annexure 2 - district health system · 27 annexure 2 - district health system situation analysis...

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ANNEXURE 2 - DISTRICT HEALTH SYSTEM

Situation analysis The delivery of PHC services remains dependant on the DHS. However, the Province has an outstanding task of defining the role of Local Government in delivery o Primary Health Care. The National Health Act, Act No. 61 of 2003 defines Municipal Health services as Environmental Health services excluding port health, malaria control and control of hazardous substances. The 13 February 2001 MINMEC resolved that provinces must:

Establish a Provincial Health Authority and Provincial Health Advisory Committee Establish District Health Authorities and Community Health Committees Ensure planning and coordination of delivery of a comprehensive and integrated district

health services Delegate the delivery of primary health care services where appropriate capacity, support

and resources exist Develop services agreements with clear performance indicators between province and

municipalities/districts Audit all health care resources in each district or metropolitan area Provide support for development of district based service plans.

The Province has continued to use the DHS to facilitate the implementation of PHC. The decentralisation of services has taken a form of de-concentration with District Management structures reporting to the provincial office. The provincial Department of health has finally decided to keep the delivery of Primary Health Care as a provincial competence as stipulated in the National Health Act, Act No. 61 of 2003, several municipalities will enter into a service level agreement with the Department for rendering primary health care. Whilst the DHS by definition is limited to District Hospital Services and Primary Health Care, the Provincial Department of Health gave it a broader meaning. For KwaZulu- Natal purposes, the DHS relates to all health services that operate within a District. This is inclusive of all PHC, hospital services, emergency medical and rescue services. The aim of this programme is to improve the health status of all individuals living within a District. The following sub-programmes will be discussed under Programme 2.

• District Management • Community Health Clinics • Community Health Centres • Community Based Services • Other Community Services

Health promotion strategies including health information, education and counselling are implemented at district level supported by Provincial Health Programmes. The DHS draws its priorities and plans from the Department’s Strategic Goals. These are

• Effective implementation of the comprehensive HIV and AIDS strategy • Strengthen Primary Health Care and provide caring, responsive and quality health

services at all levels

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• Promote health, prevent and manage illnesses with emphasis on poverty, lifestyle, trauma and violence

• Human resource management for Public health • Infrastructure investment in health technology, communication, management

information systems and buildings Demographic Profile Approximately 88% of the population of KwaZuluNatal is uninsured and thus relies on the Public health services for health care. Although fifty-three percent (53%) of the population is urbanised, a high proportion of this live in underdeveloped informal settlements. The rest of the communities reside in deep rural and rural settlements. The sparse settlement pattern found in these areas poses a challenge in improving access to health care at District level. The mountainous topography, with deep valleys, compounds the challenge of making services accessible. Cross border flows occur at Sisonke, Ugu (1,4% of Eastern Cape population) as well as at Zululand and Umkhanyakude Districts (± 30 000 Mozambique population and 15 000 Swaziland population respectively). This poses further challenges for District Health Service provision. Health service demand is also increased by the disease burden emanating from relatively high poverty levels and unemployment. Backlogs in the provision of water, sanitation and housing contribute to the morbidity profile at District level.

Appraisal of Service Performance Since 1994, 125 additional clinics have been built and the access to services has improved 236 clinics to date and the headcount has increased from 16 313 406 in 2001/2002 to 18 411 276 in 2003/2004. The relationships between Provincial and Local Government Health Service Managers are being strengthened through joint planning and service monitoring processes at District and Local Municipality level. Although the service packages are not fully implemented with 80% of the package being implemented Provincially training of staff to expand the programme is under way and planned for the financial year. Improving access through additional Community Health Workers, Community-Based Lay Counsellors, Home-Based Carers and Mobile Teams is essential given the terrain in the Province. Although the average population per fixed PHC clinic was reduced to 17 379 across the Province in 2003/2004 this will have to be addressed through additional facilities in order to reach the national norm of 10 000 population per facility. Recruitment and retention of staff especially to facilitate provision of 24-hour services in rural areas will increase the financial demands at District level. This will reduce the referrals to higher levels of care, long queues and improve access to the community with accompanied lower costs per visit. Programme development e.g. TB, STI, HIV and AIDS, Chronic Diseases, as well as Mental Health will have to be given priority in order to enhance the quality of life of the Districts’ populations. The expansion in the MCWH and Health Promotion Programmes will be critical in order to address the needs of women and children both at community level and through the Health Promoting Schools Programme given the gaps in performance against National Targets. The resourcing of these Programmes has financial implications.

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Table DHS1: District health service facilities by health district

Health District Facility type No. Population Population per PHC facility

or per hospital bed

Per capita Utilisation Rate

Non fixed clinics: Mobile Teams

14 99 132 2.3

Visiting Points

219

Fixed Clinics 47 15 421 1.3 CHC’s 0 0 0 Sub-total Clinics + CHC’s

61

15 421

2.14

District 21 Ugu (Rural Node)

District Hospitals 3

90 740

231 309 1.06 Non fixed clinics: Mobile Teams Visiting Points

11 243

87 344

3 500

2.8 2.8

Fixed Clinics 48 20 016 2.0 CHC’s 3 320 262 2.20 Sub-total Clinics + CHC’s

51

960 786

18 838

2.25

District 22 uMgungun-dlovu

District Hospitals 3 2 40 965 1.04 Non fixed clinics: Mobile Teams

13 10 072 1.75

Visiting Points

330 396 1.06

Fixed Clinics 37 15 097 2.15 CHC’s 0 0 0 Sub-total Clinics + CHC’s

37

692 548

15 097

1.8

District 23 uThukela

District Hospitals 2 134 800 0.76 Non fixed clinics:

