1 DEPARTMENT OF HEALTH & WELFARE Portfolio Committee on Health 16 April 2003 2 INTRODUCTION Vision, mission and core functions Health Progress report per program 2002/3 Health priorities 2003/4 Health budget pressures 2003/4 and service implications Concluding remarks 3 VISION AND MISSION VISION A caring and developmental health and welfare system which promotes well-being, self-reliance and humane society in which all people in the Northern Province have access to affordable and good quality services. MISSION Through providing comprehensive, integrated and equitable Health and Welfare services which are sustainable, cost effective and focus on the development of human potential in partnership with relevant stakeholders. 4 DEMOGRAPHY TOTAL POPULATION = 5.8 Million (DWAF, CWSS Study, 2000) 89% OF THE POPULATION LIVE IN RURAL AREAS. 54.3% 0F THE POPULATION ARE WOMEN 36.9% 0F THE POPULATION AGED LITERACY RATE FOR 20 YRS & OLDER PEOPLE WAS 63.1 % IN 1996 46% UNEMPLOYMENT RATE GDP CONTRIBUTION = 4.2 % IN 1996 6 DISTRICTS 44 HOSPITALS & 477 CLINICS POPULATION DISTRIBUTION 5 MORTALITY INDICATORS 2000 IndicatorLimpopoNational Infant mortality rate/1000 live births Under 5 mortality rate/1000 live births Maternal mortality ratio / live births Source: SAHRS 2000 6 MAJOR CAUSES OF DEATH CausePercentage Ill define (All natural)23.5 Undetermined injuries9.1 Cardiovascular disease7.4 Stroke5.9 Tuberculosis5.6 Lower Respiratory Infections4.8 Diarrhoeal Diseases3.9 Diabetic Mellitus3.1 Ischaemic Heart Disease3.0 Road Accidents1.8 Source: MRC 2001 7 Core Functions Provide Regional and Specialised hospital services & Academic Health Services Render and co-ordinate Medical Emergency Services Render Medico-legal services. Quality control of all health services and facilities. Formulate and implement provincial health policies, norms, standards and legislation. Develop & Manage District Health Services Provide technical and logistical support to health districts. Render specific provincial services programmes, e.g. TB programme. Provide non-personal health services. Provide and maintain Health Care Technologies. Research on, monitor and evaluate health services/programmes. 8 PROGRAMME 1 Health Administration 9 POLICIES ACHIEVEMENTS: 11 Policies and guidelines on the following areas have been developed Procedures for recruitment and appointment of employees Employee suspension; Subsidized motor transport Departmental cellular phone; Procurement Policy Minimum sanctions and misconduct; Managing discipline Remuneration outside Public Service Employee compensation and over time Transfer of employee; Work Environment CONSTRAINTS: Policy development inherently a lengthy process 10 STAFF ESTABLISHMENT ACHIEVEMENTS: Reviewed, finalized and approved the following establishments: Head Office with savings of R9.521m; Polokwane/ Mankweng Tertiary hospital complex; Polokwane Place of Safety; Thohoyandou childrens home; Sekutupu old age home. The following management structures were reviewed: district offices, district hospitals, regional hospitals and level 13 district hospitals, specialized hospitals including 4 revitalization project hospitals finalized. 11 HRM: STAFFING ACHIEVEMENTS: 1110 vacant posts have been filled, this number also includes doctors and nurses. Rank and leg promotions for 4400 employees arrear payment have been finalized as planned for 2002/03 A total number of 390 employees arrear payments are still outstanding Performance management and development system implementation plan has been initiated. Advertised 3 posts of General Manager, 1 CEO, 1 Senior Manager and reasonable number of managers posts. A further R181m is required to fully implement 2 nd and 3 rd notch promotions in terms of DPSA circular which extends beyond once off payment stipulated in the Provincial circular. There is vacancy rate of 41,2%, and 6,03% staff turnover 12 HRM: STAFFING contd TRANSFORMATION AND RESTRUCTURING IN TERMS OF RESOLUTION 7 OF 2002: List of excess personnel has been compiled and employees have started with the process of