reasonable condition but needs minor maintenance3 Facility in need of major maintenance work4 Facility in poor state of repair but could be renovated5 Facility dilapidated and should be condemned

1 Design of rooms and layout of entire facility generallyadequate for the service rendered

3 Design of rooms and layout of entire facility adequate, butwith some areas which are definitely inadequate

5 Design of rooms and layout of entire facility largely inadequatefor the service rendered

1 Less than five FUs3 5-10 FUs7 11-20 FUs

10 More than 20 FUs

0 No1 Yes

0 No1 Somewhat2 Yes

1 Low priority2 Medium priority3 High priority

0 Yes2 No

1 Note: where different priorities were ascribed by different health authorities, the average was taken.

Table 3. Criteria and ratings for the prioritization of small clinics

Criteria Rating

The presence of an existing health care facility

Functional Units required

Presence of geographic barriers

Presence of high density residential areas (e.g. informalsettlements, hostels)

Priority accorded at joint planning meeting betweenhealth authorities and the Soweto Civic Association

Other (extra points were given when the communities inthe area are very poor and the area is underserved)

0 If facility exists1 If no facility exists

1 Less than five FUs5 5-10 FUs

10 More than 10 FUs

0 No1 Yes

0 No1 Yes

1 Low priority3 Medium priority5 High prioity

024


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example, it was emphasized that clinics could bescaled down relative to one another if resources werescarce, or if other community needs were to receivehigher priority. Also, the design of all facilities shouldaccommodate the later addition of extensions whennecessary.

The final plan was summarized into short lists whichindicated the clinics' location, size and priority at aglance. In addition, a detailed report was written oneach clinic. Each report analyzed the physical andfunctional suitability of the clinic at length, anddetailed the structural and cosmetic changes that arenecessary to upgrade the clinic to a suitable standard.

Section 3: The limitations and merits ofthis planning approachThe difficulty faced continuously by this researchproject was that decisions with substantial resourceimplications had to be made in the context of greatpolitical uncertainty (see Part I; Rispel et al. 1996)and on the basis of incomplete information. Was itjustifiable to neveithless continue with the planningof facilities in Soweto in the absence of clear policyguidelines on the future structure of health services,the mode of delivery of primary health care, or levelsof personnel and expenditure? The final plan did notcomment on the number and sort of personnel thatwould be required to run the services provided in thenew and upgraded facilities, and the cost implicationswere not calculated. These issues are part of the nextstage of the planning process which will hopefullyoccur in a more conducive environment, and will in-form how the plan should be scaled down, if at all.The pattern of referral from one clinic to another,and on to the hospital, was also not outlined, as thisshould be developed according to principles of soundmanagement, once the various authorities operativein Soweto are integrated into a single health service.

Another question that could be posed is: can one beconfident of a plan developed on the basis of so manyassumptions? The final plan recommended severalfacilities of a relatively large size, and it is possiblethat the plan could have been very different in natureand extent if more accurate information wereavailable. However, as the articles in this two-partseries have argued, the logic of the planning processwas continuously checked against the opinions ofstakeholders, while the plan itself was designed withflexibility in mind. The planning was useful in thatit attempted to overcome the stalemate in service

development which had existed in Soweto fordecades, and encouraged informed decisions to bemade in the light of extensive, and open, debate.

Other questions for which it is impossible to provideconclusive answers are ones which perennially facefacility planners. In Soweto, is it logical to provideadditional facilities as opposed to other health careresources such as personnel, simply because there ismoney available for capital expenditure? ShouldSoweto benefit from its ability, in terms of skills andfunding, to develop a comprehensive plan, when thereare certainly more deprived areas spread throughoutthe country? Should health services be receivingattention whilst other services, such as water, sani-tation and housing are so poorly developed? Thesequestions highlight the need for rational decision-making at a political level concerning the national andregional allocation of resources.

ConclusionThis research project attempted to introduce anelement of systematic planning and fairness into asituation which hitherto had been characterized byfragmented and politically motivated planning. Theresearch had the added benefits of introducing part-icipatory research and decision-making during asensitive political period. The overall approach,and specifically the approach to the problem of in-complete data, may help planners in other areas toovercome what might otherwise seem to be paralyz-ing obstacles. Obviously there is need for furtherrefinement of the approach, but the research teambelieve that it should prove useful to other urban areasin South Africa and other parts of the world.