Mobile Teams

9 41 855 67.82(for all PHC services)

Visiting Points

115 No info N/A

Fixed Clinics 37 13 154 N/A CHC’s 0 N/A N/A Sub-total Clinics + CHC’s

37

455 124

13 154

67.82 (for all

PHC services)

District 24 Umzinyathi (Rural Node)


Mobile Teams

7 110 669 No info

Visiting Points

127 No info No info

Fixed Clinics 21 20 122 No info

District 25 Amajuba

CHC’s 0

492 000

0 No info

30


or per hospital bed


Sub-total Clinics + CHC’s

21

20 122

2.21


Mobile Teams

12 71 231 No info

Visiting Points

258 3 313 No info

Fixed Clinics 54 15 829 1.4 CHC’s 0 91 585 N/A Sub-total Clinics + CHC’s

54

854 779

15 829

1.4

District 26 Zululand (Rural Node)

District Hospitals 5 612 28.7 Non fixed clinics:

Mobile Teams

14 36 197 No info

Visiting Points

No info No info No info

Fixed Clinics 50 11 555 No info CHC’s 0 0 No info Sub-total Clinics + CHC’s

64

598 000

11 555

1.8

District 27 Umkhanya- kude (Rural Node)


Mobile Teams

14 15 385 1.4

Visiting Points

224 30 807 No info

Fixed Clinics 50 97 613 1.9 CHC’s 1 0 0.1 Sub-total Clinics + CHC’s

55

903 663

128 420

2.0

District 28 Uthungulu


Mobile Teams

11 64 119 2.42

Visiting Points

137 56 039 1.25

Fixed Clinics 29 22 195 3.89 CHC’s 2 288 537 2.9 Sub-total Clinics + CHC’s

31

577 073

20 610

3.0

District 29 iLembe


Mobile Teams

5 15 788 2.0

Visiting Points

213 - -

Fixed Clinics 18 12 630 2.1 CHC’s 1 252 607 2.5

District 43 Sisonke

Sub-total Clinics + CHC’s

19

283 383

11 170

2.0

31


or per hospital bed


District Hospitals

4 63 152 3.14

Non fixed clinics:

Mobile Teams

24 5 877 3.96

Visiting Points

353 399 3.96

Fixed Clinics 133 16 553 2 CHC’s 6 123 248 0.5 Sub-total Clinics + CHC’s

163

3 152 405

48 595

2.1

eThekwini (Urban Node) Incl. i.e. Inanda & KwaMashu


No info No info

Mobile Teams

123 63 872 No info

Visiting Points

Fixed Clinics (incl. Local Council clinics)

450 21 543 No info

CHC’s 14 697 675 No info Sub-total Clinics + CHC’s

464

8 916 006

20 898

2.39

Province

District Hospitals 36 185 097 1,77 The inequitable distribution of the population and resources can be seen from the Table DHS1 above. Districts that are more densely populated tend to be better resourced. For an example it can be noted that DC21, 24, 25, & 27 do not have CHCs. Since the major forms for 24 hr PHC services in 2005/06 is on CHCs, these districts will require a different approach. Table DHS2: Personnel in district health services by health district

Health District Personnel Category

Posts Filled

Posts Approved

Vacancy Rate (%) Number in post per

1000 uninsured people

PHC facilities Medical Officers 0 0 0 0 Professional Nurses 170 222 23.4 0.01 Pharmacists 0 0 0 0 Community Health Workers 317 317 0 0.6 District Hospitals Medical Officers 15 34 55.9 0.002 Professional Nurses 222 251 11.6 0.01

District 21 Ugu

Pharmacists 6 1 14.3 0.007

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Posts Filled

Posts Approved



PHC facilities Medical Officers 2 6 66.7 0.4 Professional Nurses 160 214 25.2 0.27 Pharmacists 0 3 100 0 Community Health Workers 246 280 12 0.3 District Hospitals Medical Officers 30 67 55.2 0.12 Professional Nurses 446 621 28.1 0.51

District 22 uMgungun- dlovu

Pharmacists 5 13 61.5 0.01 PHC facilities Medical Officers 0 1 100 0 Professional Nurses 133 172 22.3 0.03 Pharmacists 0 2 100 0 Community Health Workers 270 325 17 0.05 District Hospitals Medical Officers 10 22 54.6 0.007

District 23 Uthukela

Professional Nurses 129 157 17.8 0.04 Pharmacists 1 3 66.7 0.009

PHC facilities Medical Officers 0 0 0 0 Professional Nurses 78 111 29.7 0.24 Pharmacists 0 0 0 0 Community Health Workers 267 267 0 No info District Hospitals Medical Officers 17 45 62.2 0.05 Professional Nurses 351 450 22 1.02

District 24 Umzinyathi

Pharmacists 1 5 80

0.01

PHC facilities Medical Officers 0 0 0 0 Professional Nurses 56 84 33.3 0.28 Pharmacists 0 0 0 0 Community Health Workers 198 323 38 - District Hospitals Medical Officers 6 15 60 - Professional Nurses 121 141 14.2 -

District 25 Amajuba

Pharmacists 2 5 60 - PHC facilities Medical Officers 1 3 67 - Professional Nurses 215 262 18 0.25 Pharmacists 0 1 100 0 Community Health Workers 606 606 0 0.72 District Hospitals Medical Officers 33 84 61 0.074 Professional Nurses 414 620 33.2 0.810