placement into vacant posts. CONSTRAINTS: Employees turnover rate=6,03%; Vacancy rate 41,2% Staff retention strategy Total staff establishment loss of 1085.This included 407 that have left the Department through resignation and transfer. A number of outstanding promotion arrear payments Payment of outstanding 2 nd and 3 rd notches not finalized Staff establishments for institutions and district offices are not finalized yet to enable restructuring and redeployment process to run smoothly 13 LABOUR RELATIONS AND LEGAL SERVICES ACHIEVEMENTS: District and institutions have been delegated management and handling of disciplinary cases 186 misconduct cases were reported and 144 cases finalized of which 13 cases were dismissals, only 42 cases still pending 15 Disputes (Conciliation and Arbitration) cases were reported and 11 cases finalized, only 4 still pending 8 Appeals reported, 1 finalized and 7 still outstanding 42 grievances have been reported, 28 were finalized, 14 are still being investigated. CONSTRAINTS: Capacity building of line managers 14 FLEET MANAGEMENT ACHIEVEMENTS: Fleet audit is finalized Vehicle replacement plan developed A total of 93 new vehicles have been ordered, broken down as follows :40 Ambulances, 8 response vehicles, 25 pool cars for hospital administration and 20 for mobile services. 10 Ambulances, 23 patients transport and 1LDV have been delivered. 15 FLEET MANAGEMENT cont. CONSTRAINTS: -Vehicles take a long time to be delivered -355 vehicles have traveled more than kms. -Almost 50% of vehicles (including EMS) are always in Garages for repairs 16 EMPLOYMENT EQUITY ACHIEVEMENTS: Complied with the Department of Labour with regard to submission of Equity progress reports The Department has achieved 70/30 targets, however with regard to Provincial Demographics ratio of 56:44, the equity status is as follows:- CONSTRAINTS: No disabled persons in management 17 BATHO PELE PRINCIPLES & SERVICE DELIVERY PLAN ACHIEVEMENTS: 12 consultative workshops on standards development and service delivery plan conducted Workshops conducted monthly in all districts to review, develop and implement domain specific standards Manual on Promotion of Access to Information Act, 2000 compiled and approved Departmental annual Merit Award Ceremony was held to recognize good performance of employees Suggestion boxes have been installed in 95 % of the institutions, client satisfaction surveys done in all hospitals 18 Financial Planning and Budgeting ACHIEVEMENTS: Achievability exercise, MTEC hearings, quarterly reports & IGFR all assisted to provide a credible adjustment budget that dealt with personnel under funding and inflationary pressures. The new Chart of Accounts for 2003/04 based on the nationally agreed programme structure and Departmental restructuring has been finalised. Strategic plans in new format have been developed. CONSTRAINTS: Lack of staff due to resolution 7. 19 Donor Funds ACHIEVEMENTS: R1m was donated to Shiluvana Health Centre by Flemish government for the eye centre. R has been commited so far. Business plan for EUs PDPHC in place. CONSTRAINTS: Systems for administering donor funds are new and therefore there is a learning curve involved. 20 Revenue Generation ACHIEVEMENTS: The revised fees schedule was implemented as from 1 st October 2002 with a potential 10% decrease in income. Some private wards have been established to entice private patients. R43.2m of revised target of R56.99m(98.8% of tgt) CONSTRAINTS: Incorrect personal data provided by patients. 92% of patients not on medical aid. 21 PROGRAMME 2 District Health Services 22 80% communities reached on community awareness +/-10 million male condoms distributed 21 sites for female condom distribution established and +/ female condoms distributed All 8 Regional offer PMTCT services and 33 District Hospitals offer Nevirapine 233 VCT sites established and functional PEP treatment is being provided at all hospitals PREVENTION AND CONTROL OF HIV/AIDS 23 HIV/AIDS/STDIS/TB cont. ACHIEVEMENTS :ICHB CARE PROGRAMME 20 Community Based Organisations offering ICHBC services 25,666 (inclusive of all chronic conditions) clients were attended to. 636 Care-givers trained and offering ICHBC services 3641 orphans (of which 2157 HIV/AIDS orphans) are benefiting from ICHBC services 2 Step-down facilities approved and started operating. (Kgapane & St Ritas) Constraints: Community Home base care kits not always available to all clients. 