Endnotes1 This article is based on a project conducted jointly by the

Centre for Health Policy, Chris Steel Architects, and Rosmarinand Associates. The team members were, in alphabetical order:Jane Doherty, Fezile Makiwane, John Maytham, Andre Odendaal,Laetitia Rispel, Chris Steel and Nick Webb. Team members weretrained in epidemiology, health systems evaluation and planning,town planning and architectural design.

2 Following the provision of free services to pregnant womenand to children under five by the new government in mid-1994,Soweto clinics have reportedly already experienced a substantiallyincreased load.

3 There are many determinants of geographical access ratherthan distance (such as the difficulty of the terrain and the modeof transport), and many other determinants of access rather thangeographical location, including financial constraints and theappropriateness of the health service, but these were beyond thebrief of the research team to address.


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4 A small clinic is the equivalent of a satellite clinic describedin the international literature. The term 'satellite' is avoided herebecause, at the time of the research, a controversial programmeto build satellite clinics in Soweto had been proposed by the pastgovernment. These satellite clinics would not have provided in-tegrated, comprehensive care, but would have been limited to thenarrowly-defined responsibilities of the local authority healthdepartments.

5 The Council for Scientific and Industrial Research has des-igned a series of economical functional units (FUs) for differentpurposes. For example, there are modular designs for consultingrooms with and without an examination couch. These modules canbe arranged into a design that suits an individual community. EachFU contributes a number of square metres to the size of the clinic.The area associated with each FU includes all the ancillary ac-commodation required to support the FU (such as store rooms,toilets and sluice rooms). Other spaces, such as health educationrooms or waiting areas are not included.

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Rispel L, Doherty J, Makiwane F, Webb N. 1996. The develop-ment of a plan for primary health care facilities is Soweto, SouthAfrica. Part I: Guiding principles and methods. Health Policyand Planning 11(4): 385-93.

Rispel L, Beattie A, Xaba M, Form S, Cabral J, Marawa N. 1995.A description and evaluation of primary health care servicesdelivered by the Alexandra Health Centre and University Clinic.Johannesburg: Centre for Health Policy.

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AcknowledgementsThe authors wish to acknowledge the considerable contributionsby the following people to the research project: the other membersof the research team, Chris Steel, Fezile Matdwane, John Mayrhamand Andre Odendaal; the staff of the Soweto, Diepmeadow andDobsonville City Health Departments, the Soweto CommunityHealth Centres and the TPA Directorate of Community andHospital Services; the Soweto Civic Association; the Soweto CityEngineers Department; the Johannesburg City Council; the CentralWitwatersrand Metropolitan Chamber; the Central WitwatersrandRegional Services Council; and the Council for Scientific and In-dustrial Research. This article draws on an abridged version ofthe project's technical report which was published by the Centrefor Health Policy as a monograph. Comments made by Peter Barronon the monograph were taken into account in writing this article.

BiographiesDr Jane Doherty is a senior researcher who has worked for fiveyears at the Centre for Health Policy in the Department of


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Community Health of the Medical School of the University of theWitwatersrand in Johannesburg, South Africa. She received aBVSc from the University of Pretoria (South Africa) in 1985,an MPhil in International Relations from the University ofCambridge (UK) in 1987, and a Diploma in Health ServicesManagement from the University of the Witwatersrand (SouthAfrica) in 1991. Her experience includes health services eval-uation, household surveys, costing studies and health facility plan-ning, usually within the context of disadvantaged communities.She currently leads the Health Financing and EconomicsProgramme of the Centre.

Ms Laetitia Rispel is a senior researcher and one of the deputydirectors of the Centre for Health Policy. She obtained her BScNursing degree at the University of Cape Town (South Africa)in 1982, an honours in epidemiology from the University ofStellenbosch (South Africa) in 1987 and an MSc (Med) in Com-munity Health at the University of the Witwatersrand (South Africa)

in 1991. For the past 8 years she has been working at the Centrefor Health Policy, focusing on the areas of policy analysis and criti-que of nursing in South Africa; development of strategies forprimary health care in South Africa; initiatives for transformationof the South African health sector; health sector integration in theSouthern African region and health systems research. She currentlyleads the Health Service Evaluation and Planning Programme ofthe Centre.

Mr Nick Webb graduated from the University of Natal in Durban(South Africa) with a BSc and MSc in Town and Regional Plan-ning. His work relates in the main to urban development andregional planning. He presently works for the local authority inDurban, but at the time of the research was employed by a privatefirm, Rosmarin and Associates, in Johannesburg.

Correspondence: Dr Jane Doherty, Centre for Health Policy,SAJMR, PO Box 1038, Johannesburg, 2000, South Africa.


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Health Policy Plan. 1996 DOHERTY 394 405

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