District 26 Zululand

Pharmacists 4 9 56 - PHC facilities Medical Officers 0 0 0 0 Professional Nurses 151 193 22 0.30

District 27 Umkhanya- kude

Pharmacists 0 0 0 0

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Posts Filled

Posts Approved



Community Health Workers 604 672 10 1.03 District Hospitals Medical Officers 20 50 60 0.07 Professional Nurses 259 359 28 0.76

Pharmacists 0 4 100 0 PHC facilities Medical Officers 0 3 100 0 Professional Nurses 143 223 36 0.35 Pharmacists 0 2 100 0 Community Health Workers 233 238 0.02

-

District Hospitals Medical Officers 31 79 61 - Professional Nurses 435 588 26

District 28 Uthungulu

Pharmacists 1 7 86 - PHC facilities Medical Officers 0 3 100 0 Professional Nurses 74 96 23 0.45 Pharmacists 0 1 100 0 Community Health Workers 220 220 0 .38 District Hospitals Medical Officers 5 12 58.3 - Professional Nurses 79 102 23 .46

District 29 iLembe

Pharmacists 1 2 50 .005 PHC facilities Medical Officers 0 0 0 0 Professional Nurses 67 85 21.2 0.26 Pharmacists 0 2 100 0 Community Health Workers 189 235 19.6 0.62 District Hospitals Medical Officers 10 29 66 0.73 Professional Nurses 211 289 27 0.05

District 43 Sisonke

Pharmacists 0 5 100 0.17 PHC facilities Medical Officers 9 28 68 - Professional Nurses 585 717 18.4 - Pharmacists 9 26 65.4 - Community Health Workers 988 1 119 11.71 .38 District Hospitals Medical Officers 62 126 51 .026 Professional Nurses 687 1 106 38 .204

eThekwini

Pharmacists 29 39 26 .008 PHC facilities Medical Officers 12 44 73 - Professional Nurses

1 832

2 379

23 -

Pharmacists 9 37 76 - Community Health Workers

4 102

4 420

7.2

-

District Hospitals

KZN Province

Medical Officers 239 563 58 -

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Posts Filled

Posts Approved



Professional Nurses 3 354

4 684

28

-

Pharmacists 50 93 46.9 No info The challenge of shortage of staff is mainly felt in the rural sparsely populated districts like can be seen on Table DHS 2. Highest vacancies in Medical Officers, Professional Nurses and Pharmacists are in Districts like Sisonke, Umzinyathi and Zululand.

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Table DHS3: Situation analysis indicators for district health services

Indicator Type Province wide value 2001/02 Province wide value 2002/03 Province wide value 2003/04 Input Uninsured population served per fixed public PHC facility No No info No info No info Provincial PHC expenditure per uninsured person R 173.06 172.02 204.03 Local government PHC expenditure per uninsured person R 7.02 7.84 7.02 PHC expenditure (provincial plus local government) per uninsured person R 180.08 179.86 211.04 Professional nurses in fixed PHC facilities per 100,000 Uninsured person No No info No info No info Sub-districts offering full package of PHC services % No info No info No info EHS expenditure (provincial plus local govt) per uninsured person R 8.01 7.76 9.61 Process Health districts with appointed manager % No info No info No info Health districts with plan as per DHP guidelines % No info No info No info Fixed PHC facilities with functioning community participation structure % No info No info No info Facility data timeliness rate for all PHC facilities % No info No info No info Output PHC total headcount No 16 313 406 17 369 006 18 411 276 Utilisation rate – PHC No 1.8 1.8 1.9 Utilisation rate - PHC under 5 years No 3.7 3.8 3.7 Quality Supervision rate % No info No info No info Fixed PHC facilities supported by a doctor at least once a week % No info No info No info Efficiency No info No info No info

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Indicator Type Province wide value 2001/02 Province wide value 2002/03 Province wide value 2003/04 Provincial PHC expenditure per headcount at provincial PHC facilities R No info No info No info Expenditure (provincial plus LG) per headcount at public PHC facilities R No info No info No info Outcome Health districts with a single provider of PHC services % No info No info No info

Table DHS3 CONTINUED Situation Analysis indicators for district health services

Indicator Type DC21 DC22 DC23 DC24 DC25 DC26 DC27 DC28 DC29 DC43 METRO National Target 2003/04

Input Uninsured population served per fixed public PHC facility No 13 595 27 170 17 724 12 452 26 321 15 541 11 874 20 430 14 009 14 685 21 063 <12,200 Provincial PHC expenditure per uninsured person R R119.46 R56 R91.56 R101.68 R32.87 R90.69 R155 R208 R330 R533.77 R86.95 N/A Local government PHC expenditure per uninsured person R R12.48 R63.20 R26.43 R67.11 R3.53 R25.98 N/A R145 R56 R63 R253.41 N/A PHC expenditure (provincial plus local government) per uninsured person R R121.06 R63.20 R91.56 R107.30 R36.40 R59.15 R155 R155 R297 R37 R243.63 227 Professional nurses in fixed PHC facilities per 100,000 uninsured person No 0.37 0.27 0.67 0.24 0.28 0.25 0.28 0.35 0.45 0.79 0.9 107 Sub-districts offering full package of PHC services** % 100 68 72 100 100 N/A - 100 96 60 100 60 EHS expenditure R R6.82 R4.16 R4.27 R3.42 R20.07 R4.96 R155 R6.42 R13 R2.70 R3.77 9