24 NATIONAL VS. LIMPOPO HIV TRENDS 2001 vs HIV PREVALENCE BY AGE GROUP 26 TB CASE FINDING 27 TB CONTROL & MANAGEMENT Achievements TB Case detection increased from 6468 in 2000 to 7793 in 2001) DOT Support work Community awareness Overall TB cure rate improved from 52,8 in 2000 to 53,2% 2001 MDR/TB Clinic established at Polokwane Hospital Business plan for establishment of MDR/TB Unit F. H. Odendaal Hospital submitted. Establishment of mobile laboratories services Challenges Sputum Turn- around time of days which is higher than expected National recommendation of 4 days Collapse of mobile services in some districts affecting the transportation of specimen 28 Integrated Mother,Child and Women health services ACHIEVEMENTS: Approximately 80% PHC facilities provide IMCI which resulted in reduction of incidences diarrheal from 16.2 in 2001 to 13.5 in 2002, and upper respiratory infections from 25.1 in 2001 to 23.4 in 2002 5 clinics per districts offer PAP services and the rest on demand. 3715 women access PAP services. Family planning services are offered in all clinics and mobiles 29 hospitals offer TOP. 29 TERMINATION OF PREGNANCY 30 TOP BY AGE GROUP 31 TOP BY GESTATIONAL AGE 32 Prevention and Control of Communicable Diseases ACHIEVEMENTS: 75% of targeted household for February 2003 are already sprayed 80 temporary spraying operators are appointed. Cases fatality for Malaria reduced from 86/ population in 2001 to 51/ population for 2002 CHALLENGES Emerging and re-emerging infectious diseases such as Anthrax, Severe Acute Respiratory Syndrome 33 IMMUNIZATION COVERAGE (%) UNDER 1 YEAR BY DISTRICT 34 AFP SURVEILLANCE YEARTargetDetected Detection Rate No. Adequate Stool Stool Adequacy rate (%) 35 UNDER 5 MORBIDITIES INDICATOR LimpopoNational Average Incidence severe malnutrition under 5 years 0.84 per 1K0.61 per 1K0.56 per 1K Diarrhoeal incidence per 1K per 1K per 1K per 1K Lower Respiratory Infections 3.87per 1K per 1K per 1K 7.1 per 1K Source: DHIS 36 5 TOP NOTIFIABLE MEDICAL CONDITIONS 37 Environmental Health Related Conditions ACHIEVEMENTS: males enrolled for initiation. Of which 648 were admitted to hospitals and one died. 465 cholera cases were reported with fatality rate of 0.4% Of the 813 villages with access to water supply, 200 of them were monitored and found to have safe water supply (quality & quantity). CONSTRAINTS: Poor water supply and sanitation 38 INTEGRATED NUTRITION PROGRAMME NUTRITION PROGRAMME: 68 of the 105 projects are sustainable. 2747 schools are participating. A total number of children qualifying for PSNP 1,173 million and only 1,131 million benefiting from the programme. 7 additional hospitals obtained BFHI status. A total of 21 hospitals obtain BFHI status. Stunting decreased from 34.2%in 1994 to123.1% in 2001 Wasting increased from 3.8% in 1994 to 7.5% 2001 Underweight increased from 10.4% in 1994 to 15% in 2001 CONSTRAINTS: Logistical problems and management problem 39 Occupational Health Related Conditions ACHIEVEMENTS: 50% of hospitals have trained Occupational Health Officers. CONSTRAINTS: Lack of training in the implementation of the Occupational Health and Safety Act in the Workplace. 40 PHC SERVICES Accessibility & Availability of PHC Services ACHIEVEMENTS: 24 hour services have increased from 183 to 233 10 clinics increased hours of services from 8 hours to 12 hours 142 care groups activated and 18 new care groups established. PHC service delivery at social security paypoint has been started in Vhembe and Mopani district. PHC service delivery started in Prisons in the Vhembe districts. Antenatal coverage is 77.5% and antenatal visits per client is 3.7 CONSTRAINTS: budget for security at clinics not available. 41 PHC UTILIZATION RATE BY DISTRICTS 42 ANTENATAL VISITS PER ANTENATAL CLIENT BY DISTRICTS Source: DHIS 43 DHS Development & Devolution Support Achievements; Devolution of PHC Services: Newly Demarcated District Re-alignment A Multi-Sectoral Task Team was established in July 2002 to develop a Devolution Strategy for Limpopo Province Draft 1 of the Strategy is under consideration by Department of Health & Welfare, Local Government & Housing and other key stakeholders. Plan A of the strategy deals with the transfer of EHS to district Municipalities while Plan B contain measures to address delegations of PHC services to district council municipalities. Draft services level agreements have been developed for signing with each municipality that will receive devolved service functions. Heads of Health district have been appointed and given delegated powers and functions 44 E MERGENCY MEDICAL SERVICES Achievements: 3 New stations were opened Hospital Based staff have been taken over by EMS 118 posts have been filled at various stations and the 4 shift system is being implemented at stations with sufficient staff. Constraints: Community misunderstandings of EMS Restructuring Programme vs Community Expectations 45 PROGRAMME 3 Regional and Specialised Hospital Services 46 Equitable access to Health Care Services Polokwane /Mankweng complex has reduced referrals to Ga- Rankuwa by 25%. Referrals into PMHC 3271 Referrals out of PMHC 418 47 HOSPITAL PERFORMANCE INDICATORS PER DISTRICT DISTRICTSNO. BEDS BORALOSNORMAL DEIVERY RATE LIVE BIRTH RATE STILL BIRTH RATE C/S RATE Bohlabela Capricorn Mopani Sekhukhune Vhembe Waterberg 48 HOSPITAL PERFORMANCE INDICATORS BY LEVELS OF HOSPITALS LEVELSNO. BEDS BORALOSNORMAL DEIVERY RATE LIVE BIRTH RATE STILL BIRTH RATE C/S RATE DISTRICT HOSPITALS REGIONAL HOSPITALS TERTIARY HOSPITALS TOTAL 49 PROGRAMME 4 Health Sciences 50 HEALTH SCIENCES Achievements NURSING Level 1 training material for outcome based and community based education developed. Total enrolment stand at 690. Constraints Absence of Selection Criteria for Rural Schools Recruitment 51 COLLEGE OF EMERGENCY CARE Achievements: 60 of the 72 enrolled EMS Practitioners have completed the course. 65 completed rescue technique course. 52 HR DEVELOPMENT AND PLANNING ACHIEVEMENTS: A total of 515 new bursaries were awarded to students in various health and medical related fields.. 53 PROGRAMME 5 Health Care Support Services 54 Improved access to medicine at all Health Facilities Achievements: 90% of medicines is available at depot 85% of medicines available at Hospitals 75% medicines available at clinics 8 Hospitals have Therapeutic committees 55 PROGRAMME 6 Health Facilities Dev. And Maint. 56 PHYSICAL RESOURCES ACHIEVEMENTS: 35 projects to the value of R139 million were completed at 20 hospitals and R2m spent on clinic water supply. 5 revitalisation hospitals: completed initial phase; Lebowakgomo 2 nd phase almost completed. Institutions have completed and already implementing their annual maintenance plans CONSTRAINTS: Most physical facilities projects were put on hold due to budget cuts Tendering process take too long resulting in projects not being completed in time Clinic electrification has stopped since April 2002 due to lack of funds 57 Provisional expenditure and revenue 2002/03 58 Expenditure 2002/03 per program It should be noted that all figures for 2002/03 as presented in this section should be considered provisional as the Department has had financial systems problems since the last week of March 2003. 59 CONDITIONAL GRANTS 60 Revenue collected 2002/03 & MTEF budget 61 Financials for MTEF 62 Equitable Share & Conditional Grants 63 REVENUE ESTIMATES 64 Summary of Expenditure & Estimates 2000/ /06 65 Summary of Expenditure & Estimates by Std Items 2000/01 2005/06 66 CONDITIONAL GRANTS 67 Expend analysis 00/01 to 05/06 The personnel expenditure as a % of the budget has been declining since 2000 (64.43% to 61.84% in 2002/3). The personnel numbers have declined over this period from 23,607 to 23,569. 