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(provincial plus local govt) per uninsured person Process Health districts with appointed manager % 100 100 100 100 100 100 100 100 100 100 100 92 Health districts with plan as per DHP guidelines % 100 100 100 100 100 100 0 100 100 0 0 48 Fixed PHC facilities with functioning community participation structure % 89 68 85 80 100 94 80 100 85 85 34 69 Facility data timeliness rate for all PHC facilities % 98 100 100 100 100 99 90 100 98 100 90 80 Output PHC total headcount No 1 492 811 1 789 285 1256410 891 514 996 362 1363911 1 331539 1 823 372 1029119 623786 5813157 N/A Utilisation rate – PHC No 2.05 1.86 1.85 2.6 1.89 2.06 1.64 2.24 1.99 1.77 2.02 1.82 Utilisation rate - PHC under 5 years No 3.76 3.45 3.62 3.72 5.05 3.21 4.33 3.94 3.54 3.68 3.62 3.8 Quality Supervision rate % 67 100 75 100 100 88 90 100 100 45 60 78 Fixed PHC facilities supported by a doctor at least once a week % 38 35 23 27 20 35 44 15 33 35 25 31 Efficiency Provincial PHC expenditure per headcount at provincial PHC facilities R 51.57 R44 58.50 49.17 34 59.20 47 62.72 49.15 63 49 99 Expenditure (provincial plus LG) per headcount at public PHC facilities R 61.91 41 67 58.50 31.47 59.15 47 65.50 51.10 37 79 99 Outcome Health districts with a single provider of PHC services % 0 0 0 0 0 0 100 0 0 0 0 50 Service volumes

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Clinic headcounts No 1035342 861895 842152 637398 807871 1107388 1068197 1405037 528387 290546 1864804 - CHC headcounts No -* 185573 -* -* -* -* -* -* 207 848 60569 1 367 147 - Mobile headcounts No 214 014 198142 253 590 139562 68768 209365 263342 213441 137 271 133121 189766 - Mobile headcount as a % of Total PHC headcount % 14 11 20 15 6 15 19 11 13 21 3 -

*No CHC’s in these districts

**Services are rendered through districts and not sub-districts

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Table DHS4: Situation analysis indicators for district hospitals sub-programme

Indicator Type Province wide value

2001/02

Province wide value

2002/03

Province wide value

2003/04 Input Expenditure on hospital staff as % of district hospital expenditure % 71.87 76.12 67.98 Expenditure on drugs for hospital use as % of district hospital expend % 5.71 7.19 6.46 Expenditure by district hospitals per uninsured person R 220.98 222.91 236.37 Process District hospitals with operational hospital board % 80 80 80 District hospitals with appointed (not acting) CEO in post % 80 90 98 Facility data timeliness rate for district hospitals % - - 100 Output Caesarean section rate for district hospitals % - 19 20 Quality District hospitals with patient satisfaction survey using DoH template % - - 95 District hospitals with clinical audit (M and M) meetings every month % - - 80 Efficiency Average length of stay in district hospitals Days 6 7 6 Bed utilisation rate (based on usable beds) in district hospitals % 63 54 56 Expenditure per patient day equivalent in district hospitals R No info No info No info Outcome Case fatality rate in district hospitals for surgery separations % - 7 5

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Table DHS4 CONTINUED: Situation analysis indicators for district hospitals sub-programme

Indicator Type DC21 DC22 DC23 DC24 DC25 DC26 DC27 DC28 DC29 DC43 METRO National target 2003/4

Input Expenditure on hospital staff as % of district hospital expenditure % 70 72 74 77 74 71 71 79 76 73 67 - Expenditure on drugs for hospital use as % of district hospital expend % 6.4 4.8 6.7 14 32 7.7 7 11.82 9 59 10.7 11 Expenditure by district hospitals per uninsured person R 280 218 117.5 714 120.9 291 155 310 473 531 576 - Process District hospitals with operational hospital board % 100 100 100 75 100 100 100 83 100 75 78 76 District hospitals with appointed (not acting) CEO in post % 100 100 100 100 66.6 100 100 100 100 100 71 69 Facility data timeliness rate for district hospitals % 100 100 100 100 100 99 100 85 80 100 55 34 Output Caesarean section rate for district hospitals % 29 35 15 27 40 21.48 12 20.3 24 16.9 30 12.5 Quality District hospitals with patient satisfaction survey using DoH template % 100 100 100 100 100 100 100 100 100 100 100 10 District hospitals with clinical audit (M and M) meetings every month* % 100 100 100 25 100 57 80 100 100 100 67 36 Efficiency Average length of stay in district hospitals Days 6 4 5 6 4 6 9 8 10 5 6 4.2 Bed utilisation rate (based on usable beds) in district hospitals % 55 63 57 53 51 51 57 54 57 58 65 68 Expenditure per patient day equivalent in district hospitals R 762 506 611.5 432.58 509 625 481 579 684 517 9

814 in 2003/04 prices

Outcome Case fatality rate in district hospitals for surgery separations % 4 3.4 4.3 4.3 1.6 3.9 8.5 4.6 4.3 2.6 7 3.9

*Clinical audits refer to peri-natal services

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Policies, priorities and strategic goals To have adequate, appropriately utilised, competent and motivated health workers in the Health

Services Cluster To have equitably allocated, effectively utilised and maintained resources in line with PHC

imperatives and the package of services provided by the respective Districts. To have appropriately designed, located, accessible and well maintained health facilities. To have well established and user-friendly Communication, Management and Health Information