68 Fiscal Equity Issues The Budget for DHS: increased from 49.2 % in 1996/97 to 52.3 % in 2002/03 (excl pharmac. & capex). With pharmac. & capex included this figure moves to 63.0%. Population served by Public Sector: By 1999, LP had 92.4 % people without Medical Aid Cover. Per capita Health Expenditure: LP is the lowest. In 2002/03 LP spent R586 per uninsured person, which was 27% below the national average and about 1/3 of Gautengs R1580. (IGFR 2003) Using constant 2002 prices the LP showed a decline from 1997/98 (R611/uninsured) to 2002/03(R586/uninsured) of 4.1%. By 1997, LP was spending R24/person on medicines compared to the National average of R42 /person & currently LP spends R37.14/person which = 3 times less than that of Gauteng. 69 Fiscal Equity Issues Percentage Growth of the Health Budget: Has been consistently lower than national and provincial norm. In 02/03 the growth was 18.11% compared to the Provincial budget growth of 22.26%. The comparative figures for 03/04 budget growth are 10.17% for Health and 11.66% for the Province. The national average growth in Health budgets is 10.87% for 2003/04 The department got 16,43 % of the provincial budget compared to Educations 41,55 % in 02/03. In 03/04 the comparative figures are 16,21% vs 39,83%. The national averages for % of education budget are 36,7% (02/03) and 35,6% (03/04) % is less than the 19% national guideline and less than the national average of 22.3% (03/04) and 16.43% is less than the national average of 22.9% (02/03). Equity within the LP still needs to improve as demonstrated by the above Tables & notes. 70 HEALTH PRIORITIES 2003/04 71 HEALTH PRIORITIES 2003/04 HIV/AIDS/STI CONTROL & MANAGEMENT: Introduction of VCT sites in private sectors Rollout of the PMTCT services in all remaining 319 clinics in the province by end of 2003 To reach and train more of commercial sex workers. To establish Youth Information, Education and Counselling in all border gates. Health Promotion Strategies TB CONTROL & MANAGEMENT: Decreasing number of patients infected with both TB and HIV. Consider Stipends for DOTS supporters Accessibility of Laboratory services Capacity for Management MDR TB Strengthening & Consolidation of Care Groups 72 HEALTH PRIORITIES 2003/04 COMMUNICABLE DISEASE CONTROL: Polio Eradication by 2004 Strategy Expanded Programme on Immunisation Laboratory Services & Malaria Control PHC SERVICES & DHS DEVELOPMENT: Devolution of Environmental Health & other PHC Services to District Municipalities Improve 24 Hour Services at Clinics Security at Clinics and Total Risk Management Capacity for Disaster Management Integrated Nutrition Programme Integrated Management of Childhood Illnesses (IMCI) Referral System Non- personal Health Programmes 73 HEALTH PRIORITIES 2003/04 EMERGENCY MEDICAL SERVICES: Decentralisation of EMS & Patients transport to rural settings LOGISTICAL SUPPORT SERVICES: Adequate Medicines at Facilities. Better Mx. of Health Technologies & Assistive Devices Roll out Cost Centres Capacity for Strategic Planning & Policy Analysis Capacity for Financial & General Management Consolidation of Procurement policies Capacity for in-house Fleet Management Labour Relations, Litigations & Legislative Reforms Implementation of the remaining Health information system modules 74 HEALTH PRIORITIES 2003/04 INFRASTRUCTURE DEVELOPMENT: Focus on 5 revitalization hospitals Upgrading of 21 clinics Improve water, sanitation & electricity at clinics 75 FINANCIALS 2003/04 WITH SERVICE IMPLICATIONS 76 HEALTH PRIORITIES 2003/04 HUMAN RESOURCE DEVELOPMENT: Consolidate Health Districts Organograms Consolidate a Departmental HR Plan Management of Bursaries Nursing and EMS Training Colleges PHC Nurse Training & Community Rehabilitation Workers Training Professional Training & Development HUMAN RESOURCE MANAGEMENT: Filling of Critical Posts & Retention of Staff Rural Staff Incentives Strategy Conditions of Service for Staff (2 nd & 3 rd Notch, etc.) 77 HEALTH PRIORITIES 2003/04 COMMUNICATION, COLLABORATION AND PARTICIPATION: The following PPP projects are envisaged - Phalaborwa hospital, Duiwelskloof hospital, Laundry & Boiler services and Renal Dialysis unit. To conduct feasibility studies for possible Expansion of PPP Initiatives. Quality Improvement & Management Corporate Communication & Media Liaison Transformation & Inter-governmental Relations & Gender Issues Health Promotion TERTIARY SERVICES: REVENUE GENERATION: 78 PRIORITY BUDGET 79 BUDGET ANALYSIS FOR 2003/04 - VOTE 7: HEALTH Table 1: SUMMARY OF EXPENDITURE AND ESTIMATES 80 BUDGET ANALYSIS FOR 2003/04 - VOTE 7: HEALTH Table 2: SUMMARY OF ECONOMIC CLASSIFICATION 81 OVERVIEW OF BUDGET 2003/04 As can be seen the nominal increase between 2002/03 adjusted estimates and 2003/04 is R319,8m. This equates to a 10% increase in the budget. The inflation for 2002 was also 10%. (CPIX figure provided by Statistics SA) There is therefore no growth in Healths budget. Besides the problem of no growth it should be remembered that health inflation(pharmaceuticals, surgical supplies, medical equipment, etc.) is always more than general inflation, resulting in less services to the community. The main reason why health inflation is so high is due to the fact that most of these items are imported. The per capita expenditure on Health in this Province is the lowest in the country (IGFR 2001). With a no growth budget this situation is unlikely to change. The implications of this are that the people of this Province will not be able to have the standard of Health care that they should have. The budget pressures section will expound on this issue. 82 Table 3: EVOLUTION OF EXPENDITURE OF BUDGET IN CONSTANT 2002/03 PRICES (R MILLION) As can be seen from the table there has been a slight real growth of 2% over the years. This has been due to the above inflation increase of personnel expenditure. This is less than the population growth. As a result the provincial per capita health expenditure has decreased annually by about R5. This again is an indicator that despite the province being the lowest funded per capita in the country the situation is unlikely to improve unless the funding situation improves. 83 BUDGET PRESSURES FOR 2003/04 The indicative budget for 2003/04 according to GFS 2002/03 was R3,109,083,000. The final budget allocated for 2003/04 is R3,465,572,000. The increase is R356,489,000. The following table shows the allocation of this additional money. Following the table there will be some more detailed explanations of the service implications of the lack of sufficient budget. 84 Table 4: ALLOCATION OF FUNDS FOR BUDGET PRESSURES 2003/04 85 BUDGET PRESSURES FOR 2003/04 (continued) Human resource service implications (shortage of R138m) Health is a human resource intensive service. Due to the budget shortage there is inadequate money for filling most of the vacant critical posts. This will make it difficult to improve service delivery at the clinics. As a result the best scenario will be the maintenance of existing services. Security service implications at clinics (shortage of R37m) Security at the clinics can not be improved everywhere. Clinics with no adequate security will not be able to provide 24 hour services. The lack of security will also have a detrimental effect on retention and recruitment of staff. 86 BUDGET PRESSURES FOR 2003/04 (continued) EMS service implications (shortage of R6m & HR portion) Emergency Medical Services can not be expanded. The response time to very rural areas will therefore not be able to be improved. This will most likely result in some unnecessary deaths due to the fact that there is a golden hour in which to get emergency patients to a hospital for them to have a good prognosis. Infrastructure service implications (shortage of R44m) Infrastructure development cannot be fast tracked. It is well known that there are a large number of clinics with no water, no electricity, insufficient equipment and inadequate facilities. The development of the tertiary facilities will also be delayed. Maintenance of medical equipment will still be inadequate though better than 02/03. 87 Thank You