Systems guiding decision-making in the Health Service Cluster. To have responsive, integrated, efficient and accountable delivery of health services in the province

aligned to provincial and national priorities. To have timeous delivery of high quality health services. To have effective community participation in governance, preventive, promotive rehabilitative and

curative care in the Province. To have sound relationship with training institutions ensuring curricula are responsive to health

service delivery. Analysis of constraints and measures planned to overcome them To have adequate, appropriately utilised, competent and motivated health workers in the

Health Services Cluster

The recruitment of staff to the rural areas of the Province remains a major stumbling block towards the attainment of Provincial goals. The HOD is considering a designation for the deep rural areas of the Province that will assign allowance equivalent to the rural nodes. An attempt to provide accommodation to the rural areas might help in attracting young professionals. However the developments in the health system e.g. expansion of community services to other groups translate to increase in accommodation requirements. The insufficient financial management capacity at District level hampers the health planning, budgeting and monitoring and evaluation initiatives. The financial management and performance based budgeting training programme that will run from 2004 to 2005 will assist in capacity development.

To have equitably allocated, effectively utilised and maintained resources in line with PHC imperatives and the package of services provided by the respective Districts

The interpretation of equity amidst the different geographic settings of this Province poses a challenge. In the allocation resources the formula goes beyond the conventional elements to include factors like distances, road conditions etc. as these have a major impact on costs.

To have appropriately designed, located, accessible and well maintained health facilities

The design and location of the Province’s older clinics and hospitals in some instances does not meet the health service needs. The Facilities Management unit has developed a multi-year plan facilities upgrading and construction. The principles of these plans especially the Clinic Upgrading and Building Programme (CUBP) draws the plans in consultation with local communities and District management teams.

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To have well established and user friendly communication, management and health

information systems guiding decision-making in the Health Service Cluster

The implementation of policies has been in a number of instances hampered by the poor communication through the different levels of governance. Whilst the Province displayed the value of well-structured communication in 1999/2000, whilst managing the Cholera outbreak, that system was not sustained. The 5-Year Review (1999 – 2004) revealed that there was a lack of a baseline and data sources were in some instances unreliable. The development of a Health Information Unit will assist in strengthening and monitoring the DHIS.

To have responsive, integrated, efficient and accountable delivery of health services in the Province aligned to provincial and national priorities

Provincial management arrangements for the delivery of health services have been promoting a silo mentality in the provision of emergency hospital and PHC services. The people of the Province were getting a raw deal in terms of responses to queries and the overall planning of the services. Towards the end of 2004 the Provincial arrangements were charged to District Managers becoming responsible and accountable for the delivery of all health services within a District. The concept of Area Managers was also brought in where the General Managers (Chief Directors) are responsible and accountable for a cluster of Districts.

This arrangement is improving 9information flow as well as implementation of Provincial Priorities.

To have timeous delivery of high quality health services

Quality is measured in terms of the following dimensions:

• Access to services • Clinical quality • Patient experience/perception

In an effort to ensure that the Province delivers quality health services, the focus has been on strengthening the foundations by:

• Developing a team culture throughout the organisation • Striving to adhere to the set of standards set by the national Department of Health • Working on the motivation of staff • Improving the information systems

A participative strategic planning process for health services supported these initiatives.

• The promotion of evidence based clinical practice through a network of family medicine specialists, District Medical Officers, Primary Health Care and Community Health Workers.

• Service monitoring and evaluation • Continuous improvement initiatives by Quality Improvement Programme teams at all

institutions

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To have effective community participation in governance, preventive, promotive,

rehabilitative and curative care in the Province

Community involvement in the issues of governance at District level has so far been limited to hospitals. The Clinic Committees will be appointed and trained in 2005/2006. The proposed organisation structure at Districts will assist in the facilitation of health promotion and rehabilitative programmes in the Districts. The terrain of the Province requires that approaches to health promotion take into consideration the social, cultural issues prevailing in the Province.

To have sound relationship with training institutions ensuring curricula are

responsive to health service delivery

The mismatch between the skills required in the Provincial health system and the enrolments at the tertiary institutions has been identified by the Province as a constraint towards an appropriate skills base. The Province is conducting an audit of health problems per District and the current skills availability at District level. A Provincial picture will then be drawn. The Departmental Bursary Scheme will be channelled towards training of individuals in the identified areas of skill deficiency.

Description of Planned Quality Improvement Measures

• The DHS portfolio has set up a quality assurance pilot study in DC 28 (Uthungulu) with the assistance of the National Department of Health and Equity. This pilot project integrates all levels of services in the District and it is hoped that once the results are available this project can be extended to the remaining 10 Districts.

• The DHS portfolio is embarking upon a process to ensure that all 421 clinics in the Province will have clinical governing committee structures. These structures will ensure, due to the community participation, that optimal and appropriate PHC services are rendered to the community.

• The CHW Programme will be integrated into the mainstream DHS Health Care System to ensure that quality health care services and follow-up care is rendered by Community Health Workers to patients on chronic medication (e.g. Hypertension and Diabetes) and TB patients (HAST)

Specification of Measurable Objectives and Performance Indicators The DHS portfolio has developed the following performance indicators linked to targets and objectives for the next 20 years. The development of these targets will ensure that the PHC Services delivery is achieved in the most rural sub-districts of the Province and also ensure that the most vulnerable sector of the population have access to health care services closest to their residences. The following table provides more details.

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Table DHS5: Provincial objectives and performance indicators for district health services

Objective Indicator 2001/02 (actual)

2002/03 (actual)

2003/04 (actual)

2004/05 (estimate)

2005/06 (target)

2006/07 (target)

2007/08 (target)

To develop District Health Plans based on the National DHS planning guidelines

% Districts with DHS plan based on the guidelines

50% 100% 100% (sub-districts)

100% (KZs)

To provide DHS services throughout the Province

% Districts providing full package of services at all levels

Access to:

• CHW

• Mobiles*

• Clinics (1:10 000)

• CHC’s (1 per District)

• EMRS (1 ambulance per 10 000 population)

• District Hospitals

• A Regional Hospital within District

170

40% of Districts

6 500

180

11

50% of Districts

7 500

220

11

60% of Districts

80% package

7 districts

8 500

240

11

70% of Districts

90% package

9 districts

9 500

260

100% package

11 districts

To decrease morbidity and mortality of vulnerable groups

% Districts implementing integrated health programmes targeting as priority:

• Tb

• STI’s/HIV and AIDS/ARV roll out

• Malaria

• MCWH

60% districts 75% districts 80% districts 100%

45


2002/03 (actual)

2003/04 (actual)

2004/05 (estimate)

2005/06 (target)

2006/07 (target)

2007/08 (target)

• Mental Health

To develop and implement a work plan for the assignment/ devolution of PHC functions to and from Local Government and SANTA

% Environmental services devolved to Local Government

% Non-Metro PHC services devolved to Province

% Hospitals with TB beds

Number of beds provided for MDR

% Districts with step-down facilities

10%

50%

50%

40%

40%

100%

75%

60%

60%

100%

100%

100%

100%

To develop and implement strategies for full integration of EMRS into DHS services

% EMRS functions integrated into DHS

50% integration 100% integration

100% integration

To implement functional and effective clinical governance systems

% Districts implementing quality improvement programmes ito:

• Risk management

• Defaulter tracing

• Quality of care

• Medical coverage for PHC services

• Mortality and morbidity reviews

• Pharmacy Therapy Committees

60%

80%

100%

100%

46


2002/03 (actual)

2003/04 (actual)

2004/05 (estimate)

2005/06 (target)

2006/07 (target)

2007/08 (target)

• Hotel aspects

• Waiting/service times

• Client satisfaction surveys

• Effective client complaint mechanisms

% Institutions with effective governance structures

50%

70%

90%

100%

To implement effective community participation programmes and governance systems including poverty alleviation

% Institutions participating in poverty alleviation programmes

% Contracts awarded to WOE’s/SMME’s and BEE’s

25%

25%

50%

50%

75%

75%

100%

100%

To establish effective collaboration and co-operation between the western trained health professional workers and Traditional Healers

% District forum for western trained health professionals and Traditional Healers

25% 50% 75%

To develop mechanisms for intersectoral collaboration

% District incorporating elements of the District health Plan into IDP

50%

75%

100%

100%

To establish equitable, efficient and effective management of resources

% Districts with integrated HR Plan

% District institutions implementing PMDS

% Districts with functional

60%

20%

80%

60%

100%

80%

100%

100%

47


2002/03 (actual)

2003/04 (actual)

2004/05 (estimate)

2005/06 (target)

2006/07 (target)

2007/08 (target)

Resource Planning Committee

% Districts conducting DHER

% Districts implementing the recommendation of DHER

100%

60%

100%

25%

100%

100%

50%

100%

100%

75%

100%

100%

100%

To establish effective management information and communication systems

% Districts with functional health information systems

% Districts with communication systems

% Districts with functional referral patterns

25%

50%

40%

60%

75%

60%

80%

100%

100%

100%

100%

100%

DISTRICT MEDICAL OFFICER SERVICES

To distribute Community Service Officers with geographic equity within underserved areas

No. of CSO’s placed outside urban

areas each year:

Urban

Rural

114

128

128

160

131

186

56

294

57

115

To implement two-year internship training in prescribed hospitals

No. of two-year interns accredited in prescribed hospitals against the original number of 1 year interns

1 year interns

2 year interns

No. of hospitals accredited with two-year internship each year

224

N/A

N/A

224

N/A

N/A

239

N/A

N/A

284

N/A

N/A

280

20

5

172

108

9

115

165

11

48

Table DHS6: Performance indicators for district health services

Indicator Type 2003/04 2004/05 2005/06 2006/07 2007/08 National target

2007/08 Input Uninsured population served per fixed public PHC facility No 19 983 17 379 No info No info No info <10,000 Provincial PHC expenditure per uninsured person R 204.03 218.26 269.70 327.47 374.52 N/A Local government PHC expenditure per uninsured person R 7.02 8.16 8.94 9.52 10.00 N/A PHC expenditure (provincial plus local government) per uninsured person R 211.04 227.02 278.65 336.99 384.62 274 Professional nurses in fixed PHC facilities per 100,000 uninsured person No 0.41 No info No info No info No info 130 Sub-districts offering full package of PHC services % 79 No info No info No info No info 100 EHS expenditure (provincial plus local govt) per uninsured person R 7.69 9.52 10.49 12.27 13.49 13 Process Health districts with appointed manager % 100 100 100 100 100 100 Health districts with plan as per DHP guidelines % 64 No info No info No info No info 100 Fixed PHC facilities with functioning community participation structure % 81 No info No info No info No info 100 Facility data timeliness rate for all PHC facilities % 100 100 No info No info No info 100 Output PHC total headcount No 18411276 18805785 No info No info No info N/A Utilisation rate – PHC No 2.1 2 No info No info No info 3.5 Utilisation rate – PHC under 5 years No 4 4 No info No info No info 5.0 Quality Supervision rate % 91 80 No info No info No info 100 Fixed PHC facilities supported by a doctor at least once a week % 41 No info No info No info No info 100 Efficiency Provincial PHC expenditure per headcount at provincial PHC facilities R 50 No info No info No info No info 78 Expenditure (provincial plus LG) per headcount at public PHC facilities R 52 No info No info No info No info 78 Outcome Health districts with a single provider of PHC services % 9 No info No info No info No info 100 1 'Fixed' means clinics plus community health centres. 'Public' means provincial plus local government facilities.

49

Table DHS7: Performance indicators for district hospitals sub-programme

Indicator Type 2003/04 2004/05 2005/06 2006/07 2007/08 National target

2007/08 Input Expenditure on hospital staff as % of district hospital expenditure % 67.98 66.34 65.20 64.45 63.50 62 Expenditure on drugs for hospital use as % of district hospital expend % 6.46 6.13 7.11 8.50 9.75 11 Expenditure by district hospitals per uninsured person R 236.37 258.63 265.78 292.28 307.11 No info Process District hospitals with operational hospital board % 87 No info No info No info No info 100 District hospitals with appointed (not acting) CEO in post % 89 No info No info No info No info 100 Facility data timeliness rate for district hospitals % 100 No info No info No info No info 100 Output Caesarean section rate for district hospitals % 16 18 No info No info No info 11 Quality District hospitals with patient satisfaction survey using DoH template % 100 No info No info No info No info 100 District hospitals with clinical audit (M and M) meetings every month % 85 No info No info No info No info 100 Efficiency Average length of stay in district hospitals Days 6 6 No info No info No info 3.2 Bed utilisation rate (based on usable beds) in district hospitals % 58 59 No info No info No info 72 Expenditure per patient day equivalent in district hospitals R 630 No info No info No info No info 814 in

2007/08 prices

Outcome Case fatality rate in district hospitals for surgery separations % 4.5 5 No info No info No info 3.5

50

Table DHS8: Transfers to municipalities and non-government organisations (R '000)

Transfers to municipal authorities and non-government organisations should be detailed in the table below. Transfers not included in the GFS book should be included in the table, but specified as such. More detail on service level agreements can be added in the text. Municipalities Purpose

of transfer

Base year 2004/05

(estimate)

Year 1 2005/06 MTEF

projection)

Year 2 2006/07 (MTEF

projection)

Year 3 2007/08 (MTEF

projection) Abaqulusi 1,2 387 421 449 471 Amajuba District Municipality

4 731 741 789 828

Dannhauser 1,2 453 492 524 550 EDumbe 1 688 747 796 836 Emnambithi/ Ladysmith 1,2 2,124 2,309 2,459 2,582 ENdondakusuka 1,2 758 825 878 922 Endumeni 1,2 1,599 1,738 1,851 1,944 eThekwini 1,2,3,4 36,120 39,844 42,413 44,622 Hibiscus Coast 1,2 2,383 2,591 2,760 2,897 Ilembe District Municipality 4 916 1,016 1,082 1,136 Kokstad 1,2 792 967 1,030 1,082 KwaDukuza 1,2 2,707 2,942 3,134 3,291 Matatiele 1,2 950 1,032 1,099 1,154 Mpofana 1 709 770 820 861 Msunduzi 1,2,3,4 8,269 9,122 9,715 10,201 Mthonjaneni 1 342 371 395 415 Newcastle 1,2 1,180 1,284 1,368 1,436 Okhahlamba 1 590 641 683 717 Richmond 2 53 59 63 66 Ubuhlebezwe 2 21 23 24 25 Ugu District Municipality 4 867 892 950 997 Ulundi 2 45 50 53 56 Umdoni 1,2 1,001 1,079 1,160 1,218 uMgungundlovu District Municipality 4 2,775 2,970 3,163 3,321 UMhlathuze 1,2 1,431 1,559 1,660 1,743 Umkhanyakude District Municipality 4 940 955 1,017 1,068

Umlalazi 1,2 1,115 1,212 1,291 1,355 uMngeni 1,2 935 1,017 1,083 1,138 uMshwathi 1,2 306 332 354 372 Umtshezi 1,2 1,193 1,297 1,381 1,450 uMuziwabantu 1,2 458 498 531 557 Umvoti 1,2 882 959 1,021 1,072 Umzinyathi District Municipality 4 817 907 966 1,014

Uphongolo 2 24 27 29 30 Uthukela District Municipality 4 644 654 697 732

51

Uthungulu District Municipality 4 1,315 1,465 1,560 1,638

Utrecht 2 18 20 21 22 Zululand District Municipality 4 1,104 1,119 1,192 1,251 TOTAL MUNICIPALITIES

77,642 84,947 90,461 95,070

NOTE: Please refer to the following codes, which indicate the main purpose of the individual municipal clinics in respect of transfers: 1. General Clinics 2. Environment Health Clinics 3. HIV and AIDS Clinics 4. Payment of Regional Service Levies

Non-Government Organisations Austerville Halfway House

4

121

128

135

143 Azalea 4 128 135 143 151 Benedictine Clinic 1 211 245 259 274 Bekulwandle Bhekimphilo Trust

1

3,756

4,450

4,706

4,976

Charles James Hospital

1,3

6,808

7,480

7,910

8,363

Cheshire DCC 4 62 66 70 74 Clermont DCC 4 74 79 84 88 Day Care Club 91 4 37 39 41 44 Day Care Club 92 4 37 39 41 44 Don McKenzie Hospital

1

787

830

878

928

Don Mckenzie Hospital (TB) 3

6,828

7,430

7,857

8,307

Doris Goodwin Hospital 1,3

4,593

5,100

5,393

5,702

Dunstan Farrell Hospital (SANTA)

1,3

5,930

7,220

7,635

8,073

Durban School for Hearing the Impaired

8

122

130

137

145

Durnacol Clinic 1 0 1,000 1,057 1,118 Ekuhlengeni Sanitorium

4

46,948

48,060

50,823

53,735 Ekukhanyeni 1 116 153 162 171 Elandskop 1 250 300 317 335 Enkumane 1 170 180 190 201 Fosa 1,3 4,748 5,190 5,488 5,803

52

Happy Hours Amaoti 4 59 62 66 69 Happy Hours Durban North

4

20

22

23

25 Happy Hours Durban Overport

4

22

24

25

27

Happy Hours Kwaximba 4

35

37

39

41

Happy Hours Mariannhill 4

27

28

30

31

Happy Hours Mphumalanga 4

84

88

93

98

Happy Hours Ninikhona 4

22

24

25

27

Happy Hours Nyangwini 4

47

50

53

56

Happy Hours Phoenix 4

10

11

12

12

Hlanganani Ngothando DCC 4

44

83

88

93

Ikwhezi Cripple Care 4

418

445

471

498

Ikwhezi DNS 1 102 108 114 121 Jewel House 4 77 82 87 92 Joan Tennant 4 81 85 90 95 John Peattie 4 440 465 492 520 Jona Vaughn 4 712 780 825 872 Khotsong Santa Centre

1,3

781

1,000

1,057

1,118 Lynn House 4 108 115 122 129 Madeline Manor 4 407 430 455 481 Masada 4 40 42 44 47 Masimbambaneni DC

4

30

32

34

36 Matikwe Oblate 1 303 350 370 391 McCords Hospital 1,3,6 40,638 42,900 45,366 47,966 Mhlumayo Clinic 1 340 360 381 403 Montebello Chronic Sick Home

8

2,938

3,115

3,294

3,483

Mountain View Hospital 1,3

4,041

4,615

4,880

5,160

Noya Bazi 1 650 650 687 727 Oakford 1 481 660 698 738 Phrenaid 4 34 36 38 40 Pongola Hospital 5 1,481 1,580 1,671 1,767 Rainbow Haven 4 154 165 174 184 Richmond Chest 3,7 29,933 30,440 32,190 34,035 Rosary 1 715 1,290 1,364 1,442 Santa Motivators DC 22

3

239

255

270

285 Santa Motivators DC 23

3

105

110

116


3

103

200

211

224 Santa Motivators Ethekwini

3

109

116

123


3

200

215

227

240

53

Santa Motivators DC 29 3

100

106

112

119

Scadifa 4 308 325 344 363 Sibusisiwe Home 4 124 130 137 145 Siloah Lutheran Hospital

1,2,5

6,665

7,550

7,984

8,442 Sparks Estate 4 427 455 481 509 St Lukes 4 176 187 198 209 St Mary’s Mariannhill

1,3,5,7

50,913

55,520

58,711

62,076 Sunfield Home 4 55 60 63 67 The Dream Centre 2 1,490 0 0 0 Umlalazi Halfway House

4

81

86

91

96 Unallocated 967 3,743 3,958 3,769 TOTAL: NGO’S 229,062 247,486 261,712 276,296

NOTE: (a) Please refer to the following codes, which indicate the main purpose of the individual

institutions in respect of transfers: 1. General Clinics 2. HIV and AIDS 3. Tuberculosis 4. Psychiatric 5. District Hospitals 6. General Hospital 7. Private enterprises providing a service to the Department 8. Other (b) The above figures are subject to change as final negotiations with the institutions

are still in progress.

54

Past expenditure trends and reconciliation of MTEF projections with plan

Table DHS9: Trends in provincial public health expenditure for district health services (R million)

Expenditure 2001/02 (actual)

2002/03 (actual)

2003/04 (actual)

Average annual

percentage change

2004/05 (estimate)

2005/06 (MTEF projection)



Current prices Total 3 326 700 3 363 876 3 771 028 6.47 4 130 858 - - - Total per person R352.93 R354.44 R393.72 5.62 R427.37 - - - Total per uninsured person R401.05 R402.77 R447.41 5.62 R485.65 - - - Total capital2 - - - - - - - - Constant (2004/05) prices Total 4 051 921 3 730 538 3 967 121 (1.84) 4 130 858 4 630 789 5 352 526 5 882 880 Total per person R429.87 R393.07 R414.20 (1.84) 427.37 R479.09 R553.76 R608.63 Total per uninsured person R488.48 R446.67 R470.68 (1.84) R485.65 R544.42 R629.27 R691.63 Total capital - - - - - - - -

Expenditure Trend: The increasing trend in the expenditure/budget allocation in this programme is mainly related to: The policy of providing access to less expensive, but the most important level of health services, i.e. Clinics, Community Health Centers and District Hospitals; The commissioning of new clinics; The establishment and expansion of the District Management Offices; Provision for and the roll-out of the PMTCT, CVT and PEP HIV and AIDS Programmes; The increase in the incidence of tuberculosis, especially in relation to HIV and AIDS; The extension of the Community Service Programme to Environmental Health Workers and Therapists; The roll-out of the Anti-retroviral Therapy Programme from 2004/05

annexure 2 - district health system · 27 annexure 2 - district health system situation analysis...

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